Hypertrophic pulmonary osteoarthropathy without clubbing of the digits

Atypical and incomplete pulmonary hypertrophic osteoarthropathy in the left distal femur: a case report

Background

Pulmonary hypertrophic osteoarthropathy (PHO) is a rare paraneoplastic syndrome that mainly occurs in patients with lung cancer. Most symptoms occur symmetrically, and unilateral symptoms without clubbing are infrequent. This report presents the case of a rare atypical symptom that was highly suspected of being PHO.

Case presentation

A 77-year-old woman with swelling and severe pain in the left femur for 2 months was referred to our hospital. Radiography revealed a remarkably osteogenic thickening and sclerotic lesion in her distal femur. Preliminary diagnoses of malignant bone tumor and hematological tumor were made based on laboratory test results, radiological examination, and clinical manifestation. A needle biopsy was performed, which ruled out the diagnosis of malignant bone tumors. A low-grade bone tumor was still suspected. After that, en bloc resection was performed, followed by replacement of the femur with a mega-prosthesis. Pathological analysis revealed no malignant tumor cells, and immunohistochemical staining for CDK4 and MDM2 yielded negative results. Meanwhile, pulmonary large cell carcinoma was identified on biopsy. Based on published studies, a diagnosis of atypical PHO was made according to clinical and imaging manifestations.

Conclusions

This is an infrequent case of PHO with unilateral symptoms in the left femur. When clinical manifestations and radiological findings are inconsistent with the pathological results, the possibility of benign lesions with malignant clinical manifestations or imaging features should be carefully considered.

Hypertrophic pulmonary osteoarthropathy: an unusual presentation

Objectives

Hypertrophic pulmonary osteoarthropathy (HPOA) is a syndrome characterized by the triad of periostitis, digital clubbing and painful arthropathy of the large joints, especially involving the lower limbs. HPOA without clubbing of the digits is considered an incomplete form of HPOA and has been rarely reported. We are presenting here a case of HPOA without clubbing in a patient with lung cancer.

Methods

A 52-year-old female active smoker presented with a complaint of multiple joint pains with associated morning stiffness, swelling and weight loss for 3 months. On examination, the patient had tenderness to palpation over the anterior shin, but no obvious clubbing was noted. X-rays of the lower extremities revealed periosteal thickening compatible with HPOA.

Results

A bone scan showed increased uptake along the periosteum and cortex of the long bones. In view of her smoking history and weight loss, a chest X-ray was done that revealed an upper lung mass. A diagnosis of lung carcinoma was made on biopsy.

Conclusion

Our case demonstrates that the unusual finding of HPOA in the absence of clubbing is a rare entity and can often be missed. Once diagnosed, a prompt search of other associated conditions should be conducted.

Hypertrophic osteoarthropathy in a young adult male from Berber, Sudan (2nd-3rd century CE)

Hypertrophic osteoarthropathy (HOA) is a pathological condition characterised by extensive periosteal new bone formation (NBF) on the diaphyses of the long bones, metacarpal and metatarsal bones. In modern clinical contexts, the secondary form of the disease is common and most often occurs secondary to intra-thoracic cancer and other forms of chronic pulmonary disease. Paleopathological evidence for HOA on the other hand has only occasionally been reported. Here we report a young adult male from the Meriotic cemetery at Berber in Sudan (2nd-3rd century CE) displaying widespread NBF on the diaphyses of the upper and lower limb bones, metacarpal and metatarsal bones, as well as the pelvis and scapulae. While several pathological conditions have to be considered as differential diagnostic options for NBF in the post-cranial skeleton, HOA is the most likely diagnosis, based on the distribution of the changes observed in this individual, as well as their macroscopic and radiographic characteristics. A chronic pulmonary condition as indicated by NBF on the visceral side of the ribs may represent the underlying cause for the HOA. This individual represents the first paleopathological case of HOA reported from an archaeological site in Africa.

Periostitis and hypertrophic pulmonary osteoarthropathy: report of 2 cases and review of the literature

OBJECTIVES

To demonstrate the clinical spectrum of hypertrophic osteoarthropathy (HOA).

METHODS

We report 2 cases of HOA and performed a computer-assisted search of Medline/PubMed for the medical literature from 1960 to June 2008 using the keywords HOA, periostitis, and clubbing. These were also combined with the text words cancer, rheumatic disease, etiology, pathogenesis, hypothesis, transplant, and treatment. Only the English language literature, with pertinent information, was included.

RESULTS

Our 2 cases include 1 HOA case with clubbing, in a patient with a right to left shunt from cryptogenic cirrhosis and interstitial lung disease, and 1 HOA case without apparent clubbing, in a patient with chronic lung transplant rejection secondary to tobacco smoking and related emphysema. Review of the literature has shown that HOA is associated with a wide variety of disorders, approximately 80% are found with primary or metastatic pulmonary malignancies. Various rheumatic diseases, such as systemic vasculitis, can also be associated with HOA. With respect to the pathogenesis, vascular endothelial growth factor, platelet-derived growth factor, and platelets may play crucial roles. Therapeutically, bisphosphonates, such as pamidronade or octreotide, may be tried to relieve symptoms in refractory cases.

CONCLUSIONS

HOA, especially periostitis without clubbing, may go unrecognized. Involvement of vascular endothelial growth factor, platelet-derived growth factor, and platelets in the pathogenesis of HOA has been postulated and supported by recent data. HOA may present as a partial syndrome without clubbing and about 20% of cases have HOA without detectable malignancy. One of our cases represents the first report of the association of HOA with lung transplantation.

Prevalence, aetiologies and significance of clubbing in a department of general internal medicine

BACKGROUND

Clubbing remains an amazing clinical sign. Its strong association with serious disease is still a clinical enigma. Moreover, the significance of diagnosing clubbing is not well established. The aim of our study was to evaluate prevalence, aetiology and clinical significance of clubbing in a department of general internal medicine.

PATIENTS AND METHODS

During one year (1511 admissions), all patients with digital clubbing assessed by determining ratio of the distal phalangeal depth (DPD) to the interphalangeal depth (IPD) and with the presence of Swamroth sign were included. Fifteen patients were diagnosed with clubbing (10 males and 5 females). They underwent complete physical examination, pulmonary CT-scan, bone scintigraphy, blood gas analysis and were compared with 86 matched controls.

RESULTS

Aetiology were renal cell carcinoma, pulmonary arteriovenous malformation, AIDS, inflammatory pseudo-tumour of the lung, adenocarcinoma of unknown origin in one case and in one case, Pet-scan suspected neoplasia but histology was not obtained. In 9 cases, no aetiology was found. Bone scan was normal in 14 cases and revealed periostitis in one case (idiopathic clubbing). Compared to control group, there was no difference in blood gas analysis but emphysema was more often present in patients with clubbing (p<0.01). No patient without aetiology developed cancer in the one year follow-up.

CONCLUSION

Clubbing is present in 1% of admission in a department of general internal medicine and is associated in nearly 40% with serious disease. In 60% of cases, aetiology is not identified but follow-up do not disclosed cancer.

Postchemotherapeutic reversibility of hypertrophic osteoarthropathy in a patient with bronchogenic adenocarcinoma

A 54-year-old man with bronchogenic adenocarcinoma had features of the hypertrophic osteoarthropathy syndrome. The syndrome is treated by surgical resection of the primary tumor, with rapid remission of the symptoms within 24 hours after surgery. In the case reported here, the tumor (T3N3M0) could not be resected. Clinical and scintigraphic regression of the hypertrophic osteoarthropathy was evident after chemotherapy. Bone scintigraphy is valuable when determining a patient's response to treatment for this paraneoplastic syndrome.