A 56-year-old man comes to the emergency department with right leg swelling. He noticed the swelling yesterday and has not had injury to that leg or a recent fall. The patient has no chronic medical conditions and takes no medications. On review of systems, he endorses frequent nosebleeds and occasional gum bleeding, which began recently. He has also had persistent, nagging epigastric and back pain. The patient has lost 4.5 kg (10 lb) over the past 3 months despite no change in diet or activities. He has smoked a pack of cigarettes daily for 30 years. The patient does not use alcohol or illicit drugs. Temperature is 36.9 C (98.4 F), blood pressure is 110/80 mm Hg, pulse is 96/min, and respirations are 16/min. Chest examination is unremarkable. Mild epigastric tenderness is present. There is moderate, asymmetric right lower extremity edema. Peripheral pulses are full and symmetric. Further evaluation is most likely to reveal which of the following?

Question

A 56-year-old man comes to the emergency department with right leg swelling.  He noticed the swelling yesterday and has not had injury to that leg or a recent fall.  The patient has no chronic medical conditions and takes no medications.  On review of systems, he endorses frequent nosebleeds and occasional gum bleeding, which began recently.  He has also had persistent, nagging epigastric and back pain.  The patient has lost 4.5 kg (10 lb) over the past 3 months despite no change in diet or activities.  He has smoked a pack of cigarettes daily for 30 years.  The patient does not use alcohol or illicit drugs.  Temperature is 36.9 C (98.4 F), blood pressure is 110/80 mm Hg, pulse is 96/min, and respirations are 16/min.  Chest examination is unremarkable.  Mild epigastric tenderness is present.  There is moderate, asymmetric right lower extremity edema.  Peripheral pulses are full and symmetric.  Further evaluation is most likely to reveal which of the following?

Quizplus · Accepted Answer

11ec25c8_d413_ff90_bc81_2da4db1f127f_MD0003_00 In this patient with asymmetric leg swelling suggestive of deep venous thrombosis (DVT), several features are concerning for chronic disseminated intravascular coagulation (DIC) in the setting of cancer. His long history of smoking combined with unintentional weight loss and nagging epigastric and back pain raises suspicion for pancreatic cancer. Mucin-producing tumors (eg, pancreatic, gastric, ovarian, breast) often secrete tissue factor into the blood, which intermittently triggers the coagulation cascade and can lead to chronic DIC, a consumptive coagulopathy. As with other consumptive coagulopathies, the risk of arterial or venous thrombosis (eg, DVT) is significantly increased in patients with chronic DIC; in addition, periodic mucocutaneous bleeding (eg, gums, nose) can occur, as seen in this patient. However, because patients with chronic DIC are usually able to compensate for intermittent coagulation and fibrinolysis via increased production of coagulation factors, platelets, and fibrinogen, they may be asymptomatic and frequently have normal platelet counts and coagulation times. In contrast to chronic DIC, acute DIC usually arises in the setting of sustained procoagulant exposure (eg, lipopolysaccharide in sepsis) and is marked by massive activation of the coagulation cascade, with rapid consumption of platelets, coagulation factors, and fibrinogen. Most cases present with acute bleeding rather than thrombosis. (Choice A) Antiphospholipid antibodies increase the risk of venous thromboembolism and fetal loss. Bleeding risk is not generally increased. In addition, antiphospholipid antibodies are most often associated with systemic lupus erythematosus, not pancreatic cancer. (Choice C) Cryoglobulinemia, a small- to medium-sized vessel vasculitis caused by the precipitation of circulating antibodies, is most common in the setting of infection (eg, hepatitis C), monoclonal gammopathy (eg, multiple myeloma), or connective tissue disease. Patients generally have palpable purpura, weakness, renal insufficiency, and arthritis/arthralgias. Thrombosis and bleeding are atypical, and the condition is not typically linked to pancreatic cancer. (Choice D) Factor V Leiden is a disorder marked by an inherited resistance to activated protein C. Because protein C is an anticoagulant, patients are at increased risk for thromboembolism. However, bleeding risk is not increased, and the condition is not associated with pancreatic cancer. (Choice E) Thromboangiitis obliterans is a small- and medium-sized vessel vasculitis of the extremities that typically occurs in young patients who smoke. It generally causes distal extremity ischemia, digit ulcers, and/or digit gangrene. This older patient with epigastric pain, unintentional weight loss, and evidence of both bleeding and thrombosis is more likely to have chronic DIC due to cancer. Educational objective: Chronic disseminated intravascular coagulation is common in patients with mucin-producing tumors (eg, pancreatic cancer) due to periodic release of tissue factor into the bloodstream, which triggers low-grade coagulation and fibrinolysis. Patients frequently have normal platelet counts and coagulation times but are at increased risk for venous and arterial thrombosis and, to a lesser extent, mucocutaneous bleeding.

A 56-Year-Old Man Comes to the Emergency Department with Right