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BMJ Case Rep. 2010; 2010: bcr0920092310.
Published online 2010 October 28. doi:  10.1136/bcr.09.2009.2310
PMCID: PMC3030101
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An elderly man with a non-healing heel ulcer

Description

An 80-year-old man presented with abdominal discomfort, constipation, malaise, loss of appetite and weight loss of 6 months duration. On local examination, there was a hyperpigmented lesion (17×13 mm) (figure 1) on the sole of the right heel which was asymmetrical, had irregular borders and colour variegation. It had central ulceration. Also, there were satellite lesions around it. On systemic examination, there was hepatomegaly. The striking finding was a bunch of matted lymph nodes in the right inguinal region (figure 2).

Figure 1
Sole hyperpigmented ulcer.
Figure 2
Inguinal lymphadenopathy.

On digital rectal examination, there were impacted faecoliths. Abdominal ultrasonography revealed hepatomegaly with a small hypoechoic lesion (7×7 mm). There was a conglomerate lymph node mass (85×48 mm) along right ilial vessels causing elevation of iliac vessels anterolaterally and compression of the large bowel (figure 3).

Figure 3
Abdominal ultrasound revealed a conglomerate lymphoid mass.

On fine needle aspiration cytology of inguinal mass, black watery material was aspirated. Cytology showed dispersed malignant cells with marked nuclear pleomorphism and prominent nucleoli with abundant cytoplasm-containing pigment, confirming the diagnosis of metastatic deposits of melanoma (figure 4). There was no evidence of metastasis in the lungs or bones.

Figure 4
Cytology showed dispersed malignant cells with marked nuclear pleomorphism and prominent nucleoli with abundant cytoplasm-containing pigment.

The case illustrates acral lentiginous malignant melanoma in the right sole with lymphatic metastasis in the right inguinal and pelvic lymph nodes associated with haematogenous spread in the liver (AJCC stage 4). Unfortunately, the patient came for the first time to the hospital with metastasis.

Discussion

Plantar and subungual melanomas exhibit a higher misdiagnosis rate relative to other anatomic sites. The differential diagnoses of these include wart, callus, foreign body, crusty lesion, sweat gland condition, blister, non-healing wound, mole, keratoacanthoma, subungual haematoma, onychomycosis and ingrown toenail.1 The prevalence rate of melanoma is 10–20 times lower in dark skinned Asian population than whites but acral lentigenous melanoma is more common. Metastatic melanoma is generally incurable with survival in patients with visceral metastasis of less than a year.2 Lymph nodes in the right iliac region were initially thought to be responsible for constipation in our patient, although we could not demonstrate any evidence of mechanical obstruction in the investigations. Paraneoplastic symptoms manifesting as abnormal gastrointestinal motility especially constipation have also been reported as an initial manifestation of cancer.3 Also, other factors like low appetite and poor nutritional status could contribute to the constipation in our case.

Acknowledgments

To all who cared for this patient (including his relatives).

Footnotes

Competing interests None.

Patient consent Obtained.

References

1. Soon SL, Solomon AR, Jr, Papadopoulos D, et al. Acral lentiginous melanoma mimicking benign disease: the Emory experience. J Am Acad Dermatol 2003;48:183–8. [PubMed]
2. Sober AJ, Tsao H, Washington CV. Cancer of the skin. In: Fauci AS, Braunwald E, Hauser SL, eds. Harrison's Principles of Internal Medicine. 17th edition Vol 1 California: McGraw Hill; 2001:541–7.
3. Jun S, Dimyan M, Jones KD, et al. Obstipation as a paraneoplastic presentation of small cell lung cancer: case report and literature review. Neurogastroenterol Motil 2005;17:16–22. [PubMed]

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