OVARIAN CARCINOMA MIMICKING SYSTEMIC SMALL VESSEL VASCULITIS: CASE REPORT

ABSTRACT

Background: Few cases of digital ischemia and gangrene associated with primary solid tumors have been described in literature[3]. The exact mechanism of severe occurrence has not been completely understood and the available treatment options have an extremely limited utility [1,2].In the most cases the patients were elderly women with adenocarcinomas of digestive or gynaecologic apparatuses [4]. Objectives: We describe a new case of digital gangrene as unusual presentation of ovarian cancer in a 36 years old woman. Methods: 36 years old female was admitted to our Reheumatology deparment with blackish Blackish discoloration of the toes of one week duration. She had history of COVID-19 infection 8 months prior to the presentation then developed hemoptysis, picture suggestive of ILD, generalized anasarca and skin rash;accordingly an initial diagnosis of post COVID-19 vasculitis was made by dermatologist. The blood tests were ESR21 mm/hr, CRP25.7, D.Dimer8.8, Ferri-tin575 ng/ml, lymphopenia0.9, S.Creatinine2, 24 h urinary protein 325 mg/24h and all autoimmune markers were negative except anti nuclear antibody (ANA) with titer1/160. Further assessment revealed that she had multiple site coag-ulopathy;internal jugular vein thrombosis, bilateral lower limbs Deep Venous Thrombosis (DVT). Neck ultrasound surprisingly showed bilateral enlarged suspicious looking supraclavicular lymph node with lost hilum which was Biopsied for histopathological correlation which revealed focally necrotizing adenocarci-noma with signifcant signet ring differentiation. Searching for the primary malignancy, tumor markers were sent CA125 584 u/ml (up to 35), Pelvi-abdominal Magnetic resonance imaging (MRI) revealed Left ovarian mass measuring 3.6 x 3.4 x 4.4 cm highly suspicious of malignant neoplastic growth for histopatho-logical correlation, Suspicious looking pelviabdominal lymph nodes mostly representing malignant lymphadenopathy, Scattered peritoneal nodules suspicious of metastatic deposits. Results: During admision the patient received full dose anticoagulation (Low Molecular Weight Heparin 60 iu/12 h). Upon diagnosis we arrange the transferal to the oncology department to continue her management plan. Unfortunately;the case was terminal for palliative therapy and she died after 2 weeks. Conclusion: Bluish discoloration of digits and toes may be a clue for diagnosis of many diseases not only vasculitis. Malignancy can disturb the immune system in a way that mimic any systemic connective tissue disease. Acute insult aggressive multiple site deep venous thrombosis (DVT) necessitate thinking outside the box and consider other causes of coagulopathy like visceral malignancy.