Clinical case 1

Irene, a 36 years old Caucasian mother of two children presents to your clinic because of painful joints and fever. Her
joints became swollen and painful 2 weeks ago. Five weeks ago she underwent a dental procedure after which flu-like
symptoms arose. She was treated with antibiotics and an extensive local search for complications of the procedure was
negative.
The fever is spiking up to 40 degrees Celsius in the evening. She has lost 5 kg in weight. There are no eye symptoms or
symptoms of infection of either the gastrointestinal tract or the urogenital tract. She stopped smoking, rarely uses
alcohol and only uses paracetamol (acetaminophen).
The physical examination shows an obviously sick women. Length 164 cm weight 58 kg, BP 140/70 mmHg;
temperature 39.6 degrees Celsius. Pulse rate 96 /min; tachypneic. Heart, lungs, abdomen, skin and eyes were all
normal. There were signs of mild inflammation (stress pain, joint-line tenderness) of the left wrist, left knee (plus small
effusion) and right ankle, and painful restriction and anterior joint-line tenderness of the left shoulder. After specifically
inspecting the patient during fever in the evening a salmon-red like rash on the trunk was observed.
The laboratory tests revealed an ESR of 56 mm/1h; C-reactive protein 78 mg/l; leucocyte count 19.2 109/l; serum ferritin
concentration was 3200 g/l. creatine 57 mol/l; all minerals were normal. Endocrine tests including thyroid function
were normal. Urine analysis was normal.

1. Based upon the case description and the laboratory tests what is the best diagnosis?
a. Adult Still's Disease
False. The diagnostic clues in the case description are spiking fever of unknown origin, painful inflamed joints, the
typical rash, leucocytosis and a large increase in serum ferritin concentration. This might very well fit with the onset of
Adult Still's disease (ASD). Although serum ferritin concentrations above 1000 g/l in the rheumatological setting are
very suggestive of adult Still's disease we must realize that in oncology and haematology these concentration are
suggestive of malignancy.
b. Malignancy
False. The diagnostic clues in the case description are, spiking fever of unknown origin, painful inflamed joints, the
typical rash, leucocytosis and a large increase in serum ferritin concentration. This might very well fit the onset of any
malignancy. Although serum ferritin concentration above 1000 g/l in the oncological setting are very suggestive for a
malignancy of unknown origin we must realize that in rheumatology these concentration are suggestive for Adult Still's
disease. The diagnostic clue of painful inflamed joints is therefore crucial.
c. Infection
False. The diagnostic clues in the case description are, spiking fever of unknown origin, painful inflamed joints, the
typical rash, leucocytosis and a large increase in serum ferritin concentration. This does not fit an infectious disease very
well. However, rare infections like Whipple's disease, leptospirosis; Yersiniosis; Parvo virus B19 must be excluded. Of
course all common infections, including endocarditis, should be excluded because of the balance between the clinical
consequences of curable diseases. However, serum ferritin concentration above 1000 g/l in the rheumatological
setting are very suggestive of adult Still's disease.
d. None of the above answers
True. Although ASD is especially from the rheumatology point of views the likely answer oncological, haematological
and infectious aetiologies for the signs and symptoms need to be excluded. So, at this stage of the case, a diagnosis of
certainty may not be made.
After exclusion of infectious diseases as well as malignant conditions a clinical diagnosis of Adult Still's disease (ASD)
was made.
2. What primary treatment would you choose?

a. Corticosteroids
True. Corticosteroids are still the treatment of choice in ASD. In many patients remission can be induced and
corticosteroids can be tapered off gradually.
b. Methotrexate
False. Although methotrexate became the anchor treatment for rheumatoid arthritis, ASD cannot be merged into the
same disease concept. Corticosteroids are still the treatment of choice in ASD. In many patients remission can be
induced and corticosteroids can be tapered off gradually. Methotrexate will be used in that case if the patient is
dependent or resistant to corticosteroids.
c. anti-TNF
False. Although the impressive effectiveness of TNF blockers in rheumatoid arthritis and ankylosing spondylitis led to
their use in some cases of ASD the effects were disappointing. Therefore ASD, although clinically resembling TRAPPS
syndrome, seems to have another pathogenesis and is in need of other treatments. Still, corticosteroids are the
treatment of choice in ASD. In many patients remission can be induced and corticosteroids can be tapered off gradually.
d. Azathioprine
False. Although in many respects ASD resembles a systemic disease and azathioprine is frequently used in these
conditions, neither in systemic auto immune diseases nor in ASD is azathioprine the first choice of drug therapy.
e. IL-1 blockade
False. Although there are now few published series of patients suffering from ASD previously treated with steroids,
methotrexate and etanercept in whom IL-1 blockers or tocilizumab were very successful, the first choice remains
corticosteroids. In case of ASD with arthritis as the predominant symptoms, methotrexate will be chosen as the second
line therapy. If systemic disease is predominant, IL-1 or IL-6 blockers may be discuss as second line (before trying
methotrexate) or third line therapy (after trying methotrexate).
f. Il-6 blockade
False. Although there are now few published series of patients suffering from ASD previously treated with steroids,
methotrexate and etanercept in whom IL-1 blockers or tocilizumab were very successful, the first choice remains
corticosteroids. In case of ASD with arthritis as the predominant symptoms, methotrexate will be chosen as the second
line therapy. If systemic disease is predominant, IL-1 or IL-6 blockers may be discuss as second line (before trying
methotrexate) or third line therapy (after trying methotrexate).
Irene was treated with high dosages of prednisone and recovered completely. Within days clinical signs and symptoms
disappeared. Moreover, laboratory findings normalized. Prednisone could be tapered and eventually stopped after 6
months of treatment.
3. What is your advice after cessation of treatment and clinical remission?
a. Discharge; the patient is cured and not in need of medication
False. Although this patient can be instructed to contact you again when symptom of exacerbation occur, severity of
disease manifestations justify regular clinical follow up including screening for preclinical parameters like ESR,
C-reactive.
b. Follow the patient; exacerbations of ASD are not uncommon after a first remission.
True. After a first remission exacerbations of ASD are not uncommon. One-third of patients with ASD have a self-limiting
or monophasic (so will be cured after only one flare), one-third have intermittent or polycyclic systemic pattern and one
third a chronic articular pattern.
One year after the initial flare Irene again was admitted because of fever, fatigue and painful joints. There was no rash
and no signs of joint inflammation. After excluding other possible diagnoses, she was treated with prednisone. Her
symptoms improved and her fever lessened, but remission could not be achieved. Therefore, methotrexate (increasing
up to 25 mgs weekly) was added. Her symptoms and fever gradually decreased but methotrexate was badly tolerated.

After one year methotrexate was stopped on request by Irene. The objective parameters of disease activity were normal
but she complained of progressive pains, worse on usage, in her shoulders. On examination limited function and
anterior joint-line tenderness but no inflammatory signs were seen.
4. What would be your two most likely diagnosis?
a. Periarthritis humeroscapularis (PHS)
False. One should always consider the possibility of a non-related condition. Benign as well as malignant conditions can
appear in patients diagnosed with a chronic disease as well as in healthy people. Therefore a prevalent condition likes
PHS should be considered. Although joint inflammation was never pronounced in this patient, longstanding ASD is
known for its silent but impressive destruction of large joints.
b. Osteonecrosis
True. Irene was treated with high dose prednisone so osteonecrosis must be considered seriously. Although joint
inflammation was hardly ever noticed in this patient, longstanding ASD is known for its silent but impressive destruction
of large joints. Also her pain was not night-predominant and was worse on usage
c. ASD articular flare
False. Because her pains are mechanical and because there is no systemic symptoms and non inflammatory syndrome,
this response is not quite probable.
d. Inflammatory joint destruction
True. Indeed, longstanding ASD is associated with silent but impressive destruction of large joint. In contrast with
rheumatoid arthritis, joint destruction does not seem to be clearly associated with time integrated joint inflammation.
Conclusion :
X-ray (see picture) and MRI revealed a typical picture of arthropathy as seen in inflammatory conditions (i.e.
generalized joint space narrowing with no new bone response).
There were no signs of disease activity. Local and symptomatic therapy did not succeed in either controlling pain or
restoring of function. A total shoulder arthroplasty was performed with great success. In the meanwhile, methotrexate
was replaced by hydroxychloroquine and prednisone was tapered and stopped without signs of disease flare. The
overall course of this disease is shown in the figure below.

Clinical case 2
Paul is a 43 year old male, born in Indonesia. 20 years ago, following an episode of flu in February he suffered from
pains in his shoulders and upper arms and diminution in the quality of his sleep. He presented to the clinic in September
of that year because of the persistence of these rheumatic complaints.

1. Which action would you have taken at that point?

a. I would have reassured the patient. After all, post viral arthralgia is most common and can last up to one year.
False. No. Reassurance based on a limited history and physical examination is never right. Although viral infections
commonly include symptoms of pain and stiffness, rheumatic signs and symptoms in the majority of patients last for only
a few weeks. Rarely, especially in case of Parvo virus B19 or hepatitis C virus infection, arthritis may last months or
even years. In these patients more specific signs and symptoms of Parvo virus B19 infection (now called erythrovirus
B19) like the specific exanthema might be a diagnostic clue (see figure). Moreover, clinical evaluation especially
demonstration of antibodies against Parvo B19 helps to establish this diagnosis.
b. I would have completed a limited clinical history focusing on post viral arthritis as well as on polymyalgia rheumatica/
temporal arteritis.
False. No. Undertaking only a limited history and physical examination is hardly ever right. Focusing on post-viral

arthritis and polymyalgia rheumatica/temporal arteritis will limit your clinical awareness. Furthermore, this patient was
only 23 too young to have polymyalgia rheumatica or temporal arteritis. Start your history as a structured interview
guided by the patients complaints and answers and your medical knowledge. After completing the history a complete
physical examination should be performed with special emphasis on the likely diagnoses as suggested by the history.
c. I would have completed a full structured clinical history and a complete physical examination.
True. Starting a clinical examination is mandatory since rheumatic signs and symptoms in the majority of patients with
viral infections last for only a few weeks. Start your history as a structured interview guided by the patients complaints
and answers and your medical knowledge. After completing the history a complete physical examination should be
performed with special emphasis on the likely diagnoses as suggested by the history.
An extensive clinical history did not reveal additional information. Moreover, the complete physical examination was
unremarkable except for a discrete enlarged liver (2 fingers below the costal margin). However, blood tests showed an
C-reactive protein 79 mg/L but normal renal function, liver enzymes, protein spectrum, electrolytes and calcium.
Moreover urine analysis was normal. Antinuclear antibodies and rheumatoid factor were negative. The patient was
negative for HLA B27.
2. What three actions could you have taken?
a. I would have reassured the patient
False. we disagree! At this point reassurance would be very wrong. An ESR of 79 without explanation warrants an
extensive workup.
b. I would have ordered an hemogram
True. Malignant haematological disease (lymphoma and acute leukaemia) may be suspected in a such young patient.
Hemogram and blood smear studies are necessary.
c. I would have ordered a biopsy of the temporal artery
False. we disagree! In a 23 year old patient temporal arteritis is highly unlikely.
d. I would have ordered skeletal scintigraphy
False. we disagree! A skeletal scintigraphy is hardly ever diagnostic; however it is very sensitive for skeletal disease
except for primarily osteolytic conditions like plasmocytoma (Kahler's disease).
e. I would have ordered a chest X-ray
True. Of course a chest X-ray is mandatory. Lung cancer and tuberculosis are easily detected by radiography. Although
tuberculosis is rare in Western Europe, drug abuse, AIDS and migration have led to a revival of tuberculosis. In Eastern
Europe and in the South tuberculosis is still present and also increasing again.
f. I would have ordered a CT thorax and abdomen
True. In the case of a fever of unknown origin or elevated ESR of unknown origin either a lymphoma or a urothelial cell
carcinoma are common explanations. Moreover the liver was enlarged on physical examination. CT scan will be helpful
in the validation and explanation of this finding
Twenty years ago the workup only revealed a discrete increased scintigraphic activity of the sterno-clavicular joints. A
definite diagnosis could not be made. For many years the patient's symptoms were treated with either NSAIDs or
prednisone.
Twenty years later, at age 43, his general practitioner requested clinical admission because of fatigue, depression and
increased ESR. In the interval the patient survived by removal of a subdural hematoma during coumadin therapy due to
peripheral vascular disease. The clinical history revealed fatigue for 2 months, depression for 6 months weight loss of 20
kg and prostatism. He was using pravastatin, co-approved; low dose aspirin; esomeprazole and duloxetine. The
physical examination showed height 156 cm weight 59 kg; BP 138/81 mmHg; pulse 88/min; temperature 35.7 and signs
of dehydration. No other specific signs or symptoms were found.

Laboratory tests showed ESR 69 mmh; C-reactive protein 94 mg/l; serum creatinine 329 mol/l; potassium 4.4 mmol/l;
calcium 3.89 mmol/l; albumin 39 g/l
3. What are the first two steps to be taken in this patient with renal insufficiency and hypercalcaemia?
a. Start corticosteroids to treat hypercalcaemia. The renal function will improve after normalization of serum calcium.
False. Although corticosteroids are beneficial in hypercalcaemia, their mode of action is too slow to be effective in a
case of life threatening extreme hypercalcaemia.
b. Start calcitonin as the fist line therapy to treat hypercalcaemia. The renal function will improve after normalization of
serum calcium.
False. Although calcitonin may be beneficial in hypercalcaemia, It is used only as third line therapy after hydration and
bisphosphonate, and only for calcaemia>3.5mmol/L. Intravenous bisphosphonate associated with saline
hyperhydration is the drug of choice in case of extreme hypercalcaemia but it is contraindicated in case of severe
renal failure. Infusion could be started when creatinine will be decreased. If renal failure persists reduced dose and/or
slower infusion rate is needed. Bisphosphonate maximum effect occurs in two to four days. Calcitonin may be discussed
in that case.
c. Start hyper-hydration to treat hypercalcaemia. The renal function will improve after normalization of serum calcium.
True. This life threatening hypercalcaemia needs immediate action by hyper -hydration. However post renal obstruction
ought to be excluded first by urgent renal ultrasound investigation.
d. Perform an ultrasound of the kidney to exclude post renal obstruction. Thereafter start-hyper hydration to treat
hypercalcaemia.
True. You should exclude post renal obstruction first by immediate ultrasound, without delay hyper hydration should be
started.
e. Repeat the laboratory test for serum calcium concentration.
False. Hypercalcaemia of 3.89 mmol/l is extreme and an acute threat for life. Immediate action is required.
After exclusion of post-renal obstruction hyper-hydration and bisphosphonates infusions succeeded in controlling
hypercalcaemia and restoring renal function. Although malignancy was considered the most likely explanation for this
extreme hypercalcaemia, an extensive clinical workup excluded this cause. Furthermore, hyperparathyroidism and
ectopic PTH production were both excluded.
X-Ray as well as CT scan revealed some bilateral hilar and retroperitoneal lymph nodes. Moreover osteolytic lesions in
the femur and pelvis were found (see pictures).
4. Which diagnostic procedure would you next choose?
a. I would prefer a bone biopsy (go where the money is!)
False. If you still consider malignancy a bone biopsy would be indicated. However, as mentioned before an extensive
clinical workup made malignancy very unlikely. The diagnostic performance of a bone biopsy for sarcoidosis is limited.
The material is often necrotic and non-conclusive. A bronchoalveolar lavage is sensitive and specific for sarcoidosis
when radiological signs like lymphadenopathy etc are present.
b. I would prefer a bronchoscopy and a bronchoalveolar lavage
True. Bronchoscopy with systematic biopsies and broncho-alveolar-lavage in this case, where radiology revealed hilar
lymphadenopathy, has the highest diagnostic value. The broncho alveolar lavage revealed an increased lymphocyte
count as well as an increased CD4/CD8 ration.
c. I would prefer an MRI
False. we disagree! MRI has no additional diagnostic value in this clinical situation. A broncho-alveolar-lavage has the
highest diagnostic value is this typical case.
Conclusion : After fully twenty years the diagnosis of sarcoidosis was made. In these 20 years the patient had never had

pulmonary symptoms or signs. All previous chest x-rays were normal. Until the final admission serum calcium was
always normal.
The patient recovered rapidly following treatment with intermediate dosages of corticosteroids. ESR 46 mmh; c-reactive
protein below 10 mg/l; CBC normal; creatinine 162 mol/l; calcium 2,18 mmol; albumin 39 g/l
Clinical case 3
A 35 year old Caucasian male, born in Germany, complains of pain in both ankle joints and in both distal tibiae for the
past 6 months. The NSAID diclofenac relieves the pain. He also mentions episodic heart burn and a voluntary weight
loss of 7kg over the past 6 months. For 8 weeks he has noticed paronychial swelling of several phalanges. See pictures.
The physical examination shows:
- diffuse compression pain at both ankle joints
- slight bilateral enlargement (clubbing) of the distal phalanges II V
- no synovitis and no effusion of any joint

1. Which action would you have taken?

a. I would have reassured the patient because there are no signs of arthritis and benign enlargement of some phalanges
is quite common.
False. we disagree! Distal phalangeal enlargement is a common feature, but in some patients can be a hint to an
underlying disease for example hyperparathyroidism, macrodactyly, hypertrophic osteoarthropathy or pseudo clubbing
due to many causes such as systemic sclerosis.
b. I would have completed a limited clinical history focusing on symptoms of joint inflammation.
False. we disagree! A frequent mistake in rheumatology is to focus on the joints only a full patient assessment is
required.
c. I would have completed a full structured clinical history, a complete physical examination and FBC (Full blood count).
True. In a full rheumatological examination a structured clinical history, a full physical examination and appropriate blood
investigations should be obligatory.
The FBC reveals:
Sodium 135(136-145) l
Potassium 3,8(3,6-4,8)
Calcium 2,4(2,1-2,7)
Uric Acid 4,6(3,4-7,0)
Urea 13(17-43)
Creatinine 0,75(0,5 - 1,2)
Bilirubin0,5( Alk Phosph. 74 (50-160)
AST 775 (1-15)
ALT 473 (1-17)
GGT 100 (4-18)
Protein 72 (66-83)
Albumin 36 (35-55)
Amylasis 63( LDH 809 ( Glucose 104(70-110)
ESR 19/37 ( CRP 7 ( Hb 11 (13-16)
Mean corpuscupar volume 102 (80-100)
Leukocytes x103 2,4 (4-10)
Platelets. x103 52(150-400)

Quick test 82% (>70)

Appt 36 (28-40)
2. What would be your next action?
a. I would have reassured the patient, as his test results are not significant.
False. At this point reassurance would be wrong, as we do not have an explanation for the patient's symptoms nor for
his blood results.
b. I would have ordered a biopsy of the thickened distal phalangeal bone.
False. A biopsy of the lesion on the distal phalanges would probably not lead to a proper diagnosis and would be
unnecessary.
c. I would have ordered a chest X-ray, to search for a neoplasm, as these changes might represent a paraneoplastic
syndrome.
True. The proper next step is to search for an intrapulmonary neoplasm by chest X-ray.
d. None of the above.
False. This patient may have an intrapulmonary neoplasm and requires a chest x-ray
See Pictures. Result: no visible abnormality
3. The chest X-ray showed no visible abnormality, what would you do next?
a. Do an ultrasound of the ankles, to search for effusions and pathological joint changes.
False. An ultrasound of the ankles would fail to show abnormalities, as the symptoms are not directly along the joint but
the adjacent periosteal bone. Also no joint swelling was observed.
b. Do an X-ray of both ankle joints including both distal tibiae, as that is the focus of complaints during the last 6 months.
True. Radiographs of the ankles and distal tibiae showed bilateral periosteal proliferation at the tibia and fibula.
c. Discharge the patient, as a paraneoplastic aetiology was excluded.
False. A negative chest X-ray is not conclusive since a chest x-ray does not exclude existence of a pulmonary lesion.
d. None of the above.
False. An x-ray of both ankles and distal tibiae should be undertaken these showed the underlying cause of his
symptoms.
See ankle X-rays.
Based on the x-rays and the finger clubbing, the differential diagnosis is:
1.)Chronic arterial hypoxia, due to:
a.)Restrictive lung disease
b.)Obstructive lung disease
c.)Cyanotic heart disease
2.)Paraneoplasia (Marie-Bamberger syndrome)
a.)Bronchial or pleural neoplasms
b.)Oesophageal neoplasms
3.)Others
a.) Inflammatory bowel disease
b.) Thyroid- or liver disease
c.) Infections such as endocarditis, HIV or tuberculosis
4. Which of the following diagnostic procedures would you next choose?
a. Colonoscopy

False. Colonoscopy is quite invasive and so far not indicated, haemoglobin is low but macrocytic and we have no
abnormal stools.
b. Arterial gas analysis
True. Arterial gas analysis is fast, cheap and gives us good information about the pH, O2, CO2, lactate and bicarbonate
levels, but did yield normal values in this patient.
c. Echocardiography
False. Heart echocardiography is a good examination, but so far there is not any other sign of heart disease and the
patient is young without past history of vascular disease.
d. Bronchoscopy
False. Bronchoscopy is quite an invasive examination and so far we have no solid indication for a pulmonary process
e. Bone marrow aspiration or biopsy
True. Bone marrow aspiration (or biopsy in that case) is indicated since pancytopenia with macrocytic anaemia are
present. It may find bone marrow invasion by cancer cells and will eliminate an haematological malignancy even though
digital clubbing and periostitis as signs of hypertrophic osteoarthropathy are not classically associated with
haematological malignancies but solid tumours. Invasion with cancer cells are very likely in that case.
f. HIV testing
True. The blood tests and the clinical presentation does not point towards a HIV infection except leukopenia, but HIV
infection always has to be excluded in a young patient. Moreover malignancy are more frequent in HIV infected patients.
g. Tuberculosis testing
False. The patient displays no other symptoms suggesting infection with Mycobacterium tuberculosis, such as
lymphadenopathy, night sweats, fever, weight loss or cough.
Concerning the periostal proliferation seen in the X-rays, the differential diagnoses are:
1.) Inflammatory:
Enthesitis
2.) Infectious
Chronic osteomyelitis
3.) Malignant
Primary bone tumour
4.) Paraneoplastic
Hypertrophic Osteoarthropathy (Marie-Bamberger syndrome)
5. Which next examination would be the best, to guide the differential diagnosis?
a. Ultrasound examination of the bone
False. Ultrasound examination of the bone is not specific and does not help us to exclude any of the differentials
b. MRI or 18 FDG-PET/CT
True. MRI could be used to detect a primary bone tumour or osteomyelitis in the tibia. 18FDG-PET/CT is a very good
imaging method to search for a malignancy and would also cover a paraneoplastic origin of symptoms caused by a
malignancy distant from the painful bone region. In the patient significant tracer uptake was found in the distal
oesophagus.
c. 99m Technetium scintigraphy
False. 99m technetium scintigraphy, is an appropriate technique to depict bone changes, but may miss the detection of
a tumour.
d. Bone biopsy of the tibia

False. Bone biopsy of the tibia is invasive and dependent on positive imaging results.
e. Analysis of tumour markers in serum
False. Peripheral tumour markers in the blood are non-specific, expensive and of uncertain value in the diagnosis of a
tumour.
See pictures. F-FDG-PET-CT:
6. What investigation would you like to do next?
a. An MRI scan to validate the last result
False. We would not do further imaging as histological validation is needed.
b. An oesophago-gastroscopy
True. An oesophago-gastroscopy is the next logic examination because histological validation of the lesion can be done.
This showed an exophytic, ulcerating, growing oesophageal tumour reaching the cardia. Histological examination
revealed a low differentiated neuroendocrine carcinoma of the oesophagus.
c. A barium swallow
False. A barium swallow shows only disorders in peristalsis and stenosis, so it does not help us to identify the underlying
diagnosis.
d. None of the above - I would give a proton pump inhibitor, because the uptake is probably due to chronic oesophageal
reflux and I will perform a new 18F-FDG-PET-CT after 2 months of treatment.
False. Giving a PPI with for suspected chronic oesophageal reflux is not appropriate without validation of the suspected
malignancy in the distal oesophagus.
See pictures. Oesophago-Gastrocopy results:
7. What kind of treatment would you plan?
a. Radiation therapy as all oesophageal tumours are radiosensitive.
False. Oesophageal tumors are to a certain degree radiosensitive, but monotherapy is not curative.
b. Surgical resection of the distal oesophagus with a jejunal graft.
False. Surgical resection can be curative, but only in combination with neoadjuvant and adjuvant chemotherapy.
c. Installation of a PEG Catheter, neoadjuvant chemotherapy, followed by oesophagectomy with jejunal graft, and
subsequent adjuvant chemotherapy.
True. PEG Catheter, neoadjuvant chemotherapy, followed by oesophagectomy and jejunal graft as well as adjuvant
chemotherapy is the currently best medical standard.
d. Palliative treatment as all oesophageal tumours have a bad prognosis.
False. In general the prognosis of oesophageal cancer in quite poor, mostly because most patients present with
advanced disease. As such the five-year-survival is less than 5 %. However the individualized prognosis depends
largely upon the stage. In this patient it was an early stage and he is in clinical remission until now.
Conclusion :
Thus, the diagnosis in this patient is:
Hypertrophic Osteoarthropathy (Marie-Bamberger-Syndrome) due to an Oesophageal Cancer
The clinical triad of Hypertrophic Osteoarthropathy is:
Digital clubbing / "Hippocratic" Nails
Joint and/or Bone Pain
Proliferative Periostitis

It is a classic paraneoplastic syndrome with intrathoracic tumours and one of the oldest mentioned conditions in the
literature:
Hippocrates: the patient has fever and cough; the breathing is fast; the feet do swell; the nails seem bend; the
patient suffers, as if he would have pus in the lung