Hypertrophic Osteoarthropathy Differential Diagnoses

Updated: Jan 13, 2021
  • Author: Vishnuteja Devalla, MD; Chief Editor: Herbert S Diamond, MD  more...
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Diagnostic Considerations

The importance of recognizing hypertrophic osteoarthropathy (HOA) cannot be overstated. A previously healthy individual with any manifestation of the syndrome should undergo a thorough evaluation for an underlying illness. Direct special attention toward the lungs and heart.

Other disorders to consider in the differential diagnosis include acromegaly, thyroid acropachy, and scleromyxedema, syphilitic periostitis, osteopetrosis, and Paget disease. The disfigurements in facial and skeletal appearances have been confused with leprosy and syphilis, which are especially important considerations in some developing countries. 

Inflammatory arthropathy may be incorrectly diagnosed in cases of malignant lung tumors, in which painful arthropathy can be the presenting feature of HOA. HOA is more likely when the following factors are present:

  • Pain that extends beyond the joint into the adjacent bone
  • Absence of rheumatoid factor
  • Noninflammatory synovial fluid

Acromegaly may be suggested in cases of exuberant skin hypertrophy and enlarged hands and feet. [95]  However,  in acromegaly, bones in general are larger in the face, jaw (prognathism), skull, and limbs; this is very evident in a radiographic study in the absence of signs of periostosis.Normal growth hormone levels and the absence of both prognathism and enlarged sella turcica exclude acromegaly.

Fingertip changes due to other conditions that may be confused with HOA include the following:

Other diseases associated with periostitis should be included in the differential diagnosis. In HOA, the periostitis involves the distal diaphysis of long bones and metacarpal joints, while in other diseases, the involvement is as follows:

  • Psoriatic onycho-pachydermo periostitis - Terminal phalanx
  • Psoriatic arthritis - Phalanges of fingers and toes
  • Reactive arthritis - Phalanges of fingers and toes
  • Athletic overuse (running, jumping) - Upper and lower extremities
  • Ossifying fasciitis - Variable
  • Periostitis ossificans - Variable
  • Polyarteritis nodosa - Lower extremities
  • Facial infections - Mandible, orbital
  • Florid reactive periostitis - Phalanges of hands and feet
  • Osteoblastoma - Variable
  • Bizarre parosteal osteochondromatous proliferation (Nora tumor) - Bones of the hands and feet
  • Chondrosarcoma - Variable
  • Treatment with interleukin-11 - Clavicle, long bones
  • Osteomyelitis - Variable
  • Chronic leg ulcers - Tibia
  • Synovitis-acne-pustulosis-hyperostosis (SAPHO) syndrome - Variable

Various causes of unidigital clubbing include the following:

  • Aortic/subclavian aneurysm
  • Brachial plexus injury
  • Shoulder subluxation
  • Superior sulcus (Pancoast) tumor
  • Median nerve injury
  • Trauma
  • Maffucci syndrome
  • Gout, sarcoidosis
  • Severe herpetic whitlow
  • Hemodialysis

Localized clubbing, similar to unilateral digital clubbing, has been described in association with local vascular lesions such as aneurysms; arteriovenous fistulas; and venous abnormalities of the arm, axilla, and thoracic outlet. [61, 62]  

Pretibial edema may be due to thrombophlebitis, venous stasis, or pretibial myxedema and may mimic periostosis.