home Audience 12 Symptom of drumsticks pathogenesis. What is watch glass and its characteristics

Symptom of drumsticks pathogenesis. What is watch glass and its characteristics

People suffering from chronic pathologies of the lungs, heart and liver may have a flask-shaped appearance. In medicine this is called syndrome drumsticks. The disease, as a rule, does not cause noticeable pain and does not affect the tissues of the skeletal system. Soft fabrics all fingers of both hands and toes change their thickness, changing the angle towards increasing in the interval between the nail plate and the nail fold of the back wall of the nail. The nail takes on a distorted appearance and becomes deformed.

general information

The world first learned about the existence of drumstick-shaped fingers from Hippocrates, who mentioned them in his description of purulent accumulations in the body and genitals. After this, this pathology of the limbs began to be called the fingers of Hippocrates.

Doctors Eugene Bamberger, a German by birth, and Frenchman Marie Pierre, back in the nineteenth century, identified osteoarthropathy of hypertrophic etiology, in which pathology developed on the phalanges of the fingers called drumsticks. It was then that doctors determined that the cause of this disease was chronic pathogenic infections.

Forms of the disease

Often, fingers that resemble drumsticks appear on the feet and hands at the same time. However, there are cases when pathology occurs in isolation, only on the legs or arms. Special cyanotic changes in the extremities appear in people with chronic heart disease, when only one half is supplied with blood human body: lower or upper, respectively.

“Drumsticks” on the phalanges of the limbs are of several types:

Soft tissues grow around the entire phalanx. Real flask-shaped sticks.
The distal phalanx increases in size only on one side. Visually they resemble the beak of a parrot.
The nail becomes deformed due to the growth of soft tissues under the plate. This type is similar to watch glass.

Main reasons

The main reasons that provoke the symptom of drumsticks:

Pulmonary diseases, including: abscesses, oncological diseases, pleurisy, lung cyst, fibrous type alveolitis, chronic suppuration processes.
Diseases of the cardiovascular system: heart disease of congenital etiology, endocarditis infectious origin. In such cases, the disease is accompanied by additional swelling and cyanosis. skin on the arms and legs.
Diseases gastro- intestinal tract: gastric ulcers, liver cirrhosis, colitis, enteropathy.

There are a number of other diseases that cause symptoms:

This pathology of the extremities is the main type of Marie-Bamberger syndrome, which affects the tubular bones in the body and is aggravated by a bronchogenic type of cancer. The second name is hypertrophic osteoarthropathy.

Reasons that provoke the appearance of unilateral pathology of the limbs:

The presence of an inflammatory process in the lymphatic vessels.
Pancoast formation is a tumor that appears on the first pulmonary segment.
The use of an arteriovenous fistula during the treatment of renal failure using hemodialysis.

Mechanism of disease development

Even today there is no clear answer to the question: why does the symptom of drumsticks on the limbs develop and how does it develop? Medicine has established that pathology occurs through disruptions in blood microcirculation, which causes a lack of oxygen exchange in tissues. As a result, chronic hypoxia develops, which provokes expansion blood vessels in the fingers and toes. Blood flow increases in the phalanges.

Malfunctions hormonal system lead to their increase by growth between the nails and bones. This increases the risk of hypoxemia, as well as endogenous intoxication. The fingers begin to thicken, taking on rough shapes.

In persons suffering from chronic pathologies of the intestinal tract, hypoxemia does not develop. Fingers change in the presence of Crohn's disease in the body, exacerbation of intestinal forms of manifestation of the disease.

What are the symptoms

Almost always, the disease develops without pain or noticeable discomfort, which prevents the patient from paying attention to the problem in time. Visible symptoms:

Over time, other signs of the disease make themselves felt. Osteoarthropathy is added to the main diseases, which is accompanied by an additional number of symptoms:

Neurovascular pathology in the feet.
Subcutaneous tissues become rough.
Availability pain syndrome in the skeletal system.
One or more joints are modified as in arthritis.

Diagnosis

In order to correctly determine the presence of a symptom of drumsticks, you need to contact qualified specialist and undergo a series of studies. The presence of these criteria will help establish a diagnosis:

When palpated, increased elasticity of the nail is felt. By pressing the skin around and then releasing it, a springy effect occurs.
Lovibond's corner is not completely visible. This can be checked with a pencil. Apply along the length of the finger, if the gap is not visible, this will be a symptom of pathology on the phalanges.
Excessive ratio of the entire thickness of the distal phalanx of the cuticle and the joint between the phalanges. If a person has drumstick syndrome, the ratio will be higher than the normal norm, which is 0.895.

When conducting diagnostics to identify this pathology, it is necessary to determine the very cause of the disease using the following procedures:

Routine urine and blood tests.
Studying the medical history.
A series of ultrasound examinations: heart, liver, lungs.
X-rays of the chest.
Check how external breathing functions.
Determine the composition of gas in the blood.

How to treat?

In order for the affected fingers, first of all, it is necessary to eliminate the cause that led to this problem. For this, doctors recommend following a diet, taking medications to strengthen the immune system, and also prescribe anti-inflammatory drugs and antibiotics. Having thus eliminated the cause, you can return the limbs to their original normal appearance.

back in antiquity, 25 centuries ago, Hippocrates described changes in the shape of the distal phalanges of the fingers, which occurred in chronic pulmonary pathology(abscess, tuberculosis, cancer, pleural empyema), and called them “drumsticks.” Since then, this syndrome has been called by his name - Hippocratic fingers (Hippocratic fingers) (digiti Hippocratici).

Hippocrates' finger syndrome includes two signs: “hour glasses” (Hippocrates' nails - ungues Hippocraticus) and club-shaped deformation of the terminal phalanges of the fingers like “drumsticks” (Finger clubbing).

Currently, PG is considered the main manifestation of hypertrophic osteoarthropathy (HOA, Marie-Bamberger syndrome) - multiple ossifying periostosis.

The mechanisms of development of PG are currently not fully understood. However, it is known that the formation of PG occurs as a result of microcirculation disturbances, accompanied by local tissue hypoxia, disruption of periosteal trophism and autonomic innervation against the background of prolonged endogenous intoxication and hypoxemia. In the process of formation of PG, the shape of the nail plates (“hour glasses”) first changes, then the shape of the distal phalanges of the fingers changes into a club-shaped or flask-shaped shape. The more pronounced the endogenous intoxication and hypoxemia, the more severely the terminal phalanges of the fingers and toes are modified.

Changes in the distal phalanges of the fingers according to the “drumstick” type can be established in several ways.

It is necessary to identify a smoothing of the normally existing angle between the base of the nail and the nail fold. The disappearance of the “window”, which is formed when the distal phalanges of the fingers are compared with their dorsal surfaces facing each other, is the most early sign thickening of the terminal phalanges. The angle between the nails does not normally extend upward more than half the length of the nail bed. As the distal phalanges of the fingers thicken, the angle between the nail plates becomes wide and deep (Fig. 1).

On unmodified fingers, the distance between points A and B should exceed the distance between points C and D. With “drumsticks” the relationship is the opposite: C - D becomes longer than A - B (Fig. 2).

Another important sign of PG is the size of the ACE angle. On a normal finger this angle is less than 180°; with “drumsticks” it is more than 180° (Fig. 2).

Along with the “fingers of Hippocrates,” in paraneoplastic Marie-Bamberger syndrome, periostitis appears in the area of the end sections of long tubular bones (usually the forearms and legs), as well as the bones of the hands and feet. In places of periosteal changes, severe ossalgia or arthralgia and local palpation pain may be noted; X-ray examination reveals double cortical layer, caused by the presence of a narrow dense strip separated from the compact bone substance light interval(symptom of “tram rails”) (Fig. 3). It is believed that Marie-Bamberger syndrome is pathognomonic for lung cancer; less often it occurs with other primary intrathoracic tumors (benign lung neoplasms, pleural mesothelioma, teratoma, mediastinal lipoma). Occasionally, this syndrome occurs in cancer of the gastrointestinal tract, lymphoma with metastases to the mediastinal lymph nodes, and lymphogranulomatosis. At the same time, Marie-Bamberger syndrome also develops in non-oncological diseases - amyloidosis, chronic obstructive pulmonary disease, tuberculosis, bronchiectasis, congenital and acquired heart defects, etc. One of distinctive features of this syndrome in non-tumor diseases there is a long-term (over the course of years) development of characteristic changes in the osteoarticular apparatus, while in malignant neoplasms this process is calculated in weeks and months. After radical surgical treatment of cancer, Marie-Bamberger syndrome can regress and completely disappear within a few months.

Currently, the number of diseases in which changes in the distal phalanges of the fingers are described as “drumsticks” and nails as “watch glasses” has increased significantly (Table 1). The appearance of PG often precedes more specific symptoms. We especially need to remember the “sinister” connection of this syndrome with lung cancer. Therefore, identifying signs of PG requires correct interpretation and implementation of instrumental and laboratory examination methods for the timely establishment of a reliable diagnosis.

The relationship between PG and chronic lung diseases, accompanied by long-term endogenous intoxication and respiratory failure (RF), is considered obvious: their formation is especially often observed in pulmonary abscesses - 70–90% (within 1–2 months), bronchiectasis - 60–70% (for several years), pleural empyema - 40–60% (for 3–6 months or more) (“rough” fingers of Hippocrates, Fig. 4).

In tuberculosis of the respiratory organs, PGs are formed in the case of widespread (more than 3–4 segments) destructive process with a long-term or chronic course (6–12 months or more) and are characterized mainly by the “clock glass” symptom, thickening, hyperemia and cyanosis of the nail fold (“delicate” Hippocrates’ fingers - 60–80%, Fig. 5).

In idiopathic fibrosing alveolitis (IFA), PG occurs in 54% of men and 40% of women. It has been established that the severity of hyperemia and cyanosis of the nail fold, as well as the very presence of PG, indicate an unfavorable prognosis in ELISA, reflecting, in particular, the prevalence of active damage to the alveoli (ground glass areas detected on computed tomography) and the severity of proliferation of vascular smooth muscle cells in foci of fibrosis. PG is one of the factors that most reliably indicates a high risk of the formation of irreversible pulmonary fibrosis in patients with ELISA, also associated with a decrease in their survival.

At diffuse diseases connective tissue with the involvement of the pulmonary parenchyma, PH always reflect the severity of DN and are an extremely unfavorable prognostic factor.

For other interstitial lung diseases, the formation of PG is less typical: their presence almost always reflects the severity of DN. J. Schulze et al. described this clinical phenomenon in a 4-year-old girl with rapidly progressive pulmonary histiocytosis X. V. Holcomb et al. revealed changes in the distal phalanges of the fingers like “drumsticks” and nails like “watch glasses” in 5 out of 11 patients examined with pulmonary veno-occlusive disease.

As lung lesions progress, PGs appear in at least 50% of patients with exogenous allergic alveolitis. It should be emphasized the leading importance of a persistent decrease in the partial pressure of oxygen in the blood and tissue hypoxia in the development of HOA in patients suffering from chronic lung diseases. Thus, in children with cystic fibrosis, the partial pressure of oxygen in arterial blood and forced expiratory volume in 1 second were the smallest in the group with the most pronounced changes in the distal phalanges of the fingers and nails.

There are isolated reports of the appearance of PG in bone sarcoidosis (J. Yancey et al., 1972). We observed more than a thousand patients with sarcoidosis of the intrathoracic lymph nodes and lungs, including skin manifestations, and in no case was the formation of PG detected. Therefore, we consider the presence/absence of PG as a differential diagnostic criterion for sarcoidosis and other pathologies of the chest organs (fibrosing alveolitis, tumors, tuberculosis).

Changes in the distal phalanges of the fingers like “drum sticks” and nails like “watch glasses” are often recorded when occupational diseases occurring with the involvement of the pulmonary interstitium. Relatively early appearance of GOA is typical for patients with asbestosis; this sign indicates a high risk of death. According to S. Markowitz et al. , during a 10-year follow-up of 2709 patients with asbestosis, with the development of PG, their probability of death increased by at least 2 times.
PGs were detected in 42% of the examined coal mine workers who suffered from silicosis; in some of them, along with diffuse pneumosclerosis, foci of active alveolitis were found. Changes in the distal phalanges of the fingers like “drum sticks” and nails like “watch glasses” have been described in workers of factories producing matches who were in contact with rhodamine used in their production.

The connection between the development of PH and hypoxemia is confirmed by the repeatedly described possibility of the disappearance of this symptom after lung transplantation. In children with cystic fibrosis, characteristic changes in the fingers regressed during the first 3 months. after lung transplantation.

The appearance of PG in a patient with interstitial lung disease, especially with a long history of the disease and in the absence of clinical signs of active lung damage, requires a persistent search for a malignant tumor in the lung tissue. It has been shown that in lung cancer that develops against the background of ELISA, the frequency of GOA reaches 95%, while in cases of damage to the pulmonary interstitium without signs of neoplastic transformation, it is found more rarely - in 63% of patients.

The rapid development of changes in the distal phalanges of the fingers like “drumsticks” is one of the indications for the development of lung cancer even in the absence of precancerous diseases. In such a situation, clinical signs of hypoxia (cyanosis, shortness of breath) may be absent and this sign develops according to the laws of paraneoplastic reactions. W. Hamilton et al. demonstrated that the likelihood of a patient having PG increases by 3.9 times.

GOA is one of the most common paraneoplastic manifestations of lung cancer; its prevalence in this category of patients can exceed 30%. The dependence of the frequency of detection of PG on the morphological form of lung cancer is shown: reaching 35% in the non-small cell variant, in the small cell variant this figure is only 5%.

The development of HOA in lung cancer is associated with hyperproduction of growth hormone and prostaglandin E2 (PGE-2) by tumor cells. The partial pressure of oxygen in the peripheral blood may remain normal. It has been established that in the blood of patients lung cancer with a symptom of PG, the level of transforming growth factor β (TGF-β) and PGE-2 significantly exceeds that in patients without changes in the distal phalanges of the fingers. Thus, TGF-β and PGE-2 can be considered relative inducers of PG formation, relatively specific for lung cancer; Apparently, this mediator is not involved in the development of the discussed clinical phenomenon in other chronic pulmonary diseases with DN.

The paraneoplastic nature of the “drumstick” type changes in the distal phalanges of the fingers is clearly demonstrated by the disappearance of this clinical phenomenon after successful resection lung tumors. In its turn, reappearance This clinical sign in a patient whose lung cancer treatment has been successful is a likely indication of tumor recurrence.

PG can be a paraneoplastic manifestation of tumors localized outside the lung area, and may even precede the first clinical manifestations malignant tumors. Their formation is described in malignant tumors of the thymus, cancer of the esophagus, colon, gastrinoma, characterized by clinically typical Zollinger-Ellison syndrome, and pulmonary artery sarcoma.

The possibility of PG formation in malignant breast tumors and pleural mesothelioma, which is not accompanied by the development of DN, has been repeatedly demonstrated.

PG is detected in lymphoproliferative diseases and leukemia, including acute myeloblastic, in which they were noted on the arms and legs. After chemotherapy, which stopped the first attack of leukemia, the signs of GOA disappeared, but reappeared after 21 months. in case of tumor recurrence. One observation showed regression of typical changes in the distal phalanges of the fingers with successful chemotherapy and radiation therapy for lymphogranulomatosis.

Thus, PG, along with various types of arthritis, erythema nodosum and migratory thrombophlebitis are among the frequent extraorgan, nonspecific manifestations of malignant tumors. The paraneoplastic origin of changes in the distal phalanges of the fingers like “drumsticks” can be assumed when they form quickly (especially in patients without DN, heart failure and in the absence of other causes of hypoxemia), as well as when combined with other possible extra-organ, nonspecific signs of a malignant tumor - an increase in ESR, changes in the peripheral blood picture (especially thrombocytosis), persistent fever, articular syndrome and recurrent thrombosis various localizations.

One of the most common reasons The appearance of PG is considered to be congenital heart defects, especially the “blue” type. Among 93 patients with pulmonary arteriovenous fistulas observed at the Mauo Clinic for 15 years, similar changes in the fingers were recorded in 19%; they exceeded the frequency of hemoptysis (14%), but were inferior to murmurs over the pulmonary artery (34%) and shortness of breath (57%).

R. Khouzam et al. (2005) described ischemic stroke embolic origin, which developed 6 weeks after birth in an 18-year-old patient. The presence of characteristic changes in the fingers and hypoxia, which required respiratory support, led to a search for an anomaly in the structure of the heart: transthoracic and transesophageal echocardiography revealed that the inferior vena cava opened into the cavity of the left atrium.

PGs can “discover” the existence of pathological shunting from the left side of the heart to the right, including that formed as a consequence of cardiac surgery. M. Essop et al. (1995) observed characteristic changes in the distal phalanges of the fingers and increasing cyanosis for 4 years after balloon dilatation of rheumatic mitral stenosis, the complication of which was small defect interatrial septum. During the period that has passed since the operation, its hemodynamic significance has increased significantly due to the fact that the patient also developed rheumatic stenosis of the tricuspid valve, after correction of which indicated symptoms completely disappeared. J. Dominik et al. noted the appearance of PG in a 39-year-old woman 25 years after successful repair of an atrial septal defect. It turned out that during the operation the inferior vena cava was mistakenly directed to the left atrium.

PG is considered one of the most typical nonspecific, so-called extracardiac, clinical signs infective endocarditis(IE). The frequency of changes in the distal phalanges of the fingers like “drumsticks” in IE can exceed 50%. High fever with chills, increased ESR, and leukocytosis testify in favor of IE in a patient with PG; Anemia, a transient increase in serum activity of hepatic aminotransferases, and various types of kidney damage are often observed. To confirm IE, transesophageal echocardiography is indicated in all cases.

According to some clinical centers, one of the most common causes of the phenomenon of PH is cirrhosis of the liver with portal hypertension and progressive dilatation of the vessels of the pulmonary circulation, leading to hypoxemia (the so-called pulmonary-renal syndrome). In such patients, GOA is usually combined with cutaneous telangiectasias, often forming “fields of spider veins» .
A connection has been established between the formation of HOA in liver cirrhosis and previous alcohol abuse. In patients with liver cirrhosis without concomitant hypoxemia, PG is usually not detected. This clinical phenomenon is also characteristic of primary cholestatic liver lesions requiring liver transplantation in childhood, including congenital bile duct atresia.

Repeated attempts have been made to decipher the mechanisms of development of changes in the distal phalanges of the fingers like “drumsticks” in diseases, including those mentioned above ( chronic diseases lungs, congenital heart defects, IE, liver cirrhosis with portal hypertension), accompanied by persistent hypoxemia and tissue hypoxia. Hypoxia-induced activation of tissue growth factors, including platelet growth factors, plays a leading role in the formation of changes in the distal phalanges and fingernails. In addition, in patients with PH, an increase in the serum level of hepatocyte growth factor, as well as vascular growth factor, was detected. The connection between the increase in the activity of the latter and a decrease in the partial pressure of oxygen in arterial blood is considered the most obvious. Also, in patients with PH, a significant increase in the expression of hypoxia-inducible factors type 1a and 2a is found.

In the development of changes in the distal phalanges of the fingers of the “drumstick” type, endothelial dysfunction associated with a decrease in the partial pressure of oxygen in arterial blood may have a certain significance. It has been shown that in patients with GOA, the serum concentration of endothelin-1, the expression of which is induced primarily by hypoxia, is significantly higher than that in healthy people.
The mechanisms of PG formation in chronic diseases are difficult to explain. inflammatory diseases intestines, for which hypoxemia is not typical. At the same time, they are often found in Crohn’s disease (they are not typical in ulcerative colitis), in which changes in the fingers like “drumsticks” may precede the actual intestinal manifestations diseases.

The number of probable reasons causing changes in the distal phalanges of the fingers according to the “watch glass” type continues to increase. Some of them are very rare. K. Packard et al. (2004) observed the formation of PG in a 78-year-old man who took losartan for 27 days. This clinical phenomenon persisted when losartan was replaced by valsartan, which allows us to consider it an undesirable reaction to the entire class of angiotensin II receptor blockers. After switching to captopril, changes in the fingers completely regressed within 17 months. .

A. Harris et al. found characteristic changes in the distal phalanges of the fingers in a patient with primary antiphospholipid syndrome, while no signs of thrombotic lesions of the pulmonary vascular bed were identified in him. The formation of PGs has also been described in Behçet's disease, although it cannot be completely ruled out that their appearance in this disease was accidental.
PGs are considered among possible indirect markers of drug use. In some of these patients, their development may be associated with a variant of lung damage or IE characteristic of drug addicts. Changes in the distal phalanges of the fingers like “drum sticks” are described in users of not only intravenous, but also inhaled drugs, for example, hashish smokers.

With increasing frequency (at least 5%), PG is registered in HIV-infected people. Their formation may be based on various forms of HIV-associated pulmonary diseases, but this clinical phenomenon is observed in HIV-infected patients with intact lungs. It has been established that the presence of characteristic changes in the distal phalanges of the fingers in HIV infection is associated with a lower number of CD4-positive lymphocytes in the peripheral blood; in addition, interstitial lymphocytic pneumonia is more often recorded in such patients. In HIV-infected children, the appearance of PG is a likely indication of pulmonary tuberculosis, which is possible even in the absence of Mycobacterium tuberculosis in sputum samples.

The so-called primary, not associated with diseases, is known internal organs a form of GOA, often familial (Touraine-Solant-Gole syndrome). It is diagnosed only after excluding most of the causes that can cause the appearance of PG. Patients with the primary form of GOA often complain of pain in the area of the changed phalanges and increased sweating. R. Seggewiss et al. (2003) observed primary GOA involving only the fingers of the lower extremities. At the same time, when establishing the presence of PH in members of the same family, it is necessary to take into account the possibility that they have inherited congenital heart defects (for example, patent ductus botallus). The formation of characteristic changes in the fingers can continue for about 20 years.

Recognizing the causes of changes in the distal phalanges of the fingers according to the “drumstick” type requires differential diagnosis of various diseases, among which the leading position is occupied by those associated with hypoxia, i.e. clinically manifested DN and/or heart failure, as well as malignant tumors and subacute IE. Interstitial lung diseases, primarily ELISA, are one of the most common causes of PG; the severity of this clinical phenomenon can be used to assess the activity of lung damage. The rapid formation or increase in the severity of GOA necessitates the search for lung cancer and other malignant tumors. At the same time, one should take into account the possibility of the appearance of this clinical phenomenon in other diseases (Crohn's disease, HIV infection), in which it can occur much earlier than specific symptoms.

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Poteyko P.I., Kharkov Medical Academy of Postgraduate Education, Department of Phthisiology and Pulmonology

Even in ancient times, 25 centuries ago, Hippocrates described changes in the shape of the distal phalanges of the fingers, which occurred in chronic pulmonary pathology (abscess, tuberculosis, cancer, pleural empyema), and called them “drum sticks.” Since then, this syndrome has been called by his name - Hippocratic fingers (Hippocratic fingers) (digiti Hippocratici).

Currently, PG is considered the main manifestation of hypertrophic osteoarthropathy (HOA, Marie-Bamberger syndrome) - multiple ossifying periostosis.

Changes in the distal phalanges of the fingers according to the “drumstick” type can be established in several ways.

It is necessary to identify a smoothing of the normally existing angle between the base of the nail and the nail fold. The disappearance of the “window”, which is formed when the distal phalanges of the fingers are juxtaposed with their dorsal surfaces facing each other, is the earliest sign of thickening of the terminal phalanges. The angle between the nails does not normally extend upward more than half the length of the nail bed. As the distal phalanges of the fingers thicken, the angle between the nail plates becomes wide and deep (Fig. 1).

Another important sign of PG is the size of the ACE angle. On a normal finger this angle is less than 180°; with “drumsticks” it is more than 180° (Fig. 2).

Along with the “fingers of Hippocrates,” in paraneoplastic Marie-Bamberger syndrome, periostitis appears in the area of the end sections of long tubular bones (usually the forearms and legs), as well as the bones of the hands and feet. In places of periosteal changes, severe ossalgia or arthralgia and local palpation tenderness may be observed; X-ray examination reveals a double cortical layer, due to the presence of a narrow dense strip separated from the compact bone substance by a light gap (symptom of “tram rails”) (Fig. 3). It is believed that Marie-Bamberger syndrome is pathognomonic for lung cancer; less often it occurs with other primary intrathoracic tumors (benign lung neoplasms, pleural mesothelioma, teratoma, mediastinal lipoma). Occasionally, this syndrome occurs in cancer of the gastrointestinal tract, lymphoma with metastases to the mediastinal lymph nodes, and lymphogranulomatosis. At the same time, Marie-Bamberger syndrome also develops in non-oncological diseases - amyloidosis, chronic obstructive pulmonary disease, tuberculosis, bronchiectasis, congenital and acquired heart defects, etc. One of the distinctive features of this syndrome in non-tumor diseases is the long-term (over the course of years) development of characteristic changes in the osteoarticular apparatus, while in case of malignant neoplasms this process is calculated in weeks and months. After radical surgical treatment of cancer, Marie-Bamberger syndrome can regress and completely disappear within a few months.

In tuberculosis of the respiratory organs, PGs are formed in the case of a widespread (more than 3–4 segments) destructive process with a long or chronic course (6–12 months or more) and are characterized mainly by the “clock glass” symptom, thickening, hyperemia and cyanosis of the nail fold (“ tender" fingers of Hippocrates - 60–80%, Fig. 5).

In idiopathic fibrosing alveolitis (IFA), PG occurs in 54% of men and 40% of women. It has been established that the severity of hyperemia and cyanosis of the nail fold, as well as the very presence of PG, indicate an unfavorable prognosis in ELISA, reflecting, in particular, the prevalence of active damage to the alveoli (ground glass areas detected on computed tomography) and the severity of proliferation of vascular smooth muscle cells in foci of fibrosis. PG is one of the factors that most reliably indicates a high risk of the formation of irreversible pulmonary fibrosis in patients with IFA, which is also associated with a decrease in their survival.

In diffuse connective tissue diseases involving the pulmonary parenchyma, PG always reflects the severity of DN and is an extremely unfavorable prognostic factor.

As lung lesions progress, PGs appear in at least 50% of patients with exogenous allergic alveolitis. It should be emphasized the leading importance of a persistent decrease in the partial pressure of oxygen in the blood and tissue hypoxia in the development of HOA in patients suffering from chronic lung diseases. Thus, in children with cystic fibrosis, the values of partial pressure of oxygen in arterial blood and forced expiratory volume in 1 second were the smallest in the group with the most pronounced changes in the distal phalanges of the fingers and nails.

There are isolated reports of the appearance of PG in bone sarcoidosis (J. Yancey et al., 1972). We observed more than a thousand patients with sarcoidosis of the intrathoracic lymph nodes and lungs, including skin manifestations, and in no case did we detect the formation of PG. Therefore, we consider the presence/absence of PG as a differential diagnostic criterion for sarcoidosis and other pathologies of the chest organs (fibrosing alveolitis, tumors, tuberculosis).

Changes in the distal phalanges of the fingers like “drumsticks” and nails like “watch glasses” are often recorded in occupational diseases involving the pulmonary interstitium. Relatively early appearance of GOA is typical for patients with asbestosis; this sign indicates a high risk of death. According to S. Markowitz et al. , during a 10-year follow-up of 2709 patients with asbestosis, with the development of PG, their probability of death increased by at least 2 times.
PGs were detected in 42% of the examined coal mine workers who suffered from silicosis; in some of them, along with diffuse pneumosclerosis, foci of active alveolitis were found. Changes in the distal phalanges of the fingers like “drum sticks” and nails like “watch glasses” have been described in workers of factories producing matches who were in contact with rhodamine used in their production.

The rapid development of changes in the distal phalanges of the fingers like “drumsticks” is one of the indications for the development of lung cancer even in the absence of precancerous diseases. In such a situation, clinical signs of hypoxia (cyanosis, shortness of breath) may be absent and this symptom develops according to the laws of paraneoplastic reactions. W. Hamilton et al. demonstrated that the likelihood of a patient having PG increases by 3.9 times.

The development of HOA in lung cancer is associated with hyperproduction of growth hormone and prostaglandin E2 (PGE-2) by tumor cells. The partial pressure of oxygen in the peripheral blood may remain normal. It was found that in the blood of patients with lung cancer with a symptom of PG, the level of transforming growth factor β (TGF-β) and PGE-2 significantly exceeds that of patients without changes in the distal phalanges of the fingers. Thus, TGF-β and PGE-2 can be considered relative inducers of PG formation, relatively specific for lung cancer; Apparently, this mediator is not involved in the development of the discussed clinical phenomenon in other chronic pulmonary diseases with DN.

The paraneoplastic nature of the “drumstick” type changes in the distal phalanges of the fingers is clearly demonstrated by the disappearance of this clinical phenomenon after successful resection of the lung tumor. In turn, the reappearance of this clinical sign in a patient in whom treatment for lung cancer was successful is a likely indication of tumor recurrence.

PG can be a paraneoplastic manifestation of tumors located outside the lung area, and may even precede the first clinical manifestations of malignant tumors. Their formation is described in malignant tumors of the thymus, cancer of the esophagus, colon, gastrinoma, characterized by clinically typical Zollinger-Ellison syndrome, and pulmonary artery sarcoma.

The possibility of PG formation in malignant breast tumors and pleural mesothelioma, which is not accompanied by the development of DN, has been repeatedly demonstrated.

Thus, PG, along with various types of arthritis, erythema nodosum and migratory thrombophlebitis, are among the frequent extraorgan, nonspecific manifestations of malignant tumors. The paraneoplastic origin of changes in the distal phalanges of the fingers like “drumsticks” can be assumed when they form quickly (especially in patients without DN, heart failure and in the absence of other causes of hypoxemia), as well as when combined with other possible extra-organ, nonspecific signs of a malignant tumor - an increase in ESR, changes in the peripheral blood picture (especially thrombocytosis), persistent fever, articular syndrome and recurrent thrombosis of various locations.

One of the most common causes of PH is considered to be congenital heart defects, especially the “blue” type. Among 93 patients with pulmonary arteriovenous fistulas observed at the Mauo Clinic for 15 years, similar changes in the fingers were recorded in 19%; they exceeded the frequency of hemoptysis (14%), but were inferior to murmurs over the pulmonary artery (34%) and shortness of breath (57%).

R. Khouzam et al. (2005) described an ischemic stroke of embolic origin that developed 6 weeks after birth in an 18-year-old patient. The presence of characteristic changes in the fingers and hypoxia, which required respiratory support, led to a search for an anomaly in the structure of the heart: transthoracic and transesophageal echocardiography revealed that the inferior vena cava opened into the cavity of the left atrium.

PGs can “discover” the existence of pathological shunting from the left side of the heart to the right, including that formed as a consequence of cardiac surgery. M. Essop et al. (1995) observed characteristic changes in the distal phalanges of the fingers and increasing cyanosis for 4 years after balloon dilatation of rheumatic mitral stenosis, the complication of which was a small atrial septal defect. During the period since the operation, its hemodynamic significance increased significantly due to the fact that the patient also developed rheumatic stenosis of the tricuspid valve, after correction of which these symptoms completely disappeared. J. Dominik et al. noted the appearance of PG in a 39-year-old woman 25 years after successful repair of an atrial septal defect. It turned out that during the operation the inferior vena cava was mistakenly directed to the left atrium.

PG is considered one of the most typical nonspecific, so-called extracardiac, clinical signs of infective endocarditis (IE). The frequency of changes in the distal phalanges of the fingers like “drumsticks” in IE can exceed 50%. High fever with chills, increased ESR, and leukocytosis testify in favor of IE in a patient with PG; Anemia, a transient increase in serum activity of hepatic aminotransferases, and various types of kidney damage are often observed. To confirm IE, transesophageal echocardiography is indicated in all cases.

According to some clinical centers, one of the most common causes of the phenomenon of PH is cirrhosis of the liver with portal hypertension and progressive dilatation of the vessels of the pulmonary circulation, leading to hypoxemia (the so-called pulmonary-renal syndrome). In such patients, GOA is usually combined with cutaneous telangiectasias, often forming “spider vein fields”.
A connection has been established between the formation of HOA in liver cirrhosis and previous alcohol abuse. In patients with liver cirrhosis without concomitant hypoxemia, PG is usually not detected. This clinical phenomenon is also characteristic of primary cholestatic liver lesions requiring liver transplantation in childhood, including congenital bile duct atresia.

Repeated attempts have been made to decipher the mechanisms of development of changes in the distal phalanges of the fingers like “drumsticks” in diseases, including those mentioned above (chronic lung diseases, congenital heart defects, IE, liver cirrhosis with portal hypertension), accompanied by persistent hypoxemia and tissue hypoxia. Hypoxia-induced activation of tissue growth factors, including platelet growth factors, plays a leading role in the formation of changes in the distal phalanges and fingernails. In addition, in patients with PH, an increase in the serum level of hepatocyte growth factor, as well as vascular growth factor, was detected. The connection between the increase in the activity of the latter and a decrease in the partial pressure of oxygen in arterial blood is considered the most obvious. Also, in patients with PH, a significant increase in the expression of hypoxia-inducible factors type 1a and 2a is found.

In the development of changes in the distal phalanges of the fingers of the “drumstick” type, endothelial dysfunction associated with a decrease in the partial pressure of oxygen in arterial blood may have a certain significance. It has been shown that in patients with GOA, the serum concentration of endothelin-1, the expression of which is induced primarily by hypoxia, is significantly higher than that in healthy people.
The mechanisms of PG formation in chronic inflammatory bowel diseases, for which hypoxemia is not typical, are difficult to explain. At the same time, they are often found in Crohn’s disease (they are not typical in ulcerative colitis), in which changes in the fingers like “drum sticks” may precede the actual intestinal manifestations of the disease.

The so-called primary form of GOA, not associated with diseases of the internal organs, is known, often having a familial nature (Touraine-Solant-Gole syndrome). It is diagnosed only after excluding most of the causes that can cause the appearance of PG. Patients with the primary form of GOA often complain of pain in the area of the changed phalanges and increased sweating. R. Seggewiss et al. (2003) observed primary GOA involving only the fingers of the lower extremities. At the same time, when establishing the presence of PH in members of the same family, it is necessary to take into account the possibility that they have inherited congenital heart defects (for example, patent ductus botallus). The formation of characteristic changes in the fingers can continue for about 20 years.

“Drumstick” syndrome is a clearly marked thickening of the nail plates in a convex shape, vaguely reminiscent of curved watch glasses. From a distance, it seems that the tips of a person’s finger seem to have inflated huge balls, which are found in certain species of aquatic frogs, or they are wearing a round thimble. Due to its resemblance to the surface of a dial, the disease is often called “watch glass” syndrome.

How?

The above-described transformation of the nail surface occurs as a result of modification of the tissue lying between the nail plate and the bone. The tissue grows, but the bone itself remains unchanged.

“Drumsticks” can occur on both the arms and legs. However, in most cases, like a fish rotting from the head, the syndrome begins to develop from the fingers. At the very beginning of the disease, the angle between the nail plate and the posterior nail fold (known as the “Lovibond angle”) becomes approximately one hundred and eighty degrees, subsequently increasing (it is worth noting that the norm is one hundred and sixty degrees). In the last stages of development, the nail phalanges protrude almost half the size of the nail. This is accompanied by a feeling of constant discomfort.

When?

Drumstick syndrome can occur at any age. If a child suffers from such a disease, then it is most likely caused by some kind of congenital defect (often, for example, a heart defect leads to it). In an adult, “watch glass” syndrome can occur as a result of several types of diseases: pulmonary, gastrointestinal, cardiovascular. There is a high risk of developing “drumsticks” in heavy smokers, since the lungs of this group of people are quite weak. People suffering from liver cirrhosis, bronchogenic lung cancer, various chronic purulent lung diseases, and cystic fibrosis can also be considered at risk.

If you notice such symptoms, you should immediately consult a doctor to undergo a full medical examination and identify the cause of the disease. At the Pulmonology Center clinic you will be provided with high-quality care and will undergo a comprehensive examination, since in order to treat this problem it is vitally important to accurately determine its root cause. In the hospital, you must have an x-ray to determine whether this is really the syndrome described above or a consequence of congenital hereditary osteoarthropathy, the fundamental difference of which is the transformation of the bone.

Diagnostics:

taking anamnesis;
Ultrasound of vital organs (lungs, liver, heart);
chest x-ray;
CT scan;
ECG and ultrasound of the cardiovascular system;
study of external respiration function;
determination of blood gas composition;
general analysis blood;
general urine analysis.

Treatment:

The doctor can select an individual treatment program based on the results laboratory research, diagnosis and severity of the disease. The doctor may prescribe antibiotics, anti-inflammatory, immunomodulatory, antiviral drugs, as well as vitamin therapy, physiotherapy, diet, infusion or drainage therapy. The main thing for you is to promptly seek medical help from the Pulmonology Center. experienced specialists to find out the reasons that resulted in the appearance of “watch glasses”.

For your information:

Drumstick syndrome is often called “Hippocrates' fingers,” but the famous ancient Greek physician did not have such a disease. Hippocrates was simply the first scientist to describe this disease, and for more than two thousand years of history, medicine has skillfully dealt with “watch glasses.”

1. What are “watch glasses”?

This is a club-shaped growth of the connective tissue of the terminal phalanges, leading to a change in the normal angle between the nail and the nail bed (Lovibond angle). Especially noticeable on the back of the fingers.

2. Tell the story of the discovery of this symptom.

This symptom has attracted the attention of doctors since the time of Hippocrates, who described it in empyema. Interest in the symptom was revived in the 19th century. influenced by the German Eugen Bamberger and the French Pierre Marie, who described hypertrophic osteoarthropathy (HOA), a frequently developing accompanying (but not related to “watch glass”) change.

By the end of the First World War, watch glasses and GOAs were generally considered symptoms of chronic infection. Today they are more often associated with cancer (usually bronchial cancer).

Indeed, this combination occurs so often that HOA has even been called hypertrophic pulmonary osteoarthropathy, although the causes of HOA are by no means limited to lung diseases. Until now, despite the expansion of our knowledge and some recent interesting discoveries, the pathogenesis of these two symptoms remains an unsolved mystery.

3. Do watch glasses cause pain?

No. The watch glass never hurts, although at times patients may complain of aching sensations in the fingertips. In contrast, GOA is usually painful.

4. Is the growth of connective tissue with “watch glasses” limited to the fingers?

No. It usually affects the fingers and toes, although it can occur only on the arms or legs. Moreover, it can be bilateral and symmetrical or unilateral and affect only one finger.

Diagnostic signs"drumsticks" and "watch glasses".
(Self-portrait of Dick Ket - from the Museum of Modern Art, Arnhem, Holland.)

5. What are the reasons for this selective defeat?

"Hour glasses" only on the hands or feet usually appear when congenital defects“blue” type hearts. In this case, oxygen-poor blood selectively flows to the upper or lower halves of the body. The diseases that most often cause selective formation of “hour glasses” (and cyanosis) include:
(1) patent ductus arteriosus with pulmonary hypertension(in which the reverse discharge of blood limits the formation of “watch glasses” / cyanosis with the legs, without affecting the arms);
(2) the departure of the main blood vessels from the right ventricle of the heart (in this case, the reverse flow of blood leads to the formation of “watch glasses”/cyanosis only in the hands).

In the latter case, both the aorta and the pulmonary arteries arise from the right ventricle, which is often associated with a ventricular septal defect, patent ductus arteriosus, and pulmonary hypertension. As a result, oxygenated blood from the left ventricle enters the pulmonary trunk through the interventricular septum, enters through the patent ductus arteriosus into the descending aorta and is sent to the lower extremities.

On the contrary, oxygen-depleted blood from the right ventricle enters the ascending aorta and brachiocephalic vessels, thus reaching upper limbs. Therefore, the hands are cyanotic, with “watch glasses”, while the legs are unchanged (reverse selective cyanosis). And finally, the same and symmetrical cyanosis/formation of “watch glasses” on the fingers and toes indicates the presence of a right-to-left shunt in the heart.

6. Explain the reason for the one-sided formation of “watch glasses”.

This is usually an aortic aneurysm or subclavian artery. Also, the unilateral development of “watch glasses” can cause Pancoast tumor and lymphangitis. A less common cause is an artificially created dialysis fistula.

Lovibond angle measurement

7. Name the diagnostic criteria for “watch glasses”.

They depend on whether this is an isolated symptom or whether it is combined with periostosis. “” without periostosis - a classic symptom of “Hippocratic nails” - are characterized by the following features:

A) Disappearance of Lovibond's angle. This is the angle between the base of the nail and the surrounding tissues (subungual, or nail-phalangeal angle); normally less than 180°.
When “watch glasses” are formed, it is either completely lost (straight line) or becomes more than 180°. The disappearance of the Lovibond angle can be easily identified by placing a pencil on the surface of the nail. Normally, there should be a clear gap between the pencil and the nail. With “watch glasses” there will be no gap. That is, the pencil will lie completely on the nail.

b) Floating nails (nail bed balloting). The symptom is explained by loosening of the soft tissue at the base of the nail.

Thickness ratio of phalanx components

As a result, the nail plate “springs”: if you move the nail, squeezing the skin proximal to the nail, it will sink deep into the tissue towards the bone; if you release it, the nail will return to its original position - outward (floating of the nail bed), almost as if you push a piece to the bottom ice in a jar of water. A similar sensation can be artificially created in the following way:
Push right index finger on the skin proximal to the nail on the left middle finger. Normally, you will feel that the nail is firmly attached to the underlying bone.
Repeat the action, this time applying light pressure on the free edge of the nail with the thumb of your left hand, thus increasing the natural convexity of the nail plate. In this case, there will be a feeling that the nail plate is separated from the underlying bone and springs when pressed, almost as if it is floating on a loose nail bed.

V) Violation of the ratio of the thickness of the phalanx structures consists of an increase in the thickness of the fingertip measured at the cuticle (distal phalanx thickness - DPF) compared to the thickness at the interphalangeal joint (interphalangeal joint thickness - TMS).

Normally, the TDP/TMS ratio is on average 0.895, i.e. the distal phalanx narrows in the direction from the interphalangeal joint to the tip of the finger. On the contrary, when forming “drumsticks,” it expands with a TDP/TMS ratio of more than 1.0 (i.e., it differs from the normal value by 2.5 standard deviations).

The TDP/TMS ratio is an excellent sign for the diagnosis of “watch glasses”, with high sensitivity and specificity. For example, an indicator > 1.0 is detected in 85% of children with cystic fibrosis and in less than 5% of children with chronic asthma.

Variants of tissue growth of the distal phalanx of the finger

8. Is it possible to detect nail balloting only with “watch glasses”?

No. It can also be found in older patients in the absence of watch glasses. Nevertheless, nail balloting remains an important and valuable sign for the diagnosis of “watch glasses”.