Case Presentation: A 40-year-old Hispanic man with no past medical history presented with right thigh pain and swelling for three weeks. He had a 10 pound weight loss over the past few months. He also noted melena two months ago with recent recurrence. No recent trauma or skin infections were reported. Vital were notable for tachycardia ( HR 102/min), tachypnea (RR 27/min). Physical Exam was significant for right lateral thigh draining brown fluid with associated tenderness to palpation, 2+ edema of the entire right lower extremity (RLE). Labs were remarkable for leukocytosis (WBC 27.5), anemia (Hb 6.1), elevated platelets (1037), ESR (121), elevated CRP (9.5), procalcitonin (0.82). Patient was treated for sepsis with likely source as RLE with IV Zosyn, vancomycin and Clindamycin. CT scan of RLE was concerning for extensive abscesses for which patient underwent incision and drainage. Later on wound cultures grew Klebsiella spp. antibiotics were deescalated. CT abdomen and pelvic obtained on day 5 was concerning for rectal mass that was confirmed on flexible sigmoidoscopy revealing a ~10 cm circumferential polypoid mass – biopsies were obtained. Pathology later revealed poorly differentiated rectal adenocarcinoma with MRI staging of T3d N2b. Rectal adenocarcinoma was treated with laparoscopic diverting loop colostomy and plan for neoadjuvant chemoradiation therapy.
Discussion: Thigh masses may be representative of hematomas, cellulitis, sarcomas, or in some instances underlying abscesses. Our patient’s history and labs were concerning for weight loss and a prominent anemia – given his acute presentation this could have disguised the underlying Colo Rectal Cancer (CRC). 90% of CRC diagnoses are over age 50 yet 14,000 individuals aged < 50 are diagnosed annually with CRC. Younger patient diagnosed with CRC have a higher incidence of metastatic disease and a poorer 5-year survival of 54% compared to 71-88% in their elderly counterparts. CRC complications can arise in the acute setting such as appendicitis, bowel perforation or abscess formation that conceal an underlying malignancy in seemingly benign patient populations. CRC associated with local abscess formation is rare with an incidence of 0.3-4% and results from colonic preformation or direct invasion into adjacent structures as was seen in our patient. Abscess drainage, targeted antibiotics, surgical resection, and neoadjuvant chemoradiation therapy were the mainstays of treatment for this thorny CRC in our young patient.
Conclusions: High index of suspicion for malignancy is prudent while addressing alarming acute presentation that may delay the diagnosis of malignancy. Age is not protective of all cancers. Colo Rectal Cancer is on the rise in adults less than 40 and this trend is not well understood.
