A 50-year-old patient with long-standing chronic obstructive lung disease develops the insidious onset of aching in the distal extremities, particularly the wrists bilaterally. There is a 10-lb weight loss. The skin over the wrists is warm and erythematous. There is bilateral clubbing. Plain film of the forearms reveals bilateral periosteal thickening, possible osteomyelitis, but no joint abnormality. Which of the following is the most appropriate management of this patient?a. Start vancomycin
The clinical picture suggests hypertrophic osteoarthropathy. This process, the pathogenesis of which is unknown, is characterized by clubbing of digits, periosteal new bone formation, and arthritis. Hypertrophic osteoarthropathy is associated with intrathoracic malignancy, suppurative lung disease, and congenital heart problems. Treatment is directed at the underlying disease process. While x-rays may suggest osteomyelitis, the process is usually bilateral and easily distinguishable from osteomyelitis. The first step in evaluation of this patient is to obtain a chest x-ray looking for lung infection and carcinoma. The process is periarticular, not articular; so septic arthritis, treated with parenteral antibiotics, would not be a consideration. Although there is warmth over the wrists, the clubbing and periosteal changes would not be seen in rheumatoid arthritis, so wrist aspiration and methotrexate therapy would not address the underlying problem. An elevated sedimentation rate could be seen in neoplasm, infection, and inflammatory arthritis and would therefore be of little diagnostic value.