Paraneoplastic syndromes exist for a number of malignancies and their presentations are diverse. Some of them are self-limited, while others can be life-threatening but regardless of the outcome, understanding the presentation is vital to picking up on the diagnosis for further treatment. The case that is presented here is a rare paraneoplastic skin process called Bazex syndrome that was associated with pancreatic adenocarcinoma.

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INTRODUCTION: Cancer is a devastating finding but diagnosis can be difficult due to the vague symptoms and often indolent course. Sometimes, medical professionals have clues to possible malignancy precursors but it can easily be overlooked when they are presented in different clinical pictures. Paraneoplastic syndromes range from almost ever organ system but the case discussed here deals with a rare cutaneous manifestation that can be seen with a number of malignancies known as bazex syndrome. CASE DESCRIPTION/METHODS: This case involved a 64-year-old female with history of hypertension and paroxysmal atrial fibrillation who came to the hospital with complaints of yellow discoloration of her skin, intermittent fevers and a recent history of right upper quadrant pain with nausea. She was seen by her primary care physician who did basic labs that showed a total bilirubin of 14.3 and she was sent to the emergency room for further evaluation. Of note, patient was previously seen in the hospital 6 months prior for a skin rash on her extremities and abdomen that was biopsied and later described as psoriasiform dermatitis. It was thought to be a drug reaction from a medication but the rash still persisted after discontinuation. On this admission, a CT abdomen showed masses in the pancreatic head and neck with confluent disease encasing the periportal structures that was concerning for malignancy. Biopsy after endoscopic ultrasound showed adenocarcinoma and the patient was evaluated by oncology with gastroenterology and she had biliary sphincterotomy with stenting and was started on modified FOLFIRINOX therapy. DISCUSSION: This case highlights a rare finding with the psoriasiform dermatitis rash that erupted a few months prior to formal diagnosis of pancreatic adenocarcinoma, which is concerning for an uncommon paraneoplastic process known as bazex syndrome. What makes this case even more uncommon is that bazex is usually seen in head, neck and lung cancers and is less commonly seen in gastrointestinal malignancies. Clinicians should be made aware of these cutaneous changes, so that they can improve on early evaluation, diagnosis and possible treatment.

Background Case reports of patients with severely elevated serum triglyceride levels (>1000 mg/dL) have been documented where Insulin infusions, heparin and plasmapheresis have demonstrated rapid and successful decrease in serum Triglyceride levels. The benefits of one approach versus the other to prevent major complications such as cardiovascular events or acute pancreatitis has not been well investigated. We present the case of a patient with severely elevated serum triglyceride levels without any manifestations. Case Description A 53-year-old male presented from his primary care provider’s office due to elevated Triglycerides levels over 6000 as per outpatient lab work. Inpatient labs were unattainable initially due to hemolysis secondary to the severely high lipid content. Patient was admitted to the medical ICU for closer monitoring and initiated on an insulin drip. Two days after insulin initiation patient’s triglyceride levels returned as 2,887 with a total cholesterol count of 848. His insulin drip was continued until his TAG levels were less than 1000. Upon discharge his levels were less than 600. Discussion Most patients with hypertriglyceridemia are asymptomatic. However, in patients with levels above 1000 mg/dL, the risk of pancreatitis or cardiovascular event is of concern. Hypertriglyceridemia may account for 1 to 14 percent of cases of acute pancreatitis. Treatment is largely based upon symptoms and complications. In the event of pancreatitis or other cardiovascular complication, plasmapheresis is usually recommended. If asymptomatic, Insulin may be used. Insulin promotes synthesis of lipoprotein lipase which functions to hydrolyze triglycerides, and has been shown to be an effective lowering agent in the treatment of such individuals. Case reports of Heparin being used as a lipid lowering agent have also been documented, but was not used in our particular patient. Normal triglyceride plasma levels are defined as less than 150 mg/dL. Mild hypertriglyceridemia typically ranges between 150-499 mg/dL, moderate between 500-866 mg/dL, and severe is defined as levels greater than 886 mg/dL. Plasma triglyceride levels above 1000 mg/dL occur in fewer than 1 in 5000 individuals. It is said that patients with TAG levels above 2000 mg/dL almost always have both a secondary and a genetic form of Hypertriglyceridemia. For this reason it is very important to identify these patients as early as possible to treat appropriately. Our patient was a known alcohol abuser, yet without the presence of some polygenic familial disorder, the likelihood of our patient having TAG levels >6000 mg/dL, is very unlikely.