Addison biermer disease causes pathogenesis. Addison-Birmer pernicious anemia - symptoms and consequences

Hippocrates' fingers (symptom drumsticks) - This characteristic symptom many diseases. This pathology is also called “watch glass”, since the fingers of the limbs acquire an irregular shape. They become convex at the end areas, thicken, and the nail plate is rounded. Most often, fingers - drumsticks - can be seen in older people, but the development of the disease is not related to the age of the patient.

The key mechanism is hypoxia, that is, oxygen deficiency in tissues. The phenomenon is painless and does not cause discomfort, but it is almost impossible to return the fingers to their usual shape. Even if treatment of the underlying disease is successful, reverse development doesn't happen.

Definition and general information

The syndrome is named after the doctor who first described it and associated it with the development of diseases respiratory system: tuberculosis, empyema, abscesses and various neoplasms. Changes in the shape of the phalanges of the fingers accompanied the main symptoms of the disease or preceded their development. Today, Hippocrates' fingers are considered a sign of hypertrophic osteoarthropathy - a disease in which the mechanisms of formation of the periosteum are disrupted, and there is intense growth on it. large number bone tissue.

The diagnosis can be made if two symptoms are present simultaneously:

“watch glasses” - the nail plate becomes round and increases in size;
“drumsticks” - thickening of the distal phalanges of the fingers.

Hippocrates' fingers can form within a few weeks. This process can be stopped by treating the underlying pathology, but reverse development is almost never achieved.

Causes and mechanism of development

The main trigger for the formation of Hippocratic fingers is considered to be hypoxia, that is, a lack of oxygen in the tissues. It was not possible to study it in detail, but doctors have several assumptions. Thus, a decrease in the rate of blood supply to the periosteum and insufficient intake nutrients its deformation occurs. During hypoxia, compensatory reactions are activated, expansion occurs small vessels. This provokes accelerated division of connective tissue cells, which underlies the formation of Hippocrates’ fingers.

The disease is more often diagnosed simultaneously on the upper and lower extremities, but its symptoms appear only on the arms or legs. It is believed that the rate of development of the disease depends on the level of deficiency of vital gases, including oxygen: the lower its supply to the tissues, the faster the deformation of the phalanges of the fingers occurs.

Initially, the causes of the pathology were considered to be chronic pulmonary infections that occur with symptoms purulent inflammation and general hypoxia. However, today a large number of diseases have been discovered that can manifest as a symptom of drumsticks. They are usually classified according to the location of the affected organ.

Diseases of the respiratory system that provoke the appearance of Hippocrates' fingers are serious pathologies that are life-threatening for the patient. These include cancer, chronic progressive purulent processes, tuberculosis, the formation of bronchiectasis (local dilation of the bronchi), abscesses, empyema (accumulation of pus in the pleural cavity) and others. They all also appear respiratory failure, general hypoxia, painful sensations V chest cavity and a general deterioration in health.
Diseases of the heart and blood vessels are another group of pathologies that occur with symptoms of hypoxia. Hippocrates' fingers may be signs birth defects blue type hearts. They get their name because patients experience a bluish discoloration of the skin (Fallot's disease, tricuspid atresia, pulmonary venous drainage, transposition of the mitral vessels, common truncus arteriosus). And also the syndrome can accompany sluggish inflammatory diseases of the membranes of the heart of an infectious nature.
Gastrointestinal diseases intestinal tract may also underlie the development of Hippocratic fingers. These include cirrhosis of the liver, ulcerative colitis (inflammation of the mucous membrane of the large intestine), Crohn's disease (an inflammatory process of autoimmune origin that can manifest itself in any part of the digestive tract), and various enteropathies.

Other pathologies have also been discovered, which are characterized by changes in the shape of the distal phalanges of the fingers of the upper and lower limbs. They are not related to infectious agents or with symptoms of hypoxia. These include:

Normally, there should be a gap between the base of the two nails, at the level of the cuticle - its absence indicates drumstick syndrome.

Hippocratic fingers in most cases appear on the upper and lower extremities simultaneously. However, in some cases one can notice their one-sided formation. This may be due to several phenomena:

Pancoast tumor is a specific neoplasm that is localized in the upper part of the lung;
lymphangitis - inflammatory processes in the walls of lymphatic vessels;
atriovenous fistula - a connection between an artery and a vein, can be formed artificially to purify the blood by hemodialysis for patients with severe forms renal failure.

Hypocrates' fingers are often one of the symptoms of the Marie-Bamberger complex. This is a syndrome that manifests itself nearby characteristic features. In patients, periosteum grows simultaneously in several areas; the distal phalanges of the fingers and toes are most often affected. And inflammatory reactions are also observed in the area of the terminal sections of long tubular bones (tibia, ulna and radius), which is manifested by a pain reaction. The causes of Marie-Bamberger syndrome are considered to be diseases of the lungs, heart and blood vessels, digestive tract and other specific pathologies. With radical (surgical) removal of the root cause of the disease, there is a possibility of reverse development. In some cases, the condition of the periosteum returned to normal within a few months.

Symptoms

Hippocrates' fingers can be recognized already at the initial examination. Since changes are visible to the naked eye, diagnosis is aimed at clarifying the cause of the symptom. The process of formation of fingers resembling drumsticks is not accompanied by painful sensations and occurs gradually, so many patients skip the first stages of its development.

In the future, the diagnosis can be made based on several characteristic signs:

compaction and proliferation of connective tissue on the distal phalanges of the fingers, this leads to the disappearance of the Lovibond angle (it is formed by the base of the nail and the surrounding tissues);
Shamroth's symptom - the absence of a gap between the bases of two nails, if they are applied to each other;
overgrowth of the nail plate;
soft tissues located at the base of the nail bed become too soft and loose;
Ballooning of the nail - when pressure is applied to the nail plate, it becomes elastic and shock absorbent.

All measurements can be carried out at home. It is worth understanding that the appearance of Hippocrates' fingers - dangerous symptom and accompanies diseases that threaten the patient’s life. If you suspect one of the characteristic signs, you should urgently contact medical care for urgent diagnosis and treatment, despite the painlessness of the process.

Forms of the disease

The shape of the digital phalanges depends on the type of hypoxia and individual characteristics patient. More often, changes occur symmetrically and affect both the upper and lower extremities. Unilateral damage is typical for specific pathologies of the heart and lungs, in which only one half of the body suffers from hypoxia. Thus, there are several types of Hippocrates’ fingers depending on their appearance:

“parrot beak” - associated with the growth of the upper sections of the terminal phalanges of the fingers;
“hour glasses” - are formed when the connective tissue grows around the nail plate, as a result of which it becomes round and wide;
“drumsticks” - the distal phalanges uniformly thicken and increase in volume.

Thickening of the fingers is a painless process, but pathological changes may lead to inflammatory changes and pain in the periosteum area.

Diagnostic methods

The diagnosis of Hippocratic fingers can be made by simple examination. Primary diagnosis includes confirmation of the main signs of the syndrome. If it occurs in isolation from the Marie-Bamberger complex, the following aspects must be established:

absence of a normal Lovibond angle - this can be checked by leaning the front part of the digital phalanx against any flat surface, as well as by diagnosing Schamroth’s symptom;
increased elasticity of the nail plate - when you press on the top of the nail, it sinks into the soft tissue and then gradually levels out;
an increase in the ratio between the volume of the terminal phalanx of the finger in the cuticle area and the interphalangeal joint, but this sign does not appear in all patients.

To determine the cause of the appearance of Hippocratic nails, full examination. It includes x-ray of the lungs, ultrasound of the heart and organs abdominal cavity, clinical and biochemical tests blood and urine. If necessary, you can examine the conditions individual organs on MRI or CT - these diagnostic methods are considered the most reliable.

You can determine the appearance of Hippocrates’ fingers yourself, but more detailed diagnostics and treatment must only take place in a medical facility.

Treatment and prognosis

Therapy methods are selected individually, depending on the cause of the appearance of Hippocratic fingers. These may include antibiotic therapy, specific agents that suppress autoimmune reactions, anti-inflammatory drugs and other medications. In some cases it is shown surgery(removal of tumors). The prognosis depends on the success of treatment of the underlying disease, the patient’s age and individual characteristics.

Hippocrates' fingers are a symptom that may first appear in adulthood. It may progress slowly and not bother the patient for several years, but in some cases it occurs quickly. It is possible to make a diagnosis, including at home, but the cause of this symptom can only be determined based on additional research. Further treatment also differs and depends on the results of a complete diagnosis.

Poteyko P.I., Kharkovskaya medical academy 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).

Hippocrates finger syndrome includes two signs: “hour glass” (Hippocrates fingernails - ungues Hippocraticus) and club-shaped deformity the terminal phalanges of the fingers according to the type of “drum sticks” (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 due to a violation of microcirculation, accompanied by local tissue hypoxia, impaired trophism of the periosteum 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 PG is the value of the angle ACE. 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 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 of this syndrome in non-tumor diseases there is a long (over the course of years) development characteristic changes osteoarticular apparatus, while in case of malignant neoplasms this process is calculated in weeks and months. After radical surgical treatment 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 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 “watch glass” symptom, thickening, hyperemia and cyanosis of the nail fold (“delicate” Hippocratic 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 IFA, which is also associated with a decrease in their survival.

At diffuse diseases connective tissue involving 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 intrathoracic sarcoidosis 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 organ pathologies chest(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 is in favor of high risk 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; some of them, along with diffuse pneumosclerosis foci of active alveolitis were found. Changes in the distal phalanges of the fingers like “drumsticks” 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 clinical signs activity of lung damage, requires a persistent search for a malignant tumor in lung tissue. It has been shown that in lung cancer that developed 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.

Rapid development changes in the distal phalanges of the fingers like “drum sticks” are 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 HOA in lung cancer is associated with hyperproduction of growth hormone and prostaglandin E2 (PGE-2) by tumor cells. Partial pressure of oxygen in peripheral blood however, it 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 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 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.

PGs are 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. In one of the observations, regression of typical changes in the distal phalanges of the fingers was stated with successful chemotherapy and radiation therapy 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 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 defect 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 elimination 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 PG 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. childhood, including congenital atresia bile ducts.

Repeated attempts have been made to decipher the mechanisms of development of changes in the distal phalanges of the fingers like “drum sticks” 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 the 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 Behcet'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 Mycobacterium tuberculosis in sputum samples.

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 when most of the causes that can cause the appearance of PG have been excluded. 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.

LESSON 21-7 SYMPTOM OF DRUMSTICKS The symptom of drumsticks (Hippocratic fingers) is a flask-shaped thickening of the terminal phalanges of the fingers of the hands, less often of the toes, in chronic diseases of the heart, lungs, and liver with a characteristic deformation of the nail plates in the form of watch glasses. The tissue between the nail and the underlying bone becomes spongy, causing the nail plate to feel mobile when pressure is applied to the base of the nail. This thickening accompanies various diseases, often precedes more specific symptoms of the disease. You especially need to remember the connection of this symptom with lung cancer. The symptom of drumsticks is not an independent disease, but is a rather informative sign of other diseases, pathological processes and proceeds unnoticed at first because it does not cause pain. Thickening of the terminal phalanges can develop over many years, and in some diseases within several months (lung abscess). CAUSES One of the main reasons for the formation of the drumstick symptom is the discharge of blood from right to left - getting into venous blood into the arterial bed, bypassing the lungs or ventilated areas in them, which leads to a decrease in oxygen content in the blood, the development of hypoxemia, hypoxia and, ultimately, to vasodilation nail phalanges fingers. The discharge of blood is accompanied by an increase in P(A-a)O2 - the alveolar-arterial difference in the partial pressure of oxygen. The partial pressure of oxygen in arterial blood (PaO2) does not increase when inhaled with 100% oxygen (O2). The discharge of blood from right to left can be intracardiac and intrapulmonary. Intracardiac shunting of blood from right to left - direct entry of blood from the right parts of the heart to the left, most typical for congenital cyanotic heart defects (atrial septal defect, interventricular septum, tetralogy of Fallot) and infective endocarditis. Intrapulmonary shunting of blood from right to left - most often occurs in diseases accompanied by impaired ventilation with normal perfusion of the alveoli. This is due to multiple scattered microatelectasis - collapse of the pulmonary alveoli due to compression of the lung, blockage of the bronchial tube (for example, mucus, tumor), as well as due to obstruction and occlusion (impaired patency) of the pulmonary capillaries. Intrapulmonary shunting of blood from right to left occurs against the background of prolonged pulmonary diseases: bronchial lung cancer, bronchiectasis, pleural empyema, lung abscess, alveolitis. Less commonly, intrapulmonary discharge of blood occurs through arteriovenous fistulas. They can be congenital (eg, hereditary hemorrhagic telangiectasia) or acquired and can occur in any organ, although they are most often found in the lungs. REFLECTION OF THE SYMPTOM OF DRUM STICKS Fig. 76a, 31 year old man. Hereditary hemorrhagic telangiectasia, recurrent nosebleeds, drumstick sign in initial stage diseases. Fig. 76b, man, cyanotic heart defect, drumstick symptom in the final stage of the disease. Link to Fig.76: https://img-fotki.yandex.ru/get/69324/39722250.2/0_14b0e0_9c7cbac9_orig Hemorrhagic telangiectasia (Osler-Weber-Rendu disease) is a disease based on the inferiority of the vascular endothelium (vascular cells), resulting in different areas of the skin and mucous membranes of the lips, mouth, and internal organs Multiple angiomas and telangiectasia (capillary abnormalities) are formed, which bleed. Congenital inferiority of the vessels of internal organs is manifested by arteriovenous aneurysms, which are most often localized in the lungs, less often in the liver, kidneys, spleen and contribute to the development of pulmonary-cardiac diseases. DRUM STICK SYMPTOM - indicates reduced content oxygen in tissues (hypoxia) and the development of pulmonary-heart diseases, the cause of which in this case is hemorrhagic telangiectasia. With the symptom of drumsticks, the holes on the nails are almost always enlarged (Fig. 76a and Fig. 76b). LARGE HOLES ON THE NAILS, as well as their absence, indicate a disturbance in calcium metabolism in the body. Sometimes the hole enlarges on only one finger. One of the main reasons for enlarged holes on the nails is magnesium deficiency (Fig. 75). Reference to Fig. 75.

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. These are drumstick fingers 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 severe 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 that it takes years for a given symptom to develop. 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 open oval window, but the real serious vices are mainly 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 chronic 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? Probably most of them are associated with systemic inflammation and phenomena of tissue hypoxia secondary to metabolic disorders.

Main!

Fingers-drumsticks, with rare exceptions, are almost never an independent unit and always point to serious illnesses. 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. Ventricular septal defect is birth defect"blue" color, which 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.

IN full confidence that there would be something bad on the echocardiogram, I sent him for examination... And nothing! 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 due to a long history of 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 cause is not always true.

People suffering chronic pathologies the lungs, heart and liver may have a flask shape. In medicine, this is called drumstick syndrome. The disease, as a rule, does not cause noticeable pain and does not affect tissue 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 back wall nail The nail takes on a distorted appearance and becomes deformed.

General information

The world first learned about the existence of fingers in the form of drumsticks from Hippocrates, who mentioned them in his description 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 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.

“Drum sticks” 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, cancer, 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 of the 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 limb pathology is the main type of Marie-Bamberger syndrome, which affects tubular bones in the body, and is aggravated by cancer of the bronchogenic type. 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 in the 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 intestinal forms manifestations 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.
The presence of pain in the skeletal system.
One or several 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 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.
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?

To treat the affected fingers, first of all, you need 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.