Мир М.Афзал Атлас клинического диагноза
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ATLAS
OF
CLINICAL
DIAGNOSIS
162
Acute gout should always
be
considered
in the
differ-
ential diagnosis
of a
sudden monoarthritis (three-quarters
of
initial attacks
affect
a
single
joint).
Although over half
the
attacks
affect
the
lower extremity,
a
sudden appearance
of
an
inflamed,
painful
elbow (9.27) should alert
the
clini-
cian
to the
possibility
of
acute gout.
In
osteoarthrosis,
the
hands present
a
characteristic
picture
of a
'square
hand'
with adduction
of the first
metacarpal, bony enlargements, subluxation
of the
meta-
carpophalangeal joints, wasting
of the
small muscles
and
deformity
of the
terminal interphalangeal joints (9.28).
Women
are
more
commonly affected than
men (in a
ratio
of
3:2)
and are
particularly liable
to
develop
the
nodular
form
of
osteoarthrosis (9.29).
Heberden's
nodes (nodular swellings
of the
terminal inter-
phalangeal joints) (9.30),
often
associated with
flexion
(9.31)
or
lateral
deformity
(9.32)
of the
terminal phalanges,
are the
characteristic features
of
osteoarthrosis
of the
hands.
9.27
Acute
gout
of the
elbow
9.28
Osteoarthrosis
with
flexion
deformity
of
the
terminal
interphalangeal
joints
9.29
Nodular
osteoarthrosis
with
a
typical
'square
hand'
deformity
9.30
Heberden's
node
9.31
Heberden's nodes
on
the
terminal
interphalangeal
joints
with
flexion
deformity
9.32
Heberden's nodes
with
lateral
deformity
of the
terminal phalanges
THE
HANDS
163
Bony swellings
may
also occur
at the
proximal inter-
phalangeal joints (Bouchard's nodes) (9.33). Deformity
of
the
distal interphalangeal joints
may
also occur
in
gout (see 9.24)
and in
psoriasis (9.34); however,
neither condition
is
difficult
to
distinguish
from
osteoarthrosis.
The
shoulder joint
is
less likely
to be
involved
in
osteoarthrosis than
the
weightbearing
hip and
knee
joints.
However,
a
rapidly destructive osteoarthrosis with
a
blood-stained
effusion
may
occur
in the
shoulder joint
(9.35)
and in
other sites.
Psoriatic
arthropathy characteristically
affects
the
distal
interphalangeal joints
and
there
may be
associated pitting
of
the
nails (9.36).
In
advanced cases, there
may be an
extremely destructive arthropathy resulting
in
absorption
of
the
phalanges, giving rise
to
telescoping
of the
fingers
and the
'main-en-lorgnette'
phenomenon
in
which
the
fingers
can
be
lengthened
or
shortened
by the
examiner
(9.37,
9.38). Fortunately, most cases
of
psoriatic arthritis
are
benign
and do not
progress
to
such mutilation
(arthri-
tis
mutilans.)
Septic
arthritis
usually
affects
bigger joints
in
patients
who
have other evidence
of
septicaemia.
The
arthritis
may
appear
in
more than
one
joint
as in
this patient,
who
9.33
Bouchard's
and
Heberden's
nodes
9.34
Psoriatic
arthropathy
affecting
distal
interphalangeal
joints.
Note
the
associated
nail
dystrophy
9.35
Osteoarthrosis
with
effusion
of the
shoulder joint
9.36
Psoriasis:
pitting
of
the
nails
9.37
Arthritis
mutilans
with
telescoping
of
the
right
fourth
finger
9.38
Arthritis
mutilans
with
telescoping
and
'pencil
and
cup'
sign.
Note
the
multiple
psoriatic
plaques
ATLAS
OF
CLINICAL
DIAGNOSIS
164
developed septic arthritis
of the
left
wrist (9.39)
3
days
after
cellulitis,
septicaemia
and
septic arthritis
of the
right
knee. Nevertheless, this diagnosis should always
be
con-
sidered when there
is
arthritis
of a
single joint (9.40),
as
urgent treatment
is
mandatory.
Clinical
diagnosis
The
correct diagnosis depends upon obtaining
a
good
history, having some knowledge
of the
specific appear-
ances
and
matching these with
the
observed
findings, and
on
carrying
out
several relevant tests.
All the
arthritides
have
a
typical appearance
and the
diagnosis
is not
usually
difficult.
Some knowledge
of
what
and
where
to
look
for
obtaining supplementary evidence
is
necessary
for
making
an
accurate
diagnosis.
For
example,
rheumatoid
disease
involves almost
any
part
of the
body (9.41)
and a
com-
prehensive clinical examination will yield some
helpful
clues
to
support
the
impression gained
by
looking
at the
hands.
9.39
Septic
arthritis
of
left
wrist
9.40
Septic
arthritis
with
swollen,
inflamed
left
elbow
joint
9.41
Clinical
features
of
rheumatoid
disease
Episcleritis,
scleritis
Scleromalacia
perforans
Sjogren's
syndrome (dry
eyes)
Heart
Pericarditis
Myocarditis
(conduction
defects)
Valvular defects
-—
(Splenomegaly)
Felty's
syndrome
Hepatosplenomegaly
(Amyloidosis)
Carpal
tunnel
syndrome
Peripheral
neuropathy
Mononeuritis
multiplex
Anaemia
Cervical
spine
disease
(Atlanto-axial
subluxation)
Chest
Pleural effusion
Fibrosing alveolitis
Rheumatoid nodules
Massive
fibrosis
(Caplan's)
syndrome
Palmar
erythema,
swelling,
deformity,
ulnar
deviation
Vasculitis
Leg
ulceration
9.41
THE
HANDS
165
The
elbows
and the
tendon sheaths along
the
ulnar
border
of the
forearm must
be
inspected
for the
presence
of
rheumatoid nodules (9.42), some
of
which
may
bear
vasculitic
lesions (9.43) characteristic
of the
disease.
The
fingers and
nailfolds
should also
be
examined
for the
pres-
ence
of
vasculitic lesions (9.44).
The
asymmetrical, nodular swellings
of
tophaceous gout
(9.45)
are not
difficult
to
recognize
and the
diagnosis
can
be
reinforced
by
locating tophi
on the fingertips and the
ear
(9.46).
An
acute monoarthritis often poses
a
major
diagnostic
problem because
a
delay
in
providing
the
appropriate
treatment
may
have consequences
not
only
for the
joint
but
also
for the
patient, particularly
if an
acute septic
9.42
and
9.43
Rheumatoid
nodules.
Note
the
vasculitic
lesions
on the
surface
of the
nodules
9.44
Rheumatoid
arthritis
with
vasculitic lesions
9.45
Chronic tophaceous
gouty
arthritis
9.46
A
gouty
tophus
on
the
helix
of the ear
ATLAS
OF
CLINICAL
DIAGNOSIS
166
arthritis
is
missed. Acute gout, pseudogout,
haemarthrosis
(usually
in a
haemophiliac patient), osteoarthrosis
and
septic arthritis must
all be
considered
in the
differential
diagnosis
of
acute monoarthritis.
The
joint
is
inflamed,
swollen,
painful
and
immobile
in
septic arthritis (9.47)
but
these characteristics
can
also
apply
to the
other arthritides
mentioned above.
Although certain features including
a
past history
of
monoarthritis,
the
patient's
age and
gender (gout
and
haemophilia)
and the
associated conditions (pseudogout
with
hyperparathyroidism,
haemochromatosis,
acro-
megaly,
diabetes mellitus, Wilson's disease, hypo-
thyroidism,
etc.)
are
important pointers,
the
definitive
diagnosis
can
only
be
made
by
microscopic examination
and
culture
of the fluid
aspirated
from
the
joint.
The
immune status
of the
patient should
be
investigated;
those
with
hypogammaglobulinaemia
are
prone
to
developing septic arthritis (9.48),
and
approximately one-
third
of the
patients
with
this condition develop
a
rheumatoid-type
arthritis.
Skin
lesions
The
correct diagnosis
of a
dermatological condition
on the
hands requires
a
two-step approach. First, attention should
be
concentrated
on a
single lesion
to
make
a
descriptive
diagnosis
(e.g. macule, papule, nodule, vesicle, plaque,
tumour,
ulcer, etc.). Second,
the
rest
of the
body should
be
examined
for the
distribution
of the
lesions
and for the
presence
of any
associated signs. Skin lesions
of the
hands,
like
those
of the
face,
can be
subdivided broadly into
two
subgroups:
(i)
dermatoses;
and
(ii) lesions related
to
sys-
temic disorders.
The
commonly encountered dermatoses
are
listed
in
Table
9.1.
9.47
Septic
arthritis
with
inflamed,
swollen
and
immobile
joint
9.48
Septic
arthritis
and
wasting
in an
immunocompromised
patient
Table
9.1
Skin lesions
in the
hands
Lesions
Macules,
papules,
plaques
Nodules,
tumours
Vesicles,
bullae,
pustules,
ulcers,
erosions,
scars
Dermatoses
Erythema
multiforme,
solar keratosis,
scabies,
psoriasis,
lichen
planus,
erysipeloid
Squamous cell
carcinoma,
melanoma,
verruca,
pyogenic
granuloma
Scabies, herpes
simplex,
erythema
multiforme,
infections
System
ic
disorders
Vitiligo,
lupus
erythematosus,
secondary
syphilis,
granuloma
annulare,
mycosis
fungoides
Granuloma
annulare
Porphyria,
lupus
erythematosus,
secondary
syphilis
THE
HANDS
167
Dermatoses
Common
conditions
Scabies
is
caused
by a
mite, Sarcoptes scabiei.
It
pre-
dominantly
affects
the
hands
and the
perineum, usually
spreads
by
skin-to-skin contact,
and
causes generalized
and
intractable pruritus, with frequent secondary bac-
terial
infection.
The
characteristic lesions
are
skin-coloured
or
grey ridges overlying burrows. They
are
approximately
1 cm
long, with
a
vesicle
or a
papule
at the end
(9.49,
9.50). More
often
vesicles, crusted papules,
or
small
urticarial
papules occur
on the
hands (9.51). Even
in the
absence
of
burrows, crusted lesions
and
denuded
vesicles
on the
dorsum
and the
inner
sides
of the
fingers
(9.52)
provide
a
characteristic appearance suggestive
of
scabies. These lesions
are
scattered throughout
the
body (9.53), over
the
arms (9.54), over
and
under
9.53
9.49
Scabies:
greyish
and
erythematous
linear
ridges
with
ruptured
vesicles
9.50
Skin-coloured
ridges
with
ruptured
vesicles
9.51
Scabies:
interdigital
burrow,
papules
and
9.52
Scabies
with
scratch
marks
and
crusting
9.53
Distribution
of
scabies
ATLAS
OF
CLINICAL
DIAGNOSIS
168
the
breasts (9.55),
on the
buttocks
and in the
pubic
area
(9.56).
Eczematous plaques, indurated nodules, excoriations
and
crusts
of
superimposed bacterial infection
are
seen
on the
arms (9.57)
and
hands.
The
clinical diagnosis
is
often
suspected
on
circumstantial evidence. Poverty, over-
crowding
and
sexual promiscuity encourage skin-to-skin
spread
in
epidemic proportions. Intense
itching,
particu-
larly
at
night,
is
suggestive
of the
condition.
The
diagnosis
can
be
confirmed
by
detecting typical burrows through
a
magnifying
lens
and by
finding
the
mite.
Psoriasis
may
involve
the
elbows (9.58), hands
and
nails
(9.59)
as
well
as the
trunk
and the
legs which makes
the
diagnosis
easy. However,
the
palms
and
soles
may be the
only
areas
affected
and the
diagnostic clues
are the
sharp
demarcation
of the
lesions
and the
presence
of
silvery-
9.54
Scabies:
papulovesicular
lesions
9.55
Papulovesicular
plaques
of
scabies
under
the
breast
9.56
Scabies: papules
on
the
glans
and the
penile
shaft
9.57
Papulonodular
lesions
with
superimposed
infection
9.58
A
psoriatic
plaque
with
silvery
scales
9.59
Pitting
of the
nails
and
psoriatic
plaques
on the
dorsum
of the
hand
THE
HANDS
white
scales (9.60). This
form
of the
disease
is
often
intractable
and may
require PUVA photochemotherapy
and
retinoids.
The
areas
affected
by
psoriasis
are
shown
in
Figure
9.61.
Lichen planus often
affects
the flexor
aspect
of the
wrists
(9.62)
with
flat-topped,
umbilicated
and
violaceous
pa-
pules, some
of
which
are
discrete
and
some coalescent.
A
closer look shows
the
characteristic central umbilication
of
the flat,
violaceous papules
with
thin, lacy, white lines
known
as
Wickham's
striae (9.63, 9.64).
These
striae
are
9.60
Sharply
demarcated,
erythematous
plaques
with
silvery
scales
9.62
Lichen
planus: flat-
topped,
oval
and
polygonal,
grouped,
violaceous
papules
9.61
Areas
of the
body
affected
by
psoriasis
9.63
Flat-topped,
violaceous,
grouped
papules
with
a
shiny
surface
and
lacy
pattern
(Wickham's
striae)
9.64
Erythema
multiforme:
erythematous skin,
papules
and
ruptured
vesicles
with
crusting
ATLAS
OF
CLINICAL
DIAGNOSIS
170
better seen
with
a
hand lens.
The
papules
are
shiny
and can
be
shown
to
reflect
light.
Erythema
multiforme
is
characterized
by a
symmetrical
eruption
of
erythematous, iris-shaped papules
('target'
lesions) (9.65), erythematous macules
and
papules (9.66),
and
vesicobullous lesions. Although
in
approximately one-
half
of the
cases there
may be no
cause,
the
rash
often
follows
an
infection (e.g. herpes simplex, mycoplasma)
or
the
ingestion
of a
drug (e.g. penicillin, sulphonamides).
Pompholyx (dyshidrotic eczematous dermatitis)
is a
deep-seated vesicular type
of
recurrent eczema
on the
9.65
Iris-shaped
target
lesions
with
a
tendency
to
bullous
formation
in the
peripheral
rim
9.66
Erythema
multiforme:
a
maculopapular
eruption
feet
and
hands.
The
tapioca-like eruption occurs mostly
on
the
fingers
(9.67), palms
and
soles.
The
vesicles
are
deep
and
pruritic.
The
cause
is
unknown although sometimes
it
may
be
caused
by
either
a
fungal
infection, chromium
or
nickel.
The
hands, like other exposed areas
(face,
ears, neck),
have
a
tendency
to
develop solar keratosis.
The
lesions
are
discrete, dry, scaly
and
adherent multiple
or
single nodules
(9.68).
There
is
excessive
folding
of the
skin
in
exposed
areas. Outdoor workers, such
as
farmers
and
sailors,
in
sunny
climates
are
particularly vulnerable.
9.67
Pompholyx:
sharply
demarcated
vesicular
patches
with
irregular
margins
9.68
Solar keratosis:
papules
with
hyperkeratotic
crusts
and
increased
folding
of
the
skin
9.69
Pyogenic
granuloma
THE
HANDS
171
The
fingers
and
face
are
common sites
for
pyogenic
granuloma.
which
is a
rapidly developing,
red or
brownish-
red
nodule (9.69).
The
lesion
is
benign
but may
bleed
and
is
sometimes mistaken
for a
melanoma.
Infections
Erysipeloid
is an
acute infection
of the
hands caused
by
Erysipelothrix
insidiosa.
It is an
occupational hazard
to
fishermen,
meat processing workers, poultry workers,
poachers, abattoir workers, veterinarians
and
butchers.
The
lesions
are
usually
red, sharply defined plaques
on the
back
of
the
hands
and fingers
(9.70,
9.71).
Like
an
acute celluli-
tis,
the
lesions look red, angry
and
indurated but, unlike
cellulitis,
erysipeloid
is
neither very
hot nor
very tender.
Blood cultures should
be
performed
in
every patient
as the
infection
can
become disseminated.
Another
infection related
to fish is a
granuloma caused
by
an
atypical
mycobacterium
in
those
who
handle
and
look
after
fish in
tanks. This so-called
fish-tank
granuloma
is
a
raised, skin-coloured
or
erythematous plaque
on the
back
of the
hands
and fingers
(9.72, 9.73).
Dermatophyte,
or
fungal,
infections
are
caused
by
fungi
that thrive
on the
nonviable tissues
of the
skin
or
hair,
and
mostly
occur
in
children
or
young adults, particularly
in
immunocompromised patients.
These
are
usually
superfi-
cial
infections
and may be
well-demarcated
as in
this
patient with tinea (ringworm) infection
of the
hand (9.74).
9.70
and
9.71
Erysipeloid:
purplish-
red, cellulitic
plaques
9.72
and
9.73
Fish-tank
granuloma:
skin-coloured
and
darkish-red,
verrucous
plaques
9.74
Tinea:
well-
demarcated,
red,
scaling
plaque
with
a
raised
border
and
central
clearing