leukocytoclastic vasculitis ( lcv ) has been associated with several disease processes , such as infections , drugs , allergies , rheumatological and neoplastic diseases ( 1 ) . in neoplastic processes , lcv may present as a paraneoplastic phenomenon occurring before , synchronously with , or after the diagnosis of malignancy ( 2 ) . compared to hematological malignancies , solid tumors are significantly less likely to be associated with lcv ( 1 ) . the first case of lcv in a patient with a solid tumor was reported in 1968 ( 3 ) . since then , more patients suffering from solid tumors and vasculitis have been documented in the literature ( 4,5 ) , including patients with lung , colon , gastric and renal cancer . in these previously reported cases , the patients only developed one type of malignancy and the occurrence of multiple malignancies in patients with lcv has not been reported . we herein describe the case of a patient who developed lcv and was treated with glucocorticoids for 11 years . the patient then developed three primary tumors , including small - cell lung carcinoma ( sclc ) , gastric adenocarcinoma and colonic adenocarcinoma . to the best of our knowledge , this is the first case report of multiple malignancies developing in a patient with a history of lcv in the english medical literature . the patient was a 54-year - old man , initially presenting with rash , purpura , petechiae , bruising and desquamation on the right low limb followed by ulceration in may , 2001 at the age of 43 years . the patient was treated with glucocorticoids and initially responded to the steroid therapy very well , achieving complete response . however , the disease later relapsed , and the patient developed dry gangrene of the right foot . shock therapy with a maximum dose of 500 mg methylprednisolone for 5 days was administered repeatedly . after the disease was controlled , the patient was maintained on methylprednisolone at doses of 80 , 60 , 40 , 20 and 4 mg , adjusted according to the disease status over the following 11 years . in february , 2012 , approximately 11 years after the diagnosis of lcv , the patient presented to our hospital complaining of nausea and paroxysmal dull pain in the back and upper abdomen for 3 weeks . the patient was not a smoker and had no family history of cancer . on physical examination , the lower part of the right leg exhibited purple discoloration and desquamation , with marked deformity of the toes , possibly due to the dry gangrene the patient developed due to the deterioration of his lcv ( fig . the complete blood count revealed a white blood cell count of 10.910/l , with an absolute neutrophil count of 8.7610/l . routine urine tests showed no positive findings , while the routine stool test was positive for occult blood . blood chemistry tests revealed an alkaline kinase proteinase level of 341 u / l ( normal , 42141 u / l ) , -gt 263 u / l ( normal , 732 u / l ) and lactate dehydrogenase 624.50 u / l ( normal , 2229 u / l ) ; others were within the normal range . tumor marker tests revealed an -fetoprotein level of 3.0 ng / ml ( normal , < 10.9 ng / ml ) , carcinoembryonic antigen 3.63 ng / ml ( normal , < 5 ng / ml ) , ferritin > 1,500 ng / ml ( normal , 11306.8 ng / ml ) , carbohydrate antigen ( ca)125 > 1,000 u / ml ( normal , < 35 u / ml ) , ca153 , 78.91 u / ml ( normal , < 31.3 u / ml ) and ca199 , 112.28 u / ml ( normal , < 37 u / ml ) . the results of the cellular immunity tests were as follows : cd3 , 37% ( normal , 5084% ) ; cd19 , 4% ( normal , 518% ) , cd4 , 20% ( normal , 2751% ) , cd8 , 50% ( normal , 1544% ) ; and cd4/cd8 ratio , 0.4 ( normal , 0.712.78 ) . a ct scan of the chest and abdomen was performed and revealed bulky disease at the left lung hilus sized 4.25.6 cm , enlarged mediastinal lymph nodes sized 23 cm ( fig . 3c ) . in addition , minor incrassation of the gastric wall in the antrum of stomach was present ( fig . esophogastroduodenoscopy revealed antral ulceration ; the examination for helicobacter pylori ( h. pylori)was negative and the biopsy showed gastric adenocarcinoma , moderately differentiated ( fig . 4b ) . to confirm the pathology of the hilar mass in the left lung , , vertebral magnetic resonance imaging was performed , which revealed multiple metastases to the spine , from the twelfth thoracic to the second sacral vertebra . a vertebral compression fracture of the second lumbar vertebra was also identified ( fig . 6 ) . in summary , the patient was diagnosed with three separate maligancies : gastric adenocarcinoma , colonic adenocarcinoma and sclc , with stage iv metastatic disease . the patient received palliative chemotherapy , which included paclitaxel 120 mg ( days 1 and 8) , etoposide 100 mg ( days 15 ) and cisplatin 20 mg ( days 15 ) . during the course of chemotherapy , grade 4 bone marrow suppression ensued , complicated by pulmonary pseudomonas aeruginosa infection . the patient was started on antibiotics and chemotherapy was terminated . however , his condition deteriorated rapidly , with pronounced abdominal distention , continuously declining urine volume , liver enlargement and ascites . during this period there was no progression of lcv and no new rash , purpura , petechia or ulceration were identified . various mechanisms have been proposed for tumor - associated lcv , including antigen - antibody complexes that form in response to tumor antigens and are deposited in vessel walls , resulting in inflammation ( 6 ) . malignant neoplasms may also increase blood viscosity , causing potential endothelial damage and increasing contact time for immune complex deposition ( 7 ) . lcv , when presenting as a paraneoplastic syndrome , is usually refrractory to corticosteroid and immunosuppressant treatment , whereas its symptoms improve with effective treatment of the underlying malignancy . moreover , recurrence of lcv often occurs with the progression or metastasis of the malignancy ( 8) . in our case , lcv occurred 11 years prior to the development of the malignancies . the patient responded to methylprednisolone therapy and there was no deterioration of lcv when the malignancies were diagnosed . thus , we hypothesize that lcv was not a paranoeplastic syndrome , but rather an independent condition in our patient . however , it is likely that the immunosuppression triggered by the long - term treatment of lcv with glucocorticoids contributed to the development of multiple malignancies . it is well known that glucocorticoid administration inhibits the immune system , including induction of apoptosis in t lymphocytes ( 9 ) and inhibition of natural killer cell activity ( 10 ) . furthermore , glucocorticoids appear to contribute to the shift of t helper cells from the th1 to the th2 phenotype ( 9 ) , which facilitates cancer escape from host immune surveillance ( 12 ) . it was previously demonstrated that patients with immunological disorders treated with glucocorticoids displayed a high incidence of secondary cancers ( 13 ) . in our case , the patient had a history of lcv and received long - term glucocorticoid treatment , with the maximum dose reaching 500 mg / day of methylprednisolone . the disruption of the immune system by steroid treatment is likely the cause of cancer development . other cancer risk factors were absent in this patient , as he was not a smoker and there was no h. pylori infection identified in the gastric biopsy . to the best of our knowledge , this is the first reported case of multiple malignancies developing after long - term steroid treatment in a patient with lcv . lcv in this case was not a paraneoplastic syndrome , and the development of the malignancies is likely associated with immune dysregulation by the steroid treatment . this case report suggests that clinicians should be aware of the possible association of long - term use of glucocorticoids with the development of secondary malignancies .
leukocytoclastic vasculitis ( lcv ) is a neutrophilic inflammation of the blood vessels . 
 lcv may present as a paraneoplastic syndrome occurring before , synchronously with , or after the diagnosis of malignancy . in this study , we report a unique case of multiple malignancies developing simultaneously in a patient with a long history of lcv . 
 the patient was originally diagnosed with lcv and received long - term glucocorticoid treatment . 
 after 11 years of therapy , the patient developed three primary malignancies , including small - cell lung carcinoma , gastric adenocarcinoma and colonic adenocarcinoma . 
 it is likely that lcv was not a paraneoplastic syndrome in this case , but rather an independent process , and the development of multiple cancers is likely associated with the long - term glucocorticoid treatment , which caused imbalance of the immune system . 
 although the development of cancer during the course of glucocorticoid treatment is very rare , clinicians must be aware of this possible association and immunodysregulation may play a role in this context .