Fingers drumsticks. Drumstick-shaped fingers - causes and treatment

People suffering from chronic pathologies of the lungs, heart and liver may have a flask-shaped appearance. In medicine, this is called drumstick syndrome. The disease, as a rule, does not cause noticeable pain and does not affect tissue skeletal system. The soft tissues of all fingers of both hands and toes change their thickness, changing the angle upward in the interval between the nail plate and the nail fold of the posterior 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 that this pathology 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 changes of a cyanotic nature in the extremities appear in people with chronic heart disease, when only one half of the human body is supplied with blood: the lower or, respectively, the upper.

“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, alveolitis fibrous type, suppuration processes of a chronic nature.
• 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 of the gastrointestinal 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 causing the appearance unilateral pathology 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 dilation of blood vessels in the toes and hands. 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 drumstick symptom, you need to contact a 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 total thickness ratio distal phalanx cuticle and joint between 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.
• Row 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.

Summary

Changes in the distal phalanges of the fingers like “drumsticks” and nails like “watch glasses” (Hippocratic fingers) are a well-known clinical phenomenon indicating the possible presence of various diseases, among which the leading position is occupied by those associated with prolonged endogenous intoxication and hypoxemia, as well as malignant tumors. At the same time, one should take into account the possibility of manifestation of this clinical syndrome in other diseases (Crohn's disease, HIV infection, etc.).

The appearance of Hippocratic fingers often precedes more specific symptoms, and therefore the correct interpretation of this clinical sign, supplemented by the results laboratory methods research allows for a timely and reliable diagnosis.

Keywords

Hippocrates' fingers, differential diagnosis, hypoxemia.

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).

Hippocrates' finger syndrome includes two signs: “hour glasses” (Hippocrates' nails - ungues Hippocraticus) and a 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 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).

On unmodified fingers, the distance between points A and B should exceed the distance between points C and D. With “drum sticks” 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 “Hippocrates fingers”, in paraneoplastic Marie-Bamberger syndrome, periostitis appears in the area of ​​the end sections of the 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 observed, with x-ray examination a double cortical layer is revealed, 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 in other primary intrathoracic tumors ( benign neoplasms lungs, 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 This syndrome in non-tumor diseases 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.

Relationship between GHG and chronic diseases lungs, accompanied by prolonged 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% (within several years ), pleural empyema - 40-60% (for 3-6 months or more) (“rough” fingers of Hippocrates, Fig. 4).

In tuberculosis of the respiratory system, 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 (“ gentle" 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 with ELISA, reflecting, in particular, the prevalence of active damage to the alveoli (ground-glass zones detected with computed tomography) and the severity of proliferation of vascular smooth muscle cells in areas of fibrosis. PH 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.

For diffuse diseases connective tissue with the involvement of the pulmonary parenchyma, PG always reflects the severity of DN and is 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 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 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 “drumsticks” and nails like “watch glasses” are often recorded in occupational diseases involving the pulmonary interstitium. Relatively early appearance GOA is characteristic of patients with asbestosis; this sign is in favor of 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 “drum sticks” is one of the indications for the development of lung cancer even in the absence 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 morphological form lung cancer: reaching 35% with the non-small cell variant, with the small cell variant this figure is only 5%.

The development of GOA in lung cancer is associated with overproduction of growth hormone and prostaglandin E2 (PGE-2) 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 of the lung tumor. In turn, the reappearance of this clinical sign in a patient in whom treatment for lung cancer 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, sarcoma pulmonary artery.

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 “drum sticks” 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, non-specific 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 reasons the appearance of PG is considered birth defects hearts, 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 fever. mitral stenosis, the complication of which was a small defect of the interatrial septum. 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%. Evidence in favor of IE in a patient with PG high fever with chills, increased ESR, leukocytosis; 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. childhood, including congenital atresia of the bile ducts.

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 was detected, as well as vascular factor growth. 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. However, they are often found in Crohn's disease (with ulcerative colitis they are not typical), in which a “drumstick” type change in the fingers may precede the actual intestinal manifestations diseases.

Number probable causes, causing changes in the distal phalanges of the fingers like “watch glasses”, 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 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.

Bibliography

1. Kogan E.A., Kornev B.M., Shukurova R.A. Idiopathic fibrosing alveolitis and bronchiolo-alveolar cancer // Arch. Pat. - 1991. - 53 (1). - 60-64.
2. Taranova M.V., Belokrinitskaya O.A., Kozlovskaya L.V., Mukhin N.A. “Masks” of subacute infective endocarditis // Ter. arch. - 1999. - 1. - 47-50.
3. Fomin V.V. Hippocrates' fingers: clinical significance, differential diagnosis// Wedge. honey. - 2007. - 85, 5. - 64-68.
4. Shukurova R.A. Modern ideas about the pathogenesis of fibrosing alveolitis // Ter. arch. - 1992. - 64. - 151-155.
5. Atkinson S., Fox S.B. Vascular endothelial growth factor (VEGF)-A and platelet-derived growth factor (PDGF) play a central role in the pathogenesis of digital clubbing // J. Pathol. - 2004. - 203. - 721-728.
6. Augarten A., Goldman R., Laufer J. et al. Reversal of digital clubbing after lung transplantation in cystic fibrosis patients: a clue to the pathogenesis of clubbing // Pediatr. Pulmonol. - 2002. - 34. - 378-380.
7. Baughman R.P., Gunther K.L., Buchsbaum J.A., Lower E.E. Prevalence of digital clubbing in bronchogenic carcinoma by a new digital index // Clin. Exp. Rheumatol. - 1998. - 16. - 21-26.
8. Benekli M., Gullu I.H. Hippocratic fingers in Behcet’s disease // Postgrad. Med. J. - 1997. - 73. - 575-576.
9. Bhandari S., Wodzinski M.A., Reilly J.T. Reversible digital clubbing in acute myeloid leukaemia // Postgrad. Med. J. - 1994. - 70. - 457-458.
10. Boonen A., Schrey G., Van der Linden S. Clubbing in human immunodeficiency virus infection // Br. J. Rheumatol. - 1996. - 35. - 292-294.
11. Campanella N., Moraca A., Pergolini M. et al. Paraneoplastic syndromes in 68 cases of resectable non-small cell lung carcinoma: can they help in early detection? //Med. Oncol. - 1999. - 16. - 129-133.
12. Chotkowski L.A. Clubbing of the fingers in heroin addiction // N. Engl. J. Med. - 1984. - 311. - 262.
13. Collins S.E., Cahill M.R., Rampton D.S. Clubbing in Crohn’s disease // Br. Med. J. - 1993. - 307. - 508.
14. Courts I.I., Gilson J.C., Kerr I.H. et al. Significance of finger clubbing in asbestosis // Thorax. - 1987. - 42. - 117-119.
15. Dickinson C.J. The aetiology of clubbing and hypertrophic osteoarthropathy // Eur. J. Clin. Invest. - 1993. - 23. - 330-338.
16. Dominik J., Knnes P., Sistek J. et al. Iatrogenic clubbing of the fingers // Eur. J. Cardiothorac. Surg. - 1993. - 7. - 331-333.
17. Falkenbach A., Jacobi V., Leppek R. Hypertrophic osteoarthropathy as an indicator for bronchial carcinoma // Schweiz. Rundsch. Med. Prax. - 1995. - 84. - 629-632.
18. Fam A.G. Paraneoplastic rheumatic syndromes // Bailliere’s Best Pract. Res. Clin. Rheumatol. - 2000. - 14. - 515-533.
19. Glattki G.P., Maurer C., Satake N. et al. Hepatopulmonary syndrome // Med. Klin. - 1999. - 94. - 505-512.
20. Grathwohl K.W., Thompson J.W., Riordan K.K. et al. Digital clubbing associated with polymyositis and interstitial lung disease // Chest. - 1995. - 108. - 1751-1752.
21. Hoeper M.M., Krowka M.J., Starassborg C.P. Portopulmonary hypertension and hepatopulmonary syndrome // Lancet. - 2004. - 363. - 1461-1468.
22. Kanematsu T., Kitaichi M., Nishimura K. et al. Clubbing of the fingers and smooth-muscle proliferation in fibrotic changes in the lung in patients with idiopathic pulmonary fibrosis // Chest. - 1994. - 105. - 339-342.
23. Khouzam R.N., Schwender F.T., Rehman F.U., Davis R.S. Central cyanosis and clubbing in an 18-year-old postpartum woman presenting with a stroke // Am. J. Med. Sci. - 2005. - 329. - 153-156.
24. Krowka M.J., Porayko M.K., Plevak D.J. et al. Hepatopulmonary syndrome with progressive hypoxemia as an indication for liver transplantation: case reports and literature review // Mayo Clin. Proc. - 1997. - 72. - 44-53.
25. Levin S.E., Harrisberg J.R., Govendrageloo K. Familial primary hypertrophic osteoarthropathy in association with congenital cardiac disease // Cardiol. Young. - 2002. - 12. - 304-307.
26. Sansores R., Salas J., Chapela R. et al. Clubbing in hypersensitivity pneumonitis. Its prevalence and possible prognostic role // Arch. Intern. Med. - 1990. - 150. - 1849-1851.
27. Sansores R.H., Villalba-Cabca J., Ramirez-Venegas A. et al. Reversal of digital clubbing after lung transplantation // Chess. - 1995. - 107. - 283-285.
28. Silveira L.H., Martinez-Lavin M., Pineda S. et al. Vascular endothelial growth factor and hypertrophic osteoarthropathy // Clin. Exp. Rheumatol. - 2000. - 18. - 57-62.
29. Spicknall K.E., Zirwas M.J., English J.S. Clubbing: an update on diagnosis, differential diagnosis, pathophysiology, and clinical relevance // J. Am. Acad. Dermatol. - 2005. - 52. - 1020-1028.
30. Sridhar K.S., Lobo S.F., Altraan A.D. Digital clubbing and lung cancer // Chest. - 1998. - 114. - 1535-1537.
31. The ESC Task Force. ESC Guidelines on prevention, diagnosis and treatment of infective endocarditis // Eur. Heart J. - 2004. - 25. - 267-276.
32. Toepfer M., Rieger J., Pfiuger T. et al. Primary hypertrophic osteoarthropathy (Touraine - Solente - Gole syndrome) // Dtsch. Med. Wschr. - 2002. - 127. - 1013-1016.
33. Vandemergel X., Decaux G. Review on hypertrophic osteoarthropathy and digital clubbing // Rev. Med. Brux. - 2003. - 24. - 88-94.
34. Yancey J., Luxford W., Sharma O.P. Clubbing of the fingers in sarcoidosis // JAMA. - 1972. - 222. - 582.
35. Yorgancioglu A., Akin M., Demtray M., Derelt S. The relationship between digital clubbing and serum growth hormone level in patients with lung cancer // Monaldi Arch. Chest Dis. - 1996. - 51. - 185-187.

Have you ever seen such unusual fingers? This looks like thickening of the fingertips and rounding of the nails. At the same time, to the touch it seems that the nail does not hold well and “floats” a little. This - fingers-drumsticks or, as they are also called, “watch glasses”. In English literature the term "clubbing" is most often used. Their historical name is “Hippocrates’ fingers”. You've probably seen these in older men, but sometimes they also occur in people young. There is an opinion that their development is associated with hard physical labor, however, this assumption is a myth.

The main reason for this phenomenon is tissue hypoxia. But to this day it is not clear why nature came up with such a strange response to hypoxia - what function it has. In addition, it is not entirely clear why not all diseases associated with hypoxia develop a similar condition.

A common misconception is the assumption that for development this symptom it takes years. In fact, drumstick fingers can form in just a couple of weeks. Unfortunately, there is practically no reverse development in this case (even after the underlying disease has been cured).

Here is a list of the most common causes of these mysterious fingers:

Heart defects . But not minor developmental anomalies, such as an open oval window, but real serious defects, mostly of the “blue type”.

Infective endocarditis - inflammation of the inner lining of the heart, often accompanied by the formation of acquired heart defects.

Lung diseases. Most often this Chronical bronchitis a smoker or another variant of COPD (chronic obstructive pulmonary disease). But if fingers appear, this indicates that it is high time to start treatment, including inhalation therapy, etc. This also includes all types of lung oncology, interstitial diseases, including alveolitis.

Pathology of the gastrointestinal tract: celiac disease, Crohn's disease, ulcerative colitis.

Cirrhosis.

Hyperthyroidism.

HIV.

Hypertrophic osteoarthropathy.

And a considerable list of rare reasons.

For many diseases, a natural question arises: where is the hypoxia? It is likely that most of them are associated with systemic inflammation and tissue hypoxia secondary to metabolic disorders.

Main!

Fingers-drumsticks, with rare exceptions, are almost never an independent unit and always indicate serious illness. Therefore, the detection of this symptom requires a good diagnosis and identification of the real cause!

And finally, a small story from personal practice.

Already being a cardiologist, at one of the family feasts, I noted the presence of drumstick-shaped fingers in one of my relatives. It was known that he had had heart surgery as a child. Then I clarified with his mother that in childhood the boy was diagnosed with a “ventricular septal defect” and at the age of about three years he was operated on. A ventricular septal defect is a congenital defect of a “blue” color that must be closed in a short time.

Everything came together in my head! Short, short muscle mass, blue lips, fingers - drumsticks. This means that the defect was closed late and remained pulmonary hypertension or, even worse, the defect is not completely sutured.

By the way, echocardiography was not performed even once after the operation. And for some reason the boy was not registered with a cardiologist.

Fully confident that there would be something bad on the echocardiogram, I sent him for testing... And nothing! There is no residual defect, no residual effects, the defect is well closed and the heart looks great!

However, during further examination, another pathology was revealed - severe COPD against the background long experience smoking.

This example, on the one hand, confirms the connection of the described symptom with hypoxia and COPD, and, on the other hand, illustrates that sometimes it happens that the most obvious reason is not always true.

The first mention of such a problem as drumstick fingers was found in the writings of Hippocrates, which is why the disease is also called “Hippocrates’ fingers.” He identified a similar deviation in a patient with empyema - an accumulation of pus in any organ. The symptom and its causes were described in more detail at the beginning of the 20th century, but in those days doctors considered the disease solely a sign of chronic infections.

Drumstick syndrome

Drum fingers, or the symptom of drumsticks, is a flask-shaped painless thickening of the first (terminal) phalanges on the hands and feet. At the same time, a specific deformation of the nail plates occurs, which is called “watch glass nails.” The ICD-10 code for this pathology is R68.3.

With advanced lesions of the fingers and nails, it is difficult not to notice external signs. The tissue between the nail plate and the bone becomes spongy, so the nail takes on a convex shape, and when you press on it, there is a feeling of mobility. Drum fingers do not become an independent pathology; they are inherent in a variety of serious illnesses internal organs or immune system.

Forms of the disease

Usually the fingers become like drumsticks on the top and lower limbs simultaneously. Much less often, thickenings occur only on the arms or isolated on the legs, which can only happen with special forms circulatory disorders (when one half of the body is poorly supplied with blood).

By appearance The following forms of symptoms are distinguished:

• “parrot’s beak” - the patient’s proximal part of the terminal phalanx of the fingers thickens and becomes deformed;
• “watch glasses” - changes are noticeable mainly on the nails - at the base the nail plates grow greatly;
• “classical” form - the fingers thicken along the entire circumference of the terminal phalanx.

Symptoms of drumsticks and watch glasses

Not all patients immediately pay attention to the ongoing pathological changes, because drum fingers do not cause pain or other discomfort. But upon careful examination, it is possible to identify violations in the form of the following signs even at the initial stage:

• visually and tactilely noticeable increase soft fabric in size - in this case the phalanx becomes wider, more voluminous, and the natural angle between the base of the finger and its fold disappears;
• smoothing the gap between the nails when matching the corresponding fingers on the right and left hand and foot;
• increasing curvature and convexity of the nail, growth of the nail bed, excessive softness of the area at the base of the nail;
• Balloting of the nail - gaining strength and specific elasticity.

In the vast majority of cases, the fingers begin to change at a serious stage of the underlying disease, so its symptoms also appear. Many patients have already been diagnosed, but some still do not know about the disorders occurring in the body. If the disease affects the lungs, the person suffers from a chronic cough, there is sputum that is difficult to separate, and mucus and blood appear.

Often found and systemic disease joints – hypertrophic pulmonary osteoarthropathy. In this case, tympanic fingers with periostosis are diagnosed - a non-inflammatory change in the periosteum in the form of a layering of osteoid tissue on the cortical layer of the tubular bones. As a result, bone calcification occurs, as well as a number of dystrophic processes. Osteoarthropathy is characteristic of metastases of lung cancer to the bones, as well as cystic fibrosis, chronic empyema. In this case, the symptoms are varied:

• constant pain in the bones - mild or more severe, aching and twitching;
• pain when feeling bones;
• symmetrical joint damage;
• coarsening of soft tissues in the area of ​​the hands, feet, and, less often, the face;
• increased sweating of the hands and feet, decreased sensitivity.

After surgery or therapeutic treatment, all symptoms decrease or disappear completely (if the disease has not reached a severe stage).

Causes of pathology

Most often symptom drum fingers cause lung and heart diseases. Among pulmonary diseases, there are acute and chronic ones, and in the first case, thickening of the fingers is possible already after 7-10 days from the development of the main pathology. Chronic pulmonary diseases can cause drumstick fingers:

• cancer of the lung, bronchi, pleura, diaphragm;
• lymphoma, lymphogranulomatosis;
• metastases to the bronchi, lungs;
• chronic bronchiectasis;
• cystic fibrosis in cystic fibrosis;
• alveolitis of various forms;
• purulent diseases;
• COPD;
• altitude sickness;
• silicosis, asbestosis and other occupational diseases of the respiratory system.

Their heart and vascular diseases in the etiology of the symptom are played by various congenital defects, especially the blue type - tetralogy of Fallot, TMS, pulmonary atresia. Fingers can change shape after suffering inflammation of the valves - endocarditis. Very rarely does a symptom become a consequence long-term use antihypertensive drugs based on losartan and its analogues.

In advanced forms of celiac disease (without following a diet), Crohn's disease and ulcerative colitis, liver cirrhosis, the shape of the fingers may also change. Similar signs are observed when the body is infected with whipworms and trichuriasis. Less common causes of pathology are erythremia, diffuse toxic goiter and hyperthyroidism, HIV and AIDS, diffuse connective tissue diseases. If the fingers are affected on only one side, the problem may be caused by:

• hemodialysis;
• lymphangitis;
• apical lung cancer.

In the presence of these diseases, abnormal growth of the connective tissue of the phalanges occurs. The reasons are violation humoral regulation, development of chronic oxygen starvation tissues, compensatory dilation of blood vessels on the fingers.

Diagnostics

Mark external changes and the presence of a symptom can be determined by a number of physical tests:

• smoothing of the Lovibond angle, determined by applying a pencil and identifying a small gap between the base of the nail and the surrounding skin (normally less than 180 degrees);
• Shamroth's symptom - when the bent index fingers touch the nails, a diamond-shaped lumen is normally visible, but in case of disease it disappears;
• balloting - when you press on the skin above the nail, the finger seems to sink into it, and when released, the nail springs back;
• measurement of the phalanges - the ratio of the thickness of the distal phalanx in the cuticle area and the thickness of the interphalangeal joint increases (normally it is about 0.895).

As for the last test, in people with severe lung diseases the indicator may be 1 or more, for example, with cystic fibrosis, this problem is found in the vast majority of children.

To find the cause of the disease, additional examinations must be carried out:

• CT scan of the lungs or radiography;
• Ultrasound of the heart, ECG;
• Ultrasound of internal organs;
• bone radiography or scintigraphy;
• blood biochemistry, etc.

Treatment and prognosis

Since the cause of the pathology is developing underlying diseases, treatment is aimed at their correction or elimination. For heart defects and tumors, operations are performed (if possible). Cancerous tumors require radiation and chemotherapy. With endocarditis, purulent diseases They also operate on the patient and administer an intensive course of antibiotic treatment. In parallel, for any reason for finger lesions, therapy with immunomodulators, vitamins, and a balanced diet are recommended.

The prognosis depends on the type and stage of the underlying disease. For advanced cancer tumors, the prognosis is disappointing; for cystic fibrosis, it is serious; for diseases of the gastrointestinal tract and thyroid gland, long-term remissions or complete cure are possible.