The patient is a 57-year-old female with past medical history of central hypopituitarism, secondary adrenal insufficiency, and untreated gastric adenocarcinoma, who presented to the emergency room with diffuse cramping abdominal pain and generalized weakness. Additionally, she complained of fatigue, poor appetite, confusion, nausea & vomiting, and upper & lower extremity swelling. These symptoms had persisted intermittently for 1 week. Her gastric adenocarcinoma was diagnosed in 2017, but she declined surgical resection of the tumor at that time. In 2020, she underwent upper endoscopy, which showed an ulcerated intramural (subepithelial) lesion in the lesser curve of stomach, at 6 cm distal to the gastroesophageal junction. Sonographically, the lesion was hypoechoic and appeared to originate from the superficial luminal mucosa with invasion into the serosa. Two abnormal lymph nodes were observed in gastrohepatic ligament. Biopsies taken from the lesser curve ulcer, antrum, and pyloric channel revealed signet ring cell adenocarcinoma (Fig. 1).
Initial vitals in the emergency department demonstrated blood pressure 81/45, heart rate 79, respiratory rate 18, and peripheral capillary oxygen saturation of 96% on room air. Physical exam showed scattered ecchymoses on the back and pitting edema in bilateral upper and lower extremities. Initial laboratory results were significant for sodium of 118 mmol/L, potassium 6.8 mmol/L, hemoglobin 6.5 mg/dL, platelet count 17 K/uL. Liver enzymes were mildly elevated with alanine aminotransferase 37 mg/dL, aspartate transaminase 48 mg/dL, and significant elevation in alkaline phosphatase to 1901 mg/dL. Given the bicytopenia, a peripheral smear was obtained which demonstrated normocytic, normochromic anemia suggestive of hypoproliferation and anemia of chronic disease. Computerized tomography of the chest, abdomen and pelvis showed bilateral pleural effusions and anasarca reflecting total body fluid overload, as well as diffuse sclerosis of the axial and proximal appendicular skeleton suggestive of metastatic disease (Fig. 2). Endocrinology was consulted and recommended stress dose steroids for acute adrenal insufficiency. Sodium rapidly increased to 129 mmol/L but dropped to 122 the following day. Since the administration of hydrocortisone temporarily restored the sodium level, undertreated adrenal insufficiency was thought to have induced the hyponatremia. Further hyponatremia workup showed albumin 3.2 mg/dL, serum osmolality 256 mOsm/kg, urine osmolality 195 mOsm/kg, and urine sodium < 11 mmol/L, which suggested a component of hypoalbuminemia and consequential reduced intravascular effective volume.
Thrombocytopenia persisted throughout the patient’s hospital course despite several transfusion attempts. Hematology-oncology was consulted, and a bone marrow biopsy was obtained on day 3 which showed clusters of glandular epithelioid cells, some with signet ring cell morphology, consistent with metastatic gastric adenocarcinoma (Fig. 3). On day 4, the patient developed worsening diffuse ecchymoses over entire body, epistaxis, oral mucosal bleed, and bleeding from peripheral intravenous sites. DIC was confirmed with elevated D-dimer > 20.0 ug/mL, prolonged PT of 24.6s (INR 2.1), prolonged PTT of 37s, as well as decreased fibrinogen of 191 mg/dL. Given the bone marrow findings, the DIC was thought to be caused by bone marrow carcinomatosis and bone marrow failure. As the clinical status continued to worsen, the patient decided to pursue hospice care.