010 A rare case of palmar fasciitis with polyarthritis of ovarian malignancy

Abstract

Background: A 57 year old Caucasian female presented with rapidly progressing swelling and stiffness in both hands five weeks after injuring her left palm with a thorn during gardening. This was promptly removed but an erythematous patch developed over the same area two weeks later. This progressed to affect multiple small joints of her hands with associated swelling and tightness of the skin. Later, both knees became painful and swollen, and she developed flexion deformity in hands and knees. She was systemically well with no symptoms to suggest underlying connective tissue disease. There were no recent infections, vaccinations or travel abroad. Past medical history included hypothyroidism and epistaxis. There were no new medications or known allergies. She was a non-smoker and teetotal. Her mother had breast cancer aged 48 and her brother was treated for leukaemia. Methods: On examination there was patchy erythema, skin thickening, tightening and tethering of the palms and fingers with some flexion contracture of the fingers. Bilateral hand grips were compromised. Bilateral knee effusions were evident but no other joints were affected. Skin was normal in the forearm and upper arms and she had no telangiectasia. Cardiovascular, respiratory and gastrointestinal examinations were unremarkable. Breast examinations did not reveal any masses or lymphadenopathy. Results: Blood tests were unremarkable and she had negative immunology and vasculitic screen. MRI of both hands showed soft tissue oedema but no synovitis. Knee aspirate was negative for microscopy, culture and cytology. Skin biopsy of her left palm showed non-specific neutrophil infiltration and was negative for IgG4. Nail fold capillaroscopy was normal. A CT of her chest, abdomen and pelvis revealed omental thickening and caking, of uncertain significance. Her CA 125 was mildly raised but other tumour markers were normal. Omental biopsy demonstrated high grade serous adenocarcinoma. Conclusion: This was a challenging case with wide differential diagnoses at presentation, requiring multiple speciality input. An erysipeloid reaction was suspected on initial review by dermatology but no improvement was seen with a week of IV tazocin. Eosinophilic fasciitis was considered but skin biopsy and the lack of peripheral blood eosinophilia were not supportive. Whilst awaiting the omental histology, a rapidly progressing scleroderma was considered in view of subpleural fibrosis on HRCT and small pericardial effusion on echocardiogram. However, the absence of Raynaud's, normal nail fold capillaroscopy and negative immunology were not supportive. Mild improvement was achieved with low dose prednisolone. Her malignancy is suspected to be of peritoneum or fallopian tube in origin. Therefore, her symptoms are likely to be consistent with palmar fasciitis and polyarthritis of ovarian malignancy; a paraneoplastic syndrome. She has recently undergone neoadjuvant chemotherapy prior to surgery and we hope that some of her symptoms will improve after treatment.