Nail clubbing

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Clubbing
Other namesDrumstick fingers/toes, Hippocratic fingers/toes, digital clubbing, watch-glass nails [1]
Dedos con acropaquia.jpg
Clubbing
Specialty Pulmonology

Nail clubbing, also known as digital clubbing or clubbing, is a deformity of the finger or toe nails associated with a number of diseases, anomalies and defects, some congenital, mostly of the heart and lungs. [2] [3] When it occurs together with joint effusions, joint pains, and abnormal skin and bone growth it is known as hypertrophic osteoarthropathy. [4]

Contents

Clubbing is associated with lung cancer, lung infections, interstitial lung disease, cystic fibrosis, or cardiovascular disease. [5] Clubbing may also run in families, [5] and occur unassociated with other medical problems. [6] [7]

Clubbing has been recognized as a sign of disease since the time of Hippocrates. [5]

Causes

Clubbing is associated with

Nail clubbing is not specific to chronic obstructive pulmonary disease (COPD). Therefore, in patients with COPD and significant degrees of clubbing, a search for signs of bronchogenic carcinoma (or other causes of clubbing) might still be indicated. [12] A congenital form has also been recognized. [13]

Hypertrophic pulmonary osteoarthropathy

Bone scan of a patient with HPOA Marie-Bamberger2.jpg
Bone scan of a patient with HPOA

A special form of clubbing is hypertrophic pulmonary osteoarthropathy (HPOA), known in continental Europe as Pierre Marie-Bamberger syndrome. 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.[ citation needed ]

Primary hypertrophic osteoarthropathy

Primary hypertrophic osteoarthropathy is HPOA without signs of pulmonary disease. This form has a hereditary component, although subtle cardiac abnormalities can occasionally be found. It is known eponymously 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. [14]

Pathogenesis

The exact cause for sporadic clubbing is unknown. Theories as to its cause include:

Diagnosis

Clubbing of the fingernail: The red line shows the outline of a clubbed nail. Clubbing.svg
Clubbing of the fingernail: The red line shows the outline of a clubbed nail.
Schamroths window test, done to identify nail clubbing Schamroths.jpg
Schamroths window test, done to identify nail clubbing

When clubbing is observed, pseudoclubbing should be excluded before making the diagnosis. Associated conditions may be identified by taking a detailed medical history—particular attention is paid to lung, heart, and gastrointestinal conditions—and conducting a thorough clinical examination, which may disclose associated features relevant to the underlying diagnosis. Additional studies such as a chest X-ray and a chest CT-scan may reveal otherwise asymptomatic cardiopulmonary disease. [12]

Stages

Clubbing is present in one of five stages: [12]

Schamroth's sign or Schamroth's window test (originally demonstrated by South African cardiologist Leo Schamroth on himself) [16] is a popular test for clubbing. When the distal phalanges (bones nearest the fingertips) of corresponding fingers of opposite hands are directly opposed (place fingernails of same finger on opposite hands against each other, nail to nail), a small diamond-shaped "window" is normally apparent between the nailbeds. If this window is obliterated, the test is positive and clubbing is present.

Epidemiology

The exact frequency of clubbing in the population is not known. A 2008 study found clubbing in 1%, or 15 patients, of 1511 patients admitted to a department of internal medicine in Belgium. Of these, 40%, or 6 patients, turned out to have significant underlying disease of various causes, while 60%, or 9 patients, had no medical problems on further investigations and remained well over the subsequent year. [7]

History

At least since the time of Hippocrates, clubbing has been recognized as a sign of disease. [5] The phenomenon has been called "Hippocratic fingers".

Self-portrait by Dick Ket showing nail clubbing. Dick Ket - Autoportrait.jpg
Self-portrait by Dick Ket showing nail clubbing.

The Dutch painter Dick Ket had nail clubbing as is seen from his paintings. He had an underlying disease, probably dextrocardia. [17]

See also

Related Research Articles

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Pulmonary fibrosis is a condition in which the lungs become scarred over time. Symptoms include shortness of breath, a dry cough, feeling tired, weight loss, and nail clubbing. Complications may include pulmonary hypertension, respiratory failure, pneumothorax, and lung cancer.

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<span class="mw-page-title-main">Acropachy</span> Skin disorder associated with Graves disease

Acropachy is a dermopathy associated with Graves' disease. It is characterized by soft-tissue swelling of the hands and clubbing of the fingers. Radiographic imaging of affected extremities typically demonstrates periostitis, most commonly the metacarpal bones. The exact cause is unknown, but it is thought to be caused by stimulating auto-antibodies that are implicated in the pathophysiology of Graves' thyrotoxicosis. There is no effective treatment for acropachy.

<span class="mw-page-title-main">Hypertrophic osteoarthropathy</span> Bone and joint disorder

Hypertrophic osteoarthropathy is a medical condition combining clubbing and periostitis of the small hand joints, especially the distal interphalangeal joints and the metacarpophalangeal joints. Distal expansion of the long bones as well as painful, swollen joints and synovial villous proliferation are often seen. The condition may occur alone (primary), or it may be secondary to diseases like lung cancer. Among patients with lung cancer, it is most associated with adenocarcinoma and least associated with small cell lung cancer. These patients often get clubbing and increased bone deposition on long bones. Their presenting signs and symptoms are sometimes only clubbing and painful ankles.

Shell nail syndrome is a medical condition defined by the concurrence of large, rounded fingernails and bronchiectasis. Despite the visual similarity between the two conditions, shell nail syndrome and clubbed fingernails are opposites. Shell nail syndrome results from atrophy to the nail bed, whereas clubbed fingernails results from a bulbous, hypertrophic growth of soft tissue. The concurrence of the syndrome and bronchiectasis is well-established, however the exact causes of the deformity remains unknown. The syndrome has been observed affecting both the hands and larger toenails.

Tripe palms, also known as acanthosis palmaris, is a medical sign characterized by thick ridged velvety palms, typically as part of a paraneoplastic syndrome. It resembles the lining of the stomach of some animals (tripe). Other signs that may be noted at the same time include most frequently acanthosis nigricans (AN), and less commonly finger clubbing and Leser-Trélat sign.

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References

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