Stauffer's Syndrome in Pancreatic Cancer: First Case Report

Stauffer Syndrome: Another Strange Case of the Internist's Tumor

Stauffer syndrome is a paraneoplastic disorder associated with renal cell carcinoma (RCC), which often can be the first manifestation of the tumor. It is characterized by nephrogenic hepatic dysfunction that reverses after removing the primary tumor. Stauffer syndrome has been associated with a worse prognosis in patients with RCC. We are presenting a case of a patient with an uncommon cholestatic jaundice variant. The patient also had hepatic profile alterations, but no metastasis existed. These findings meet the diagnostic criteria for Stauffer syndrome in the context of RCC as the first clinical manifestation in the diagnostic approach to malignancy-associated disease. A 74-year-old patient, with a history of obesity, hypertension, and type 2 diabetes mellitus, went for advice due to right upper abdominal pain, icterus accompanied by emetic episodes, and a cholestatic pattern in the hepatic profile. Autoimmune hepatitis was ruled out based on immunological testing. Imaging revealed evidence of a mass in the lower pole of the right kidney, suspicious of malignant neoplasia, and a distant paraneoplastic syndrome consistent with the cholestatic variant of Stauffer syndrome. This is an exciting case of Stauffer syndrome as the initial presentation of RCC associated with a cholestatic variant, providing relevant information about this uncommon condition in our setting.

Metastatic Renal Cell Carcinoma Presenting as Prolonged Pyrexia and Stauffer's Syndrome: Can a Routine Ultrasound Scan Fail to Detect a Renal Cell Carcinoma?

Background

Prolonged pyrexia and weight loss are recognised paraneoplastic manifestations of renal cell carcinoma (RCC). Stauffer's syndrome is a rarely described paraneoplastic manifestation, which is described early in the course of RCC. We report a patient who presented with unresolving fever with multiple pulmonary opacities with biochemical evidence of hepatic choleastasis and was later diagnosed to have metastatic RCC with Stauffer's syndrome.

Case Presentation

We report a 54-year-old female who was investigated for a poorly resolving fever and recent weight loss for two months. During her course of illness, she developed bilateral multiple opacifications in the chest radiograph with negative pyogenic, mycobacterial microbiological studies. Despite intravenous antibiotics, her fever continued. She was found to have elevated alkaline phosphatase and gamma-glutamyl transferase and she underwent imaging with ultrasound scan of abdomen twice, which did not reveal demonstrable abnormalities. Later, contrast CT of abdomen and chest was performed and detected a renal cell carcinoma of the right upper pole of the kidney with multiple lung metastases, which was concluded as a metastatic RCC with paraneoplastic Stauffer's syndrome.

Conclusion

Prolonged pyrexia with loss of weight and Stauffer's syndrome could be features to suggest renal cell carcinoma in the absence of positive microbiological studies. Isoechoic RCC could be missed in routine ultrasonography. When a RCC is suspected in the setting of a pyrexia of unknown origin, ultrasound with doppler or a contrast CT should be requested to aid diagnosis.

Stauffer's syndrome: A comprehensive review and proposed updated diagnostic criteria

BACKGROUND

Stauffer's syndrome corresponds to a set of clinical and analytical changes of paraneoplastic nature firstly recognized more than 50 years ago, in association to renal cell carcinoma. A definitive review including universal diagnostic criteria and updated knowledge since the original description is lacking.

BASIC PROCEDURES

The authors conducted a comprehensive bibliographical review and propose updated diagnostic criteria to standardize diagnosis for clinical practice purposes and avoid misclassification.

MAIN FINDINGS

Although having been described in association with renal cell carcinoma, the syndrome has been reported in correlation with other malignancies-either solid or hematological tumors. Additionally, a variant syndrome presenting with jaundice has also been characterized, but appears to have a similar clinical course to that of the classical Stauffer's syndrome. Although often described as rare, it may be more frequent than previously recognized. Stauffer's syndrome etiopathogenesis is still poorly understood, but immune mechanisms seem to play a role underscored by the malignancies to which the syndrome is associated, several of which having immunotherapy drugs approved for their treatment.

PRINCIPAL CONCLUSIONS

A set of diagnostic criteria should be used to simplify, broaden and standardized diagnosis, under the entity characterized by reversible paraneoplastic intrahepatic cholestasis. Clinicians should be aware of the syndrome, namely consider further investigation if a plausible cause for unexplained intrahepatic cholestasis in an otherwise healthy patient is not found. Even though no universal approach is available, investigation should be considered regarding metastatic disease after resection of a primary tumor which has revealed persistence or recurrence of symptoms.