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\begin{document}

\title{Case report: Schizophrenia and hypertrophic osteoarthropathy, a rare
syndrome hiding a life-threatening condition}



\author[1]{emna Baklouti}%
\author[1]{Mehdi  Karoui}%
\author[1]{rania  kammoun}%
\author[1]{Faten Ellouze}%
\affil[1]{Razi Hospital}%


\vspace{-1em}



  
  \date{May 08, 2024}


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\selectlanguage{english}
\begin{abstract}
Schizophrenia is associated to somatic disorders especially
cardio-vascular and auto-immune. Through this case report, we describe
an association with hypertrophic osteoarthropathy (HPO). For this
patient it was a paraneoplastic paraneoplastic syndrome secondary to
lung cancer. This syndrome is rare but important to recognize since it
could hide a life-threatening condition.%
\end{abstract}%



\sloppy


\textbf{Case report: Schizophrenia and hypertrophic osteoarthropathy, a
rare syndrome hiding a life-threatening condition}

\textbf{ABSTRACT}

Schizophrenia is associated to somatic disorders especially
cardio-vascular and auto-immune. Through this case report, we describe
an association with hypertrophic osteoarthropathy (HPO). For this
patient it was a paraneoplastic paraneoplastic syndrome secondary to
lung cancer. This syndrome is rare but important to recognize since it
could hide a life-threatening condition.

\textbf{KEY CLINICAL MESSAGE}

Schizophrenia is associated to somatic diseases. We describe an
association with hypertrophic osteoarthropathy (HPO). It is a rare
clinical entity but it could be a paraneoplastic syndrome hiding a
life-threatening condition.

\textbf{INTROODUCTION}

Hypertrophic osteoarthropathy (HPO) is a rare syndrome that can be
idiopathic or secondary to an infection, an inflammation or a
malingering cause mainly affecting intrathoracic organs.

Clinically its more prominent symptom is finger clubbing, other symptoms
can be seen such as tenderness in the palpation of tubular bones or
periosteal proliferation (1).

As a psychiatrist, it would be important to recognize this clinical
entity, because on one hand patients with schizophrenia can have
difficulties expressing their physical grievances (2) and on the other
hand as rare as this condition is it can hide a serious underlying
disease. This would be illustrated in this case report.

\textbf{PATIENT AND OBSERVATION}

HB, a 46-year-old male, married father of 3 children, and electrician.
He was diagnosed with schizophrenia in the same year. He was put on
long-acting injections (LAI).

He is a smoker with 52 packs-year, he doesn't use alcohol or other
psycho-active substances.

The patient reported pain in the hands and knees that he had for 6
months and a swelling in the same joints since a month.

\emph{The main} functional signs were; weight loss, anorexia, asthenia
and myalgia. Clinical signs consisted of swelling in both hands,
tenderness in the palpation of the right knee and the 2 legs. The
diagnosis of HPO was made by the presence of polyarthritis and finger
cubbing. Further examinations were performed to identify the underlying
cause of HPO. Routine blood tests were performed objectifying
hypocholesterolemia, hypertriglyceridemia, anemia and hypoalbuminemia.

Radiographies of the hands, knees, legs and pelvis had no anomalies.
radiographies of arms objectified osteolytic images in both humeri.

A fiberoptic endoscopy was performed with no abnormalities.

A PET-scan was performed objectifying a mediastinal tumor of 8 cm

A biopsy of the tumor objectified a lung squamous cell carcinoma staged
T4N3M1c.

The patient is going to start chemotherapy but his prognosis is bad
given that the cancer is at an advanced stage.

\textbf{DISCUSSION}

HPO is an orphan syndrome (1). It can be divided to primary HPO;
pachydermoperiostosis, mainly seen in children or young adults, with a
genetic predisposition (3) and secondary HPO that is seen in 97\% of the
cases. It is mainly due to a pulmonary affection in that case called
``hypertrophic pulmonary osteoarthropathy'' (HPOA) (3) but also it could
be secondary to a cardiac, gastric, hepatobiliary or miscellaneous
cause.

The main clinical features of the syndrome are finger and toe cubbing.
We can also see skin hypertrophy that may give coarse facial features or
swelling at the ankles. A thickening of tubular bones had been described
and it might be more noticeable in the extremities such as ankles and
wrists. Periosteal effusion may also happen causing tenderness in
palpation of concerned areas. In the particular case of lung cancer,
patients may experience burning sensation of the fingertips and bone
pain (1)

A case of HPO was described in a homeless patient with schizophrenia; it
was secondary to an infectious endocarditis (4). For of our patient,
HPOA was a paraneoplastic syndrome secondary to a pulmonary neoplasm.

Several studies have looked at the frequency of lung cancer in
schizophrenic patients. we found a review of literature that concluded
to a certain resistance of patients with schizophrenia towards cancer
(5) compared to the general population. Another study conducted on
patients with schizophrenia and their relatives found higher incidences
of cancer in the patients compared to their relatives (6). The most
frequent cancer in schizophrenia was lung cancer for men and breast
cancer for women (6), but studies had controversial results when
comparing the incidence of lung cancer in schizophrenia patients
compared to the general population. But once the diagnosis is made,
patients with schizophrenia have poorer survival rates (7) more than
twice the risk of mortality (8).

This emphasizes how important is the screening of schizophrenic patients
at risk of lung cancer (8) especially that the first risk factor of lung
cancer is smoking (9). Tobacco consumption has been documented in
schizophrenia. The patients smoke both more frequently and bigger
quantities of cigarettes, throughout all the stages starting from first
episode psychosis (FEP) to chronic disease (10). Many hypotheses tried
to find explanation to this phenomenon; smoking is thought to have a
good impact on negative symptoms, to have sedative effect or to deal
with extrapyramidal symptoms (10). A genetic study even identified a
shared loci between lung cancer and smoking (11). This should encourage
clinicians to use different available methods to reduce or stop smoking
(12) (13)

\textbf{CONCLUSION}

HPO is a rare syndrome that could be idiopathic or secondary to
inflammatory, infectious or neoplastic cause. In this case HPO was a
paraneoplastic syndrome that revealed lung cancer. Clinicians should pay
close attention to physical complaints in schizophrenia because this
population is vulnerable to some somatic affections. Patients with
schizophrenia should be screened for lung cancer as soon as risk factors
are identified.

The major risk factor for lung cancer is tobacco consumption. In this
population the consumption is more important and more frequent. So, they
should imperatively be addressed to programs to quit smoking. For now,
we have anti-tobacco strategies that are addressed to the general
population. It would be more interesting and perhaps more effective to
elaborate strategies adapted to patients with schizophrenia.

1. Mart\selectlanguage{ngerman}ínez-Lavín M. Hypertrophic osteoarthropathy. Best Pract Res Clin
Rheumatol. 1 juin 2020;34(3):101507.

2. Bonnot O, Anderson GM, Cohen D, Willer JC, Tordjman S. Are patients
with schizophrenia insensitive to pain? A reconsideration of the
question. Clin J Pain. avr 2009;25(3):244\selectlanguage{english}-52.

3. Chakraborty RK, Sharma S. Secondary Hypertrophic Osteoarthropathy.
In: StatPearls {[}Internet{]}. Treasure Island (FL): StatPearls
Publishing; 2021 {[}cite 27 juin 2021{]}. Disponible sur:
http://www.ncbi.nlm.nih.gov/books/NBK513342/

4. Case records of the Massachusetts General Hospital. Weekly
clinicopathological exercises. Case 2-1997. A 38-year-old man with
digital clubbing, low-grade fever, and a murmur. N Engl J Med. 16 janv
1997;336(3):205\selectlanguage{english}-10.

5. Catts VS, Catts SV, O'Toole BI, Frost ADJ. Cancer incidence in
patients with schizophrenia and their first-degree relatives - a
meta-analysis. Acta Psychiatr Scand. mai 2008;117(5):323\selectlanguage{english}-36.

6. Lichtermann D, Ekelund J, Pukkala E, Tanskanen A, Lonnqvist J.
Incidence of cancer among persons with schizophrenia and their
relatives. Arch Gen Psychiatry. juin 2001;58(6):573\selectlanguage{english}-8.

7. Bradford DW, Goulet J, Hunt M, Cunningham NC, Hoff R. A Cohort Study
of Mortality in Individuals With and Without Schizophrenia After
Diagnosis of Lung Cancer. J Clin Psychiatry. dec 2016;77(12):e1626\selectlanguage{english}-30.

8. Fujiwara M, Inagaki M, Nakaya N, Fujimori M, Higuchi Y, Hayashibara
C, et al. Cancer screening participation in schizophrenic outpatients
and the influence of their functional disability on the screening rate:
A cross-sectional study in Japan. Psychiatry Clin Neurosci. dec
2017;71(12):813\selectlanguage{english}-25.

9. Warren GW, Cummings KM. Tobacco and lung cancer: risks, trends, and
outcomes in patients with cancer. Am Soc Clin Oncol Educ Book Am Soc
Clin Oncol Annu Meet. 2013;359\selectlanguage{english}-64.

10. Sagud M, Mihaljevic Peles A, Pivac N. Smoking in schizophrenia:
recent findings about an old problem. Curr Opin Psychiatry. sept
2019;32(5):402\selectlanguage{english}-8.

11. Zuber V, Jonsson EG, Frei O, Witoelar A, Thompson WK, Schork AJ, et
al. Identification of shared genetic variants between schizophrenia and
lung cancer. Sci Rep. 12 janv 2018;8(1):674.

12. Tsoi DT, Porwal M, Webster AC. Interventions for smoking cessation
and reduction in individuals with schizophrenia. Cochrane Database Syst
Rev. 28 fevr 2013;(2):CD007253.

13. Pearsall R, Smith DJ, Geddes JR. Pharmacological and behavioural
interventions to promote smoking cessation in adults with schizophrenia
and bipolar disorders: a systematic review and meta-analysis of
randomised trials. BMJ Open. 28 nov 2019;9(11):e027389.

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