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[Differential diagnosis of osteoarthropathia hypertrophicans]
O Diedrich1, J M Meyer, L Perlick
1Klinik und Poliklinik für Orthopädie, Rheinischen Friedrich-Wilhelms-Universität Bonn. HOA@drdiedrich.de
Insights
Secondary hypertrophic osteoarthropathy (SHOA) presents with bone pain and clubbing, often linked to cancer. Early diagnosis via bone scan reveals characteristic signs, aiding in ruling out paraneoplastic syndromes.
Area of Science:
- Orthopedics and Radiology
- Oncology
- Pulmonology
Background:
- Secondary hypertrophic osteoarthropathy (SHOA) is a rare condition characterized by bone and joint pain, often accompanied by finger and toe clubbing.
- Its pathogenesis is not fully understood, but it is increasingly recognized as a potential bony manifestation of a paraneoplastic syndrome.
Observation:
- Two cases illustrate SHOA in patients with pulmonary carcinoma and chronic obstructive pulmonary disease (COPD).
- Patients initially present with localized bone pain, while digital clubbing and soft tissue swelling are often asymptomatic.
- Radiographic findings include symmetrical periosteal calcification, and bone scans can reveal increased bone activity and the "double stripe sign".
Findings:
- SHOA diagnosis is supported by unexplained periosteal reactions and digital clubbing.
- Bone scans are crucial for early detection, showing characteristic symmetrical uptake and the "double stripe sign".
Implications:
- Considering SHOA in patients with unexplained periosteal reactions and clubbing is essential.
- Further investigations are necessary to exclude underlying paraneoplastic syndromes, particularly in patients with malignancy or chronic lung disease.
Purpose:
Chief clinical symptoms of HOA are bone and joint plain, nearly always coupled with finger and toe clubbing. The classification of HOA distinguishes between a very seldom primary (PHOA) and the more frequent secondary hypertrophic osteoarthropathy (SHOA). The pathogenesis of the disease is as yet not wholly understood, but there is a tendency that it may be a bony manifestation of a paraneoplastic syndrome.
Results:
By means of two cases, one a 72-year old patient with pulmonary carcinoma, the second a 48-year-old patient with a long standing history of COPD, we demonstrate and discuss typical clinical, laboratory, radiographic, and scintigraphic findings associated with SHOA. Primarily the patients consulted an orthopaedic surgeon due to persisting, localised osseous pain. Clubbing of fingers and toes as well as soft tissue swelling usually remain asymptomatic. Characteristically a symmetrical diaphyseal accumulation of periosteal calcification in the vicinity of short and long cortical bones becomes radiographically apparent. Early diagnosis is best facilitated by means of a bone scan, where the symmetrical increase in bone activity and the typical "double stripe sign" can be observed.
Conclusion:
In patients in whom unexplained periosteal reaction is found and phalangeal clubbing becomes evident, the diagnosis of SHOA should be contemplated and further tests performed, so as to rule out a paraneoplastic syndrome.