The Diagnostic Significance of Clubbed Fingers*

Transcription

1 The Diagnostic Significance of Clubbed Fingers* J. K. POPPE, M.D., F.C.C.P.$* Portland. Oregon Since the association of clubbed fingers with chronic pulmonary disease has been noted from the time of Hippocrates and discussed repeatedly, especially during the past five decades, this report will only include its differential diagnostic possibilities and stress the necessity for chest x-ray examinations and bronchograms in all patients with clubbed fingers. This watch glass deformity of the fingernails, associated with broadening of the terminal phalanges and frequently accompanied by an ossifying periostitis of the long bones, Is recognized by several different names. The first description of this deformity of the extremities with chronic empyemas by Hippocrates led to the term Hippocratic fingers. When Marie and Bamberger called attention to the associated thickening and sclerosis of the long bones it became known as the Marie-Bamberger s disease. The term acropathy was applied in 1920 to simplify the nomenclature. Hypertrophic pulmonary osteoarthropathy is probably the most common name in use today for the underlying bony changes. According to Cushing1 the thickening and sclerosis of the bones is thought to present a later stage of progression of the disease, although Shapiro2 claims to have noted bony changes precede the clubbing of the nails. In addition to chronic pleuro-pulmonary diseases, clubbing of the fingers has also been frequently noted in patients with congenital heart disease, subacute bacterial endocarditis, cirrhosis of the liver and chronic intestinal diseases, such as advanced ulcerative colitis, amebic dysentery, and polyposis. It is also noted occasionally in postthyroidectomy myxedema, syphilis and malignancy of the thymus. Occasionally unilateral clubbing has been described in association with aneurism of the aorta and surrounding large vessels on the same side. Loucaides3 was able to find only 18 such cases in 1932, although a number have been reported since.4 A familial clubbing of the fingers and toes in the absence of any underlying pathology has also been reported a few times. According to Seaton,5 until 1938 there were two instances in which the clubbing was present in members of three successive genera- *From the Medical and Surgical Chest Service of Barnes Hospital and Washington University School of Medicine, St. Louis, Missouri. **Now associated with the University of Oregon Medical School, Mayer Building, Portland, Oregon. 658

2 Volume XIII SIGNIFICANCE OF CLUBBED FINGERS 659 tions and six instances on record of its presence in two successive generations. The mechanism of development of clubbed fingers and hyperthrophic pulmonary osteoarthropathy is still somewhat conjectural and has been discussed at considerable length in a number of other papers listed in the bibliography. The infectious and toxic theories are not well substantiated due to its frequent presence in the absence of any infectious process in a number of cases of congenital heart disease, pulmonary arterlo-venous aneurisms, hepatic cirrhosis and some cases of bronchogenic carcinomas without any associated pulmonary infection. The presence of unilateral clubbing associated with aneurism of the aorta and subclavian arteries also suggests a localized interference with the blood supply rather than a generalized toxemia. Compere, Adams and Compere#{176} reported no successful attempts in animals at reproduction of hypertrophic pulmonary osteoarthropathy by the injection of toxins or attempted simulation of chronic pleuro-pulmonary diseases until Mendlowitz has done some very interesting experimental work on this disease during the past few years. By measuring the digital heat elimination and arterial blood pressure he7 concluded that the maximum heat elimination and hence the blood flow of the distal phlanges of clubbed fingers secondary to lung or congenital heart disease is usually increased, as well as the digital arterial pressure. A few years later he8 reproduced a condition similar to congenital heart disease in the dog by anastomosing the left pulmonary artery to the left auricle, thereby greatly reducing the oxygen saturation of the blood by this shunt. Out of four successful experiments only one animal showed hyperhrophic pulmonary osteoarthropathy. Schlicke and Bargen#{176} report the frequent occurrence of clubbed fingers in advanced cases of ulcerative colitis, but are unable to give a satisfactory explanation except on the basis of oxygen deficiency due to anemia and circulatory insufficiency in debilitated patients with a chronic disease. The clubbing associated with hepatic cirrhosis could also be explained on a circulatory basis. The principle purpose of this report is to emphasize the importance and necessity of chest x-ray examinations and bronchograms in every patient in whom clubbed fingers are noted on a routine physical examination. A review of the records of 299 lobectomies for bronchiectasis and chronic lung abscesses at Barnes Hospital in St. Louis revealed complete descriptions of the finger nails in only 129. Of this number 103, or 79 per cent, were noted to have had clubbing of the fingers in varying degrees. Eleven chronic lung abscesses without associated bronchiectasls were present in this group in whom 10, or 90 per cent, were recorded

3 660 J. K. POPPE Nov-Dec., 1947 to have had clubbed fingers. This deformity of the fingers was present in several cases with histories of only six months from the onset of the lung abscess. When the disease was limited to one section of lung which could be completely removed at operation a marked improvement in the finger deformity was observed in some of the younger patients within a year or two following lobectomy. An effort was then made to compare bronchiectasis with tuberculosis in its effect on the finger nails. At Koch Hospital, the St. Louis City Sanatorium, 276 tuberculous patients were examined. Clubbing of the finger nails was noted in 71, or 25 per cent. Much less cyanosis of the nail beds was observed in the tuberculous patients in whom the marked palor was more suggestive of anemia. The patients in nine different divisions were examined and approximately the same ratio of finger deformity was maintained in both white and colored patients. A higher incidence was present in the males, of whom 192 were examined and 57, or 30 per cent, were found to have finger deformities in comparison with 84 females, of whom only 14, or 16 per cent, had clubbing. The most significant observation was the direct relation of the severity of the disease on the finger nail deformity. The typical watch glass deformity was much more frequent in the acutely ill and terminal patients, even those whose disease was of less than one years duration, than it was in the chronically Ill patients who had spent twenty-five years in and out of the sanatorium. This series seems to compare favorably with the reported Incidence of 21 per cent clubbed fingers in 3,551 admissions of tuberculous patients to the Henry P1hipps Institute at Philadelphia, although Kline10 reported only 11 per cent in 100 tuberculous patients picked at random at Ann Arbor, Michigan, with an average duration of symptoms of three and one half years. The frequency of hypertrophic pulmonary osteoarthropathy in patients with bronchogenic carcinoma is somewhat less marked, apparently being more conspicuous in patients with mixed tumors or malignant adenomas in whom the duration of symptoms is considerably longer. Shapiro2 reports bony changes in only four per cent of 50 consecutive patients with bronchogenic and metastatic pulmonary carcinoma. The memory of two patients in whom a pulmonary malignancy was first suspected on the basis of clubbed fingers suggests this as one of the valuable early signs. A third year medical student first noticed the finger nail deformity in a young woman (D. M.) of 22 years who brought her baby to the St. Louis Children s Hospital for an examination. He referred the matter to a chest specialist who found an obstruction of the right lower lobe bronchus on bronchography and a mixed tumor of the

4 Volume XIII SIGNIFICANCE OF CLUBBED FINGERS 661 bronchus on bronchoscopy. A pneumonectomy was performed with the successful removal of the tumor. This woman had been treated for a chronic, slightly productive cough for several years. A middle aged man was noted to have had clubbing of his fingers for six months before his pulmonary symptoms and findings became sufficient to establish a diagnosis of bronchogenic carcinoma. By this time, the tumor was inoperable, since it recurred within another five months after a total pneumonectomy. The value of complete chest x-ray examinations and bronchography is further suggested by the case of a 28 year old man which was recently reported by Goldman. Cyanosis and clubbed fingers had been noted in this patient since childhood, at which time a diagnosis of congenital heart disease had been suggested although the signs were not typical. A marked increase In the red blood cells gradually occurred with a count of around eight million, at which time a diagnosis of polycythemia vera was made. Further chest examination revealed a pulmonary lesion in the left lung which proved on subsequent surgical-pathological examination to be a large hemangioma or arterio-venous aneurism. Montaschi 2 reported a congenital lung cyst which was discovered on the basis of clubbed fingers. Since no abnormality was noted on the plain chest film and there were no pulmonary symptoms, a bronchogram was necessary to establish the diagnosis. SUMMARY 1. Clubbing of the fingers is present in about 80 per cent of severe bronchiectasis and chronic lung abscess patients. 2. Clubbing Is also noted in about 25 per cent of cases of pulmonary tuberculosis, particularly in the more advanced stages of the disease. 3. Pulmonary osteoarthropathy may be one of the valuable early signs of bronchogenic carcinoma and mixed tumor of the bronchus. 4. The relative incidence of osteoarthropathy Is low in intestinal disease, liver disease, syphilis and the other causes of clubbed fingers in comparison with that found In pleuro-pulmonary and congenital heart disease. 5. All patients with clubbed fingers should have complete chest x-ray examination, including bronchography, unless the diagnosis is obvious on the plain chest film. RESUMEN 1. Los dedos en clavija ocurren en un 80 por ciento de los enfermos de bronquiectasla avanzada y absceso pulmonar cronico. 2. Tambi#{233}n se observa este signo en un 25 por ciento de los casos

5 662 J. K. POPPE Nov-Dec de tuberculosis pulmonar, particularmente en los periodos m#{225}s avanzados de la enfermedad. 3. La osteoartropatia pulmonar puede ser uno de los valiosos signos precoces del carcinoma broncogeno y del tumor mixto del bronquio. 4. La relativa frecuencia de osteoartropatla es baja en enfermedades intestinales, hepatopatias, sifilis y en las otras causas de dedos en clavija, comparada con su frecuencia en pleuro-neumopatias y cardiopatias congenitas. 5. Todo enfermo con dedos en clavija debe recibir un completo examen radiogr#{225}fico del torax, inclusive de broncograf Ia, a menos que sea evidente el diagnostico en la simple pelicula radiografica. REFERENCES 1 Cushing, E. H.: Club Fingers and Hypertrophic Pulmonary Osteoarthropathy, International Clinics, 2: , June Shapiro, S.: Ossifying Periostitls of Bamberger-Marie, Bull. Hosp. 3 Joint Dis., 2:77, April Loucaldes, L.: Elnseitige Trommelschlegelfinger, Zeitschrift fur Medizin, 12:724, Rodgers, R. E.: Case of Unilateral Clubbing of Fingers, Brit. M. J., 2:439, Sept Seaton, D. R.: Familial Clubbing of Fingers and Toes, Brit. Med. J., 1:614, Compere, E. J., Adams, W. E., and Compere, C.: Generalized Hyperthrophic Osteoarthropathy; Experimental and Clinical Study with Report of 2 Cases, Surg., Gynec. and Obst. 61:312, Mendlowitz, M.: Same Observations on Clubbed Fingers, Clin. Sci., 3:387, Mendlowitz, M., and Leslie, A.: Experimental Simulation in Log of Cyamosis and Hyperthrophic Osteoasthropathy which are Associated with Congenital Heart Dlsease, Am. Ht. J., 24:141, Aug Schlicke, C. P., and Bargen, J. A.: Clubbed Fingers and Ulcerative Colitis, Am. J. Digest Dis., 7:17, Jan KlIne, E. M.: Chronic Hypertrophic Osteoarthropathy, Univ. Hosp. Bull., Ann Arbor, 2:28, May Goldman, A.: Cavernous Hemangioma of the Lung: Secondary Polycythemia, Dis. of Chest, 9:479, Montuschi, E.: Clubbing of Fingers and Toes Associated with Congenital Lung Cyst, Brit. M. J., 1:1310, June 1938.