Stanford Medicine 25 Blog _ What is the Specific Cause of This Patient’s Clubbing

7/3/2015 StanfordMedicine25Blog|WhatIsTheSpecificCauseofThisPatientsClubbing?

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What Is The Specific Cause of This PatientsClubbing?June3,2015

Figure1.Obviousclubbinginpatientstoes.Notetherelativeseverityinthetoescomparedtothehands.From(1)withpermission.

Thecausesofclubbingareafavouritebedsidequestiononrounds.Theycanbedividedinto:

Pulmonary(commonestthinkneoplasmuntilprovenotherwise).

BronchialcarcinomaMesotheliomaBronchiectasisCysticfibrosisInterstitialfibrosis

Cardiac

CyanoticcongentialheartdiseaseInfectiveendocarditisAtrialmyxoma

Gastrointestinal

Cirrhosis

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IBDCoeliacdisease

Congenital

Whichofthesecouldcausethedistributioninfigure1?Ifyouneedafurtherclue,hereisanotherpatientwiththesamecondition.

Figure2.Thesaturationintoesandfingersisdifferent,despitethepatientinspiringaconstantoxygenconcentration.Adaptedfrom(2),withpermission.

AnswerBelow

Thesearepathognomonicphysicalsigns.Ifapatientwithapatentductusarteriosus(PDA)developsEisenmengerssyndrometherewillbearteriovenousmixingcausingdeoxygenatedblood.CruciallythisaffectsthelowerlimbsexclusivelyasthePDAconnectspulmonaryarterytoaorticarchdistaltotheleftsubclavianartery.Theexactmechanismbywhichhypoxaemiaresultsinclubbingisnotfullyunderstood,butisthoughttoinvolvegrowthfactorsinvascularendotheliumandplatelets(Seethisarticletolearnmoreaboutthemechanism).Henceasthelowerlimbsexperiencemorehypoxaemia,theydevelopmoreclubbingandcyanosis.

Todemonstrateclubbingatthebedside,Shamrothswindowtestisperformed:

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Figure3.Shamrothswindowtestshowingobliterationofnailfoldangle(norhomboidvisible)whenclubbednailsareopposed.

Formoreexamplesofhowimportantthehandisinphysicaldiagnosis,refertotheStanford25pageonthehand.

TakeHomeMessage:ClubbingandcyanosisthatisworseinthelowerlimbsthanupperlimbscanonlybeexplainedbyapatientwithEisemengerssyndromesecondtoPDA.

Bonusquestion:Whatcardiovascularexaminationfindingswouldyouexpectinthispatient?(AnswerBelow)

Cardiacauscultationrevealedaleftparasternalheave,apalpablesecondheartsound,singleandloudS2andasoftpansystolicmurmuroftriscupidregurgitation.

Clinicaltips:OnceEisemengersdevelopsthereisnoflowmurmuracrossPDAasthepressureinrightandleftheartareequal.ThismeansasingleloudS2,whichmaybepalpableandsignsofRVhypertrophy.Oftentheremaybeassociatedflowmurmurs,butnotthecharacteristiccontinuousmachinerymurmurofaPDA.

References:1.AnoopT,GeorgeK.DifferentialClubbingandCyanosis.NEnglJMed2011364(7):666.2.MoccettiF,KaufmannBa.,ToblerD.Differentialclubbingandcyanosis:Apathognomonicfindingincardiology.EurHeartJ201435(21):1410.

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Stanford Medicine 25 Blog _ What is the Specific Cause of This Patient’s Clubbing