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At a Glance

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Characterized by hypertrophic osteoarthropathy, digital clubbing, and subperiosteal new bone formation leading to pain, cutis verticis gyrata, seborrhea, and hyperhidrosis.

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Synonyms

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Hypertrophic Osteoarthropathy Primary or Idiopathic; Touraine-Solente-Gole Syndrome.

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History

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First described by Friedreich in 1868.

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Incidence

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It is associated with more than 5% of all cases of hypertrophic osteoarthropathy. The male-to-female case ratio is approximately 7:1. It is more common in African Americans than whites. In the United States, PDP is a rare disorder and the precise incidence is unknown.

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Genetic Inheritance

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Autosomal dominant pattern with variable penetrance; autosomal recessive forms have been reported.

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Pathophysiology

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Unknown.

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Diagnosis

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Clinically with appearance during childhood and slowly progression. Although the evolution of the disease typically stops after 10 years, significant morbidity can be seen. Severe kyphosis, restricted motion, and neurologic manifestations are often significant. Life expectancy is normal except for individuals presenting severe mental impairment. Three forms have been described:

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  • Complete form with pachydermia (thickening of the facial skin and/or scalp) and periostitis;
  • Incomplete form with evidence of bone abnormalities but lacking pachydermia;
  • Form fruste with prominent pachydermia and minimal to absent skeletal changes.

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Clinical Aspects

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Features include skin anomalies (thick skin, hypoplastic hyperconvex fingernails, cutis gyrata, hyperhidrosis) and limb malformations (epiphyseal and cortical anomalies, terminal broadening fingers, arthrosis). Lordosis, dislocated hip, genu varum, osteolysis, and osteoporosis may occur. Acromegaloid facial features have been described.

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Precautions before Anesthesia

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Evaluate the airway in case of severe pachydermic and acromegaloid changes (clinical, radiographs). The thyroid gland should be checked.

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Anesthetic Considerations

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Direct laryngoscopy and tracheal intubation can be difficult and might require adapted anesthetic management. Digital pulse oximetry sensors can be of poor reliability because of fingernail deformations. Careful intraoperative positioning is needed because of skeletal involvement. Vascular access can be difficult because of skin thickening.

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Pharmacological Implications

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Avoid muscle relaxants until tracheal intubation is achieved and lung ventilation confirmed.

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Other Condition to Be Considered

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Rosenfeld-Kloepfer Syndrome: Characterized by an enlargement of the mandible and/or the maxilla; large hands, feet, nose, lips, and tongue. Other features include prominence of the upper part of the forehead; cutis verticis gyrata, and corneal leukoma. It is known as a variant of PDP.

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References

Friedreich N: Hyperostose des gesammten Skelettes. Arch Pathol Anat 43:83, 1868.
Jajic Z, Jajic I, Nemcic T: Primary hypertrophic osteoarthropathy: Clinical, radiologic, and scintigraphic characteristics. Arch Med Res 32:136, 2001.  [PubMed: 11343811]
Sinha GP, Curtis P, Haigh D, et ...

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