Hypertrophic Pulmonary Osteoarthropathy: A Rare But Treatable Condition in Palliative Medicine

Role of bisphosphonates in hypertrophic osteoarthropathy: a systematic review

BACKGROUND

The role of bisphosphonates (BP) in hypertrophic osteoarthropathy (HPOA) is unclear. We presented a case of primary HPOA and performed a systematic review of literature on the effect of BP on treatment response in primary and secondary HPOA.

METHODS

The study was prospectively registered in PROSPERO (CRD42022343786). We performed a PubMed literature search that restricted to the English language. We included patients diagnosed with primary or secondary HPOA who received BP. The primary endpoint assessed was the effectiveness of BP on response to pain or arthritis. Secondary outcomes included timing, degree, and duration of response, comparison to other HPOA therapies, impact of BP on radiology, bone scan, bone turnover markers, and adverse effects of BP.

RESULTS

Literature search retrieved only case reports. Forty-five patients (21 primary, 24 secondary HPOA) had received BP. Majority(88.3%) experienced improvement in pain or arthritis. Response was gradual for primary HPOA and within a median of 3 to 7 days for secondary HPOA after treatment with BP. Most patients had reduced bone scan uptake after BP. When other HPOA therapies were tried, half responded to BP after not having previously responded to other therapies, while a third received the treatments concurrently, making it difficult to attribute treatment response to a drug. Reporting of other secondary outcomes was very heterogenous and qualitative to draw conclusions. No major adverse effects have been reported for BP in HPOA.

CONCLUSION

Bisphosphonates provide an effective and safe treatment option for primary and secondary HPOA. However, there is a lack of randomized controlled trials.

Pharmacology update: pamidronate for hypertrophic pulmonary osteoarthropathy in palliative care

Hypertrophic pulmonary osteoarthropathy (HPOA) is a rare syndrome that causes clubbed fingers, periostitis, and synovial effusions. It can adversely impact a patient's quality of life. It occurs secondary to pulmonary disease - most commonly pulmonary malignancy. The most effective treatment for HPOA is to treat the underlying disease, usually through surgical resection, chemotherapy, or radiation. However, symptomatic treatments rather than definitive treatments (surgical, chemotherapy, or radiation) are more appropriate for the palliative care patient. Pamidronate is a promising medication for the treatment of HPOA for its safety and rapid onset of action. Further research is indicated to determine whether pamidronate is consistently effective.

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.

Sudden onset polyarthritis as a paraneoplastic syndrome from non-small cell lung cancer

A 48-year-old male presented to the emergency room for 2 weeks of joint pain and swelling of his four extremities. His symptoms started suddenly and were quite debilitating. His hands, fingers, knees, and ankles were so swollen and painful that he was unable to get out of bed and had to use crutches to ambulate. He also complained of anorexia, nausea, and lack of energy over the past few months, but denied any other complaints. His only medical history was a traumatic left tibia fracture 1 year ago. The patient had a 30-pack year history of smoking tobacco and used marijuana daily.

The patient recently had an arthrocentesis at an outside hospital which was non-diagnostic and showed no infection. Given his symptoms, a thorough rheumatic workup was ordered. The ESR and CRP were elevated. ANA, rheumatoid factor, HLA B27, HIV, hepatitis panel, TSH, T4, Coombs antibodies, gonorrhea, chlamydia, CCP, alpha 1 antitrypsin, parvovirus, fungal antibodies, and myeloperoxidase antibodies were all within the normal range. X-rays of the hands, knees, and ankles were ordered. The images showed diffuse joint swelling with no fractures, dislocations, or hardware mispositioning. It also showed tissue swelling in the fingers that could not exclude hypertrophic pulmonary osteoarthropathy. A chest x-ray revealed a large 8.5 cm oval mass in the right upper lobe. A follow-up CT revealed a massive right upper lobe lung mass concerning for malignancy versus fungal etiology. A CT guided biopsy of the mass was performed and revealed a poorly differentiated non-small-cell lung cancer, favoring adenocarcinoma. Further CT imaging revealed limited stage disease. During the hospitalization, the patient was provided with NSAIDs for his joint pain, which provided minimal benefit. There was little to no improvement in his joint swelling. Oncology was consulted and further evaluation in the outpatient setting was recommended to determine if he would be a surgical candidate and/or to decide the best chemotherapeutic regimen. This case demonstrates an unusual presentation of non-small-cell lung cancer and highlights the importance of maintaining malignancy on the differential diagnosis for sudden arthritis.

Nociceptive pain unmasking a serious pathology - paraneoplastic hypertrophic osteoarthropathy: A case report

RATIONALE

Hypertrophic osteoarthropathy, also named Pierre Marie-Bamberger syndrome, represents a rare medical condition that may be considered either a primary or a secondary disease, and lung malignancies are responsible for more than two-thirds of the cases with secondary forms of the disease.

PATIENT CONCERNS

We present the case of a 41-year-old man referred to our Neurology Department for pain that was considered secondary to cervical disc protrusions. The neurologic examination was normal. However, the general examination showed digital clubbing, right lateral cervical adenopathy, and pachydermia. The radiographic examinations of the upper and lower limbs depicted osseous abnormalities typical for periostosis, and the computed tomography of the thorax showed the presence of a mass lesion in the right upper pulmonary lobe. High values of vascular endothelial growth factor were also found. The patient was admitted to the Pneumology Clinic, where biopsy was performed from the lateral cervical adenopathy.

DIAGNOSES

The anatomopathological examination revealed multiple neoplastic infiltrates suggestive of adenocarcinoma metastasis. Based on the clinical examination and radiological and histologic findings, the diagnosis of pulmonary adenocarcinoma with lymph nodes metastases and paraneoplastic hypertrophic osteoarthropathy was established.

INTERVENTIONS

The patient received treatment with nonsteroidal antiinflammatory drugs and opiate analgesics that relieved the pain.

OUTCOMES

The patient was referred to the Oncology Department for further treatment of the primary pathology. He received different types of chemotherapeutics, immunotherapy, and radiotherapy. However, despite all therapeutic measures, the disease rapidly progressed and the patient died 9 months later.

LESSONS

This is an interesting case of a patient with an overlooked pathology, which was refereed to our clinic for further investigations of a pain that was considered neuropathic, secondary to small cervical protrusions. Conversely, the pain proved to be nociceptive and Pierre Marie-Bamberger syndrome was the positive diagnosis in our patient, as it can be associated with numerous diseases, especially of neoplastic origin.

Co-morbidity with hypertrophic osteoarthropathy: A possible Iron Age Sarmatian case from the Volga steppe of Russia

PURPOSE

Hypertrophic osteoarthropathy (HOA) is a condition that can be inherited or acquired. It causes diffuse periosteal new bone formation on the long bones, with a predilection for the appendicular skeleton. When acquired, it is a nonspecific indicator of systemic disease that arises following a primary condition. This paper reviews the palaeopathological literature associated with this rare condition. It also describes the first possible case of co-morbidity associated with hypertrophic osteoarthropathy in an adult skeleton (cal. BC 170 - 1 cal. AD) from the mobile pastoralist Sarmatian culture of the Volga steppes of Russia.

METHODS

Macroscopic and radiological examination provide differential diagnoses of the lesions, while clinical and bioarchaeological analyses offer insights into the possible experience of disease and social implications of care among the nomadic populations of Iron Age Russia.

RESULTS

The analysis of Sk. 6524.102 displays lesions that may be due to both hypertrophic osteoarthropathy and osteomalacia. The man was physically impaired and his participation in physically challenging activities would have been limited.

CONCLUSIONS

The study stresses that co-morbidity is a key parameter when interpreting disease in past populations, particularly when the diagnosis involves hypertrophic osteoarthropathy.

SIGNIFICANCE

This is the first case of hypertrophic osteoarthropathy identified in Eurasian prehistoric populations. The research emphasises the significance of co-morbidity in the past.

LIMITATIONS

The diagnosis of co-morbid diseases in human remains is extremely complex and the conditions were identified as most probable by a process of elimination.

SUGGESTIONS FOR FURTHER RESEARCH

Further studies should be dedicated to understanding co-morbidity in the past.