A 58-year-old female patient with no pertinent past medical history presented to the emergency department as a transfer from an outside hospital for computerized tomography (CT) findings of retroperitoneal lymphadenopathy with nodularity and stranding of the omental fat, concerning for malignancy/metastatic disease requiring higher level of care for malignancy workup. The patient stated she experienced increasing fatigue, a decrease in appetite, and an unmeasured amount of weight loss over the past month. The patient stated that over the past two weeks, her symptoms had worsened significantly. She endorsed increased thirst, but denied fevers, chills, headache, cough, dyspnea, night sweats, chest pain, or sick contacts. She denied recent travel, stating she had only travelled to Thailand greater than 10 years previously.
On physical exam, the patient was afebrile with stable vital signs. She had clear lung sounds bilaterally, was nontender to abdominal palpation with a negative Murphy's sign, and had an unremarkable cardiac exam. A 2 cm mass in the 4 o'clock position of the left breast was palpated on clinical breast exam.
Laboratory analysis was remarkable for leukocytosis of 13.9x10e9/L, alkaline phosphatase of 310 U/L, and aspartate aminotransferase of 78 U/L. Malignancy workup was obtained: cancer antigen 19-9 and carcinoembryonic antigen were elevated to 301.4 U/mL and 9.0 ng/mL, respectively, with alpha-fetoprotein tumor marker within normal limits. Evaluation for acute and chronic liver pathology was positive solely for hepatitis A, with kidney microsomal antibodies, mitochondrial antibodies, antinuclear antibodies, alpha-1-antitrypsin, and ceruloplasmin all being negative. An iron panel demonstrated findings consistent with anemia of chronic disease (ferritin 2410.3 ng/mL, total iron 47 mcg/dL, and total iron binding capacity 80 mcg/dL). Blood cultures and urine cultures demonstrated no growth. Interferon-gamma release assay (IGRA) for tuberculosis was indeterminate.
The patient received extensive imaging. A CT abdomen/pelvis demonstrated retroperitoneal lymphadenopathy, nodularity and stranding in the omental fat, thickened ring along the periphery of the liver, and cholelithiasis. A CT chest demonstrated mediastinal lymphadenopathy, multiple small nodules scattered in the lungs bilaterally, and a small left pleural effusion. Cardiac bedside ultrasound showed no apparent focal wall motion abnormality and demonstrated adequate systolic left ventricular systolic function with an ejection fraction greater than 60%. Abdominal bedside ultrasound demonstrated multiple gallstones within an enlarged gallbladder measuring approximately 10 cm. Formal right upper quadrant ultrasound demonstrated cholelithiasis with sludge and gallbladder wall thickening as well as a nodular hepatic contour. Magnetic resonance cholangiopancreatography (MRCP) was unable to be obtained due to a history of a bullet wound to the left breast with retained metal fragments. The patient's hepatobiliary iminodiacetic acid (HIDA) scan demonstrated nonvisualization of the bladder supporting cystic duct obstruction and acute cholecystitis. Mammogram showed a 2.5 x 2.7 cm breast mass of the left breast.
The patient was started on Zosyn for cholecystitis and underwent an esophagogastroduodenoscopy (EGD) and colonoscopy which demonstrated nodular gastric mucosa and duodenal erosions. During her hospital course, she underwent multiple biopsies, including an ultrasound-guided core biopsy of her left breast mass, a colon biopsy, a retroperitoneal node biopsy, and a gastric mucosa biopsy. Throughout her hospital course, consultants from hematology/oncology, general surgery, and surgical oncology services informed the patient of the high likelihood of a cancer diagnosis upon pathologic examination of biopsied tissue. However, the patient left the hospital against medical advice before the biopsy results were available.
Upon outpatient hematology/oncology follow-up, the patient received her biopsy results. Her colon biopsy and gastric mucosa biopsy demonstrated no abnormalities. However, her left breast biopsy demonstrated a new diagnosis of cT2N0 grade-2 estrogen receptor-positive, progesterone receptor-positive, and her2-negative invasive carcinoma of no special time with lobular features with a minor component of ductal carcinoma in situ. Her retroperitoneal node biopsy demonstrated lymphoid tissue with necrotizing giant-cell granulomas, positive for mycobacteria on acid-fast bacilli staining. Treatment of the abdominal tuberculosis was to be coordinated by infectious disease and hematology/oncology before undergoing surgical treatment for the breast mass. Upon phone call to confirm an appointment, the patient's husband informed medical staff that the patient had passed away, less than two weeks after her discharge.