Oosting et al. Journal of Medical Case Reports 2010, 4:10 http://www.jmedicalcasereports.com/content/4/1/10 Nausea is the most frequent side effect, however, this is easily controllable with modern anti-emetics. Case presentation In November 2007, a 52-year-old Caucasian man of Dutch origin presented with upper abdominal pain, anorexia, nausea, dyspnea on exertion, and a general decline in condition for the past few weeks. His medi- cal history revealed a subarachnoid hemorrhage eight years prior to presentation, from which he recovered completely, and essential hypertension that was well- controlled. On physical examination, a lymphadenopathy in the patient’s left axilla and neck was found, in combination with a distended abdomen with shifting dullness and an enlarged irregular liver. Laboratory tests showed a slight leukocytosis and thrombocytosis, normal haemoglobin, creatinine and electrolytes levels, a lactate dehydrogen- ase (LDH) level of 373IU/L that increased to 6969IU/L in eight days, normal alkaline phosphate, normal transa- minases and bilirubins. A computed tomography (CT) scan of his chest and abdomen revealed lymphadenopa- thy in the mediastinum, lung hili and left axilla, as well as ascites with an omental cake and multiple lesions in an enlarged liver. Ascitic fluid was sent to pathology, and a gastroduodenoscopy was also performed. Multiple dark gastric and duodenal lesions were found, which were suspect for metastatic melanoma or Kaposi’s sar- coma (Figure 1). A biopsy of one of these lesions was consistent with melanoma (Figure 2), as was the cytolo- gical analysis of the ascitic fluid. Subsequently, on re-examination of the skin, a 1.5 cm irregular lesion over the left clavicle was found. The lesion was partially pigmented and partially depigmen- ted, which was consistent with a melanoma in regres- sion (Figure 3). Page 2 of 4 Figure 2 Histological examination of a duodenal lesion, Melan A staining. Two days after an uncomplicated paracentesis, our patient received 1560 mg (800 mg/m2) dacarbazine intravenously. He was discharged the next day. Five days after chemotherapy he was readmitted with severe abdominal pain. On physical examination, an acute abdomen was found. A chest X-ray showed the presence of free intraperitoneal air (Figure 4) and a clin- ical diagnosis of gastrointestinal perforation was made. His serum LDH level had fallen to 1827IU/L. A naso- gastric tube was given and the patient was started on broad spectrum antibiotics. The benefits and risks of laparotomy were discussed with the patient and his family, and he decided to go home with supportive care. He died 11 days after the diagnosis of gastrointestinal perforation was made. Discussion Melanoma can originate anywhere in the digestive tract, but the majority of digestive tract lesions are metastatic Figure 1 Upper gastrointestinal endoscopy showing multiple dark duodenal lesions measuring 5 mm to 10 mm. Figure 3 Pigmented skin lesion over the left clavicle measuring 15 mm × 8 mm with partial depigmentation consistent with a melanoma in regression.