A smoker with joint pain
BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3149 (Published 20 July 2017) Cite this as: BMJ 2017;358:j3149
- Annabel Suarez, core medical trainee,
- Benjamin Faber, core medical trainee,
- Andrew Stanton, respiratory consultant
- Correspondence to A Suarez annabel.suarez{at}nhs.net
A 45 year old man presented with a 6 month history of painful joints, cough, fever, and weight loss. He had a smoking history of 15 pack years. On examination there was synovitis of the hands, feet, and ankles. Radiographs were taken of the chest, ankle (fig 1), hands, and feet. The chest radiograph and computed tomography image of the thorax showed a lung mass. A biopsy found a poorly differentiated epithelioid malignancy (non-small cell lung cancer). What does the radiograph of the ankle show?
Answer
Hypertrophic pulmonary osteoarthropathy, a syndrome associated with lung cancer that is characterised by finger clubbing, a periosteal reaction of distal extremities, and synovial effusions.
Discussion
Radiographs of the patient’s hands (fig 2), ankles, and feet show florid periosteal elevation consistent with hypertrophic pulmonary osteoarthropathy. The main differentials for periosteal reaction on a radiograph include localised fracture repair, thyroid acropachy, hypervitaminosis A, and voriconazole induced periostitis.1 Hypertrophic pulmonary osteoarthropathy usually occurs secondary to primary or metastatic lung carcinoma,2 or conditions associated with chronic lung or pleural inflammation.34 It is reported in fewer than 1% of people with lung cancer.3 Treatment of the underlying cause, for example surgical resection or systemic chemotherapy, can result in prompt improvement of the hypertrophic pulmonary osteoarthropathy symptoms and radiographic findings.3 While there is no clear guidance and limited evidence to support any one treatment for pain relief, consensus from case reports recommends non-steroidal anti-inflammatory drugs, bisphosphonates, octreotide, or a vagotomy.5 The lack of standardised treatment likely reflects both the rarity of the condition and the poorly understood pathogenesis.
Learning point
A chest radiograph is important in the assessment of all smokers with an otherwise unexplained acute inflammatory arthropathy, as the musculoskeletal radiological signs of hypertrophic pulmonary osteoarthropathy can be subtle.
The mainstay of treatment is definitive management of the primary pathology, but symptomatic therapies can be used for the rapid relief of pain and swelling.
Footnotes
We have read and understood BMJ policy on declaration of interests and declare that we have no competing interests.
Patient consent obtained.
Provenance and peer review: not commissioned; externally peer reviewed.