Department of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital, Mibu, Tochigi, 321-0293, Japan.
J Med Case Rep. 2021 May 21;15(1):256. doi: 10.1186/s13256-021-02795-5.
The incidence of colorectal cancer in persons aged < 50 years has been increasing. The diagnosis of colorectal cancer is not difficult if the patient has typical symptoms; however, diagnosis may be difficult in cases with atypical symptoms and signs. We present here an atypical case of metastatic colorectal cancer with fever and sudden onset paraplegia as the sole manifestations. The patient had multiple osteolytic lesions without gastrointestinal symptoms or signs, which resulted in a diagnostic delay of colorectal cancer.
A 46-year-old Japanese man was transferred to our hospital for evaluation of fever. He had developed fever 8 weeks previously and had been first admitted to another hospital 5 weeks ago. The patient was initially placed on antibiotics based on the suspicion of a bacterial infection. During the hospital stay, the patient experienced a sudden onset of paralysis and numbness in his both legs. Magnetic resonance imaging showed an epidural mass at the level of Th11, and the patient underwent a laminectomy. Epidural abscess and vertebral osteomyelitis were suspected, and antimicrobial treatment was continued. However, his fever persisted, and he was transferred to our hospital. Chest, abdominal, and pelvic computed tomography (CT) with contrast showed diffusely distributed osteolytic lesions. Fluorodeoxyglucose-positron-emission tomography showed high fluorodeoxyglucose accumulation in multiple discrete bone structures; however, no significant accumulation was observed in the solid organs or lymph nodes. A CT-guided bone biopsy obtained from the left iliac bone confirmed the evidence of metastatic adenocarcinoma based on immunohistochemistry. A subsequent colonoscopy showed a Borrmann type II tumor in the sigmoid colon, which was confirmed to be a poorly differentiated adenocarcinoma. As a result of shared decision-making, the patient chose palliative care.
Although rare, osteolytic bone metastases as the sole manifestation can occur in patients with colorectal cancer. In patients with conditions difficult to diagnose, physicians should prioritize the necessary tests based on differential diagnoses by analytical clinical reasoning, taking into consideration the patient's clinical manifestation and the disease epidemiology. Bone biopsies are usually needed in patients only with sole osteolytic bone lesions; however, other rapid and useful non-invasive diagnostic tests can be also useful for narrowing the differential diagnosis.
50 岁以下人群的结直肠癌发病率一直在增加。如果患者有典型症状，诊断并不困难；然而，如果症状和体征不典型，诊断可能会很困难。我们在此介绍一例以发热和突发性截瘫为唯一表现的转移性结直肠癌不典型病例。该患者有多处溶骨性病变，无胃肠道症状或体征，导致结直肠癌的诊断延迟。
一名 46 岁的日本男性因发热被转入我院进行评估。他在 8 周前开始发热，并在 5 周前首次入住另一家医院。患者最初因疑似细菌感染而接受抗生素治疗。住院期间，患者突然出现双下肢瘫痪和麻木。磁共振成像显示 T11 水平硬膜外肿块，患者接受了椎板切除术。怀疑为硬膜外脓肿和脊椎骨炎，继续进行抗菌治疗。然而，他的发热持续存在，因此被转至我院。胸部、腹部和骨盆 CT（增强）显示弥漫性溶骨性病变。氟脱氧葡萄糖正电子发射断层扫描显示多个离散骨结构中有高氟脱氧葡萄糖摄取；然而，实体器官或淋巴结未见明显摄取。左髂骨 CT 引导下的骨活检通过免疫组化证实转移性腺癌的证据。随后的结肠镜检查显示乙状结肠有 Borrmann Ⅱ型肿瘤，证实为低分化腺癌。根据共同决策，患者选择姑息治疗。
尽管罕见，但结直肠癌患者可能仅以溶骨性骨转移为表现。对于难以诊断的患者，医生应根据分析性临床推理的鉴别诊断，优先考虑必要的检查，同时考虑患者的临床表现和疾病流行病学。对于仅有单一溶骨性骨病变的患者，通常需要进行骨活检；然而，其他快速且有用的非侵入性诊断测试也可有助于缩小鉴别诊断范围。
