Recurrent paraneoplastic wells syndrome in a patient with metastatic renal cell cancer

Abstract

A 58-year-old man with a history of hyperlipidemia and hypertension presented to the dermatology clinic with a 3-month history of a sudden onset, progressively worsening pruritic eruption involving the torso and extremities. Prior treatment included azithromycin and oral and intramuscular steroids, without improvement. Laboratory results demonstrated a serum eosinophil count of 7x10 3 /uL (normal 0-4). A 4-mm punch biopsy of the plaque on the patient's left thigh revealed a diffuse dermatitis with innumerable eosinophils with formation of "flame figures." Histologically, these findings are consistent with a diagnosis of Wells syndrome (WS). A work up for possible underlying malignancy found that the patient had underlying clear cell renal carcinoma. The eruption largely resolved following right laparoscopic nephrectomy with negative surgical margins, thus confirming the diagnosis of paraneoplastic WS. However, 2 years later the patient developed metastasis to his liver, lungs, and ribs. The patient's cancer has continued to progress despite treatment with high-dose interleukin-2, oral sunitinib, afinitor. avastin, azacytidine, and currently axitinib. Our case is the first to describe eosinophilic cellulitis arising in a patient with underlying renal cell carcinoma.

Pathology in Practice

“…For example, large indurated plaques, peripheral eosinophilia, pruritus, prolonged waxing and waning courses, and association with neoplasia may be seen in humans with Wells syndrome but are not typically in dogs with CAEDE. 3,[5][6][7][8] Therefore, this may be a unique cutaneous reaction in dogs. 3,5 In the present report, none of the aforementioned features of Wells syndrome were appreciated.…”

Clinical Entity Mimicking Infectious Cellulitis: Eosinophilic Cellulitis (Wells’ Syndrome)

“…In some patients, systemic signs such as fever, fatigue, and arthralgia may accompany the condition (3,4). Some infections, insect bites, medications, and malignancies have been described as possible causative factors of this disease (5)(6)(7)(8)(9). It differs from infectious cellulitis by being unresponsive to antibiotics and recurring (1).…”