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Indian Journal of Dermatology, Venereology and Leprology
Medknow Publications on behalf of The Indian Association of Dermatologists, Venereologists and Leprologists (IADVL)
ISSN: 0378-6323 EISSN: 0973-3922
Vol. 71, Num. 3, 2005, pp. 197-198

Indian Journal of Dermatology, Venereology and Leprology, Vol. 71, No. 3, May-June, 2005, pp. 197-198

Case Report

Malignant acanthosis nigricans with liver secondaries from an occult primary adenocarcinoma of gastrointestinal tract

Nair Pradeep S., Moorthy Prasanna K., Suprakasan S., Jayapalan Sabeena, Sarin M.

Department of Dermatology and Venereology, Medical College Hospital, Trivandrum - 695 011, Kerala

Correspondence Address: Kamala Sadan, Thampuran Mukku, Kunnukuzhy, Trivandrum - 695 037, Kerala, bijili@asianetindia.com

Code Number: 05063

ABSTRACT

A 38-year-old female presented with hyperpigmented velvety plaques on the nape and the sides of the neck with diffuse pigmentation of the face and flexures suggestive of acanthosis nigricans. The dorsa of both the hands showed increased rugosity, hyperpigmentation and hyperkeratosis of the palms, suggestive of tripe palms. Investigations revealed multiple secondaries in the liver. Histopathology showed the secondaries to be from adenocarcinoma of the gastrointestinal tract.

Keywords: Malignant acanthosis nigricans, Tripe palms, Secondaries, Adenocarcinoma

INTRODUCTION

Acanthosis nigricans (AN) can be benign, associated with endocrinopathies or obesity, or drug-induced.[1] Malignant AN presents with diffuse hyperpigmentation of the face, flexures and the oral cavity. It is considered to be a paraneoplastic manifestation of adenocarcinoma of the gastrointestinal tract (GIT).[2] Tripe palms is characterized by diffuse hyperpigmentation, increased rugosity and hyperkeratosis of the palms. Here we report malignant AN with tripe palms and multiple secondaries in the liver due to adenocarcinoma of the GIT.

CASE REPORT

A 38-year-old female presented with a history of progressive pruritic dark discoloration of the face of 2 years′ duration. The hyperpigmentation first started in the face and within a period of 6 months spread to the flexures and dorsa of the hands. She also complained of recent loss of weight. There was no history of hematemesis, melena, hemoptysis, cough or dyspnea.

General examination revealed pallor, but no jaundice. Dermatological examination showed diffuse hyperpigmentation with thickening of the skin of the face, neck, flexures, external genitalia and anus [Figure - 1]. The hands showed hyperpigmentation, increased rugosity on the dorsum and diffuse hyperkeratosis of both palms [Figure - 2]. The tongue was fissured. No organomegaly was detected on systemic examination.

With these clinical findings a diagnosis of AN with tripe palms was made and the patient was investigated. Hemogram, liver function and renal function tests were normal and serological tests for syphilis, HIV, HBsAg and HCV were negative. Urine bile salts and bile pigments were negative and urinary urobilinogen was normal. The alpha-fetoprotein levels were normal.

Chest X-ray and ECG were normal. Upper gastrointestinal tract (GIT) endoscopy was normal while colonoscopy showed hemorrhoids. There was no evidence of GIT malignancy. Ultrasound abdomen showed a heterogeneous lesion in the left lobe of the liver with enlarged peripancreatic and para-aortic lymph nodes. A high contrast CT scan of the abdomen showed a mass on the left lobe of the liver with invasion of the left and main portal vein and enlarged para-aortic, peripancreatic and celiac lymph nodes.

On exploratory laparotomy, multiple deposits were seen on the liver. Biopsy showed them to be secondaries from adenocarcinoma of the GIT. FNAC of the lymph nodes showed no metastatic cells. The final diagnosis was malignant AN with liver secondaries from an occult primary adenocarcinoma of the GIT.

DISCUSSION

Classical clinical features of malignant AN with tripe palms prompted us to investigate the patient. Usually, malignant AN is associated with adenocarcinoma of the GIT as a paraneoplastic manifestation.[3],[4] However, in our case, endoscopy and a CT scan showed the GIT to be normal. The biopsy of the deposits on the liver confirmed the diagnosis of secondaries from adenocarcinoma of the GIT even though the primary site in the GIT could not be determined. Since the secondaries were not surgically resectable, we are considering palliative therapy for our patient.

The other malignancies associated with malignant AN are of the bladder, kidney, thyroid, bile duct, bronchus and rarely lymphomas.[5] Isolated tripe palms may also be associated with internal malignancy[6] although they may occur as a part of malignant AN.[7] An interesting feature in this case is that in spite of having multiple secondaries in the liver the patient did not have jaundice or any systemic illness.

REFERENCES

1.Curth HO. Classification of acanthosis nigricans. Int J Dermatol 1976;15:592-3.  Back to cited text no. 1  [PUBMED]  
2.Anderson SH, Peacock HM, Muller AF. Malignant acanthosis nigricans: Potential for chemotherapy. Br J Dermatol 1999;141:714-6.  Back to cited text no. 2    
3.Hage E, Hage J. Malignant acanthosis nigricans-a paraendocrine syndrome? Acta Derm Venereol 1977;57:169-72.  Back to cited text no. 3  [PUBMED]  
4.White H. Acanthosis nigricans and wart like lesions associated with metastatic carcinoma of the stomach. Cutis 1976;17:931-3.  Back to cited text no. 4  [PUBMED]  
5.Schwartz RA. Acanthosis nigricans. J Am Acad Dermatol 1994;31:1-19.  Back to cited text no. 5  [PUBMED]  
6.Requena L, Aguilar A, Renedo G, Martin L, Pique E, Farina MC, et al. Tripe palms: A cutaneous marker of internal malignancy. J Dermatol 1995;22:492-5.  Back to cited text no. 6  [PUBMED]  
7.Cohen PR, Grossman ME, Almedia L, Granstein L. Tripe palms and malignancy. J Clin Oncol 1989;7:669-78.  Back to cited text no. 7    

Copyright 2005 - Indian Journal of Dermatology, Venereology and Leprology

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