Images in Clinical Rheumatology
Hypertrophic osteoarthropathy as a complication of pulmonary tuberculosis
Osteoartropatía hipertrófica como complicación de la tuberculosis pulmonar
Muñoz Carlos Horacio, Vásquez Gloria María, González Luis Alonso
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Division of Rheumatology, School of Medicine, Universidad de Antioquia, Hospital Universitario San Vicente Fundación, Medellín, Colombia
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Six months later, he presented to the emergency room complaining of pain and swelling of the ankles, knees and wrists for four weeks prior to admission with no constitutional (fever, night sweats, fatigue, weight loss) and respiratory symptoms. On physical examination, finger clubbing was evident and confirmed by observation of the Schamroth's sign (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Chest computer tomography showed cystic bronchiectasis and cavitations in the left lower and upper lobes (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). X-rays of wrists and legs showed periosteal reaction along the metacarpals, distal radius, ulna, tibia and fibula (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) but not acro-osteolysis of the distal phalanges of the hands and feet. Human immunodeficiency virus antibody test was negative. Pharmacologic therapy with nonsteroidal anti-inflammatory drugs was effective in relieving pain from hypertrophic osteoarthropathy (HOA) during his hospital stay and after 3 months of follow-up.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">HOA is a syndrome characterized by digital clubbing, periostosis of tubular bones and noninflammatory arthritis of large joints.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Digital clubbing is characterized by an increase of the normal 160-degree angle between the nail bed and the proximal nail-fold (Lovibond's angle). In clubbing, this angle exceeds 180 degrees, while in pseudoclubbing it is preserved. Contrary to digital clubbing, finger involvement is asymmetrical in the majority of the reported cases of pseudoclubbing, and acro-osteolysis instead of an overgrowth of the phalangeal tufts seen in clubbing, is the typical radiographic finding in pseudoclubbing.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">HOA is classified as either primary (pachydermoperiostosis) or secondary to pulmonary, cardiac, liver or gastrointestinal diseases characterized by arteriovenous shunt.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Pulmonary malignancies are the most common disorders associated with HOA (80%). Chronic infections associated with cystic fibrosis, subacute bacterial endocarditis, acquired immunodeficiency syndrome and pulmonary tuberculosis are also associated with HOA.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Our case illustrates the HOA as a rare late complication of pulmonary tuberculosis.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The pathogenesis of HOA is unknown, although an impaired lung function due to the exclusion of this organ from part of the circulation is common in most diseases associated with HOA. It has been suggested that in hypoxic conditions, megakaryocytes bypass the pulmonary circulation through arteriovenous shunts and directly reach the distal sites in the systemic circulation and interact with endothelial cells, releasing growth factors, such as vascular endothelial growth factor (VEGF), resulting in angiogenesis and thus digital clubbing.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,5–8</span></a> VEGF is a platelet-derived factor induced by hypoxia that produces vascular hyperplasia, new bone formation, edema, and fibroblast/osteoblast proliferation, which are histological alterations of HOA.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6–8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Although the association of HOA with pulmonary tuberculosis has been rarely reported,<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9–12</span></a> physicians should consider HOA as a complication of non-neoplastic diseases, such as pulmonary tuberculosis, an endemic infection of the world's population.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Ethical disclosures</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Protection of human and animal subjects</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Confidentiality of data</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Right to privacy and informed consent</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conflicts of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Discussion" ] 1 => array:3 [ "identificador" => "sec0015" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Right to privacy and informed consent" ] ] ] 2 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-05-09" "fechaAceptado" => "2014-10-16" "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 642 "Ancho" => 1301 "Tamanyo" => 105094 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Digital clubbing. (A) Clubbed appearance of distal phalanges. (B) Positive Schamroth's sign: the normal diamond-shaped window created by placing the dorsal surfaces of terminal phalanges on opposing fingers together is obliterated in clubbing.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1029 "Ancho" => 950 "Tamanyo" => 112166 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Chest computer tomography scan showing cystic bronchiectasis and cavitation in the left lower and upper lobes.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 788 "Ancho" => 1800 "Tamanyo" => 162603 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Radiographs of wrists (A and B) and legs (C) showing periostosis (arrows) at metacarpals, distal ends of the radius, ulna, tibia and fibula.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Digital clubbing and hypertrophic osteoarthropathy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 7 | 16 | 23 |
| 2024 Octubre | 45 | 38 | 83 |
| 2024 Septiembre | 44 | 29 | 73 |
| 2024 Agosto | 63 | 42 | 105 |
| 2024 Julio | 61 | 43 | 104 |
| 2024 Junio | 77 | 43 | 120 |
| 2024 Mayo | 75 | 32 | 107 |
| 2024 Abril | 71 | 38 | 109 |
| 2024 Marzo | 88 | 42 | 130 |
| 2024 Febrero | 82 | 33 | 115 |
| 2024 Enero | 112 | 31 | 143 |
| 2023 Diciembre | 68 | 31 | 99 |
| 2023 Noviembre | 151 | 28 | 179 |
| 2023 Octubre | 141 | 34 | 175 |
| 2023 Septiembre | 131 | 35 | 166 |
| 2023 Agosto | 156 | 16 | 172 |
| 2023 Julio | 140 | 25 | 165 |
| 2023 Junio | 111 | 15 | 126 |
| 2023 Mayo | 138 | 26 | 164 |
| 2023 Abril | 84 | 7 | 91 |
| 2023 Marzo | 117 | 25 | 142 |
| 2023 Febrero | 77 | 26 | 103 |
| 2023 Enero | 84 | 23 | 107 |
| 2022 Diciembre | 114 | 50 | 164 |
| 2022 Noviembre | 122 | 22 | 144 |
| 2022 Octubre | 123 | 31 | 154 |
| 2022 Septiembre | 90 | 56 | 146 |
| 2022 Agosto | 126 | 51 | 177 |
| 2022 Julio | 121 | 48 | 169 |
| 2022 Junio | 91 | 37 | 128 |
| 2022 Mayo | 142 | 61 | 203 |
| 2022 Abril | 97 | 58 | 155 |
| 2022 Marzo | 116 | 60 | 176 |
| 2022 Febrero | 134 | 43 | 177 |
| 2022 Enero | 140 | 42 | 182 |
| 2021 Diciembre | 94 | 45 | 139 |
| 2021 Noviembre | 114 | 50 | 164 |
| 2021 Octubre | 107 | 57 | 164 |
| 2021 Septiembre | 119 | 41 | 160 |
| 2021 Agosto | 147 | 50 | 197 |
| 2021 Julio | 160 | 44 | 204 |
| 2021 Junio | 120 | 51 | 171 |
| 2021 Mayo | 111 | 43 | 154 |
| 2021 Abril | 332 | 137 | 469 |
| 2021 Marzo | 158 | 30 | 188 |
| 2021 Febrero | 100 | 32 | 132 |
| 2021 Enero | 75 | 22 | 97 |
| 2020 Diciembre | 82 | 26 | 108 |
| 2020 Noviembre | 92 | 27 | 119 |
| 2020 Octubre | 113 | 22 | 135 |
| 2020 Septiembre | 75 | 29 | 104 |
| 2020 Agosto | 55 | 15 | 70 |
| 2020 Julio | 70 | 25 | 95 |
| 2020 Junio | 78 | 55 | 133 |
| 2020 Mayo | 78 | 31 | 109 |
| 2020 Abril | 74 | 51 | 125 |
| 2020 Marzo | 62 | 27 | 89 |
| 2020 Febrero | 78 | 29 | 107 |
| 2020 Enero | 76 | 26 | 102 |
| 2019 Diciembre | 73 | 27 | 100 |
| 2019 Noviembre | 48 | 27 | 75 |
| 2019 Octubre | 54 | 22 | 76 |
| 2019 Septiembre | 33 | 31 | 64 |
| 2019 Agosto | 70 | 16 | 86 |
| 2019 Julio | 88 | 26 | 114 |
| 2019 Junio | 90 | 19 | 109 |
| 2019 Mayo | 102 | 108 | 210 |
| 2019 Abril | 48 | 40 | 88 |
| 2019 Marzo | 60 | 26 | 86 |
| 2019 Febrero | 52 | 25 | 77 |
| 2019 Enero | 73 | 28 | 101 |
| 2018 Diciembre | 126 | 74 | 200 |
| 2018 Noviembre | 120 | 17 | 137 |
| 2018 Octubre | 105 | 16 | 121 |
| 2018 Septiembre | 62 | 13 | 75 |
| 2018 Agosto | 57 | 14 | 71 |
| 2018 Julio | 23 | 10 | 33 |
| 2018 Mayo | 2 | 3 | 5 |
| 2018 Abril | 45 | 9 | 54 |
| 2018 Marzo | 93 | 17 | 110 |
| 2018 Febrero | 34 | 11 | 45 |
| 2018 Enero | 20 | 8 | 28 |
| 2017 Diciembre | 35 | 7 | 42 |
| 2017 Noviembre | 32 | 7 | 39 |
| 2017 Octubre | 30 | 9 | 39 |
| 2017 Septiembre | 25 | 19 | 44 |
| 2017 Agosto | 33 | 18 | 51 |
| 2017 Julio | 33 | 18 | 51 |
| 2017 Junio | 55 | 10 | 65 |
| 2017 Mayo | 70 | 13 | 83 |
| 2017 Abril | 36 | 5 | 41 |
| 2017 Marzo | 51 | 15 | 66 |
| 2017 Febrero | 95 | 14 | 109 |
| 2017 Enero | 26 | 5 | 31 |
| 2016 Diciembre | 54 | 9 | 63 |
| 2016 Noviembre | 53 | 7 | 60 |
| 2016 Octubre | 84 | 15 | 99 |
| 2016 Septiembre | 112 | 16 | 128 |
| 2016 Agosto | 18 | 12 | 30 |
| 2016 Julio | 16 | 9 | 25 |
| 2015 Diciembre | 2 | 0 | 2 |
| 2015 Noviembre | 2 | 27 | 29 |
| 2015 Octubre | 4 | 27 | 31 |
| 2015 Septiembre | 2 | 0 | 2 |
| 2015 Agosto | 6 | 64 | 70 |
| 2015 Julio | 57 | 57 | 114 |
| 2015 Junio | 51 | 37 | 88 |
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