PMC7154248_01
Dermatological findings. a Right foot (dorsal view). b Right foot (ventral view). c Left foot (dorsal view). d Left foot (ventral view). e Right hand (dorsal view). f Left hand (dorsal view).
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F1
Physical examination revealed a dark violaceous patch throughout the second toe with bluish discoloration noted on the third and great toe (right foot; Fig. 1a, b), a dark violaceous patch on the tip of the third toe with mild violaceous discoloration on the second toe (left foot; Fig. 1c, d), a large necrotic eschar on the dorsal hand with undermining borders and mild erythema (right hand; Fig. 1e), and a large necrotic eschar extending from the dorsal hand over to the fifth digit with circumferential necrosis of the digit from the tip to just distal of the proximal interphalangeal joint (left hand; Fig. 1f).
Radiographic findings. a TEE mobile plaque on the mitral valve. b TEE mobile plaque on the mitral valve. c CT chest with contrast. Acute pulmonary embolism within a right lower lobe segmental pulmonary artery. d CT chest with contrast. Acute pulmonary embolism within a right upper lobe lobar to segmental pulmonary artery. e CT chest with contrast. Left upper lobe mass (approximately 6.6 x 5.9 x 6.4 cm) with left pulmonary artery narrowing. f CT chest with contrast. Lymphangitic carcinomatosis. g CT abdomen and pelvis with IV contrast. Multiple ill-defined hypo-attenuating metastatic hepatic lesions (2.3 x 2.1 cm segment IVb lesion and an adjacent 2.1 x 2.3 cm lesion). h CT abdomen and pelvis with IV contrast. Left common femoral vein deep vein thrombosis. i MRI brain with and without contrast. A few scattered punctate foci of restricted diffusion in the bilateral cerebral white matter (left greater than right) compatible with embolic phenomenon. j MRI brain with and without contrast. Enhancing lesion in the right postcentral gyrus with associated intrinsic T1 hyperintense signal and susceptibility artifact, compatible with hemorrhagic metastatic lesion.
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F2
TEE demonstrated a normal left ventricular ejection fraction (65%), two small mobile masses (the largest of which is on the anterior leaflet and measures 0.3 cm in diameter) noted on the anterior and posterior leaflets (Fig. 2a, b), severe mitral valve regurgitation, and a small amount of immobile plaque involving the descending aorta. Computed tomography (CT) of the chest with contrast demonstrated several pulmonary emboli within the right lower lobe segmental pulmonary artery (Fig. 2c) and right upper lobe lobar to segmental pulmonary artery (Fig. 2d). There was a mass in the left upper lobe with extension to the hilum (Fig. 2e) causing narrowing of left upper pulmonary artery. There were multiple enlarged mediastinal and subcarinal lymph nodes, diffuse nodular septal thickening compatible with lymphangitic carcinomatosis (Fig. 2f), and numerous sclerotic osseous metastases. Subsequent CT of the abdomen with contrast demonstrated multiple hepatic hypo-enhancing metastases (Fig. 2g), left femoral deep vein thrombosis (Fig. 2h), and numerous sclerotic osseous metastases in the thoracolumbar spine and pelvis. Magnetic resonance imaging of the brain with and without contrast revealed numerous foci of restricted diffusion scattered throughout multiple vascular distributions concerning for embolic infarcts (Fig. 2i). In addition, there were multiple enhancing cortical and subcortical lesions compatible with metastatic disease (Fig. 2j).