R Makkar, A Monga, A Gupta, S Jain, S Jain
cutaneous mucinoses, cutaneous mucinosis, internal malignancy, mucin, skin metastasis
R Makkar, A Monga, A Gupta, S Jain, S Jain. Cutaneous Mucinosis As Metastatic Lesions In A Young Woman With Visceral Malignancy. The Internet Journal of Dermatology. 2002 Volume 2 Number 1.
Mucigenous skin eruptions are an exceedingly rare form of cutaneous metastasis and have been reported in very few cases. We hereby report a young woman who presented with multiple "mucinous" papulonodular eruptions on the skin as evidence of distant metastasis from an unknown visceral primary site. The presence of such lesions in cancer patients may be a sign of widespread metastases foreboding a grave prognosis.
Place of work: Sitaram Bhartia Institute of Science and Research, New Delhi, India
A 31-year-old woman was brought to the emergency in a poor general condition with history of generalized weakness, anorexia, weight loss and progressive distension of abdomen for 2-3 months. She had developed multiple skin nodules all over the body over last 2 months that were subcutaneous papulonodular eruptions. The eruptions, initially misdiagnosed as ‘xanthomas', were chiefly distributed over face, neck, chest, back, arms and thighs (Figure 1 and 2).
The lesions were shiny in appearance, firm and fleshy in consistency and were mildly tender to touch. The overlying skin was dry and not fixed to the underlying tissue. She also had multiple firm but discrete cervico-axillary lymph nodes. Chest and abdominal examination showed bilateral pleural effusion and ascites, respectively. The pleural fluid and ascitic fluid examination, both showed atypical cells suggestive of internal malignancy. A CT scan of the abdomen revealed bilateral tubo-ovarian masses along with the ascites. Cervical lymph node biopsy (Figure 3) suggested metastatic mucin-secreting carcinoma lymph node.
Biopsy from the skin nodule (Figure 4 and 5) also showed carcinomatous deposits of ‘mucin' type. The raised CA-125 (52 U mL -1 , normal <30 U mL -1 ) levels in the presence of tubo-ovarian masses suggested a primary mucinous carcinoma of the ovary, but a metastatic mucin-secreting cancer from the gastrointestinal tract (Krukenberg tumor) could not be ruled out in view of bilateral ovarian involvement. The disease showed a very rapid and fulminant course and the patient expired on the third day of admission. An autopsy to look for the primary site of the malignancy was refused by the husband.
Cutaneous mucinoses are a heterogenous group of conditions in which ‘mucin' accumulates in the skin. They have been reported in the past in diseases such as lichen-myxedematosus, lupus-erythematosus, scleredema, dysthyroidotic mucinoses (mucinoses associated with thyroid diseases), reticular erythematous mucinosis, acral persistent mucinosis, juvenile cutaneous mucinosis, cutaneous mucinosis of infancy, cutaneous toxic-oil mucinoses, neuropathy-related cutaneous mucinosis, urticaria-like mucinosis, hereditary mucinous histiocytosis and primary mucinous skin (sebaceous and sweat glands) carcinomas. [1,2]
The appearance of ‘mucigenous skin deposits' as a sign of internal malignancy is an extremely rare phenomenon (given the fact that skin is the site of metastases in only 3-5% cases among those with any evidence of metastases).  Though, such lesions have been reported in very few cases in the past [4,5], to the best of our abilities, we could not find any clinical picture/photograph showing 'metastatic' ‘mucigenous skin lesions' in the medical literature.
The new occurrence of these lesions may be a sign of ‘mucin-producing' ovarian or gastrointestinal malignancy. We believe that every practitioner should be aware of this possibility in order to make a timely diagnosis of the underlying malignancy as the presence of such lesions in these patients may entail a very poor prognosis.
Ravinder PS Makkar, MD D-40, Preet Vihar, New Delhi-110092, India Tel: 91-11-22545183, Fax: 91-11-23352701 E-mail: email@example.com