Caceres’s Corner Case 62 (Update: Solution)


Dear Friends,

Muppet is running out of chest cases and wishes to show a bone case instead. Presenting an AP radiograph of both hands of a 59-year-old male with pain in the joints.


1. Rheumatoid arthritis
2. Psoriatic arthritis
3. Hyperparathyroidism
4. None of the above

59-year-old male with pain in the joints (AP view)

59-year-old male with pain in the joints (AP view)

Click here for the answer to case #62

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    Apr 2013
    DISCUSSION 28 Comments

    28 Responses to : Caceres’s Corner Case 62 (Update: Solution)

    1. gaborini says:

      the subperiosteal resorptions are quite suspicious for hyperparathyreoidism, so i go with answer 3.

    2. Ricardo Macareno says:

      4. In hyperparathyroidism subperiosteal bone resorption is identified along the medial sides of the middle phalanges.

    3. HIM says:

      joint spaces are preserved in distal joints..can’t be arthropathy..
      it may be secondary hyper Hyperparathyroidism…sub periosteal resorption is pathognomonic for HPT , left wrist is almost destroyed with extensive sclerosis(like neuropathic joint).

      • Jose Caceres says:

        Changes in left wrist are due to faulty positioning. It occurs whn both hands are radiographed together and the patient bends the wrist to be more comfortable.

    4. Yp says:

      Hypertrophic osteoarthropathy

    5. Marco Pietravalle says:

      Early psoriatic arthritis.

    6. Marco Pietravalle says:

      Alternatively hypertrophic (pulmonary?) osteorathropathy.

    7. vijay kumar ichpujani says:

      psoriatic arthritis is less likely no DIP involvement .. no obvious periosteal reaction. No brown tumours or diffue osteopenia or chondrocalcinosis.
      Carpal bone erosions and sclerosis with juxtaaricular osteopenia favour rheumatoid arthritis.. but no marginal erosions and male patient put the diagnosis in quesion.. Anyhow I would go with 1. rheumaotid arthritis or 2. none of the above

      • Marcolino says:

        – Clubbing fingers.
        – Joint pain.
        – Periosteal reaction of tubular bones, sometime linear e regular, without underlying osseous abnormality.
        – Periosteal reaction involving the diaphysis of a long bone (distal ulna).
        These clues suggest hypertrophic pulmonary osteoarthropathy.
        Muppet needs to rule out lung cancer;)

    8. gus says:

      thyroid acropachy

    9. Maria Luis Salgado says:

      I would consider hyperparathyroidism,(answer 3).

    10. Maria Luis Salgado says:

      I would consider hyperparathyroidism,(answer 3). Blood analysis would follow…

    11. Alberto Montemayor Martinez says:

      none of the above

    12. gus says:

      There is soft tissue swelling in fingers in both hands simetrical,that means could a seronegative arthitis but i now the sausage-digit sign in Psoriatic arthritis is in one digit. it could be periosteal reaction in Psoriatic arthritis but no simetrical.Gout there is not because deposit of crystals is near the joins…
      Hyperparathyroidism no way.
      It looks like thyroid acropachy but thyroid acropachy is painless.i dont know…..

      • Jose Caceres says:

        I agree with you about excluding hyperparathyroidism. It does not have subperiosteal resorption, which is the hallmark of the disease. But there is other condition (already mentioned) with widespread periostitis.

        • gus says:

          Profesor Caceres did you mean Hypertrophic osteoarthropathy? it’s often in the hands?.Hypertrophic osteoarthropathy produce pain but i thing in the long bones.

          • Jose Caceres says:

            Hypertrophic osteoarthropathy occurs in the hands. I don´t know how often (will ask Muppet), but I have seen it many times.

            • gus says:

              Thank you profesor for your beautiful case.
              i think Muppet is gonna be angry with me if you ask for..:)have a nice weekend

    13. gus says:

      maybe is non carpal bone erosions…we dont have the prof.view to prove it if there is deposition disease.or CPPD or something else?

    14. maria says:

      thyroid acropachy

    15. genchi bari italia says:

      Il pattern osseo non è di tipo erosivo iuxta-articolare: no AR.Il pattern osseo non è di tipo riassorbitivo( tunnelizzazione corticale) in sede metadiafisaria: non IPerparatiroidismo. Anche l’artrite psoriasica è di tipo distruttiva e , di solito mono-articolare. La risopota è la 4: quello che mi soprende è la “tumefazione ” della parti molli della dita, il che potrebbe indicare una entesopatia(ECD-Doppler), siero-negativa.NB nel caso precedente ho mancato in pieno il bersaglio: scusa!Cosa dice Alice?

    16. Dr Ashraf Abohadeed says:

      Both hands Ap view.
      Bilateral symmetrical soffit tissue swelling is seen at 2′,3′,,’4 digits.
      Bilatera linear l periosteal reaction along the ulnar side of 1st metacarpal bones .
      Bilateral Symmetrical spotty fluffy periosteal reaction at mid shaft of 2’3’4 proximal phalanges .
      Erosion at right trapezium and left pisiform
      Normal DIP and PIP joints .
      Normal carpal joints .
      Provisional diagnosis is seronegative arthropathy as psoriasis and Rieter,syndrome .
      Hand involvement is in favor of psoriatic arthritis .
      Visible periosteal reaction excludes rheumatoid arthritis .
      No visible sub periosteal bone resorption , so hyperparathyroidism is less likely .
      Diagnosis : psoriatic arthritis.

    17. vijayeta says:

      rheumatoid arthritis

    18. genchi bari italia says:

      S. di Reiter: la triade classica include l’artropatia , con dita a salsiciotto e periostosi.Risposta n 4.

    19. Alice says:

      No. 4 Hypertrophic osteoarthropathy as mentioned above (first by Yp)