ECG in a Man With Metastatic Malignancy

A 48-year-old homeless man, who has smoked 1 1/2 packs of cigarettes per day for 30 years, presented to our hospital for the first time with fever, chills, night sweats, and abdominal pain. He gave a history of left nephroureterectomy for transitional cell carcinoma nearly six years ago. Four months before admission here, a transurethral resection of bladder tumors revealed high-grade multifocal transitional cell carcinoma invading the bladder muscle. Ten weeks ago, urinary obstruction and urosepsis required placement of a right-sided nephrostomy tube. Six weeks before admission, he underwent a robotic-assisted laparoscopic radical cystoprostatectomy with bilateral pelvic lymph node dissections and creation of an ileal conduit urinary diversion. He also reported a 30-pound weight loss over the past several months and recent lumbar back pain, cough, and dyspnea. Exam revealed a temperature of 102° F, a pulse of 110 beats/minute, a soft abdomen with bilateral lower quadrant tenderness, normal breath and heart sounds, and a normal appearing ileal conduit stoma and right nephrostomy stent. Chest radiograph showed multiple bilateral subcentimeter pulmonary nodules suspicious for metastatic disease. Computed tomogram of the abdomen and pelvis demonstrated omental and peritoneal deposits, a large mass of pelvic lymph nodes, and multiple L3-L4 lytic bone lesions. Urinalysis was positive for nitrites and numerous white blood cells. Hematocrit was 19%, and white blood cell count was 21,000/mm 3 of blood. The patient was admitted for treatment of urosepsis, transfusion, and further assessment of his presumed metastatic disease. An electrocardiogram was recorded (Figure below).