Hypertrophic Osteoarthropathy in Cirrhosis of the Liver

Abstract

Hypertrophic osteoarthropathy is a relatively common clinical syndrome characterized by clubbing of the digits, swelling and pain in the joints, and periosteal thickening of the phalanges and extremities. It occurs in conjunction with a great number of diseases affecting the cardiovascular, pulmonary, and gastrointestinal systems (5). Intrathoracic malignant conditions, notably carcinoma of the lung and tumor of the pleura, have been the most commonly associated illness (6). Although digital clubbing, with or without cyanosis, is common in patients with cirrhosis of the liver, hypertrophic osteoarthropathy is rare. The purpose of this paper is to report two cases of cirrhosis of the liver and hypertrophic osteoarthropathy which were seen in Pusan, Korea. The incidence of cirrhosis of the liver is much higher in Korea than in the United States, probably accounting for the observation of two such cases within a two-year period. The reason for the increased incidence of cirrhosis in the Orient has not been established. Case Reports Case I: A 39-year-old Korean man was admitted to the hospital because of ascites and painful swollen joints. Two years previously he had been treated for hepatic coma at another hospital where the diagnosis of cirrhosis of the liver had been made from clinical and laboratory findings. After his recovery gradual swelling of the joints in the extremities, together with clubbing of the fingers, had developed. Family history was not remarkable. Physical examination revealed a chronically ill-appearing man with generalized edema, minimal jaundice, and normal temperature, pulse, respiratory rate, and blood pressure. Telangiectasia and spider nevi were present on the face and neck. Facial and axillary hair was sparse. The abdomen was tense with ascites. All joints in the extremities were swollen, enlarged, and tender. The toes and fingers were markedly clubbed, but there was no cyanosis. Pertinent laboratory findings were as follows; hemoglobin 11.9 g per 100 ml; no bilirubin on urinalysis; total protein 4.9 g per 100 ml (albumin 2.1 g per 100 ml and globulin 2.8 g per 100 ml); total bilirubin 4.4 mg per 100 ml with 2.7 mg per 100 ml direct component; alkaline phosphatase 4.0 Bodansky units; Bromsulfalein retention 26 per cent at forty-five minutes; cephalin flocculation 4+ at twenty-four hours; prothrombin time 23 seconds (control twelve seconds). Radiological examination of the chest and gastrointestinal tract was within normal limits. Examination of hands, wrists, knees, and ankles demonstrated extensive periosteal thickening along the long bones and digits (Fig. 1, A and B). There was also bulbous enlargement of the distal phalanges of both hands. Percutaneous biopsy of the liver revealed portal cirrhosis.