The aetiology of clubbing and hypertrophic osteoarthropathy

Primary pulmonary lymphoepithelioma-like carcinoma accompanied by hypertrophic pulmonary osteoarthropathy in a non-epidemic region: a case report and literature review

Pulmonary lymphatic epithelioma-like carcinoma (LELC) is a rare and unique subtype, accounting for 0.9% of all lung cancers. To date, just over 200 cases have been reported worldwide. The Epstein–Barr virus plays a role in the pathogenesis of LELC. Most patients are from East Asia, especially southeastern China. Chest computed tomography mainly shows a single lump or nodule around the lung. In this article, we report a 49-year-old male patient from a non-epidemic area who was hospitalized for “intermittent blood in his phlegm for more than 4 months”. Imaging revealed two nodules in the left lower lobe of his lung. Transbronchial lung biopsy was performed on one of the nodules, and he was diagnosed with primary LELC. Single-photon emission computed tomography revealed that he had hypertrophic pulmonary osteoarthropathy, which is a rare symptom of paraneoplastic syndrome. Because the preoperative evaluation considered early-stage disease, video-assisted thoracoscopic surgery for the left lower lobe and mediastinal lymph node dissection were performed. Both lesions were eventually diagnosed as LELC. Fortunately, lymph node metastasis did not occur, and he did not receive other postoperative treatments. He was followed up for 1 year, and no recurrence was found.

Painful nails: A practical approach to the diagnosis and management of painful nail conditions

Because several nail disorders share similar clinical features, their diagnosis and management can be challenging to clinicians. The physical examination may disclose localized abnormalities or point to an underlying systemic disease, requiring additional workup. Furthermore, cosmetic distress and nail-related symptoms (e.g., tingling, stinging, numbness, and pain) are common factors that influence the patient's search for medical assistance. Nail pain (i.e., onychalgia) can accompany both localized and systemic pathology. Onychalgia can be acute or chronic according to the time of evolution; patients may describe it as intermittent or constant, and as a throbbing, burning, sharp, or shooting sensation denoting the nature of the pain. It may be exacerbated by colder temperatures, touch, and increased activity (e.g., manipulating objects, walking). We present four main groups of conditions that might cause nail pain: nail tumors, nail deformities, inflammatory or infectious diseases, and external or traumatic agents. Our article includes an overview of the clinical features, as well as diagnosis and management pearls for each entity. Physicians (dermatologists and nondermatologists) should be aware that abnormalities of the ungual and subungual space are not exclusive of dermatological disorders but may also be present in noncutaneous contexts.

Eight pillars of oncorheumatology: Crossroads between malignancies and musculoskeletal diseases

ONCORHEUMATOLOGY

RELATIONSHIP BETWEEN MALIGNANCIES AND MUSCULOSKELETAL DISEASES: Oncorheumatology is the meeting point of tumor formation and rheumatic musculoskeletal diseases (RMD). Multiple interactions exist between these two medical specialties. One major field is the topic of malignancies associated with rheumatic diseases, while the other topic covers the development of musculoskeletal disease in cancer patients. Within the first group, secondary malignancies may be associated with rheumatic diseases. Mostly sustained inflammation is responsible for transition into cancer. Tumor-associated antigens (TAA) with adhesive properties are present on tumor cells. These molecules may also be expressed by inflammatory leukocytes and soluble TAA levels may be elevated in RMDs. There has been continuous debate with respect to the possible carcinogenicity of conventional and targeted antirheumatic drugs. Very recent data from registries suggest that neither biologics, nor JAK inhibitors increase cancer risk in arthritis patients. The issue of physiotherapy in rheumatic patients with recent or current cancer has also been controversial. Some modalities, primarily exercise, may be safely applied to patients with RMD and cancer. The second large topic includes paraneoplastic syndromes. Musculoskeletal paraneoplasias are triggered by tumor-derived mediators. These syndromes are sometimes slightly different from the classical RMDs. Various chemotherapies may also be associated with autoimmune side effects. Recently, these immune-related complications have also been observed in cancer patients treated with immune-checkpoint inhibitors. Sex hormone-deprivation therapies, such as aromatase inhibitors and anti-androgens are widely used for the treatment of breast and prostate cancer, respectively. These compounds may induce bone loss and lead to osteoporosis. Finally, primary and secondary malignancies of the musculoskeletal system may also interest rheumatologists. In this review, the clinical, practical aspects of these eight pillars of oncorheumatology will be discussed.

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.

Combination of recurrent oral aphthae and dry eye syndrome may constitute an independent risk factor for oral cavity cancer in elderly women

Background

Few studies have evaluated the risk of oral cavity cancer (OC) in patients with recurrent oral aphthae (ROA) and dry eye syndrome (DES). This study assessed the risk of OC in patients who had received diagnoses of ROA and DES in Taiwan.

Methods

A population-based frequency-matched case–control study was conducted in which data were analyzed from the National Health Insurance Research Database of Taiwan. Patients with ROA and DES were identified as the case cohort. Patients and controls without ROA and DES were frequency matched (1:4) on the basis of age, sex, monthly income, geographical location, and urbanization level. Chi-squared tests were conducted to compare demographic factor distributions between the patients and controls. Cox proportional hazards models were used to calculate the adjusted hazard ratios (aHRs) and 95% CI of OC diagnoses among the patients and controls. Risk consistency between the two cohorts was determined using subgroup analysis.

Results

A total of 7,110 patients with ROA and DES and 28,388 controls were identified. The OC risk was significantly higher for female patients than controls (aHR=3.41, 95% CI=1.69–6.86). Furthermore, women aged 50–69 years exhibited a higher risk of OC than those in the other age groups. Female patients aged 50–59 years exhibited the highest aHR for OC (aHR=5.56, 95% CI=1.70–18.25), followed by those aged 60–69 years (aHR=4.34, 95% CI=1.26–15.99).

Conclusion

ROA and DES may be associated with a high risk of OC in elderly women.

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.

Potential contribution of erythrocyte microRNA to secondary erythrocytosis and thrombocytopenia in congenital heart disease

BackgroundChildren with cyanotic heart disease develop secondary erythrocytosis and thrombocytopenia via unknown mechanisms. Mature erythrocyte microRNAs may reflect clinical pathologies and cell differentiation processes pre-enucleation. This study evaluated erythrocyte microRNAs in children with cyanotic heart disease.MethodsErythrocyte microRNAs from children with cyanotic and acyanotic heart disease and without cardiac disease were quantified with Ion PGM System (n=10 per group). Differential expression was confirmed by quantitative PCR (qPCR; n=20 per group).ResultsMir-486-3p, mir-486-5p, and mir-155-5p increased in patients with cyanotic heart disease compared with those without heart disease: fold differences (95% confidence interval): mir-486-3p: 1.92 (1.14-3.23), P=0.011; mir-486-5p: 2.27 (1.41-3.65), P<0.001; and mir-155-5p: 1.44 (1.03-2.03), P=0.028. Mir-486-5p was increased, and let-7e-5p and mir-1260a were decreased in patients with acyanotic heart disease compared with those without heart disease: mir-486-5p: 1.66 (1.03-2.66), P=0.035; let-7e-5p: 0.66 (0.44-0.99), P=0.049; and mir-1260a: 0.53 (0.29-0.99), P=0.045.ConclusionSeveral microRNA levels changed in children with cyanotic and acyanotic heart disease. Mir-486-3p and -5p are associated with hematopoietic differentiation. Mir-486-3p regulates the erythroid vs. megakaryocyte lineage fate decision. Mir-155 is a hypoxia-inducible microRNA, whose overexpression inhibits megakaryocyte differentiation. Erythrocyte microRNA expression changes may contribute to erythrocytosis and thrombocytopenia in children with cyanotic heart disease.

Evaluation of infectious and non-infectious complications in patients with primary immunodeficiency

INTRODUCTION

Primary immunodeficiency diseases (PIDs) are a heterogeneous group of genetic immune disorders. PID patients suffer from a variety of complications. The aim of this study was to determine the infectious and non-infectious complications among PID patients.

MATERIAL AND METHODS

This retrospective cohort study was performed on recorded data of 202 PID patients who were diagnosed with eight major categories: common variable immunodeficiency (CVID), X-linked agammaglobulinemia, hyper-IgM syndrome, hyper IgE syndrome, chronic granulomatous disease (CGD), ataxia telangiectasia, hereditary angioedema and leukocyte adhesion deficiency. For all patients, infectious and non-infectious manifestations and laboratory data were collected in a comprehensive questionnaire.

RESULTS

Infectious complications were more frequent than non-infectious complications. Pneumonia and otitis media were the main infectious problems in PID patients, especially in patients with antibody deficiencies. Among the non-infectious complications, splenomegaly and hepatomegaly were the most common complications in PID patients, and were more commonly seen in CGD patients than others. Splenomegaly, hepatomegaly and autoimmunity were the most common findings in CVID patients. A significant correlation was observed between diagnostic delay and bronchiectasis in CVID patients (p = 0.042).

CONCLUSIONS

PID patients are at risk of multiple infectious and non-infectious problems. Timely diagnosis of PIDs not only improves their outcome and quality of life, but also helps prevent these troubling complications.

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.

[Pulmonary MALT lymphoma and paraneoplastic syndromes]

INTRODUCTION

Primary pulmonary lymphoma is a rare disease; diagnosis is often delayed because of atypical clinical presentation and slow progression.

OBSERVATION

A 42-year-old woman consulted because of haemoptysis. Chest CT-scan showed multiple nodular calcified masses. A lung biopsy led to the diagnosis of pulmonary amyloidosis with pulmonary MALT lymphoma (mucosa-associated lymphoid tissue). The patient developed two paraneoplastic syndromes: a hypertrophic osteoarthropathy and mucinosis.

CONCLUSION

Multiple nodular amyloidosis can be a mode of presentation for pulmonary lymphoma. Paraneoplastic syndromes must be systematically considered and can help in early diagnosis of the disease and its relapse.

Validation of the megakaryocyte fragmentation theory of finger clubbing in patients with cardiopulmonary diseases

Dickinson and Martin had proposed that finger clubbing is caused by distal impaction of large-sized platelets that escape physiological fragmentation in lung vasculature. Empirical evidence to support this theory, however, is limited and conflicting. Moreover, this theory has not been verified in patients with lung diseases. We conducted a cross-sectional analytic study to validate the megakaryocyte fragmentation theory in patients with cardiopulmonary diseases. We studied four groups - patients with cyanotic heart diseases and clubbing (n = 20); patients with non-malignant lung diseases and clubbing (n = 25); patients with non-malignant lung diseases but no clubbing (n = 25); and healthy individuals (n = 25). We measured the distal phalangeal depth ratio, estimated the platelet volume indices, and examined the peripheral blood smear for the presence of large platelets. We found that patients with clubbing due to cyanotic heart diseases had a significantly lower platelet count (median [IQR] 201 [157-241] vs. 303 [258-334] × 10(3)/μl; p < 0.001), higher platelet volume (mean difference, Δ [95% CI] = 0.93 fl [0.37-1.49 fl]; p = 0.002) and platelet large cell ratio (Δ = 7.99% [3.71%-12.26%]; p < 0.001) as compared to healthy individuals. They were also significantly more likely to have large platelets on peripheral blood smear as compared to healthy individuals (9/25 vs. 0/25; p = 0.002). However, in patients with lung diseases, irrespective of the presence or absence of clubbing, platelet count and platelet volume indices were not different from healthy individuals. Our findings support the megakaryocyte fragmentation theory of finger clubbing in patients with cyanotic heart diseases. However, this theory does not explain the clubbing seen in non-malignant lung diseases.

Esophageal adenocarcinoma and hypertrophic osteoarthropathy with improvement following resection of esophageal cancer

Esophageal cancer usually presents late and carries a grave prognosis. Early diagnosis dramatically improves outcomes, and hence recognition of the varied presenting features, including hypertrophic osteoarthropathy (HOA), may be important. Hypertrophic osteoarthropathy is a rare manifestation of esophageal adenocarcinoma and indeed may herald the presence of this neoplasm, as it did in the case we present. A 59-year-old man presented with signs and symptoms suggestive of inflammatory wrist, ankle, and knee arthritis, and imaging revealed changes of HOA. He reported dysphagia mainly to solids, and endoscopic biopsy showed adenocarcinoma. Cancer resection treatment led to clinical resolution of his musculoskeletal symptoms. This case highlights the importance of recognition of HOA as a feature of this increasingly common cancer.

Multifocal nodular periostitis associated with prolonged voriconazole therapy in a lung transplant recipient

We report a case of painful, nodular periostitis in a lung transplant recipient on long-term voriconazole therapy. Symptoms, signs, and laboratory abnormalities resolved quickly after drug withdrawal. The presentation more closely resembles periostitis deformans than hypertrophic osteoarthropathy, suggesting that the fluoride moiety of voriconazole may be pathogenic for this condition. Clinicians should be aware of this association.

[Tibial pain and unilateral knee arthritis: Precursors of paraneoplastic arthropathy]

Various rheumatic symptoms can occur in association with malignancies and are termed the so-called paraneoplastic arthropathy. The clinical picture is often similar to primary inflammatory rheumatic diseases. At present there exist no epidemiological data on this disease entity. The case of a patient with tibial pain and unilateral knee arthritis as precursors of a paraneoplastic syndrome is presented. The patient presented with the clinical manifestation of small cell lung cancer 2 years after the first presentation in the rheumatology clinic.

Incidence of hypertrophic pulmonary osteoarthropathy associated with primary lung cancer

BACKGROUND AND OBJECTIVE

Although the association of hypertrophic pulmonary osteoarthropathy (HPO) with lung cancer was investigated in the 1960s, the recent incidence of clinically apparent HPO is not known. Data from a large series of patients with lung cancer were analysed, in order to assess the incidence of possible HPO, based on bone scintigraphy, as well as the incidence of clinically confirmed HPO. The clinical features of confirmed HPO were also evaluated.

METHODS

The medical records of patients admitted with lung cancer between January 1986 and August 2004 were reviewed. Bone scintigraphy showing symmetrical, abnormally high uptake in joints and/or long bones was considered to be suggestive of HPO. Patients who also had finger clubbing and joint pain were considered to have a confirmed diagnosis of HPO. Clinical histories and hormone levels were then investigated in these patients, to identify possible causal factors.

RESULTS

Among the 1226 lung cancer patients, 55 (4.5%) demonstrated abnormally high uptake on bone scintigraphy, suggesting possible HPO. Ten (0.8%) patients had clubbed fingers and joint pain and were eventually confirmed as having HPO. Serum hormone concentrations were abnormally high in the patients with confirmed HPO.

CONCLUSIONS

This retrospective study indicated that 4.5% of lung cancer patients showed findings suggestive of HPO, a frequency similar to that reported previously. However, patients with HPO rarely showed the complete triad of signs. Although increased hormone concentrations may have caused the HPO, further investigation is required to confirm this.

Digital clubbing in HIV-infected patients: an observational study

Digital clubbing is characterized by bulbous enlargement of the distal phalanges due to an increase in soft tissue. It has been associated with a variety of conditions including cyanotic heart disease, neoplasms and infections of the lungs, bronchiectasis, liver cirrhosis, and inflammatory bowel disease. We conducted an observational study at an urban Veterans Affairs Medical Center outpatient HIV clinic to confirm our clinical impression that clubbing is common in HIV-infected patients and to identify factors that might be associated with it. Clinical, laboratory, and physical examination data including measurement of the circumference of the nail bed and distal phalanx of each finger were obtained on 78 HIV-infected patients seen for their routine care over a 3-month period. A digital index (DI), the ratio of the nail bed:distal phalanx circumference was determined for each patient. Clubbing was found in 28 patients (36%). Clubbed patients did not differ from nonclubbed patients with respect to most patient characteristics; CD4 cell counts and quantitative HIV RNA were similar in both groups. Clubbed patients had a significantly higher DI than controls (1.03 versus 0.96, p < 0.001), were younger (45 versus 49 years, p = 0.04), and had longer duration of HIV disease (48 versus, 42 months, p = 0.03). HIV infection should be considered in the differential diagnosis of acquired digital clubbing.

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.

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.

[The Herbst triad: finger clubbing, hypoproteinemia and iron deficiency anemia associated with gastroesophageal reflux]

Gastroesophageal reflux with hiatal hernia has been associated with unusual presentations, including rumination syndrome, Sandifer syndrome (reflux esophagitis, iron deficiency anemia and head cocking) and the Herbst triad (iron deficiency anemia, hypoproteinemia and finger clubbing). We report a new case of this rare disease. Lack of awareness of gastroesophageal reflux as a possible cause of these striking symptoms could lead to complications and delayed surgery.

Hypertrophic osteopathy associated with infective endocarditis in an adult boxer dog

A 20-month-old, entire male boxer dog was presented with lethargy and intermittent shifting limb lameness. Diagnostic tests revealed aortic valve vegetations suggestive of infective endocarditis causing severe aortic outflow obstruction, and hypertrophic osteopathy of all four limbs. The dog was treated symptomatically and euthanised four days later. The association of infective endocarditis and hypertrophic osteopathy has been poorly documented in the veterinary literature. The pathogenesis of hypertrophic osteopathy is unknown; however, four theories have been put forth to explain this disease: pulmonary shunting, vagal nerve stimulation, humoral substances produced by neoplastic cells and megakaryocyte/platelet clump hypothesis.

Pathogenesis of thrombocytopenia in cyanotic congenital heart disease

Although a significant minority of patients with cyanotic congenital heart disease (CCHD) are thrombocytopenic, the pathogenesis and prevalence have not been established. This study was designed to address these 2 issues. We included 105 patients with CCHD (60 men and 45 women; aged 21 to 54 years). Systemic arterial oxygen saturations were 69% to 78%. Hematocrits were 62% to 74% with normal iron indexes. In 26 of 105 patients (25%), platelet counts were <100x10(9)/L. The diagnosis was Eisenmenger syndrome in all 26 patients with thrombocytopenia. Platelet production was determined by flow cytometric reticulated platelet counts. Megakaryocyte mass was determined indirectly by thrombopoietin levels. Disseminated intravascular coagulation was based on prothrombin time, activated partial thromboplastin time, and D-dimers. Platelet activation was determined by levels of platelet factor 4 and beta thromboglobulin. Reference ranges were derived from 20 normal acyanotic controls. A reduction in absolute reticulated platelet counts implied decreased platelet production (p<0.001). Normal thrombopoietin levels implied normal megakaryocyte mass. Normal prothrombin time, activated partial thromboplastin time, and D-dimers excluded disseminated intravascular coagulation. Normal platelet factor 4 and beta thromboglobulin indicated absent or minimal platelet activation. Twenty-five percent of the patients with CCHD were thrombocytopenic because platelet production was decreased despite normal megakaryocyte mass. We hypothesized that right-to-left shunts deliver whole megakaryocytes into the system arterial circulation, bypassing the lungs where megakaryocytic cytoplasm is fragmented into platelets, thus reducing platelet production. In conclusion, platelet counts in CCHD appear to represent a continuum beginning with low normal counts and ending with thrombocytopenia.

Hepatopulmonary syndrome in patients with chronic liver disease: role of pulse oximetry

Background

Hepatopulmonary syndrome (HPS) is a rare complication of liver diseases of different etiologies and may indicate a poor prognosis. Therefore, a simple non-invasive screening method to detect HPS would be highly desirable. In this study pulse oximetry was evaluated to identify patients with HPS.

Methods

In 316 consecutive patients with liver cirrhosis (n = 245), chronic hepatitis (n = 69) or non-cirrhotic portal hypertension (n = 2) arterial oxygen saturation (SaO₂) was determined using a pulse oximeter. In patients with SaO₂ ≤92% in supine position and/or a decrease of ≥4% after change from supine to upright position further diagnostic procedures were performed, including contrast-enhanced echocardiography and perfusion lung scan.

Results

Seventeen patients (5.4%) had a pathological SaO₂. Four patients (1.3%) had HPS. HPS patients had a significant lower mean SaO₂ in supine (89.7%, SD 5.4 vs. 96.0%, SD 2.3; p = 0.003) and upright position (84.3%, SD 5.0 vs. 96.0%, SD 2.4; p = 0.001) and had a lower mean PaO₂ (56.2 mm Hg, SD 15.2 vs. 71.2 mm Hg, SD 20.2; p = 0.02) as compared to patients without HPS. The mean ΔSaO₂ (difference between supine and upright position) was 5.50 (SD 7) in HPS patients compared to non-HPS patients who showed no change (p = 0.001). There was a strong correlation between shunt volume and the SaO₂ values (R = -0.94).

Conclusion

Arterial SaO₂ determination in supine and upright position is a useful non-invasive screening test for HPS and correlates well with the intrapulmonary shunt volume.

Digital clubbing in tuberculosis--relationship to HIV infection, extent of disease and hypoalbuminemia

Background

Digital clubbing is a sign of chest disease known since the time of Hippocrates. Its association with tuberculosis (TB) has not been well studied, particularly in Africa where TB is common. The prevalence of clubbing in patients with pulmonary TB and its association with Human Immunodeficiency Virus (HIV), severity of disease, and nutritional status was assessed.

Methods

A cross-sectional study was carried out among patients with smear-positive TB recruited consecutively from the medical and TB wards and outpatient clinics at a public hospital in Uganda. The presence of clubbing was assessed by clinical signs and measurement of the ratio of the distal and inter-phalangeal diameters (DPD/IPD) of both index fingers. Clubbing was defined as a ratio > 1.0. Chest radiograph, serum albumin and HIV testing were done.

Results

Two hundred patients (82% HIV-infected) participated; 34% had clubbing by clinical criteria whilst 30% had clubbing based on DPD/IPD ratio. Smear grade, extensive or cavitary disease, early versus late HIV disease, and hypoalbuminemia were not associated with clubbing. Clubbing was more common among patients with a lower Karnofsky performance scale score or with prior TB.

Conclusion

Clubbing occurs in up to one-third of Ugandan patients with pulmonary TB. Clubbing was not associated with stage of HIV infection, extensive disease or hypoalbuminemia.

Clubbed fingers in a patient with inflammatory gingival hyperplasia

The association of clubbing with miscellaneous diseases and its diagnostic implications are such that its detection should prompt consideration of the underlying etiology. We encountered a 48-year-old woman with clubbed fingers and a cauliflower-like gingival swelling on the hard palate of the upper jaw. There were no conventionally well-known causes for clubbing. Histological examination of gum biopsy specimen revealed a diagnosis of inflammatory gingival hyperplasia. As an etiology of clubbed fingers, gingivitis was suggested, since clubbing was regressed in parallel with remission of the gingivitis after the treatment by extraction of anterior teeth. Possible involvement of an autoimmune process in the pathogenesis was also considered, because of concomitant elevation of serum anti-double strand DNA antibodies. We recommend examination of the oral cavity for search of an inflammatory disease in cases with clubbed fingers, particularly when other common causes are not apparent.

Periostitis and hypertrophic osteoarthropathy: etiologies and bone scan patterns in 115 cases

BACKGROUND: Periostitis, usually seen on X-ray, may be diagnosed on bone scan as non-nodular cortical bone hyperactivity. Both the complete form (including clubbing, arthritis and periostitis) and the incomplete form have been described in association with chronic pulmonary disease, neoplasm, hepatopathy and inflammatory bowel disease. It is not known whether the bone scan pattern of non-nodular cortical bone hyperactivity varies with the etiology. METHODS: We conducted a retrospective study to analyze the etiologies and bone scan patterns of 115 cases of non-nodular cortical bone hyperactivity. RESULTS: Eighty percent of our patients were asymptomatic. Thirty-four percent of all cases of periostitis (all bilateral) were associated with cancer. The rate of cancer in cases of periostitis involving both lower limbs was 28.5%; it was 61.3% when both lower and upper limbs were involved. The duration of the disease was not correlated with either the distribution of periostitis or the intensity of uptake. Moreover, the intensity of uptake was not correlated with the importance of the symptomatology. Bone scan pattern (regular versus heterogenous uptake, localized versus diffuse uptake) was not correlated with the etiology. CONCLUSIONS: Bilateral upper and lower uptake should alert the clinician to the risk of association with neoplasm. Bone scan pattern and intensity of uptake are not necessarily correlated with etiology.

Baqueteamento digital como manifestação inicial de neoplasia pulmonar

Os autores descrevem caso de baqueteamento digital, o qual possibilitou diagnóstico de carcinoma broncogênico em paciente assintomático. Baseados em levantamento bibliográfico, discutem sua fisiopatologia, associações com alterações sistêmicas e métodos para diagnóstico precoce, enfatizando sua importância, vista a associação do mesmo com várias doenças, incluindo neoplasias pulmonares.

Arthralgia and digital clubbing in a child: hypertrophic osteoarthropathy with inflammatory pseudotumour of the lung

Arthralgia in childhood is an unspecific symptom. One rare cause of arthralgia is hypertrophic osteoarthropathy associated with digital clubbing. We present a child where hypertrophic osteoarthropathy led to the rare diagnosis of an inflammatory pseudotumour of the lung. In a 12-year-old girl with arthralgia and digital clubbing, a chest radiograph disclosed a large round mass in the right upper lobe, and the following chest computed tomography scan showed a large solid homogenous, round, well marginated lesion with little contrast enhancement. A lobectomy of the right upper lobe was performed, and histological examination showed an inflammatory pseudotumour. The postoperative course was without problems: arthralgia and digital clubbing disappeared.

Hypertrophic osteoarthropathy may be a marker of underlying sympathetic bias

Hypertrophic osteoarthropathy (HOA) is a condition that accompanies many seemingly unrelated diseases. It is commonly associated with various clinical conditions such as pregnancy, aging, pulmonary diseases, cancers, and other systemic illnesses. The condition has been attributed to various causes such as platelet abnormalities, hormonal disturbances, and cytokine dysfunction, but the exact underlying mechanism has been elusive. We propose a unifying hypothesis that activation of the adrenergic system is the common thread that links all of the disparate clinical associations of hypertrophic osteoarthropathy. In diseased states, autonomic stimulation may occur as a result of chemoreceptor activation in response to acidosis, hypoxia, or hypercapnia. Examples include sleep apnea, congestive heart failure, renal failure, and tumor-induced hypoxia. In this setting, clinical signs of HOA may be a marker of underlying autonomic dysfunction. Autonomic stimulation may also occur as a normal part of pregnancy or as an abnormal component of aging. The exact pathway linking adrenergic excess to HOA remains to be clarified, but a plausible scenario based on current molecular evidence is offered.

Hypertrophic osteoarthropathy in a child with biliary atresia

Hypertrophic osteoarthropathy is a syndrome characterized by clubbing of the digits of the hand/foot, periosteal reaction and arthralgia or arthritis which is usually secondary to cyanotic congenital heart disease and chronic pulmonary infections. This syndrome rarely occurs in association with chronic liver disease in childhood. Here, we report on a child with biliary atresia who developed arthralgia and arthritis during follow-up and which was diagnosed as hepatic hypertrophic osteoarthropathy. It is emphasized that hypertrophic osteoarthropathy should be considered in the differential diagnosis of arthralgia and arthritis in children with long-standing chronic liver diseases, especially if finger clubbing is also present.

Management of paraneoplastic syndromes in lung cancer

Paraneoplastic syndromes are common complications of lung cancer. Although most frequently associated with advanced disease, paraneoplastic syndromes may also occur at early stages. Occasionally, the paraneoplastic syndrome may be the presenting symptom of lung cancer. For most paraneoplastic syndromes, the best treatment is to treat the underlying malignancy. However, in many cases, treatment of moderate efficacy or urgent therapy is required. Specific recommendations for the management of the most common paraneoplastic syndromes, including cachexia, hypercalcemia, and hyponatremia, are provided.

Possible association between deep infection and hypertrophic osteoarthropathy. Report of three cases and review of the literature

Hypertrophic Osteoarthropathy is classically associated with chronic pulmonary disease, cancer or inflammatory bowel disease. However, deep infection such as vascular graft infection is an etiology important to recognize because of the risk of life-threatening complication (aorto-enteric fistula). In this study, we reported two cases of aortic graft infection and one case of para-anal abscess associated with hypertrophic osteoarthropathy. The previously reported cases are reviewed.

Unusual presentation of thymic carcinoma: hypertrophic osteoarthropathy

Hypertrophic osteoarthropathy is characterized by clubbing and periosteal new bone formation along the shaft of the long bones of the extremities. Although various intrathoracic malignancies have been associated with the development of HOA, it has been extremely rare for HOA to occur in a patient with a thymic carcinoma. Recently, we experienced a 63-year-old woman diagnosed as a thymic carcinoma with hypertrophic osteoarthropathy. She had both digital clubbing and cortical thickening in her lower extremities identified radiologically. We herein describe this case with a review of the literature.

Hypertrophic osteoarthropathy associated with metastatic phyllodes tumor

Hypertrophic osteoarthropathy (HOA) is a paraneoplastic syndrome consisting of digital clubbing, polyarthralgias, and periostosis that sometimes accompanies primary bronchogenic carcinoma and other pulmonary malignancies. We report a case of HOA as the initial manifestation of pulmonary metastases in a 42-year-old woman with malignant phyllodes tumor of the breast. Since the treatment for malignancy-associated HOA is targeted at the underlying neoplasm, it is important to make the diagnosis in a timely fashion so that appropriate therapy may be initiated without delay. HOA symptoms generally improve, as they did in our patient, if the cancer responds to treatment. The pathophysiology of HOA is poorly understood, but a role for tumor-associated humoral mediators has been postulated. The hypothesized mechanisms underlying HOA are reviewed, and evidence for a prominent role for platelet-derived growth factor in mediating this syndrome is examined. This unusual case illustrates the importance of suspecting HOA in a patient with a history of cancer who presents with otherwise unexplained polyarthralgias.

Thyroid acropachy: report of 40 patients treated at a single institution in a 26-year period

Thyroid acropachy is an extreme manifestation of autoimmune thyroid disease. It presents with digital clubbing, swelling of digits and toes, and periosteal reaction of extremity bones. It is almost always associated with ophthalmopathy and thyroid dermopathy. During a 26-yr period at our institution, of 178 patients with thyroid dermopathy, 40 had acropachy. Clubbing associated with thyroid dermopathy (pretibial myxedema) was seen in 35 patients. Clubbing usually was not a patient complaint and was noted only by clinical observers. Four of eight patients with hand and extremity radiographs had periosteal reaction. Seven had associated extremity and joint pain; this pain was absent at long-term follow-up. Half of the patients required systemic corticosteroid therapy, 53% required transantral or transfrontal orbital decompression for severe ophthalmopathy, and 18% had the elephantiasic form of dermopathy. Cigarette-smoking rates were 81% for women and 75% for men (mean, 28 pack-years). All 13 patients who had thyroid-stimulating Ig measurement had high titers. Long-term follow-up (median, 12.5 yr) revealed that acropachy was not a complaint in follow-up visits or questionnaires. The data suggest that thyroid acropachy is an indicator of severity of ophthalmopathy and dermopathy. It is a source of clinical concern only if dermopathy is persistent and severe.

Pulmonary impairment and disability

Respiratory disorders, including occupational and environmental lung diseases, are prevalent. Physicians are frequently called upon to determine impairment and aid in the assessment of disability caused by these conditions, either as the treating physician or as an independent medical examiner. In this article we reviewed the role of physicians in determining the presence and severity of pulmonary disorders. A comprehensive clinical assessment and appropriate standardized tests, to objectively characterize the severity of impairment, are the key elements of the evaluation. This assessment may also include the physician's opinion regarding causative factors. Finally, disability determination is made by nonclinicians, through administrative means, based on the degree of impairment and a review of circumstances specific to the individual. Knowledge of these components of disability evaluation will help physicians to better serve their patients and supply appropriate data to the adjudicating system.

Tumor debulking by radiofrequency ablation in hypertrophic pulmonary osteoarthropathy associated with pulmonary carcinoma

A 73-year-old male with stage IV lung adenocarcinoma presented with leg swelling and clubbing of the fingers on both hands upon physical examination, and bone scintigrams demonstrated marked accumulation of 99mTc-MDP in the long bones adjacent to the patellae. A diagnosis of hypertrophic pulmonary osteoarthropathy associated with primary lung cancer was made. Radiofrequency ablation (RFA) was utilized for cytoreduction, because the patient refused chemotherapy. One-month follow-up CT scans revealed low density of the ablated area associated with ablation necrosis. Cytoreduction by RFA rapidly alleviated the arthralgia and swelling, but not the clubbing of fingers. Follow-up bone scintigrams demonstrated a reduction in patellar uptake after RFA.

The prevalence of clubbing in different types of lung cancer

BACKGROUND

The aim of the study was to determine the relative frequency of digital clubbing in small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC), and to find out whether there is a gender predominance in the frequency of clubbing.

PATIENTS AND METHODS

The study was a single center prospective study conducted at the Pulmonary Medicine Department in a university hospital. Between January 1988 and December 1998, 738 patients with histopathologic diagnoses of SCLC or NSCLC were enrolled. Twenty-six patients with a diagnosis of in differentiated lung cancer were excluded.

RESULTS

Clubbing was present in 128 (17.3%) of the 738 patients and was detected in 17.5% of patients with NSCLC vs. 16.7% of patients with SCLC (chi(2) test, P>0.05), and it was more common in males (18.6%) than in females (4.4%, Fisher's exact test, chi(2)=8.74, P<0.01).

CONCLUSION

The incidence of clubbing was similar in both SCLC and NSCLC patients, which is inconsistent with classical knowledge in the literature, and digital clubbing was significantly more common in males than in females with lung cancer.