Letters to the Editor
To the Editor:
The paraneoplastic syndromes occur in as many as 10% of patients with lung cancer, more frequently associated with small-cell carcinoma. Among the paraneoplastic manifestations, the Trousseau's syndrome (TS) is a rare entity.1,2 We report a case of a 57-year-old woman, a heavy smoker, who presented with fever, myalgias, and pain in the left leg (she reported similar episodes before in the right leg). The patient had a history of hypertension, dyslipidemia, and an important vascular comorbidity (a transient ischemic attack in 2002 and a deep venous thrombosis in the left leg diagnosed 4 mo before actual admission). On physical examination, the left leg was found red, swollen, and hot from the thigh to the knee. The laboratory tests were normal except for leukocytosis with neutrophilia. The autoimmunity panel and erythrocyte sedimentation rate were normal. The lupic anticoagulant was negative and no mutations were found for Factor V Leiden or for prothrombin 20210A. Doppler ultrasonography of the lower extremities showed a thrombus in the left ileofemoropopliteal territory. Computed tomographic scanning of the thorax, abdomen, and pelvis (Fig. 1) showed mediastinal adenopathies of 2 cm in the lower right paratracheal area (4R) and of 1.5 cm in the subcarinal area (7) associated with centrilobular emphysema. Positron emission tomography (Fig. 2) confirmed the existence of adenopathies with abnormal enhancement in the 4R (SUV 6.7) and 7 (SUV 6.3) areas. With these data, an endobronchial ultrasound was performed to puncture these adenopathies. Specimens were obtained from both areas and showed metastasis of adenocarcinoma. The diagnosis of pulmonary adenocarcinoma associated with thrombophlebitis migrans as a paraneoplastic syndrome was made and the patient was sent to the Oncology Service, where chemotherapy was started. We consider this case significant because the unique alteration in the imaging studies was the mediastinal adenopathies being the first case in which the diagnosis of TS was made by endobronchial ultrasound.
TS is characterized by a recurrent and migratory venous thrombosis that mainly affects the legs but can affect unusual sites, such as arms or chest, as well. Local inflammatory signs, leukocytosis, and a high erythrocyte sedimentation rate are frequently seen. In 1 review3 of patients with TS, the following associated tumors were seen: pancreas (24%), lung (20%), prostate (13%), and stomach (12%). Mucins produced by adenocarcinomas may trigger this syndrome by reacting with leukocytes, platelet selectins, and thromboplastin released by the tumor resulting in the production of platelet-rich microthrombi.4,5
Rocío Díaz Campos MD
Ricardo Luján MD
Eduardo Poch MD
1. Richardson G, Johnson B. Paraneoplastic syndromes in lung cancer Curr Opin Oncol.. 1992;4:323–333
2. Spiro S, Gould M, Colice G. Initial evaluation of the patient with lung cancer: symptoms, signs, laboratory tests and paraneoplastic syndromes: ACCP evidenced—based clinical practice guidelines (2nd edition) Chest.. 2007;132:149S–160S
3. Sack GH, Levin J, Bell WR. Trousseau's syndrome and other manifestations of chronic disseminated coagulopathy in patients with neoplasms: clinical, pathophysiologic and therapeutic features Medicine (Baltimore).. 1977;56:1–37
4. Varki A. Trousseau's syndrome: multiple definitions and multiple mechanisms Blood.. 2007;110:1723–1729
© 2011 Lippincott Williams & Wilkins, Inc.
5. Wahrenbrock M, Borsig L, Le D, et al. Selectin—mucin interactions as a probable molecular explanation for the association of Trousseau's syndrome with mucinous adenocarcinomas J Clin Invest. 2003;112:853–862