Poster - #TAFP3 - Acroosteolysis in the setting of well-controlled lupus

Acroosteolysis in a Patient with Systemic Lupus Erythematosus

Cindy Thaung, MS; Jovan M. Popovich, MD
Texas A&M College of Medicine; Houston Methodist Hospital

ABSTRACT
Introduction: Acroosteolysis is the progressive resorption of bone in the distal phalanges of the hands and feet, often associated with digital ischemia, calcinosis, and neuropathy. Diagnosis is made by plain radiographs showing bone resorption at the terminal tuft or distal phalanx. The following describes the rare finding of acroosteolysis in a patient with systemic lupus erythematosus (SLE). Case presentation: A 53-year-old male with a history of SLE first diagnosed in 1994 was stable on hydroxychloroquine for many years. He had intermittent joint pain, including episodic mild joint pain in the bilateral hands. In 2020, he reported mild tenderness at the fingertips with slowly progressive flattening of the fingernails of the 1st-3rd digits bilaterally. He denied skin changes, cold sensitivity, neuropathy, or joint swelling. Physical exam was significant for discoloration of multiple nail beds and pseudoclubbing. Labs showed stable ds-DNA at 144 IU/mL with normal ESR and complement levels. X-rays of the hands were significant for osteolysis of the distal phalanges of the 1st through 3rd digits bilaterally. Discussion: Rheumatic disorders presenting with acroosteolysis include systemic sclerosis, psoriatic arthritis, mixed connective tissue disease, and Raynaud phenomenon. The pathogenesis may involve repeated trauma from vascular or neurologic damage; angiography of affected patients shows vascular occlusions and stenoses near points of manual stress. Acroosteolysis is an extremely uncommon finding in SLE and to date has been described in only two case reports. While joint involvement in SLE is common, it classically presents as arthralgias, synovitis, and morning stiffness. Bony erosions or deformities are atypical. In our case, the scleroderma panel was negative, ruling out the development of “overlap” syndromes in which acroosteolysis is more common. There is no radical cure of acroosteolysis due to rheumatic disease but management includes treating the underlying condition and controlling digital ischemia to limit progression.