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On evaluation with scintigraphy and SPECT-CT, he was diagnosed to have incomplete form of PHOA(skeletal manifestations without skin changes) . Vascular endothelial growth factors which have been implicated in the clinical features of pachydermoperiostosis, have also been shown to be present in Chronic hepatitis and implicated in the Malignant transformation of hepatitis b infection to hepatocellular Carcinoma . To the best of our knowledge there is one reported case of pachydermoperiostosis with Chronic hepatitis b infection . It is the primary form of Hypertrophic osteoarthropathy (HOA) and there are some rare associations of PDP with other disorders . PDP was suspected and endocrinological and radiological studies were conducted for the evaluation of underlying disease .
The initial study should be Chest x-ray, but if results are negative and suspicion remains, the clinician should obtain a computed tomography scan with contrast . SLCO2A1 is also a causal gene of primary Hypertrophic osteoarthropathy (PHO) . Genetic studies have identified the impaired PGE2 metabolism as a culprit for Hypertrophic osteoarthropathy in PHO cases . Chest high resolution CT showed nonspecific interstitial pneumonia pattern in 1 case, and nonspecific interstitial pneumonia pattern with organizing pneumonia pattern in 4 cases . With this scenario he was diagnosed as primary hypertrophic osteoarthropathy (Pachydermoperiostosis) .
We highlight the importance of ruling out secondary forms of Hypertrophic osteoarthropathy and of a close follow-up of these patients because of complications that might develop on long-term . Based on two causative genes, hydroxyprostaglandin dehydrogenase (HPGD) and solute carrier organic anion transporter family member 2A1 (SLCO2A1), PHO is categorized into two subtypes: hypertrophic osteoarthropathy, primary, Autosomal recessive 1 (PHOAR1) and hypertrophic osteoarthropathy, primary, Autosomal recessive 2 (PHOAR2) . CT of the Chest showed a nonspecific interstitial pneumonia pattern distributed mainly in the lower lobes . The diagnosis of pachydermoperiostosis was confirmed by the detection of a homozygous Mutation in the HPGD gene . The second case concerned a 41-year-old male with Acral and cephalic pachydermia (cutis verticis gyrata), and palmoplantar Keratoderma .
There is a scarcity of cases in the literature related to acute Renal Failure secondary to infective Endocarditis treated with peritoneal dialysis . In this paper, the case of a 48-year-old Saudi male is reported, who presented with features suggestive of infective Endocarditis and who developed acute Kidney injury that was treated successfully with high tidal volume automated peritoneal dialysis . In addition, gastric Mucosa Hyperplasia was observed in all affected individuals and interleukin-6 (IL-6), Tumor Necrosis factor-alpha (TNFα) and receptor activator of nuclear factor kappa ligand (RANKL) expression were elevated in Hypertrophic gastric Mucosa . After three months, their arthralgia was partly relieved and IL-6, TNFα and RANKL expression were decreased in accordance with their relieved Hypertrophic gastric Mucosa . In the evaluation of patients with acromegaloid appearances, pachydermoperiostosis should be considered as a differential diagnosis .
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