An unusual case of periumbilical discolouration – Cullen’s sign

A 71-year-old man presented with periumbilical bluish black discolouration of 3 days duration. He was admitted to the surgical gastroenterology department for pain abdomen. On physical examination, we observed a solitary well-defined hyperpigmented patch with a violaceous border in umbilical and periumbilical areas [Figure 1]. His BP was 96/60 mm hg, pulse rate of 104/min, oxygen saturation 96% at room air, temperature 37.6°C and respiratory rate of 18 per minute. Alpha fetoprotein levels were 331.9 (normal: up to 10 IU/mL). Computed tomography (CT) scan of the abdomen revealed a lesion suggestive of hepatocellular carcinoma with haemorrhage. Based on clinical findings and investigations, a diagnosis of Cullen’s sign secondary to haemorrhage in the previously undetected hepatocellular carcinoma was made.

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Figure 1:

Well-defined hyperpigmented-violaceous patch over the umbilical and periumbilical region.

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Cullen’s sign should alert the dermatologist to the possibility of significant intra-abdominal bleeding or pathology and warrants further investigation and appropriate management. A mortality rate of 37% is reported in patients with acute pancreatitis with the presence of Cullen’s sign.¹ Cullen’s sign carries a dismal prognosis with most case reports describing a short survival.²