A 68‐year‐old woman was initially diagnosed with metastatic rectal adenocarcinoma in 2009. She received chemoradiation at that time with excellent response. 2 years after her initial diagnosis, she developed metastatic recurrence in her mediastinal, hilar, and supraclavicular lymph nodes with an increasing CEA level. She was reinitiated on chemotherapy at that time. Three months later, the patient was admitted to the hospital with rectal and vaginal pain and a severely painful, pruritic rash. The rash began to develop several weeks prior to her admission. It had initially started in her vulvar and pelvic region and had continued to spread upward to her lower abdomen and bilateral flanks. She had tried hydrocortisone cream at home without relief. She had also been treated with a course of fluconazole for possible candidal infection without improvement. On physical exam, an erythematous maculopapular rash with areas of raised and vesicular appearing lesions were found along the lower abdomen, bilateral groin, vagina, rectum, bilateral flanks, and upper thighs. Her rash was initially felt to be due to recall radiation dermatitis with possible overlying skin infection. She was initiated on antibiotics, antivirals, and antifungals with minimal improvement. HSV and genital cultures were obtained and found to be negative. Dermatology was consulted during her hospitalization. Punch biopsy of a skin lesion along her suprapubic region was obtained. Biopsies revealed adenocarcinoma consistent with the patient's primary rectal cancer. Following discharge, she was resumed on chemotherapy for treatment of her cutaneous metastases.
Cutaneous metastases are considered relatively rare. Common cancers metastasizing to the skin include breast, lung, ovarian, and melanoma. They can present in numerous ways ranging from inflammatory nodules to clusters of painless, flesh colored lesions to a vesicular rash resembling herpes zoster. Cutaneous metastases associated with rectal cancer are considered even more uncommon, occurring in less than 4% of patients. They typically have a nodular appearance. Those patients with high clinical suspicion for cutaneous malignancy should undergo biopsy as soon as possible. Prompt diagnosis of cutaneous metastases is essential, as they may be the first sign of an internal malignancy and are often indicative of a poor prognosis.
A common challenge faced by hospitalist is the appropriate diagnosis and treatment of a variety of skin conditions. The purpose of reporting this case is to encourage hospitalists to strongly consider cutaneous metastases as a potential etiology for skin conditions in their patients with malignancy as well as those patients with high clinical suspicion for underlying malignancy.
To cite this abstract:Hill E, Grenier M. Not Your Ordinary Rash: A Case of Metastatic Cutaneous Rectal Adenocarcinoma. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 342. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/not-your-ordinary-rash-a-case-of-metastatic-cutaneous-rectal-adenocarcinoma/. Accessed March 31, 2020.