Casebook: CASE 2

CASE 2:
A case of pachydermoperiostosis (primary hypertrophic osteoarthropathy)
(Courtesy: Departments of Nuclear Medicine and Internal Medicine, MEDUNSA/Ga-Rankuwa Hospital.
Provided by: Drs MM Sathekge and A Bassi)

CASE 1

Clinical information:

56 year old male
Four year history of pain and swelling of ankles and knees and painful lower back and hips
Clinical findings of oily skin, large hands and feet, clubbing and dystrophic nail changes. Tender and swollen knee and ankle joints
X-rays: periosteal proliferation and cortical thickening of distal ends of tibiae, fibulae, ulnae and radii.

Scintigraphic findings:

Tc-99m MDP bone scintigraphy performed:

Intense increased pericortical linear tracer uptake along the distal ends of tibiae, fibulae. ulnae and radii. Increased activity was also noted in the terminal phalanges and metacarpophalangeal joints of both hands.

Conclusion:

Findings are more in favour of pachydermoperiostosis rather than secondary hypertrophic osteoarthropathy (SHOA) since higher uptake occurs at the distal ends of tibiae, fibulae, ulnae and radii..

Comments:

Distinction between secondary hypertrophic osteoarthropathy (SHOA), thyroid acropachy and pachydermoperiostosis is important because the latter has a benign course. SHOA usually shows diffuse symmetric increased uptake in the diaphyses and metaphyses of tubular bones, along their cortical margin "parallel track". Thyroid acropachy shows uptake in the diaphyseal region, usually confined to the hands and wrists and rarely involving long bones. Hence, in patients with joint pains without any other causes of hypertrophic osteoarthropathy, symmetrical increased activity along the distal ends of long bones is suggestive of pachydermoperiostosis.

- Drs M M Sathekge & A Bassi

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