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Tripe palm: a paraneoplastic manifestation of carcinoma stomach

Usually gastrointestinal malignancies present with low SAAG ascites. But when there is diffuse liver infiltration following malignancy, high SAAG ascites can occur. So liver infiltration can masquerade as cirrhosis. Malignant acanthosis and tripe palm are the paraneoplastic manifestations seen in GI malignancies. We are reporting a case which was initially managed as a straightforward case of cirrhosis ,but later turned out to be a case with tripe palms, malignant acanthosis and carcinoma stomach as primary with diffuse liver infiltration having high SAAG ascites.


INTRODUCTION
The serum to ascites albumin gradient identifies the presence of portal hypertension and is helpful than protein based exudate/transudate concept. 1 Presence of a gradient >1.1 indicate that patient has portal hypertension. 1 Usually cirrhosis with portal hypertension can produce high SAAG ascites. But diffuse liver infiltration secondary to malignancy can produce a similar clinical scenario. Acanthosis nigricans is characterized by velvety, hyperkeratotic plaques that predominantly appear on the flexural aspect of the neck, axillae,and groin. Usual associations being benign conditions such as obesity, insulin resistance. Rarely it is associated with malignancies, especially adenocarcinoma, of which , 55% to 61% are gastric adenocarcinoma. 2 Gross and eruptive itchy acanthosis nigricans with florid cutaneous papilomatosis and tripe palm are the features typical of malignant acanthosis. 3 Malignant acanthosis is characterised by rapid spread and intense pruritus. 4 It has got a predliction to extremities, such as back of hand and wrist.

CASE REPORT
A 48 year old gentleman presented to our Emergency department with complaints of recurrent episodes of vomiting, diffuse abdominal pain, extensive hyperpigmentation over a period of 5 months. History of abdominal distension and pedal oedema since 3 months. Recently detected diabetic on treatment with glimiperide. He used to consume 2 units of brandy/day for last 5 years.
On physical examination,patient was sick looking and appeared pale. Diffuse hyperpigmentation,with velvety appearance of palms were present ( Figure 1). Abdomen was non tender, distended with evidence of shifting 1 Department of Medical Gastroenterology, Madras Medical College, Chennai, Tamil Nadu, India 2 Department of Pathology, Primex Slans'd Labs, Chennai, Tamil Nadu, India dullness. Coarse firm liver with irregular borders was palpable 3 cm below coastal margin.Generalised hyperpigmentation of face with intense itching was present ( Figure 2).  A provisional diagnosis of chronic liver disease was made and patient was treated symptomatically. Meanwhile he was investigated for etiology of liver disease. Investigations revealed anaemia 9.9 gm/dl, total count-7700/mm 3 , erythrocyte sedimentation rate-77 mm/hr. RBS-201 mg%, serum bilirubin-total-1.2 mg%, SGOT-200 u/L,SGPT-203 u/L,ALP-404 u/L,total albumin-3.3 gm%. Renal function test was within normal limits. Ascitic tap revealed high SAAG ascites and cytology negative for malignant cells. Ascitic fluid ADA was 4.5 u/l. Total count was 150, which was polymorph predominant. USG abdomen showed hepatomegaly with hetrogenous echotexture and portal vein of 13 mm. Workup for haemochromatosis came as negative. OGDSCOPY was done and an ulceroproliferative growth in the antropyloric area was noted and biopsy came as well differntiated adenocarcinoma. Dermatology opinion was sought and diagnosis of maliganant acanthosis with tripe palms was put forward.Carcinoembyronic antigen value was high (17.18 ng/ml). Contrast enhanced CT scan of abdomen was done and showed inhomogenous hepatic parenchymal enhancement with diffuse ascites with increased wall thickness of antropyloric area of stomach. Liver biopsy cannot be done due to elevated prothrombin time and ascites and inaccessibility to transjugular liver biopsy equipements. So we proceded with liver FNAC which revealed poorly differntiated carcinoma. So, clinical diagnosis of carcinoma stomach with liver infiltration was made. In spite of all the treatments,patient succumbed to the illness.

DISCUSSION
Colonic, gastric, breast, pancreatic and lung malignancies can cause peritoneal carcinomatosis and/or multiple liver metastases, which leads to ascites either because they compress portal veins or by causing liver failure. The serum-to-ascites albumin gradient (SAAG) identifies the presence of portal hypertension and is more useful than the older protein-based exudate/transudate concept for identifying portal hypertension 1 .
Only about two-thirds of patients with malignancyrelated ascites will have peritoneal carcinomatosis. 5 Patients with Hepatocellular carcinoma complicating cirrhosis and those with massive liver metastases almost always (94%) have a SAAG ≥1.1 g/dL. 5 Ascitic fluid total count can get elevated in patients with peritoneal carcinamatosis, massive liver metastasis. Our patient is having massive liver infiltration with high SAAG ascites.
The cutaneous paraneoplastic syndromes are a spectrum of skin disease caused by malignancy, but occurring at a site away from the primary metastasis site. 6 The common paraneoplastic skin manifestations include tripe palm, malignant acanthosis nigricans, florid cutaneos papilomatosis. Our patient was having tripe palm with malignant acanthosis. Tripe palm is an extremely rare paraneoplastic skin condition, seen especially in carcinoma stomach.
Paraneoplastic skin manifestations usually occur before the other gastrointestinal manifestations develop. 7 The exact pathophysiological mechanism of the paraneoplastic skin manifestation has not been well defined, but it could be related to cancer by-products. Transforming growth factor alpha, structurally related to epidermal growth factor (EGF), can be considered as possible causative agent. 8 Other skin lesions associated with carcinoma stomach are dermatomyositis, multiple seborrheic keratoses. Leser-Trélat syndrome (LTS) is an eruptive appearance of, or at least a sudden increase in, the number or size of multiple seborrheic keratoses in association with an internal malignancy. 9-10 Paraneoplastic pemphigus (PNP) is an autoimmune bullous disease characterized by the production of

CONCLUSION
Tripe palm is a very rare paraneoplastic manifestation of gastrointestinal malignancy. From simple general examination, we can arrive at the conclusion of internal gastrointestinal manifestation.