Association of non-traumatic complex regional pain syndrome with adenocarcinoma lung on 99mTc-MDP bone scan
A 56-year-old male, smoker since last 30 years presented to the physician with complaints of cough and hemoptysis since 3 weeks. A chest radiograph showed a right lung upper zone mass with surrounding consolidation []. There was no bone destruction. Non-contrast computed tomography scan of the chest showed a homogeneous mass with lobulated margins and surrounding consolidation in the right upper lobe. There was no calcification or cavitation seen in the mass. Mass showed a broad area of contact with the anterior chest wall, superior vena cava, and right brachiocephalic vein. No rib destruction or brachial plexus involvement were noted. Mass was not extending in to the paravertebral location where the stellate ganglion is located. There was no significant mediastinal adenopathy or lung metastasis seen []. A tru-cut biopsy revealed adenocarcinoma lung. The patient was referred for a bone scan to rule out metastases. The Nuclear Medicine physician observed swelling and redness in the right hand of the patient. The patient underwent a three phase 99mTc-MDP bone scan with intravenous administration of 20 mCi (740 MBq) radiotracer. Flow and pool phase study revealed diffusely increased tracer activity in the right hand and elbow []. Whole body anterior and posterior views taken 3 h later showed no evidence of metastases but right wrist joint and hand showed diffusely increased juxta-articular uptake consistent with CRPS. Also noted was increased uptake along long bones of the lower limbs especially in the tibiae, consistent with hypertrophic osteoarthropathy (HPOA) []. A radiograph of bilateral hands showed juxta-articular osteopenia consistent with CRPS and there was increased soft-tissue shadow in the right hand suggestive of subcutaneous edema. There was also periosteal reaction seen in the distal radius and ulna suggestive of HPOA []. Seven days after the diagnosis on bone scan, the patient developed pain in the affected hand. He was prescribed NSAIDS for these symptoms which did not relieve his symptoms appreciably. The patient was referred to the pain clinic of our institution for further management in addition to his oncologic treatment.