Categories
Internal Medicine

Hypertrophic osteoarthropathy (HOA)

Characterized by abnormal skin proliferation at the distal parts of the extremities as well as periosteal proliferation of the long bones

  • Paraneoplastic syndrome

Classification

Primary HOA (3-5%):

  • Pachydermoperiostosis: Disseminated skin hypertrophy

Secondary HOA (95-97%): Secondary to extraskeletal conditions

  • Hypertrophic pulmonary osteoarthropathy (HPOA): Non–small cell lung carcinoma (NSCLC) (M/C)
rg.2017160052.fig1_
Classification of HOA. | MSK = musculoskeletal. | Yap, F. Y., Skalski, M. R., Patel, D. B., Schein, A. J., White, E. A., Tomasian, A., … Matcuk, G. R. (2016). Hypertrophic Osteoarthropathy: Clinical and Imaging Features. RadioGraphics, 37(1), 157–195. https://doi.org/10.1148/rg.2017160052

Pathophysiology


Clinical features

Primary HOA:

  • Coarse facial features
  • Furrowing and oiliness of skin of face
  • Digital clubbing 
  • Cutis verticis gyrata: Marked furrowing of scalp
  • Radiographic periostitis of distal long bones

Secondary HOA:

  • Rapidly evolving joint pain and swelling of acute onset.
  • Digital clubbing “Hippocratic fingers”
  • Periostosis of tubular bones
  • Synovial effusions
bcr2012007745f02
Photograph showing digital clubbing of hand. | Nayak, H. K., Rajkumar, V. D., Kumar, N., & Kar, P. (2012). Primary hypertrophic osteoarthropathy (incomplete form) in young adults: a case report and review of literature. BMJ case reports, 2012, bcr2012007745. doi:10.1136/bcr-2012-007745

Diagnosis

Clinical diagnosis:

 

rg.2017160052.fig4_
Methods to diagnose digital clubbing at physical examination include the hyponychial angle (angle abc 192° with clubbing, right), Lovibond or profile angle (angle abd 180° for clubbing, right), phalangeal depth ratio (distal phalangeal depth [DPD]/interphalangeal depth [IPD] ratio 1 for clubbing, right), Schamroth sign (loss of normal diamond-shaped window between nailbeds when nails are placed together), and digital index (sum of nail bed circumference [NB]/distal interphalangeal circumference [DIP] ratios for all fingers, >10 for clubbing). | Yap, F. Y., Skalski, M. R., Patel, D. B., Schein, A. J., White, E. A., Tomasian, A., … Matcuk, G. R. (2016). Hypertrophic Osteoarthropathy: Clinical and Imaging Features. RadioGraphics, 37(1), 157–195. https://doi.org/10.1148/rg.2017160052

Imaging:


Management

Primary HOA:

  • Polyarthritis and bone pain: NSAIDs, corticosteroids, infliximab
  • Facial pachydermia, hyperhidrosis: Neurotoxin injections
  • Hyperhidrosis: Beta-blockers, glycopyrrolate 

Secondary HOA:

  • Primary treatment: Treatment of underlying disease
  • Symptomatic treatment:
    • Vagotomy
    • Adrenergic antagonist
    • Bisphosphonates (pamidronate or zoledronate)
    • NSAIDs (rofecoxib, ketorolac, indomethacin)
    • Octreotide
    • Gefitinib (EGFR inhibitor)

Leave a Reply