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Florid cutaneous and mucosal papillomatosis: mucocutaneous markers of an underlying gastric malignancy.

Case Report An 86-year female patient was referred to us for assessment of lip lesions and numerous cutaneous warty growths of 6-month duration. She had mild dysphagia but no systemic symptoms, including weight loss. Her only medication was risedronate for osteoporosis and she was otherwise healthy. Examination revealed confluent fine papillomatosis across the lip vermillion (Fig 1), which diffusely affected the mucosa of the oral cavity and oropharynx. There were several wartlike papules affecting the skin of her face, neck, and extremities (Fig 2). There was no cutaneous hyperpigmentation or velvety thickening. Histologic examination of cutaneous and mucosal lesions showed hyperkeratosis, acanthosis, and papillomatosis but no viral inclusion or vacuolar degeneration of keratinocytes. There was no evidence of human papillomavirus (HPV) by polymerase chain reaction. Results of complete blood count and serum chemistry were normal but tumor markers showed elevated carcinoembryonic antigen (19.3 ug/L; normal, 0 to 4 ug/L), which was suggestive of a gastrointestinal tract neoplasm. A computed tomography scan showed marked mural thickening of the gastric body and antrum and several enlarged, confluent upper abdominal lymph nodes. Upper gastrointestinal endoscopy revealed gastric mucosal friability and ulceration. Biopsies demonstrated a poorly differentiated carcinoma. Palliative measures were provided when the patient experienced a rapid deterioration in health, and she died after 3 months. The eruption of wart-like papules was suggestive of a viral genesis but, surprisingly, there was no evidence to support the presence of HPV. Florid cutaneous papillomatosis (FCP) is a rare condition characterized by the rapid onset of numerous warty papulonodules that may be widespread and result in facial disfigurement and social exclusion. Lesions are clinically indistinguishable from viral papillomas, yet have no evidence of HPV infection. FCP may occur with other cutaneous markers of malignancy, such as sign of Leser-Trélat and acanthosis nigricans (AN). Mucosal papillomatosis was exuberant in our patient and the appearance was similar to that seen with oral AN, which lacks hyperpigmentation. Though other cutaneous manifestations of AN were not identified, oral mucosal changes may have represented the primary sign, as has been previously reported.