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Sign of Leser–Trélat
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  1. Katrina Chakradeo1,
  2. Kaustubh Narsinghpura2,
  3. Adel Ekladious1
  1. 1Department of General Medicine, Mackay Hospital and Health Service, Mackay, Queensland, Australia
  2. 2Department of Radiology, Mackay Hospital and Health Service, Mackay, Queensland, Australia
  1. Correspondence to Dr Katrina Chakradeo, mkchakradeo{at}gmail.com

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Description

An 87-year-old woman presented with severe iron deficiency anaemia (haemoglobin 57 g/L). She also described a recent increase in the number of pigmented skin lesions on her trunk, which had become mildly pruritic. Her history included a right hemicolectomy 12 years earlier for tubulovillous adenoma and suspicion of malignant transformation. At that time, her serum carcinoembryonic antigen (CEA) had been normal and resection histology revealed complete margins with no evidence of malignancy. Unfortunately, she had declined colonoscopy surveillance following this.

On examination, she was found to have extensive seborrhoeic keratoses, which had recently increased in size and number (figure 1). Although the patient preferred to avoid colonoscopy, further investigations for an underlying malignancy were pursued. A CT scan of the abdomen showed suspicious bowel thickening suggestive of colorectal malignancy (figures 2 and 3) and a serum CEA was markedly elevated (167 µg/L). These findings supported not only a diagnosis of colorectal malignancy but also the suggestion of the sign of Leser Trélat.

Figure 1

Leser–Trélat sign. Multiple seborrhoeic keratoses with classical rain drop appearance on patients' back.

Figure 2

Axial CT of the abdomen shows suspicious bowel thickening concerning for colorectal malignancy.

Figure 3

Sagittal CT scan of patient's abdomen shows bowel thickening concerning for colorectal malignancy.

Sign of Leser–Trélat is a rare finding of sudden eruption of seborrhoeic keratoses associated with malignancies, usually gastrointestinal adenocarcinoma.1 ,2 The most reported malignancies associated with Leser–Trélat sign are adenocarcinoma of the stomach, colon or rectum,3 ,4 followed by breast cancer, lymphoma and lung cancer.4 It is thought to be caused by various cytokines and growth factors produced by the neoplasm.4 ,5 Seborrhoeic keratoses can also be seen in older patients without malignancy, and an abrupt appearance of seborrhoeic keratoses without malignancy has been referred to as a pseudo-sign of Leser–Trélat.2 Although this sign has been debated due to the common occurrence of seborrhoeic keratoses in the elderly, it is also well described in young patients with underlying cancer, which helps validate it as a true cutaneous paraneoplastic phenomenon.4

This case highlights the importance of considering malignancy in the differential diagnosis of patients who present with new and extensive seborrhoeic keratoses so that prompt investigation, diagnosis and subsequent management can occur.

Learning points

  • Sign of Léser–Trelat is the abrupt appearance of multiple seborrhoeic keratoses associated with an underlying malignancy.

  • The three most common malignancies associated with sign of Léser–Trelat are gastric cancer, colorectal cancer and breast cancer.

  • It is important for physicians to recognise the sign of Leser–Trélat so that early diagnosis and treatment of a potentially curable cancer can occur.

References

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Footnotes

  • Contributors The manuscript has not been published or considered for publication elsewhere. The text and figures have been created by the authors and have not been copied from other material in the literature. All authors participated in the work, reviewed the text and agree with the content. KC identified the case, researched the relevant literature and wrote the paper. AE supervised and reviewed all aspects of the report, providing critical appraisal and editing. KN provided radiology images and their interpretation.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.