We describe a case in which pattern recognition of a rheumatologic condition disclosed an underlying malignant process. To our knowledge this is the first reported case of unilateral palmar fasciitis and polyarthritis syndrome, which has traditionally been described as bilateral inflammatory arthritis and fasciitis1,2,3,4.
The patient, a 70-year-old woman, had a 5-week history of gradually worsening flexion contractures of the left hand along with a 3-week history of left hand pain and swelling. There were no symptoms to suggest an underlying connective tissue disease or a generalized arthropathy. Clinical examination revealed thickened fascia of left palm with flexion contractures of all fingers of the left hand (Figure 1). Synovitis of the wrist, metacarpophalangeal, and proximal interphalangeal joints was notable (Figure 2). The left palm showed palmar thickening, induration, and digital contracture (Figure 3). Her hand radiographs were unremarkable. The clinical syndrome of palmar fasciitis and polyarthritis syndrome was suspected. The patient was an active smoker, and as this condition is frequently associated with an underlying malignancy, we performed a computed tomography scan of the thorax. The scan demonstrated an occult bronchogenic carcinoma — a 3.1 × 3.3 cm mass in the anterior segment of the left upper lobe, with enlarged precarinal, aortopulmonary, and subcarinal lymph nodes. Subsequent lymph node biopsy confirmed metastatic non-small cell lung carcinoma. There was no clinical and radiological (magnetic resonance imaging) evidence of brachial plexus involvement.
The patient has since received palliative chemotherapy; however, her joint and palmar fascia changes persist. Pattern recognition is important in classifying rheumatologic diseases, and atypical presentations should prompt a thorough evaluation to exclude sinister pathology.