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1mediterranean journal
of RHEUMATOLOGY
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2023
©2023 The Author(s).
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CLINICAL IMAGE
Striatal Hand Deformity in Parkinson's Disease Mimicking Rheumatoid Arthritis
Debashis Maikap, Prakashini MV, Prasanta Padhan
Department of Clinical Immunology and Rheumatology, Kalinga Institute of Medical Sciences, KIIT University, Bhubaneswar, Odisha, India
Mediterr J Rheumatol 2023;34(3):396-7 https://doi.org/10.31138/mjr.20230804.sh
Article Submitted: 5 Dec 2022; Revised Form: 10 Jan 2023; Article Accepted: 15 Jan 2023; Available Online: 4 Aug 2023
Keywords: parkinsonism, rheumatoid arthritis, arthritis, deformity
CLINICAL IMAGE
A 65-year-old male presented with complaints of painless deformity of right hand followed by left hand for 6 months. He also had pill rolling tremor of right hand with dystonia. He had mask-like face, bradykinesia, cogwheel rigidity seen in both upper limbs, more marked on right side. Secondary causes of parkinsonism such as drugs, trauma, and toxins were excluded. On examination, he had flexion and ulnar deviation at the metacarpophalangeal joint (MCP) joint, correctable Z-deformity of thumb on left hand; flexion of the MCP, and distal interphalange-al joints and medialization of thumb (U shaped - "monkey-wrench sign") at right hand (Figure 1). Investigation revealed normal erythrocyte sedimentation rate, C-reac-tive protein. Serology for autoimmune diseases such as antinuclear antibody, rheumatoid factor and anti-cyclic citrullinated peptide antibodies were negative. Magnetic resonance imaging of brain was normal. X-ray and mus-culoskeletal ultrasound of both hands did not show features of inflammatory arthritis.
DISCUSSION
The term 'striatal hand' is originally used by Charcot,1
seen in Parkinson's disease (PD) even in early stage and other atypical parkinsonian syndromes. The term "striatal deformity" suggests that the abnormal postures of the hand, foot, or spine are related to pathology in the part of basal
Figure 1. Flexion and ulnar deviation at the MCP joint, correctable Z-deformity of thumb on left hand and flexion of the metacarpophalangeal joint and distal interphalangeal joints and medialisation of thumb (U shaped - "monkey-wrench sign") at right hand.
ganglia known as striatum (caudate and putamen) that is frequently associated with various parkinsonian syndromes. The exact pathogenesis is unknown. The pathophysiological origins of striatal deformity appear to be complex and include cortical, and basal ganglia and spinal mechanisms.2
Striatal deformities are often misdiagnosed as rheumatoid arthritis, osteoarthritis, Jaccoud's arthropathy, psoriatic arthritis, Dupuytren's contracture, and trigger finger because they closely mimic common rheumatologic dis-orders.3,4
Corresponding Author:
Prasanta Padhan Professor, Department of Clinical Immunology and Rheumatology Kalinga Institute of Medical Sciences, KIIT University
Bhubaneswar, Odisha, India, PIN: 751024 E-mail: prasantapadhan@gmail.com Tel.: +91-9778940630
396 Cite this article as: Maikap D, Prakashini MV, Padhan P. Striatal Hand Deformity in Parkinson's Disease Mimicking Rheumatoid Arthritis. Mediterr J Rheumatol 2023;34(3):396-7.
STRIATAL HANDIN RHEUMATOID ARTHRITIS
In rheumatoid arthritis, the deformities usually involve both hands symmetrically with radiological signs of joint involvement, whereas in striatal hand the deformities are usually unilateral at onset, worse on the side of the PD onset, and on the side with greater PD symptoms and with normal radiological findings.4 Levodopa, antiparkinsonian drug along with joint stretching and range-of-motion exercises, are advised for striatal deformity.5 This case highlights that physicians must be conversant with striatal deformities in order to avoid misdiagnosis and order unnecessary investigations and to suggest the most appropriate treatment.
FUNDING
No specific funding was received from any funding bodies in the public, commercial or not-for-profit sectors to carry out the work described in this manuscript.
CONFLICT OF INTEREST
The authors have declared no conflicts of interest.
INFORMED CONSENT
Written informed consent for publication was obtained from the patient.
REFERENCES
1. Charcot JM. Lectures on the diseases of the nervous system, lecture V. London: New Sydenham Society, 1877: 140-47
2. Rodriguez-Oroz MC, Jahanshahi M, Krack P, Litvan I, Macias R, Bezard E, et al. Initial clinical manifestations of Parkinson's disease: features and pathophysiological mechanisms. Lancet Neurol 2009 Dec 1; 8(12):1128-39.
3. Padhan P, Danda D. Parkinsonism mimicking rheumatoid arthritis. J Rheumatol 2010 Jun 1; 37(6):1266.
4. Spagnolo F, Fichera M, Bucello S, Houdayer E, Baroncini D, Sarro L, et al. Striatal hand in Parkinson's disease: the re-evaluation of an old clinical sign. J Neurol 2014 Jan; 261(1):117-20.
5. Wijemanne S, Jankovic J. Hand, foot, and spine deformities in parkinsonian disorders. J Neural Transm 2019 Mar; 126(3):253-64.
