A 76-year-old man presents to the clinic with a complaint of back pain, toe pain, and toe discoloration. His back pain has been getting slowly worse over the past 3 months, and radiates to abdomen. His toes started bothering him 3 weeks ago. He also states he has been feeling tired for a few months and has not seen a doctor in several years. Past medical history is significant for an appendectomy at age 15 and he had emergency department visits several times 10-20 years ago for similar abdominal and back pain. He takes ibuprofen as needed when sore from golf. He is a retired lawyer and travels often to see his grandchildren. He drinks a 6 pack of beer when he goes golfing once a week and 4-5 glasses of wine about twice per week. He has a 30-pack-year history of smoking cigarettes which he quit ago. Vital signs are temperature 98.7° F (37.0° C) blood pressure 119/81, pulse 84 beats/min, and respirations 19/min. Body Mass index ( BMI) is 19 kg/m2. Physical exam shows mild midepigastric tenderness to palpation without guarding or rebound. The toes are noted to be erythematous and tender. Diagnostic studies reveal a fasting serum glucose of 220 mg/dL and an elevated serum CA19-9. CT of the abdomen reveals dystrophic calcifications of the pancreas.
This patient’s most likely diagnosis increases his risk of which of the following pathologies?
B) Diabetes mellitus
This patient has evidence of recurrent pancreatitis in his medical history, which is supported by his symptoms and alcohol use. Chronic pancreatitis increases the risk of developing pancreatic cancer. Dystrophic calcifications in the pancreas can occur due to multiple conditions including chronic pancreatitis and pancreatic neoplasms. The elevated tumor marker CA 19-9 suggest the presence of cancer, though a biopsy is necessary to establish the diagnosis. Diabetes is both a risk factor for and a possible consequence of pancreatic cancer. The elevated fasting blood sugar may indciate that diabetes mellitus is already present.
Answer choice A: Cushing syndrome, is incorrect. Cushing syndrome is associated as a paraneoplastic syndrome with small cell lung cancer and bronchial carcinoid tumors. It presents with hypercortisol effects.
Answer choice D: Diverticulitis, is incorrect. Diverticulitis presents with left lower quadrant pain, obstruction-like symptoms, and sometimes with blood in stool. It is not associated with pancreatic adenocarcinoma.
Answer choice D: Kurkenburg tumor, is incorrect. Krukenburg tumor is a rare, malignant tumor in the ovary as a result of spread from another cancer, usually diffuse gastric carcinoma.
Answer choice E: Myasthenia gravis, is incorrect. Myasthenia Gravis causes muscle weakness symptoms in association with thymoma as a paraneoplastic syndrome.
Key Learning Point
Pancreatic carcinoma increases the risk of secondary diabetes mellitus due to destruction of the pancreatic islets. Pancreatic cancer should be suspected when there is an enlarged gallbladder, prodromal symptoms, migratory thrombophlebitis, history of cigarette smoking and alcohol use, dystrophic pancreatic calcifications or pancreatic mass, and elevated tumor serum marker CA-19-9.
