An unusual case of carcinoma polyarthritis with associated vasculitis

Abstract

This report describes a patient who presented with an unusual polyarthritis syndrome. After extensive evaluation, squamous cell carcinoma of the lung was diagnosed. During the course of the illness, the patient developed vasculitic features and "rheumatoid-like" nodules. Two months after the administration of combined-modality therapy for stage IIIA non-small cell lung carcinoma, the signs and symptoms of polyarthritis and vasculitis had disappeared completely. Ten months later, the patient remains in clinical remission. This is the first published report of simultaneous vasculitic and polyarticular manifestations in a patient with carcinoma polyarthritis.Nonhematologic malignancies may involve joints either by direct invasion or by a paraneoplastic effect. Breast and lung primary cancers are the most frequent to metastasize to articular structures, often to the knees (1). Polyarticular metastases infrequently predate discovery of the cancer; severe destruction on radiographs may be a clue (2). Paraneoplastic arthropathies are among the musculoskeletal manifestations of cancer. Rarely, polyarthritis is the presenting sign of malignancy. Although the mechanism is unclear, the polyarthritis often improves with treatment of the underlying malignancy. Distinguishing features of "carcinoma polyarthritis" include sudden onset at an older age, asymmetry, and predominant involvement of the legs and sparing of wrists and small joints. Usually absent are rheumatoid nodules, rheumatoid factor, and a family history of rheumatic disease. Herein we report the case of a woman with an unusual polyarthritis syndrome with associated vasculitis. This case depicts carcinoma poly- Submitted for publication July 9, 1996; accepted in revised form November 19, 1996. arthritis with an unusual pattern of joint involvement and systemic manifestations, illustrating the difficulties in diagnosis with this presentation of carcinoma. Carcinoma should be considered early in the differential diagnosis of atypical polyarthritis syndromes. CASE REPORTThe patient was in excellent health until August 1994 when, at the age of 59, she reported the abrupt onset of arthritis and arthralgias involving the neck, hands, wrists, knees, hips, and ankles. She consulted her local physician, and was started on a regimen of methylprednisolone 32 mg/day on a tapering schedule. Initial resolution of symptoms was achieved. However, during the following 2 months, symptoms recurred every time the methylprednisolone dosage was decreased. During the relapses, she also reported episodes of jaw claudication and developed infarction of her left third finger. She consulted several physicians, and in December 1994 a presumptive diagnosis of a generalized connective tissue disorder was made. Methylprednisolone was discontinued and hydroxychloroquine was started. Minimal symptomatic response was achieved, and the drug was subsequently discontinued due to lack of tolerability.Similar episodes recurred until March 1995. At that time she presented to our hospital with a 2-da...

Migratory Polyarthritis as a Paraneoplastic Syndrome

“…Our goal is to review the differential diagnosis of inflammatory polyarthritis before specifically discussing the diagnosis, pathophysiology, and treatment of CP. Carcinomatous polyarthritis has been reported with a variety of solid tumors including lung, gastric, colon, breast, ovarian, laryngeal, and pancreatic (Table 1) 3-5, [7][8][9][10][11] . The exact prevalence is unknown, but it is thought to be rare 4,12 .…”

“…The age of onset generally reflects that of the associated malignancy. In our review including this case, patients ranged from 43-76 with a median of 61 years [3][4][5][7][8][9][10][11] . There does not appear to be a gender predilection.…”

“…There does not appear to be a gender predilection. It has been reported to precede the diagnosis of cancer anywhere from 1 to 20 months, with most malignancies manifesting themselves within 3 months of joint symptoms [3][4][5][7][8][9][10][11] . CP is a diagnosis of exclusion.…”

“…In both conditions, patients commonly present with soft tissue swelling, limited range of motion of affected joints, and morning stiffness [3][4][5][6][8][9][10][11] . Features consistent with chronic disease and inflammation, including anemia, an elevated erythrocyte sedimentation rate and c-reactive protein, are often observed [3][4][5][6][7]11 . Several distinguishing features have been proposed.…”

“…In fact, in our review of 13 cases involving 12 patients, we noted symmetric joint involvement of the wrists and hands in 12 cases. Six of 13 cases had a detectable rheumatoid factor when reported [3][4][5][7][8][9][10][11] . The presence of rheumatoid factor in such cases can be partially explained by the underlying malignancy, which is associated with a positive rheumatoid factor in 10-20 percent of patients 13 .…”