A middle aged man was referred to our department for management of his newly diagnosed locally advanced lung adenocarcinoma.
Previous medical history was significant only for lower back injury, remote history of alcohol abuse, and a 40+ pack-year smoking history resulting in chronic obstructive pulmonary disease (COPD). Family history was non-contributory for malignancy.
At his initial clinic visit he presented with significant respiratory symptoms related to the tumour and post-obstructive pneumonia, including fever and chills, cough, production of purulent sputum, and an elevated white blood cell count. Recent staging investigations including a computed tomography (CT) scan of the brain and abdomen/pelvis and bone scan revealed no evidence of metastatic disease. Because of his poor performance status (ECOG 3), significant weight loss and extensive thoracic disease, he was determined not to be a candidate for curative combined chemotherapy and radiation. He was treated with ciprofloxacin and clindamycin for his pneumonia and with 10 fractions of moderate dose palliative radiotherapy for his thoracic disease.
On follow-up 10 days after completion of radiotherapy, his pulmonary symptoms had improved with resolution in his cough, sputum production and fever. However, he reported the presence of some pain in his right second finger. Physical examination revealed a mildly tender, non-erythematous finger with mild swelling and decrease in range of motion. Hand x-ray () demonstrated only mild soft tissue swelling. He was scheduled for a follow-up in 4 weeks, with instructions to seek medical attention if the finger became inflamed or he developed a fever.
Plain x-ray taken at initial complaint of finger pain.
The patient’s finger became progressively swollen over the ensuing weeks, and he was started on cephalexin 500 mg four times daily by his family physician for presumed cellulitis. At his 1 month clinic appointment, the finger was notably swollen, erythematous and tender. An x-ray () showed an aggressive, focal destructive process at the base of the proximal phalanx of the second digit. Given the sudden progression and history of recent significant pulmonary infection, the patient was seen by an infectious diseases specialist and referred to plastic surgery with a presumptive diagnosis of osteomyelitis. A small volume joint aspirate was performed which was non-diagnostic for infection. He was admitted to hospital and treated with intravenous vancomycin/cefazolin/ciprofloxacin. His symptoms improved dramatically and he was discharged home after 5 days on oral antibiotics.
Plain x-ray taken at 4 week follow-up. Red arrowhead indicates proximal phalanx destruction; blue arrowhead demonstrates joint space preservation.
Despite initial improvement with antibiotics, in clinic 3 weeks later the entire finger was now swollen and exquisitely painful despite use of narcotics for pain control. An x-ray () showed pronounced progression of the destructive bony lesion, extending to the head of the proximal phalanx with intact subchondral bone at the base of the finger and preservation of the joint space. A biopsy was performed which revealed adenocarcinoma consistent with metastasis from his lung primary tumour.
Plain x-ray taken at 7 weeks. Red arrowhead indicates further destruction of the head of the proximal phalanx; blue arrowhead demonstrates joint space preservation.