Nail Phenomena/Clubbing

Nail Phenomena/Clubbing: Excerpt from Field Guide to Bedside Diagnosis

Differential Overview

Phenomena

❑ Pitting

❑ Transverse depression

❑ Transverse white line

❑ Nailfold telangiectasias

❑ Nailfold infarcts

❑ Splinter hemorrhages

❑ Onycholysis

❑ Spoon nails

❑ Blue-green nails

❑ White nails

❑ Half-and-half nails

❑ Yellow nails

❑ Blue lunulae

❑ Red lunulae

❑ Black longitudinal streak

Clubbing

❑ Bronchogenic cancer

❑ Tuberculosis

❑ Endocarditis

❑ Inflammatory bowel disease

❑ Familial

❑ Trauma

❑ Grave disease

❑ Cirrhosis

❑ Cystic fibrosis

❑ Cyanotic congenital heart disease

❑ Pulmonary fibrosis

❑ Mediastinal Hodgkin disease

❑ Mesothelioma

❑ Lung abscess

❑ Bronchiectasis

❑ Hypertrophic osteoarthropathy

❑ Pachydermoperiostosis

Diagnostic Approach

Nails contain an archive of information about physiologic conditions affecting their growth, similar to the way tree rings record the weather of summers past. If examined closely, they may also contain the subtlest of clues to important
systemic illness, such as endocarditis.

Clubbing is most sensitively detected by loss of the normal nail angle when seen in profile, or by putting corresponding fingers back to back and looking for loss of the diamond of light. Springiness or ballotability of the base of the nail is another early sign. The overlying skin is smooth and shiny, and the nailbeds are cyanotic. Nails of patients with chronic paronychia may be confused with clubbing.

When clubbing is present, specifically examine for findings of associated illness including peripheral stigmata of endocarditis, murmurs, splenomegaly, jaundice, wheezes, rales, pleural effusion, supraclavicular adenopathy, hepatomegaly, abdominal mass, thyromegaly, and ophthalmopathy.

Unilateral clubbing may be caused by impairment of the vascular supply to the arm. Causes include aortic or subclavian artery aneurysm, anomalous aortic arch, pulmonary hypertension with patent ductus arteriosus, brachial arteriovenous fistula, superior sulcus lung tumor, and recurrent shoulder dislocation. Unidigital clubbing may be caused by median nerve injury or sarcoidosis. Clubbing of toes without fingers can be seen in coarctation of the aorta.

Clinical Findings

Pitting  It is most commonly caused by psoriasis, but it can also seen in patients with eczema, lichen planus, and alopecia areata.

Transverse depression  Systemic stresses (e.g., severe infection, myocardial infarction or trauma) cause a transient thinning of the nail plate (Beau line), which gradually grows out.

Transverse white line  Found mostly with transient hypoalbuminemia and systemic stress (Mees line). It is also classically described with arsenic poisoning.

Nailfold telangiectasias  Observe using a +40 diopter objective on the ophthalmoscope, enhanced using an oil droplet. Thick vessels with a glomerular appearance are consistent with dermatomyositis, scleroderma, or Raynaud phenomenon. Thin, meandering vessels are consistent with lupus.

Nailfold infarcts  Bywater lesions are small, painless, red-brown nailfold infarcts seen in rheumatic vasculitis.

Splinter hemorrhages  A longitudinal distal hemorrhage with the appearance of a splinter most commonly results from trauma but is also seen in persons with endocarditis, vasculitis, and scurvy. Trichinosis should be suspected when all nails are involved.

Onycholysis  Lifting and cracking of the nail (especially the fourth finger) without cutaneous disease suggests hyperthyroidism, but it can also occur with psoriasis, dermatophyte infection, or photosensitivity due to tetracycline.

Spoon nails  The nails appear concave. When an acquired phenomenon, it may be associated with iron deficiency, syphilis, or thyroid disease.

Blue-green nails  This color is the unique hallmark of Pseudomonas infection.

White nails  Hypoalbuminemic (,2.2) states such as nephrotic syndrome and cirrhosis produce opaque white nails with pink tips.

Half-and-half nails  A red-brown distal band occupying 20% to 50% of the nail occurs in cirrhosis, diabetes, and congestive heart failure (Terry nails). A brown distal band due to melanin deposition can be found in renal failure (Lindsay nails).

Yellow nails  A yellow “oil droplet” lesion in the nail is typical for psoriasis. Dermatophyte infection and lymphedema may also cause yellowing of the lateral nail border. A “yellow nail syndrome,” with all nails yellow without cuticles, can be seen in chronic chest infections or lymphedema.

Blue lunulae  These are found in argyria (silver), hepatolenticular degeneration (Wilson disease), and antimalarial therapy.

Red lunulae  Cherry red lunulae are seen in carbon monoxide poisoning, and half moons are seen in cardiac failure.

Black longitudinal streak  Although it may be a normal finding in darkly pigmented patients, it may also be caused by a nail bed melanoma, junctional nevus, or Peutz-Jeghers syndrome.

Bronchogenic cancer  The key clues are a smoking history, hemoptysis, and weight loss. Clubbing is rare with cancer metastatic to the lung but occurs in 5% to 10% of cases of bronchogenic cancer.

Tuberculosis  Patients present with fever, night sweats, and hemoptysis. Clubbing is uncommon in uncomplicated pulmonary tuberculosis, but it may occur in as many as one-fourth of patients with chronic cavitation.

Endocarditis  Consider this diagnosis in a patient with predisposing factors such as an artificial or rheumatically scarred valve, mitral valve prolapse, or recent dental work. Findings include a new murmur, splenomegaly, peripheral emboli, and fever.

Inflammatory bowel disease  Abdominal pain, diarrhea, fever, and blood or mucous in the stools are hallmarks.

Familial  The appearance of the fingers has been commented on for the duration of the patient’s entire life.

Trauma  Jackhammer operation is a classic cause.

Grave’s disease  Pseudoclubbing of thyroid acropachy occurs in both the fingers and the toes. Eye findings of proptosis, stare, and lid lag are usually present as are tachycardia and fine tremor.

Cirrhosis  Consider this in an alcoholic or a patient with chronic hepatitis. Vascular spiders, ascites, and a nodular liver edge are clues.

Cystic fibrosis  It is usually diagnosed in childhood, manifested by chronic lung infections and malabsorption, but occasionally it first becomes overt in adulthood.

Cyanotic congenital heart disease  Cyanosis occurs when a right-to-left shunt is present and it is manifest by blue lips and digits since infancy. Clubbing does not occur with noncyanotic congential heart disease, such as ventricular septal defect, patent ductus arteriosus, or aortic coarctation.

Pulmonary fibrosis  Velcro rales are characteristic, and clubbing occurs early.

Mediastinal Hodgkin disease  “B” symptoms such as night sweats and cervical adenopathy or splenomegaly are helpful clues.

Mesothelioma  Consider this when there is occupational asbestos exposure and vague persistent chest pain.

Lung abscess  Abscess is unmistakable in a febrile patient with a chronic, productive fetid cough.

Bronchiectasis  Chronic, profusely productive cough is the primary clue.

Hypertrophic osteoarthropathy  Severe, burning, deep pain in the wrists, ankles, hands, and feet increases at night or with dependency. Warmth, redness, and brawny edema are often found over the long bones (e.g., shins). Raynaud phenomenon, peripheral cyanosis, paresthesias, and muscular weakness may also occur.

Pachydermoperiostosis  Hypertrophic osteoarthropathy is combined with acromegalic features such as cylindrical thickening of the limbs, paw-like enlargement of the hands and feet, hyperhidrosis and marked oiliness, and accentuation of folds in the face causing a leonine appearance.

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

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More About This Book: Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

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