CASE REPORT

54 year old male

Minalin, Pampanga
Admitted Dec. 26, 2015

Cc: Tumor on the left thigh

4 months
PTA

3 months
PTA

2 months
PTA

Single, nontender, enlarged left inguinal lymph node

IM Clinic in Pampanga
Unrecalled liver problem
Unrecalled medications decreased size of inguinal LN

Multiple erythematous papules over the anterior aspect of patients left

thigh
No pruritus or tenderness
Surgeon in Pampanga Herpes Zoster
Unrecalled antivirals for 10 days and vitamins

Advised consult with a dermatologist

Referred to USTH for further evaluation and management

 USTH Surgery OPD

Biopsy Benign Tumor
Unrecalled pain medications
1 1/2
Swelling of patients left leg
months PTA USTH Dermatology OPD- Dermatofibrosarcoma

1 month
PTA

5 days PTA

USTH IM OPD
Tramadol and Clindamycin
Malunggay leaves extract
Progression in size and number of the tumor
Anorexia, weight loss

BCI
Advised admission

Admission

VS stable
Multiple, erythematous, firm, nontender, nodules over left thigh, left
inguinal area, and genital area; (+) pitting edema on left lower
extremity; edema of both testicles; and MMT 4/5 LLE
Sepsis secondary to infected tumor, Left thigh; Dermafibrosarcoma,
Left thigh
Low haemoglobin (99) and haematocrit (0.31), high platelet count (550),
and normal WBC (7.90) with predominance of neutrophils (0.78)
Normal Crea, Na, K
U/A - positive leukocytes and erythrocytes, minimal pyuria, and
amorphous urate
CXR- bibasal pneumonitis, minimal pleural effusion &/or thickening
X-ray of hip - soft tissue densities at the proximal of the left thigh
Vancomycin 1g/IV in 90cc PNSS to run for 1-2 hours, first dose given at
the ER then every 12 hours thereafter
Piperacillin-Tazobactam 4.5gm in 90cc PNSS to run as IV infusion for
1-2hrs, first dose given at the ER then every 6 hours thereafter
Tetanus toxoid 0.5mL/IM; tetanus immune globulin 250 IU/IM
Celecoxib 200mg/cap 1 cap every 8 hours as needed for pain
Paracetamol 500mg/tab 1 tab every 4 hours for temperature >38.3

Admission

Dermatology
Malignant
lymphoproliferative disorder
s/p skin punch biopsy
Orthosurgery
Conservative management
Wet to dry dressing

2nd HD

3rd HD

5th HD

Tramadol + Paracetamol (Algesia) 1 tab every 6 hours

Peptamen 6 scoops in 1 glass of water TID
Piperacillin-Tazobactam was decreased to 4.5gm/infusion
every 8 hours

Decreased pain on the left lower extremity

Vancomycin increased to 1250 mg/IV in 90 cc PNSS
Vancomycin trough level was within normal range (8.30)

Wound tissue CS revealed E.Coli (ESBL positive) few,

with moderate growth of Proteus Mirabilis
Occasional pain on his left leg with yellowish foul smelling
discharge from the tumor

 Tenderness on palpation
and warmth over the left
th
6 HD flank and LUQ area

8 HD
th

Whole Abdomen UTZ with Doppler

Borderline sized to slightly enlarged liver with diffuse parenchymal
changes secondary to fatty infiltration
Multiple hepatic complex masses, both lobes; consider multiple
hepatic abscesses with vascularity
Splenic cyst; normal gallbladder, pancreas, both kidneys and urinary
bladder
Grade II prostatic enlargement with concretions
Incidentally, left sided pleural effusion
Anemia and leukocytosis with predominance of neutrophils

9th
hospital day

10th
hospital day

17th
hospital day

Referred to surgery for debridement

febrile (Tmax=39 C
Paracetamol 500mg/tablet- temporary relief
scrotal sling and Clotrimazole cream on inguinal area.

(+)facial asymmetry and sudden perioral numbness, difficulty

protruding the tongue.
Neuro Dx: intracranial (Brainstem) metastasis.
left mandibular mass.

18th
hospital day

20th

hospital day

BP elevations of SBP 130-150Amlodipine 5mg/tab OD.

Advised Panorex Scan of the Mandible and flexible
nasopharyngolaryngoscopy

shortness of breath (RR of 40)(+) crackles both lung fields

CXR : bilateral alveolar infiltrates; pleural effusion, R
HAP, with possible aspiration component, Pleural effusion, B,
R>L, probably due to a parapneumotic process vs
hypoalbuminemia
ultrasound of both hemithorax; Meropenem Imipenem 500mg
Sputum GS/CS ; advised 2D echo with Doppler Amlodipine
Enalapril 5mg/tab 1 tab OD ;Azithromycin 500mg/tab 1 tab
OD.

21st
hospital day

normotensive tachycardic (HR

110) tachypneic (RR 24)
decreased breath sounds, T7
down, L and (+) crackles on the R
lung base.
Furosemide 40mg/IV, decreased
IVF rate to 20cc/hr.
Imipenem (D1) Vancomycin (D7)
and Azithromycin (D1)
NaHCO3 2 tabs TID. CBC with
plt, SGPT, SGOT, Na/K-requested
Plan: Thoracentesis;CTT/JP
drain insertion

 ultrasound of the hemithorax: bilateral

pleural effusion with relaxation atelectasis.
Furosemide 40mg/IV
22nd
hospital day Reappraised for drainage of pleural
effusion

23rd

hospital
day

Algesia 1 tablet every 6 hours RTC;

Enalapril 5 mg/tab 1 tab OD

24th
hospital day

underwent ultrasound guided

thoracentesis of the right
hemithorax 90 cc of
xanthochromic turbid fluid sent
for pH, glucose, differential
count, cell count, gram stain,
culture and sensitivity, AFB
stain, MTB culture and
sensitivity and cell cytology.
serum creatinine-0.54
relatives expressed desire to
bring the patient home due to
financial constraints.