Hypertrophic Osteoarthropathy Masquerading as Lower Extremity Cellulitis and Response to Bisphosphonates

Abstract

Hypertrophic osteoarthropathy (HOA) is characterized by clubbing of digits and, in more advanced stages, by periosteal new bone formation and synovial effusions. Secondary HOA typically occurs in the setting of intrathoracic malignancy, infections or lung metastases. We report a case with an atypical presentation of HOA. The prominent systemic signs, presentation limited to lower extremities only and an excellent response to bisphosphonates make this case unusual.

Paraneoplastic Syndromes: An Approach to Diagnosis and Treatment

“…100 In patients with long bone involvement, nuclear bone scans will demonstrate symmetric and concentrated tracer uptake along these bones. 112 The symptoms of paraneoplastic hypertrophic osteoarthropathy may resolve with successful cancer therapy. Other treatment options include bisphosphonates, opiate analgesics, nonsteroidal anti-inflammatory drugs, and localized palliative radiation.…”

“…113 Hypertrophic osteoarthropathy may also develop as a primary disorder, termed pachydermoperiostosis. 112 Clinical features of hypertrophic osteoarthropathy, particularly digital clubbing, are present in up to 10% of patients with lung tumors. 100 In patients with long bone involvement, nuclear bone scans will demonstrate symmetric and concentrated tracer uptake along these bones.…”

“…104 HypertropHIc oSteoartHropatHy Hypertrophic osteoarthropathy is characterized by periostosis and subperiosteal new bone formation along the shaft of long bones and the phalanges ("digital clubbing"), joint swelling, and pain. 100,112 Vascular endothelial growth factor, platelet-derived growth factor, and prostaglandin E2 have all been identified as possible contributors to hypertrophic osteoarthropathy. 112,135,136 Approximately 90% of cases are paraneoplastic, with the remaining cases found in association with conditions such as pulmonary fibrosis, endocarditis, Graves disease, and inflammatory bowel disease.…”

“…100,112 Vascular endothelial growth factor, platelet-derived growth factor, and prostaglandin E2 have all been identified as possible contributors to hypertrophic osteoarthropathy. 112,135,136 Approximately 90% of cases are paraneoplastic, with the remaining cases found in association with conditions such as pulmonary fibrosis, endocarditis, Graves disease, and inflammatory bowel disease. 113 Hypertrophic osteoarthropathy may also develop as a primary disorder, termed pachydermoperiostosis.…”

“…Other treatment options include bisphosphonates, opiate analgesics, nonsteroidal anti-inflammatory drugs, and localized palliative radiation. 112,113 leukocytoclaStIc VaSculItIS Paraneoplastic leukocytoclastic vasculitis occurs most commonly with hematologic malignancies or with lung, gastrointestinal, or urinary tract tumors. 115,116 symptoms, such as fever and malaise, are also common.…”