Metastatic Melanoma

An 83-year-old man witha history of hypertensionand coronary arterydisease presented with a4-day history of mentalstatus changes, slurred speech, anddifficulty ambulating. He reported alack of appetite and weakness of severaldays.

An 83-year-old man with a history of hypertension and coronary arterydisease presented with a 4-day history of mental status changes, slurred speech, and difficulty ambulating. He reported a lack of appetite and weakness of several days.Drs Abdul M. Swied andMadhuri Trivedi of the University ofMissouri-Columbia, report that mildabdominal distention and bilaterallower extremity pitting edema werenoted. A 3 * 5-cm lesion was alsofound on the patient's back (A). Sodiumlevel was 128 mEq/L; blood ureanitrogen, 100 mg/dL; creatinine,2.8 mg/dL; mean corpuscular volume,79 μm3; and hemoglobin, 8.5 g/dL(6 months earlier, hemoglobin mea-sured 14.4 g/dL). A CT scan of thehead, taken when the patient was admittedto the hospital, was normal.Because of the anemia, a colonoscopyand an esophagogastroduodenoscopy(EGD) were performed.The EGD revealed a "bull's-eye" ulcerin the second part of the duodenum(B); a biopsy of the lesion confirmedthe diagnosis of metastatic melanoma(C). An abdominal CT scan alsoshowed metastasis to the liver andspleen (D, arrows).Metastases to the GI tract may be difficult to diagnose. These tumorsmay appear as a nodule, mass, or ulcer and can lead to obstruction and bleeding. The bull's-eye appearance is typical of melanoma metastases to the stomach or small intestine.Metastatic melanoma is incurable; treatment with chemotherapeuticor biologic agents is usually palliative. Typically, patients survive forless than 1 year.This patient refused treatment. He relocated to another state and waslost to follow-up.