The Uncommon Journey of a Jaundiced Patient Ashley Dababneh DO PGY2, Radhika Garimella MD PGY1, David Minter DO

Stauffer syndrome is an uncommon paraneoplastic syndrome associated with renal cell carcinoma and is characterized by hepatic dysfunction without metastasis. Due to the rarity of its occurrence, this case should be reported to broaden a physician's differential diagnosis for hyperbilirubinemia and jaundice to correctly manage the patient. A 55-year-old male with past medical history of traumatic brain injury,cerebrovascular accident with residual left-sided weakness and seizure disorder was sent to the emergency department from his assisted living facility due to 5 days of jaundice and markedly elevated bilirubin discovered by his primary physician. Patient denied any symptomology. The physical exam was significant for jaundice and scleral icterus. Initial labs in the ER showed total bilirubin of 8.7 with a direct bilirubin of 6.67 and indirect bilirubin of 2.0 and alkaline phosphatase was 540. Computed tomography of the abdomen/pelvis demonstrated mild gallbladder thickening and intrahepatic biliary dilatation with cholelithiasis and common bile duct prominence with no obvious obstructing stone or mass. It also showed signs consistent with low-grade colitis and a mass-like attenuation of the right kidney. Ultrasound of the abdomen displayed non-specific gallbladder distention, gallstones and biliary sludge without wall thickening. Gastroenterology was consulted and further investigation showed normal gamma glutamic transferase, carbohydrate antigen 19–9, antimitochondrial antibody, and smooth muscle antibody levels. Magnetic resonance cholangiopancreatography showed a distended gallbladder with gallstones and choledocholithiasis. It also displayed a mixed signal mass measuring 3.3 X 3.8 X 3.3 cm at the mid pole of the right kidney concerning for a neoplastic process. Endoscopic retrograde cholangiopancreatography was completed, removing an obstructing gallstone and sphincterotomy was performed. The patient was scheduled for cholecystectomy after the obstructing gallstone was removed, however, due to the rising direct bilirubin, alkaline phosphatase and repeat imaging showed no signs of filling defects, the surgery was postponed. The renal mass is initially planned to be followed up outpatient, but urology was consulted due to the concern for possible Stauffer syndrome and the patient underwent a right nephrectomy. Throughout the remainder of his hospitalization his bilirubin trended down leading to improvement of his jaundice and his pathology report showed clear-cell renal carcinoma. This case demonstrates the need to expand was differential diagnosis and to not exclude incidental findings on imaging. The jaundice variant presentation of the syndrome is rare, but a necessary addition to the differential the patient with a renal mass concerning for neoplasm and hyperbilirubinemia.