Your Observations About the Man With the Tripod Sign

Editor's note: In his recent "What's Your Diagnosis?" column (CONSULTANT, April 15, 2007, page 485), Dr Henry Schneiderman invited readers to examine the photograph (shown here) of a man with severe obstructive airways disease and psoriasis and offer additional observations. These follow, as well as Dr Schneiderman's response.

I also wonder about:

• Iatrogenic Cushing syndrome (truncal obesity, muscle atrophy seen in left arm) from corticosteroid treatment of his chronic obstructive pulmonary disease (COPD) and psoriasis.
• Depression. A clue would be the attempt to dye his hair from gray to black. Depression could stem from his chronic illness/condition (a previously "wild and free" person—indicated by his tattoo—who now is "married to an O₂ bottle"), or the depression could be caused or exacerbated by corticosteroid use.

---- Jerold Fadem, MD

One striking finding not commented on is the unusual distribution of muscle mass. The pectoralis muscle group appears highly developed, while the biceps seem almost nonexistent. Moreover, the dorsal scapular muscles (supraspinatus, teres minor, and infraspinatus) appear uncommonly weak as do the trapezius muscles. Further there is a prominent kyphotic curvature that does not suggest degenerative joint disease of the vertebrae but muscle weakness of the back muscles. In short, this is a classic picture of lipodystrophy.

The muscle wasting is accompanied by maldistribution of fat. In this case, the excess fat is deposited over the thoracic spine and a less than expected amount of fat resides in the arms and torso. This patient appears to have visceral rather than superficial fat deposition. This also is consistent with lipodystrophy.

Finally, the displacement of the scapula laterally and the underlying muscle weakness, particularly the serratus anterior and the trapezius, suggest this patient has a winged scapula; however, the angle of the photograph precludes definitive diagnosis.

---- Michael Soles, MD

I can see what appears to be supra-clavicular retraction that would indicate respiratory distress.

---- Brad Gurley, MD

I noted the anterior-posterior (AP) dimension of the chest, slight thoracic kyphosis, hypertrophy of the accessory muscles of respiration, and maybe pursed lips.

---- Bruce Coan, MD

I wondered if the tattoo could have transmitted hepatitis B, which can cause a vasculitis, although the patient could have contracted HIV later and have a psoriatic rash. It is possible that the lesions are from antiretrovirals used to treat HIV infection. The respiratory distress could be a combination of cardiomyopathy that is seen in HIV infection, and certainly this could be right- and left-sided heart failure. The depigmentation could be a result of treatment for HIV.

---- Gulshan Harjee, MD

The patient appears to be rather barrel-chested, although this is a little hard to appreciate from one lateral photo. This finding is further suggestive of emphysema/COPD.

---- Krystian Bigosinski, MD

m I would like to suggest that there is a xanthelasma under the left eye, possibly signifying an underlying lipid disorder, which would add an underlying cardiac risk to his pulmonary disorder. In addition, there seems to be a photographic suggestion of biceps-triceps/shoulder girdle muscular atrophy, possibly from corticosteroids, which would be a commonly and repeatedly used drug for his COPD. Nonetheless, the forearm muscles seem to have retained their shapes, especially around the medial and lateral epicondyles, suggesting that this man was a laborer/worker and not a professional. And although one cannot be certain, due to the limited photographic perspective, the right forearm does appear to be larger, making him right-handed (a higher probability given his age). His ethnic facial features identify him as being probably southern European in ancestry (eg, Italian, Spanish, Cuban, etc), which likely would make him a Catholic--an important consideration given the intrinsic family dynamics of the cultures as well as a potential social service need to notify a priest.

Oh, and lastly, he prefers boxers to briefs.

---- Calvin J. Maestro, Jr, MD, MBA

The patient also exhibits increased AP diameter of the chest (so-called barrel chest), which is another classic finding of COPD.

I always enjoy the column. Keep up the good work.

---- Anthony Hartzler, MD

There is evidence of significant atrophy of the shoulder muscle groups, particularly the supraspinatus, deltoid, and subscapularis. I wonder if this reflects a myopathy induced by use of corticosteroids for the lung disease. If not, one might screen for hyperadrenalism.

---- M. Swartz, MD

With his tattoo, is this an old sailor? Did he work with, or around, asbestos? This would, of course, open another whole can of thoughts, including paraneoplasia.

---- S. M. Klein, MD

His arm muscles look atrophic when compared to the "bulkiness" of the rest of his body. His breast appears enlarged, so I suspect gynecomastia and skeletal muscle atrophy from prostate cancer treatment. And he is certainly wearing a wig.

---- Nancy White, CRNP

He appears to have an increased AP diameter, the "barrel chest" also consistent with COPD, as is the apparent muscle wasting of his left arm (could also be due to aortic stenosis or perhaps cancer from that sarcoma masquerading as a lipoma!). Finally, he looks Italian to my half-Italian eyes. Not too many relevant associations in my mind: thalassemias, GP6D deficiency.

Love your columns and always look forward to reading them.

---- Marietta Angelotti, MD

The patient has either a barrel-chest deformity or a cushingoid habitus with central obesity and wasting of his peripheral extremities. Both of these findings support the diagnosis of severe obstructive airways disease and also raise the possibility of long-term treatment with corticosteroids for that disease.

---- Karen Hook, MD

I am struck by the cushingoid appearance of the patient, with acral atrophy, buffalo hump, and hyperpigmentation. He may have been treated with corticosteroids, of course, but he may also have been a heavy smoker, with a high risk of bronchogenic carcinoma and a possible paraneoplastic syndrome. Therefore, a chest film and serum cortisol studies and ionized calcium might be appropriate. The erythroderma is not a bronze hyperpigmentation, but hypoadrenalism would also be found by the above laboratory studies.

---- Herbert Hoffman, MD

Dr Schneiderman wrote, "Because this tattoo was acquired in the 1950s, HIV is out of the question—unless contracted in the interval." I was wondering if he is suggesting that there was no HIV before the 1950s? My understanding is that the incidence has increased, but it certainly did exist before 1950.

---- Barry Marged, DO, MA

First, I thank you deeply for the number and seriousness of the responses to our invitation to send in further inferences drawn from the image of the man with the tripod sign.¹ It was also deeply gratifying that several readers remarked on enjoying the columns each month.

I am delighted to suspect that somebody might be pulling my leg, for instance in claiming that teres minor can be assessed, and visually, by a non-orthopedist, and from a single image. Any caricature is most welcome. Humor improves and leavens our days, and in 2007 that is a pressing need for every health care worker. An augmentation of learning also occurs when one feels free to puncture the balloons of the instructor's foibles—in my case, inferring endlessly from the photographic images that are presented. I savor making every legitimate deduction from an image, but there is an ever-present danger of overdoing it—what we used to call "deducing the Social Security number from the arterial blood gasses." Having surely overinterpreted at times, I gladly accept parody.

In writing about so many visible physical signs, I have become profoundly aware that photographic images can mislead and misrepresent; when they do, one can start down a long spiral of misinterpretation and diagnostic-therapeutic error. The best preventative, of course, is to see the patient in person: one immediately gains a fuller and sounder sense of the case based on thousands of instantaneous impressions, and on the modulation of posture and facial expression over time—even if only over a few seconds—and on the context of the patient's gestalt. I would not want any reader to come away from this note feeling that only my own flights of inference are credited—that recalls the image of a child with the only basketball in the schoolyard who says, "We will play by my crazy rules or not at all."

So, what do I make of the particulars? First, a confession: I took this photograph 24 years ago, when I was a Chief Medical Resident at the University of Connecticut Health Center. I have never been the patient's primary care physician and have not seen him or obtained follow-up in the interval. So of necessity, my knowledge base is profoundly incomplete and out-of-date. Within those limits, and having studied the image again repeatedly and at length:

This man's arms do look very skinny compared to his trunk; iatrogenic Cushing syndrome is a most tenable diagnosis. Having acknowledged this, I would add that his posture, the angle of the camera (above and to the left), the hyperinflation of his chest, and even the bump of the lipoma combine to make the trunk look larger than it did in person, so that the disproportion was not as striking as it seems here. The comments about shoulder girdle versus elbow musculature, and size of the right forearm overestimate what can be drawn from this image, though as I stare at it again, the whole left arm from the shoulder down seems small. The right forearm might have edema from the psoriasis, or might be better exercised whether simply from right hand dominance, or for other cause.

From my perspective, the diagnosis of lipodystrophy is an over-diagnosis. I can't concur that the trapezius looks weak—the back of the neck is one of the fuller areas, and in any case, functional testing (manual muscle testing) would provide fuller and clearer assessment. I like the observations about the scapula's looking winged here—it surely does appear displaced laterally, though it is not sticking out from the chest wall with his arm in this position.^2,3 At bedside this man did not have a winged scapula, but the image absolutely does hint at it, and this is a great pickup by Dr Soles. The additional thoughts on selective atrophy of the left arm are intriguing; for what it is worth, his chest radiograph was negative for a primary cancer and for metastases—which also helps with the queries about a lung cancer and a paraneoplastic (as distinct from an iatrogenic) Cushing syndrome—and he had no features of brachial plexopathy or mononeuropathy affecting this limb.

Concerning his respiratory problems, while supraclavicular retraction would fit the overall picture, I believe that seeing it here, in the necessarily static visual image, constitutes a bit of the "eye of faith" whereby we are all quick to "perceive" what feels like primary sensory data in support of a conclusion that we have already reached. Hypertrophy of accessory muscles of respiration is possible, but I cannot read it from the image. He does give the impression of pursed-lip breathing, something I don't recall noticing in person—which could mean that the image misleads, or more attractively, that I did not have the prepared eye at that time, and my deficit has been made up by a very attentive and perceptive reader.

Regarding anterior-posterior dimension of the chest in chronic obstructive pulmonary disease, I believe Sapira's superb textbook⁴ makes the case against this as a sign, hallowed though it is, yet one certainly gets the sense here that there is not only global chest hyperexpansion, but also selective elongation in the anteroposterior dimension. I believe the readers who diagnosed kyphosis reacted to the hyperinflation that pushes the chest outward-backward, without a selective excess of the physiologic dorsal kyphosis, ie, without undue angulation. We rightly dread corticosteroid-accelerated osteoporosis, whose kyphosis adds a further element of restrictive lung disease from chest cage deformity to the underlying chronic obstructive pulmonary disease problems. To my eye—and again with the advantage of having seen him in person—the thoracic curvature is normal, the physiologic lumbar lordosis is underdeveloped, and the camera angle has not served us well to say anything more.

The dyspnea was all related to his chronic obstructive pulmonary disease, with no element of congestive heart failure.

I don't know if he had worked as a sailor; the related thought of asbestosis is always a worthwhile one; and the need to take an occupational history continues to be key.

Gynecomastia was not present; note that another reader took the prominence of the anterior chest as evidence of pectoral muscle hypertrophy, with which I also cannot agree. His skinny arm muscles can make one underestimate his fleshiness, and for an overweight man at this age, visible and palpable elevation of the breast disc of fat is standard. (I hope that in now arguing "more fleshy" after "less fleshy," I am not replicating the famous fable of Aesop, in which the same man blows on his hands to warm them, then on his porridge to cool it, whereupon the daimon that has saved him abandons him saying, "Out you go. I will have nought to do with a man who can blow hot and cold with the same breath."⁵)

The notion of depression is very sound. Truly, I think this is inferred from the history rather than from his facies (although I agree that there is a face of depression and have written one of the earlier columns about it).⁶

Regarding one of the signs of Cushing syndrome, the supraclavicular fossa is fuller than usual, but this too is exaggerated by posture: the pushed-up shoulder from his leaning on it obscures what concavity there is at the supraclavicular fossa.

I believe that hepatocellular integrity enzyme tests (aspartate aminotransferase and alanine aminotransferase), alkaline phosphatase, and bilirubin were all normal—if I recall correctly, these were monitored especially closely because of concerns about methotrexate( safety, since the clinicians were considering starting it for him. He had no clinical history nor current evidence of hepatitis B or C; those antibody panels were not tested as routinely in those days as today; nor of other hepatopathy. He was not tested for HIV in 1983: that was just before reliable tests were available. Clinically, there was nothing in the history, the examination, or the laboratory studies (such as lymphopenia) to suggest exposure to retrovirus or infection with it. While I am not a scholar of the history of this epidemic, my understanding is that the first clearly retrospectively diagnosed American case occurred in 1969, so the inference about the timing of the tattoo should be safe.

His psoriasis was idiopathic and not caused or accelerated by retroviral disease or treatment for same. Dr Hoffman's comments about bronze versus the red of his psoriasis remind us of some other valuable diagnostic considerations. I don't believe he had a cortisol level drawn; the therapeutic corticosteroid usage would, of course, make the interpretation of laboratory findings more challenging.

This man actually has no areas of cutaneous depigmentation: rather, those that look too light either have some scale and camera-flash highlight, as on the left elbow, or are spotty areas relatively spared the red remnants of psoriatic lesions, for example, on the thorax just posterior to the left upper arm. Compare the butterfly sign in chronic pruritus⁷ for a precedent in causing confusion deciding what is the lesion versus what is the background.

The bump just below the left eye was sebaceous hyperplasia, but I commend the thought of xanthelasma even though its predictive value at this age is scant.⁸

He does look Mediterranean, but there are so many exceptions to origin versus expectation that I think we must rely on what we are told, not what we see: ethnicity is so peculiar, and so immensely subject to the culture of one's childhood environs rather than one's genetic heritage.