Hypertrophic osteoarthropathy and intrathoracic Hodgkin's disease in children

Digital clubbing occurring in intrathoracic Hodgkin lymphoma: A case report

RATIONALE

Digital clubbing is rarely associated with lymphoma. This study reports a case of intrathoracic Hodgkin lymphoma with digital clubbing and reviews the current literature regarding the clinical characteristics of this condition.

PATIENT CONCERN

A 21-year-old woman presented with a 3-month history of cough and 1 month of fever, with apparent digital clubbing. A computed tomography (CT) scan of the lungs revealed a large pulmonary mass.

DIAGNOSIS

A CT-guided transthoracic needle biopsy was conducted. Pathology determined a diagnosis of Hodgkin lymphoma.

INTERVENTIONS

The patient underwent 6 courses of chemotherapy and intensification, followed by autografting.

OUTCOMES

The patient recovered and a complete hematological remission was obtained. The patient is alive with no evidence of disease 60 months after diagnosis, with the digital clubbing of the fingers and toes completely resolved.

CONCLUSION

Patients with digital clubbing and intrathoracic lesions need to be examined carefully to determine tumor malignancy.

Atypical presentation of a mediastinal mass in an adolescent: Critical care considerations

OBJECTIVE

To describe the clinical course and treatment of a large mediastinal mass with unusual presentation and critical lower airway compression in an adolescent.

DESIGN

Case report.

SETTING

Pediatric intensive care unit in a tertiary care, academic children's hospital.

PATIENTS

A previously well 15-yr-old boy presented to an outside physician with a 2-mo history of widening of his fingernail beds, progressing within a month of admission to fatigue, weight loss, progressive cough, and dyspnea on exertion. One week before admission, he developed facial swelling, headache, and large neck, chest, and abdomen veins. At the time of admission, he was hypoxic and had a large mediastinal mass with severe lower airway compromise, right-sided atelectasis and pleural effusion, as well as significant right atrial compression on chest computed tomography.

INTERVENTION

The patient was placed in the pediatric intensive care unit and underwent emergent tube thoracostomy and drainage of the pleural effusion in the upright position, using a local anesthetic.

RESULTS

: The patient developed mild reexpansion pulmonary edema with worsening hypoxia, which was managed using bilevel positive airway pressure. Pleural fluid was nondiagnostic, as was bone marrow aspirate and biopsy done in similar fashion on day 2. The patient then underwent a fine-needle biopsy in the operating room, also nonintubated and upright, which diagnosed non-Hodgkin's lymphoma, nodular sclerosing type. Treatment for tumor lysis syndrome and chemotherapy were initiated, and he progressively improved.

CONCLUSIONS

Mediastinal mass with true critical airway and vascular compromise is often discussed but infrequently seen in the pediatric intensive care unit. This case shows not only unusual associated signs of lymphoma (clubbing and caput medusae) but more importantly the rapid identification and thoughtful management of the patient's respiratory compromise. This case serves to remind the pediatric intensivist of alternative ways to provide analgesia safely in such patients for lifesaving as well as diagnostic invasive procedures.

Rhabdomyosarcoma associated hypertrophic osteoarthropathy in a child: detection by bone scintigraphy

Hypertrophic osteoarthropathy (HOA) is characterized by digital clubbing, long bone periosteal reaction, and polyarthralgias. Primary familial HOA is very rare and is not associated with underlying disorders and has a good prognosis. Secondary pediatric nonneoplastic HOA is associated with cystic fibrosis, congenital heart disease, biliary atresia, and inflammatory bowel disease. Secondary neoplastic HOA may be associated with intra or extrathoracic tumors.A 5-year-old girl was admitted to our hospital for an abdominal mass, digital clubbing, and diffuse articular pain. The bone scan revealed symmetrical tracer uptake in the long bones. Upper and lower extremity x-rays were diagnostic for HOA. Paraneoplastic HOA in childhood accounts for not more than 12% of HOA paitents. HOA has been reported in 2 other cases of rhabdomyosarcoma.

Touraine Solente Gole syndrome: the disease and associated tongue fissuring

Touraine Solente Gole syndrome, a relatively rare inherited disorder is epitomized by finger clubbing, skeletal changes and pachyderma. We report a typical case of complete pachydermoperiostosis in addition to a thick fissured tongue, a yet unrecognized association and discuss the social cum clinical relevance of identifying this relatively uncommon disorder.

Childhood intrathoracic Hodgkin lymphoma with hypertrophic pulmonary osteoarthropathy: a case report and review of the literature

Hypertrophic osteoarthropathy (HOA) is characterized by clubbing, periosteal new bone formation and polyarthritis. The pathogenesis of clubbing involves an increased expression of platelet-derived growth factor (PDGF) and vascular endothelial growth factor (VEGF) from the digitally lodged platelet clumps, which bypass the pulmonary capillary network as a result of various systemic disorders. Intrathoracic neoplasms are rare causes of HOA in children. We report here a 14-year-old boy with digital clubbing, who eventually received the diagnosis of intrathoracic Hodgkin lymphoma (HL) and HOA. Eight cases previously reported with these two diagnoses are reviewed to emphasize the prognostic significance of HOA in childhood HL.

CONCLUSION

Given the pathogenesis of clubbing and the prognostic significance of HOA, intrathoracic disease should be considered when HOA is detected in a child with a known or suspected malignant disease, and the occurrence of HOA during follow-up should alert the physicians for possible recurrence of the neoplastic disease or intrathoracic involvement.