title: An uncommon presentation of non-small-cell lung cancer with acrometastases to the great toe and index finger.
abstract: BACKGROUND
  Acrometastasis as initial presentation of metastatic cancer is an extremely rare finding. We describe an unusual case of late-stage non-small-cell lung cancer with metastatic lesions to the great toe and index fnger with associated pain in those areas as the only presenting symptom.
  A 71-year-old white woman was referred to the emergency department by her primary care physician for necrosis and swelling of the left great toe for work-up of possible osteomyelitis (Figure 1). Before she presented to her physician, she had been complaining of severe pain, swelling, and erythema of the left great toe that had lasted for 1-2 months. Infection was initially suspected. She completed 2 courses of oral antibiotics with no improvement. She was also complaining of similar symptoms on the left index finger and attributed her symptoms to an injury a month earlier (Figure 2). The pain was so severe that she was not able to bear weight on her left foot. An outpatient X-ray of her left great toe raised her physician's concerns that it might be osteomyelitis so she was referred to the emergency department.
authors.affiliation: Department of Internal Medicine, Division of Hematology and Oncology, Lehigh Valley Hospital, Muhlenberg, Pennsylvania, USA. jamie.reynolds@lvhn.org.
authors.forename: Jamie
authors.initials: J
authors.lastname: Reynolds
authors.affiliation: Department of Internal Medicine, Division of Hematology and Oncology, Lehigh Valley Hospital, Muhlenberg, Pennsylvania, USA.
authors.forename: Savitri P
authors.initials: SP
authors.lastname: Skandan
keywords: acrometastasis; denocarcinoma; lung cancer