Clubbing

Clubbing (also termed acropachy, Hippocratic or watch-glass nails, drumstick fingers), characterized by an increase of the transverse and longitudinal nail curvatures, is a feature unique to humans. In children it is frequently associated with cyanotic congenital heart disease, cystic fibrosis, and inflammatory bowel disease. The exact etiology—circulating growth factor vs hypoxia—is unclear. It can occur as early as 3 months of age.

Differential Diagnosis

• Pulmonary
  –Cystic fibrosis
  –Bronchiectasis
  –Empyema
  –Pulmonary abscess
  –Tuberculosis, aspergillosis
  –Asthma complicated by infections
  –Pulmonary alveolar proteinosis
  –Sarcoidosis
  –Interstitial pneumonitis (lymphoid, chronic)
  –Pulmonary fibrosis
• Cardiovascular
  –Cyanotic congenital heart disease
  –Congestive heart failure
  –Myxoid tumor
  –Subacute bacterial endocarditis
  –Myxomas
• Gastrointestinal
  –Inflammatory bowel disease
  –Gardner syndrome
  –Parasitosis
  –Biliary cirrhosis or biliary atresia
  –Chronic active hepatitis
  –Celiac disease
• Other
  –Diamond syndrome (myxedema, exophthalmos, clubbing)
  –Thyrotoxicosis
  –Hypervitaminosis A
  –Malnutrition
• Acquired, one or more digits
  –Aortic/subclavian aneurysm
  –Brachial plexus injury
  –Shoulder subluxation
  –Trauma
  –Maffucci syndrome
  –Gout
  –Sarcoidosis
  –Severe herpetic whitlow
• Idiopathic
• Hereditary, familial (isolated)
  –Pachydermoperiostosis
• Pseudoclubbing (broad distal phalanges with normally shaped nails)
  –Apert syndrome
  –Pfeiffer syndrome
  –Rubinstein-Taybi syndrome

Workup and Diagnosis

• Physical exam is diagnostic
  –Often begins in the thumb and index fingers; earliest signs are softening and loss of angle at the base of the nail; nail beds are excessively compressible and skin overlying the base of the nail is red and shiny
  –The ungual-phalangeal angle (Lovibond angle): Measured by visualizing a “V,” with the tip placed on the nail fold, one arm pointing toward the tip of the nail and the other arm oriented along the finger; with clubbing the angle is ≥180°
  –Opposition of the dorsum of two fingers from opposite hands in normal individuals delineates a diamond-shaped window at the base of the nail beds; in early clubbing, this window is obliterated
  –The clubbing index (CI) is a ratio of distal phalangeal depth to interphalangeal depth; CI is equal or greater to 1.0 when clubbing is present; in cystic fibrosis patients, CI correlates negatively with PaO₂, FEV₁, FEF_25-75%, and positively with the residual volume 25–75%
  –Painful clubbing is indicative of periostitis associated with hypertrophic pulmonary osteoarthropathy
  –Toe clubbing can be seen in patent ductus arteriosus, reversed shunt, and pulmonary hypertension

• Histologic changes of the nail matrix include increased dermal fibroblasts, mucoid degeneration; and interstitial edema, infiltration with plasma cells, lymphocytes, and primitive fibroblasts

Treatment

• No specific treatment available
• In general, elimination or improvement in the associated condition is associated with a decrease in the degree of clubbing
• Reversible in cystic fibrosis patients who undergo lung transplantation
  –Regression noted mostly during the first 3 months post transplantation
• Remission observed after sectioning the thoracic vagus nerve in patients with pulmonary malignancy (uncommon condition in the pediatric population), even without removing the tumor itself
  
• Colchicine can be used for the associated pain

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

Other Book Chapters Related to Clubbing

Read excerpts from these other book chapters related to Clubbing:

Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

More About Causes of Clubbing

• Back to symptom: Clubbing: Introduction (review 475 causes)
• Next Book Extract About Clubbing: CLUBBING AND PULMONARY OSTEOARTHROPATHY (Differential Diagnosis in Primary Care)
• All Book Extracts: All Online Book Extracts for Clubbing

More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

 » Next page: CLUBBING AND PULMONARY OSTEOARTHROPATHY (Differential Diagnosis in Primary Care)

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