Tripe Palms, Digital Clubbing and Jaccoud’s-type Arthropathy: A Quiz
Myriam Ben Hmida1, Ines Zaraa1*, Dalia Mrabet², Jouda Cherif3, Ines Chelly4, Mohamed Zitouna4, Majed Beji3, Slaheddine Sellami², Mourad Mokni1 and Amel Ben Osman1
Departments of 1Dermatology, 2Rheumatology, 3Pneumology, and 4Pathology, La Rabta Hospital, Jabbari, Bab Saadoun,Tunis 1007, Tunisia. *E-mail: email@example.com
A 49-year-old man presented to the rheumatologist with a 12-month history of progressive deformity of the hands associated with thickening of the skin of the palms. He had a 60 pack/year history of cigarette smoking. Physical examination revealed Jaccoud’s arthropathy (Fig. 1a), digital clubbing and hepatosplenomegaly. Cutaneous examination revealed focal hyperkeratosis of the palms, with a yellowish, verrucous appearance of the fingertips and accentuation of the normal ridges (Fig. 1b). The soles were not involved. No other cutaneous or mucous membrane signs were recorded. Complete blood counts were within normal limits, erythrocyte sedimentation rate was 40 mm/h, and the level of C-reactive protein was increased (80 mg/l).
Fig. 1. (a) Jaccoud’s-type arthropathy, digital clubbing and tripe palm. (b) Velvety change and pronounced dermatoglyphics, noted mostly at the fingertips.
What is your diagnosis? See next page for answer.
Tripe Palms, Digital Clubbing and Jaccoud’s-type Arthropathy: A Comment
Acta Derm Venereol 2011; 90: XX–XX (contd)
Diagnosis: Pachydermatoglyphy in an apparently cancer-free smoker
Tripe palms (pachydermatoglyphy) refers to an acquired palmoplantar keratoderma with enhancement of normal dermatoglyphics. It is frequently associated with neoplasia (1). Jaccoud’s arthropathy is a chronic progressive painless deformity of the hands and feet, which is occasionally paraneoplastic (2).
The term “tripe palms” was initially coined by Clarke in 1977 (3). Approximately 100 cases of this rare paraneoplastic dermatosis have been described. Of these, 90% were associated with cancer. Pulmonary and gastric neoplasms are the most common associations (1, 4). In our patient an extensive search for an underlying malignancy was negative. After one year of follow-up, and despite all these investigations, no neoplasia could be identified.
Only 12 patients in the medical literature have shown an association with various benign conditions (bullous pemphigoid, benign hepatic neoplasia and systemic mastocytosis) (5–8). The clinical appearance of idiopathic and malignant-associated tripe palms is similar. The changes are more prominent over pressure areas, e.g. thenar, hypothenar eminences and the fingertips, with thickened velvety palms and pronounced dermatoglyphics (1), as seen in our patient. Tripe palms are frequently seen in conjunction with acanthosis nigricans (77% of cases) or Leser-Trélat sign (10%); although representing distinct conditions these 3 diseases may be viewed as a continuum of epidermal responses to malignancy-associated factors, especially to the transforming growth factor-α (9). The association of tripe palms with Jaccoud’s arthropathy and digital clubbing is described here for the first time. Jaccoud’s arthropathy is a chronic, relatively painless, non-erosive, but deforming, arthropathy predominantly affecting the hand joints. It occurs most frequently in patients with systemic lupus erythematosus, and has also been reported as paraneoplastic rheumatic syndromes (10). In the literature we found only two cases of tripe palms associated with rheumatological signs, represented by paraneoplastic arthritis (4); both were associated with underlying malignancy. Clubbing of the digits, as observed in our patient, was noted in 14% of the patients with malignancy-associated tripe palms (1). The onset of tripe palms preceded malignancy in more than 40% of cases, and followed malignancy in 19% (1, 3). Our patient will be observed for signs of developing malignancy.