Dysphagia and widespread skeletal pain in the hands, feet, legs and other bones.
The patient was admitted with symptoms of dysphagia and widespread skeletal pain in the hands, feet, legs and other bones. Dysphagia was prominent especially when eating solid meals. On physical examination there was marked finger clubbing, the nails showed the watch-glass deformity and the skin was oily. The facial skin was devoid of expression, giving the impression of an exhausted, calm person. The patient also complained of excessive sweating.
Barium enema examination of the oesophagus showed a filling defect and rigidity of the lower oesophagus (Fig. 1). Plain radiography of the bones showed prominent periosteal new bone formation, widespread in the long bones (femur, humerus, tibia, fibula, radius, ulna and pelvic bones). The periosteal new bone formations were multilayered in appearance. Thickening of the cortices was also observed in the bones (Fig. 2). On computed tomography (CT), osseous structures of the cranium showed prominent thickening and increased density (Fig. 3). On magnetic resonance (MR) imaging, the cortices were detected as increased thickness and showed prominent signal loss on both T1- and T2-weighted images. Periosteal new bone formations were not as marked as in the plain radiographs (Fig. 4).
Hypertrophic osteoarhropathy may occur as a consequence of other disease processes such as bronchogenic carcinoma, abscess, bronchiectasis, pleural mesothelioma, cyanotic congenital heart disease, ulcerative colitis, Crohn’s disease and esophageal carcinoma. Bronchogenic carcinoma is the most but esophageal carcinoma is relatively less commmon diseases that cause hypertrophic osteoarthropathy (1,2). Periosteal bone deposition is the most common and initial radiographic findings. It generally involves the diaphyses of the tibiae, fibula, radii, ulnae and less frequently the femora, humeri, metacarpals, metatarsal and phalanges. With advanced disease, periosteal new bone formation progress to the metaphysis but never extend into epiphyses. Ephyseal extension can be seen in the cases of cyanotic congenital heart disease. Various types of periosteal new bone formation can be detected in secondary hypertrophic osteoarthropathy : single layer of new bone, laminated or onionskin appearance and irregular areas of periosteal elevation (1). Periosteal new bone formation can also be seen in primary hypertrophic osteoarthropathy with autosomal dominant transmission. It is most frequent and more severe in men than in women. This disease is characterized by osseous changes, finger clubbing, skin changes and hypertrophy of the gastric mucosa (3). The complete form begins in adolescence and the findings gradually develop. The predominant finding of pachydermoperiostosis is periostitis. Periostitis may be widespread and symmetric and is most pronounced in the tubular bones of the extremities, especially the tibia, fibula, radius and ulna. Diaphyses and metaphyses can be affected but extension into the epiphyseal region is most characteristic in pachydermoperiostosis. The other disease that can be associated with marked periosteal new bone formation is thyroid acropacy, hypervitaminosis A, infantile cortical hyperosteosis. In thyroid acropacy periosteal new bone formation has a predilection for small bones of the hads and feet.
Secondary hypertrophic osteoarthropathy due to esophageal carcinoma
Based on the provided X-ray, CT, and MRI images, and in conjunction with the patient’s clinical symptoms (dysphagia and widespread bone pain), the following main radiological characteristics can be observed:
Overall, the most prominent changes indicated by these images are periosteal proliferation in the diaphyses of the extremities, consistent with typical hypertrophic osteoarthropathy.
Taking into account the patient’s age (53-year-old male), dysphagia, and widespread bone pain, the following possibilities are primarily considered:
Based on the following considerations:
Therefore, the most likely diagnosis is: Hypertrophic osteoarthropathy secondary to an esophageal tumor (highly suspicious for esophageal cancer).
Further confirmation requires endoscopy, pathological biopsy, and appropriate enhanced imaging to determine the nature, extent, and stage of the esophageal lesion.
Disclaimer: The above report is a reference analysis based on the current imaging and clinical information provided and does not constitute a definitive medical diagnosis or treatment prescription. Further in-person consultation, laboratory tests, and any additional necessary specialist assessments are required for a final diagnosis and treatment plan.
Secondary hypertrophic osteoarthropathy due to esophageal carcinoma
