Clubbing
You don't need to be Editor-In-Chief to add or edit content to WikiDoc. You can begin to add to or edit text on this WikiDoc page by clicking on the edit button at the top of this page. Next enter or edit the information that you would like to appear here. Once you are done editing, scroll down and click the Save page button at the bottom of the page.
| Clubbing Classification and external resources | |
 | |
|---|---|
| Clubbing in the fingers of a 33-year old female with pulmonary hypertension. | |
| ICD-10 | R68.3 |
| ICD-9 | 781.5 |
|
WikiDoc Resources for Clubbing | |
|
Articles | |
|---|---|
|
Most recent articles on Clubbing | |
|
Media | |
|
Evidence Based Medicine | |
|
Clinical Trials | |
|
Ongoing Trials on Clubbing at Clinical Trials.gov Clinical Trials on Clubbing at Google
| |
|
Guidelines / Policies / Govt | |
|
US National Guidelines Clearinghouse on Clubbing
| |
|
Books | |
|
News | |
|
Commentary | |
|
Definitions | |
|
Patient Resources / Community | |
|
Directions to Hospitals Treating Clubbing Risk calculators and risk factors for Clubbing
| |
|
Healthcare Provider Resources | |
|
Causes & Risk Factors for Clubbing | |
|
Continuing Medical Education (CME) | |
|
International | |
|
| |
|
Business | |
|
Experimental / Informatics | |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Phone:617-632-7753
Associate Editor-In-Chief: John Fani Srour, M.D.
Please Take Over This Page and Apply to be Editor-In-Chief for this topic: There can be one or more than one Editor-In-Chief. You may also apply to be an Associate Editor-In-Chief of one of the subtopics below. Please mail us [2] to indicate your interest in serving either as an Editor-In-Chief of the entire topic or as an Associate Editor-In-Chief for a subtopic. Please be sure to attach your CV and or biographical sketch.
Overview
In medicine, clubbing, finger clubbing, or digital clubbing is a deformity of the fingers and fingernails that is associated with a number of diseases, mostly of the heart and lungs. Idiopathic clubbing can also occur. Hippocrates was probably the first to document clubbing as a sign of disease, and the phenomenon is therefore occasionally called Hippocratic fingers.
Epidemiology
The exact frequency of clubbing in the population is not known. A 2008 study found clubbing in 1% of all patients admitted to a department of internal medicine. Of these, 40% turned out to have significant underlying disease of various causes, while 60% had no medical problems on further investigations and remained well over the subsequent year.[1]
Pathophysiology
The exact cause for sporadic clubbing is unknown, and there are numerous theories as to its cause. Vasodilation (distended blood vessels), secretion of growth factors (such as platelet-derived growth factor and hepatocyte growth factor) from the lungs, and other mechanisms have been proposed. The discovery of disorders in the prostaglandin metabolism in primary osteo-arthropathy has led to suggestions that overproduction of PGE2 by other tissues may be the causative factor for clubbing.[2]
Diagnosis
Signs and symptoms
Clubbing develops in five steps:[3]
- Fluctuation and softening of the nail bed (increased ballotability)
- Loss of the normal <165° angle ("Lovibond angle") between the nailbed and the fold (cuticula)
- Increased convexity of the nail fold
- Thickening of the whole distal (end part of the) finger (resembling a drumstick)
- Shiny aspect and striation of the nail and skin
Schamroth's test or Schamroth's window test (originally demonstrated by South African cardiologist Dr Leo Schamroth on himself[4]) is a popular test for clubbing. When the distal phalanges (bones nearest the fingertips) of corresponding fingers of opposite hands are directly apposed (placed against each other back to back), a small diamond-shaped "window" is normally apparent between the nailbeds. If this window is obliterated, the test is positive and clubbing is present.
When clubbing is encountered in patients, doctors will seek to identify its cause. They usually accomplish this by obtaining a medical history— particular attention is paid to lung, heart, and gastrointestinal conditions —and conducting a clinical examination, which may disclose associated features relevant to a diagnosis. Additional studies such as a chest x-ray may also be performed.
 Clubbing of the fingernail. The red line shows the outline of a clubbed nail. |
Physical Examination
Extremities
Disease associations
Although many diseases are associated with clubbing (particularly lung diseases), the reports are fairly anecdotal. Prospective studies of patients presenting with clubbing have not yet been performed, and hence there is no conclusive evidence of these associations.
Isolated clubbing
Clubbing is associated with:
- Lung disease:
- Lung cancer, mainly large-cell (35% of all cases), not seen frequently in small cell lung cancer[6]
- Interstitial lung disease
- Tuberculosis
- Bronchiectasis
- Suppurative lung disease: lung abscess, empyema
- Cystic fibrosis
- Pulmonary hypertension
- Mesothelioma
- It is worth noting that clubbing is not associated with chronic obstructive pulmonary disease (COPD). Indeed, the presence of clubbing in a patient with COPD should prompt a search for an underlying (lung) cancer.
- Heart disease:
- Any disease featuring chronic hypoxia
- Congenital cyanotic heart disease (most common cardiac cause)
- Subacute bacterial endocarditis
- Atrial myxoma (benign tumor)
- Gastrointestinal and hepatobiliary:
- Malabsorption
- Crohn's disease and ulcerative colitis
- Cirrhosis, especially in primary biliary cirrhosis[7]
- Other liver diseases (in the "hepatopulmonary syndrome", a complication of cirrhosis)[8]
- Others:
- Hyperthyroidism (thyroid acropachy)[9]
- Familial and racial clubbing and "pseudoclubbing" (people of African descent often have what appears to be clubbing)
- Vascular anomalies of the affected arm such as an axillary artery aneurysm (in unilateral clubbing)
Clubbing associated with other symptoms
HPOA
A special form of clubbing is hypertrophic pulmonary osteo-arthropathy, known in continental Europe as Pierre Marie-Bamberger syndrome. (In dogs the condition is known as hypertrophic osteopathy.) This is the combination of clubbing and thickening of periosteum (connective tissue lining of the bones) and synovium (lining of joints), and is often initially diagnosed as arthritis. It is commonly associated with lung cancer.
Primary HOA
Primary hypertrophic osteo-arthropathy is HPOA without signs of pulmonary disease. This form has a hereditary component, although subtle cardiac abnormalties can occasionally be found. It is known in continental Europe as the Touraine-Solente-Golé syndrome. This condition has been linked to mutations in the gene on the fourth chromosome (4q33-q34)coding for the enzyme 15-hydroxyprostaglandin dehydrogenase (HPGD); this leads to decreased breakdown of prostaglandin E2 and elevated levels of this substance.[10]
Secondary HOA
It is usually associated with lung cancer, pulmonary infections, cystic fibrosis, right-to-left cardiac shunts, and less often in Hodgkin lymphoma and cirrhosis. Among patients with lung cancer, HOA is most frequently associated with adenocarcinoma and least frequently with small cell carcinoma [11] Rarely, arterial vascular prosthesis infections may be associated with HOA[12]. Clinical features suggestive of vascular infection-related HOA include clubbing or periosteal new bone formation in a single limb.
See also
- Periosteal reaction for more on HPOA and primary HOA
- clubbed thumb
Complete Differential Diagnosis of the Causes of Clubbing:
(In alphabetical order)
- Achalasia
- Arteriovenous malformations
- Arterial vascular prosthesis infections [12]
- Atrial myxoma
- Bronchial carcinomas[13]
- Bronchiectasis
- Cannabis [14]
- Celiac Sprue[15]
- Cerebrovascular insult
- Chronic obstructive jaundice
- Cirrhosis
- Cyanotic congenital heart disease[16]
- Tetralogy of Fallot
- Total anomalous venous return
- Transposition of the great vessels
- Tricuspid atresia
- Truncus arteriosus
- Cystic Fibrosis[17]
- Endocarditis[18]
- Empyema
- Hepatoma
- Hodgkin's lymphoma[19]
- Interstitial lung disease
- Liver tumors
- Lung abscess[20]
- Metastatic melanoma[21]
- Mesothelioma[22]
- Myelofibrosis[23]
- Nasopharyngeal carcinoma[24]
- Pachydermoperiostosis
- POEMS syndrome [polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes]: a rare paraneoplastic syndrome secondary to a plasma cell dyscrasia in which clubbing may be seen. Other findings including peripheral neuropathy, organomegaly, endocrinopathy, monoclonal plasma proliferative disorder, skin changes, sclerotic bone lesions, Castleman disease, thrombocytosis, papilledema, peripheral edema, pleural effusions, ascites, and white nails.
- Primary biliary cirrhosis[25]
- Pulmonic stenosis
- Pulmonary artery sarcoma[26]
- Pulmonary fibrosis
- Pulmonary metastases
- Right-to-left cardiac shunts
- Sarcoidosis of the lungs [27]
- Silicosis[28]
- Thyroid cancer
- Thyrotoxicosis
- Tuberculosis
- Ulcerative colitis
Vascular anomalies
Complete Differential Diagnosis of the Causes of Clubbing:
(By organ system)
| Cardiovascular | cyanotic congenital heart disease, right-to-left shunting, [[bacterial endocarditis, tetralogy of fallot, total anomalous venous return, transposition of the great vessels, tricuspid atresia, truncus arteriosus, arteriovenous malformations , arterial vascular prosthesis infections, atrial myxoma, pulmonic stenosis |
| Chemical / poisoning | cannabis, ]], lipoid pneumonia, |
| Dermatologic | No underlying causes |
| Drug Side Effect | cannabis |
| Ear Nose Throat | nasopharyngeal carcinoma |
| Endocrine | thyroid cancer, thyrotoxicosis |
| Environmental | mesothelioma, silicosis |
| Gastroenterologic | ulcerative colitis, crohn disease, primary biliary cirrhosis, cirrhosis of the liver, leiomyoma of the esophagus, achalasia, and peptic ulcer of the esophagus, celiac sprue, hepatoma |
| Genetic | cystic fibrosis |
| Hematologic | myelofibrosis< |
| Iatrogenic | cannabis |
| Infectious Disease | tuberculosis, empyema |
| Musculoskeletal / Ortho | No underlying causes |
| Neurologic | Cerebrovascular insult |
| Nutritional / Metabolic | No underlying causes |
| Obstetric/Gynecologic | No underlying causes |
| Oncologic | thyroid cancer, thymus cancer, hodgkin's disease, POEMS syndrome, metastatic melanoma, mesothelioma, nasopharyngeal carcinoma, myelofibrosis, atrial myxoma, |
| Opthalmologic | No underlying causes |
| Overdose / Toxicity | No underlying causes |
| Psychiatric | No underlying causes |
| Pulmonary | lung cancer, cystic fibrosis, interstitial lung disease, idiopathic pulmonary fibrosis, sarcoidosis,lipoid pneumonia, empyema, pleural mesothelioma, pulmonary artery sarcoma, cryptogenic fibrosing alveolitis, pulmonary metastases, bronchiectasis |
| Renal / Electrolyte | No underlying causes |
| Rheum / Immune / Allergy | No underlying causes |
| Sexual | No underlying causes |
| Trauma | No underlying causes |
| Urologic | No underlying causes |
| Miscellaneous | sarcoidosis |
References
- ↑ Vandemergel X, Renneboog B (July 2008). "Prevalence, aetiologies and significance of clubbing in a department of general internal medicine". Eur. J. Intern. Med. 19 (5): 325–9. doi:10.1016/j.ejim.2007.05.015. PMID 18549933.
- ↑ Uppal S, Diggle CP, Carr IM, et al (June 2008). "Mutations in 15-hydroxyprostaglandin dehydrogenase cause primary hypertrophic osteoarthropathy". Nat. Genet. 40 (6): 789–93. doi:10.1038/ng.153. PMID 18500342
- ↑ Myers KA, Farquhar DR (2001). "The rational clinical examination: does this patient have clubbing?". JAMA 286: 341–7. doi:10.1001/jama.286.3.341. PMID 11466101.
- ↑ Schamroth L (February 1976). "Personal experience". S. Afr. Med. J. 50 (9): 297–300. PMID 1265563.
- ↑ http://picasaweb.google.com/mcmumbi/USMLEIIImages
- ↑ Sridhar KS, Lobo CF, Altman RD. Digital clubbing and lung cancer. Chest 1998;114:1535-37. PMID 9872183
- ↑ Epstein O, Dick R, Sherlock S (1981). "Prospective study of periostitis and finger clubbing in primary biliary cirrhosis and other forms of chronic liver disease". Gut 22 (3): 203-6. PMID 7227854.
- ↑ Naeije R. Hepatopulmonary syndrome and portopulmonary hypertension. Swiss Med Wkly. 2003;133:163-9. PMID 12715285.
- ↑ -724565997 at GPnotebook
- ↑ Uppal S, Diggle CP, Carr IM, et al (June 2008). "Mutations in 15-hydroxyprostaglandin dehydrogenase cause primary hypertrophic osteoarthropathy". Nat. Genet. 40 (6): 789–93. doi:10.1038/ng.153. PMID 18500342.
- ↑ Sridhar KS, Lobo CF, Altman RD (December 1998). "Digital clubbing and lung cancer". Chest 114 (6): 1535–7. PMID 9872183.
- ↑ 12.0 12.1 Alonso-Bartolomé P, Martínez-Taboada VM, Pina T, Blanco R, Rodriguez-Valverde V (May 2006). "Hypertrophic osteoarthropathy secondary to vascular prosthesis infection: report of 3 cases and review of the literature". Medicine (Baltimore) 85 (3): 183–91. doi:10.1097/01.md.0000224714.27508.8b. PMID 16721260.
- ↑ Sridhar KS, Lobo CF, Altman RD. Digital clubbing and lung cancer. Chest 1998;114:1535-37. PMID 9872183
- ↑ Schuller A, Cottin V, Hot A, Cordier JF (February 2008). "Finger clubbing and altered carbon monoxide transfer capacity in cannabis smokers". Eur. Respir. J. 31 (2): 473–4. doi:10.1183/09031936.00150907. PMID 18238953.
- ↑ Gajewska J, Ambroszkiewicz J, Hozyasz KK (2005). "[The impairement of bone formation and resorption in 25-year-old man with neglected celiac disease]" (in Polish). Wiad. Lek. 58 (5-6): 338–41. PMID 16238129.
- ↑ Pineda CJ, Guerra J, Weisman MH, Resnick D, Martinez-Lavin M (May 1985). "The skeletal manifestations of clubbing: a study in patients with cyanotic congenital heart disease and hypertrophic osteoarthropathy". Semin. Arthritis Rheum. 14 (4): 263–73. PMID 3909407.
- ↑ Van Ginderdeuren F, Van Cauwelaert K, Malfroot A (May 2006). "Influence of digital clubbing on oxygen saturation measurements by pulse-oximetry in cystic fibrosis patients". J. Cyst. Fibros. 5 (2): 125–8. doi:10.1016/j.jcf.2006.01.007. PMID 16504602.
- ↑ Ozdemir B, Sentürk T, Kaderli AA, et al. (October 2008). "Postoperative regression of clubbing at an unexpected rate in a patient with aortic and mitral valve replacement due to infective endocarditis". Ir J Med Sci. doi:10.1007/s11845-008-0231-2. PMID 18843516.
- ↑ Mullins GM, Lenhard RE (March 1971). "Digital clubbing in Hodgkin's disease". Johns Hopkins Med J 128 (3): 153–7. PMID 5553121.
- ↑ Moreira Jda S, Camargo Jde J, Felicetti JC, Goldenfun PR, Moreira AL, Porto Nda S (2006). "Lung abscess: analysis of 252 consecutive cases diagnosed between 1968 and 2004". J Bras Pneumol 32 (2): 136–43. PMID 17273583.
- ↑ Thompson MA, Warner NB, Hwu WJ (December 2005). "Hypertrophic osteoarthropathy associated with metastatic melanoma". Melanoma Res. 15 (6): 559–61. PMID 16314744.
- ↑ McGavin C, Hughes P (April 1998). "Finger clubbing in malignant mesothelioma and benign asbestos pleural disease". Respir Med 92 (4): 691–2. PMID 9659538.
- ↑ Saghafi M, Azarian A, Nohesara N (April 2008). "Primary hypertrophic osteoarthropathy with myelofibrosis". Rheumatol. Int. 28 (6): 597–600. doi:10.1007/s00296-007-0477-4. PMID 18038138.
- ↑ Ali N, Abbasi AN, Karsan F, Hashmi R, Badar QA, Sheikh AJ (April 2009). "A case of finger clubbing associated with nasopharyngeal carcinoma in a young girl, and review of pathophysiology". J Pak Med Assoc 59 (4): 253–4. PMID 19402293.
- ↑ Stoller JK, Moodie D, Schiavone WA, et al. (January 1990). "Reduction of intrapulmonary shunt and resolution of digital clubbing associated with primary biliary cirrhosis after liver transplantation". Hepatology 11 (1): 54–8. PMID 2295472.
- ↑ Loredo JS, Fedullo PF, Piovella F, Moser KM (June 1996). "Digital clubbing associated with pulmonary artery sarcoma". Chest 109 (6): 1651–3. PMID 8769527.
- ↑ West SG, Gilbreath RE, Lawless OJ (September 1981). "Painful clubbing and sarcoidosis". JAMA 246 (12): 1338–9.
- ↑ Ehrlich RI, Gerston KF, Lalloo UG (January 1988). "Accelerated silicosis in a foundry shotblaster. A case report". S. Afr. Med. J. 73 (2): 128–30. PMID 3340919.
de:Trommelschlägelfingerit:Dita_ippocraticheno:Trommestikkfingre
Acknowledgement and Attribution Regarding Sources of Content
Some of the initial content on this page may be incorporated in part from copyleft sources in the public domain including wikis such as Wikipedia and AskDrWiki. Drug information for patients came from the The National Library of Medicine. Infectious disease information may have come from the Centers for Disease Control (CDC). Differential Diagnoses are drawn from clinicians as well as an amalgamation of 3 sources: 1.The Disease Database; 2. Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:3; 3. Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:7 .
