The fingers are like drumsticks. “Watch glass”: causes of nail deformation

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 commonly 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. It is especially important 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 - the entry of venous blood into the arterial bed, bypassing the lungs or ventilated areas in them, which leads to a decrease in the 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 long-term 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 inferiority vascular endothelium(vascular cells), resulting in different areas multiple angiomas and telangiectasias (capillary abnormalities) form in the skin and mucous membranes of the lips, mouth, and internal organs, which bleed. Congenital vascular deficiency internal organs manifests itself as arteriovenous aneurysms, which are most often localized in the lungs, less often in the liver, kidneys, spleen and contribute to the development of pulmonary heart 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 only on one finger. One of the main reasons for enlarged holes on the nails is magnesium deficiency (Fig. 75). Reference to Fig. 75.

Poteyko P.I., Kharkovskaya medical academy Postgraduate Education, Department of Phthisiology and Pulmonology

Even in ancient times, 25 centuries ago, Hippocrates described changes in shape distal phalanges fingers, which were found 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 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 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). Rarely, this syndrome occurs in cancer. gastrointestinal tract, lymphoma with metastases to the lymph nodes of the mediastinum, 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 its long-term (over the course of years) development characteristic changes osteoarticular apparatus, while with 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 high risk the formation of irreversible pulmonary fibrosis in patients with IFA, also associated with a decrease in their survival.

At diffuse diseases connective tissue involving the pulmonary parenchyma PG 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 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 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 GOA is characteristic of 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; 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 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.

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 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 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 overproduction of growth hormone and prostaglandin E2 (PGE-2) 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 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.

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 of various locations.

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 hemoptysis in frequency (14%), but were inferior to noises over 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 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%. 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 “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 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 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 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.

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 signs of thrombotic pulmonary lesions vascular bed he was not identified. 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 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 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 the fingers only lower limbs. At the same time, when establishing the presence of PG in members of the same family, it is necessary to take into account the possibility that they have inherited birth defects heart (for example, patent ductus botellus). 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.

Hippocrates also described fingers that looked like drumsticks when studying empyema. For this reason, this pathology fingers and nails are named after the fingers of Hippocrates. German doctor Eugene Bamberger and French doctor Pierre Marie described hypertrophic osteoarthropathy back in the 19th century and pointed to the presence of fingers with glass-shaped nails in the disease. And already in 1918, doctors began to recognize this symptom as a sign of a chronic infection.

Drumstick-like fingers generally form on both extremities, but in some cases the pathology may affect only the arms or legs separately. This selection is typical for heart disease in the cyanotic form, which developed in the womb, when blood with oxygen enters only one part of the body.

Fingers that look like drumsticks, differ in what they look like:

parrot beak;
watch glasses;
real drum sticks.

Triggers

This pathology develops in the presence of the following diseases:

lung diseases of various origins;
endocarditis;
birth defects;
gastrointestinal ailments;
cystic fibrosis;
Graves' disease;
trichocephalosis;
Marie-Bamberger syndrome.

The reasons why a lesion develops on only one side may be:

Pancoast tumor (formed when cancer first segment of the lung);
diseases of the vessels through which lymph flows;
use of a fistula during hemodialysis;
taking drugs from the angiotensin II blocker group.

Reasons

The reasons for the development of the syndrome, in which the fingers become like drum sticks, have not been identified to this day. What is known is that this pathology develops in the presence of circulatory problems. In this case, tissue oxygen supply is disrupted.

Permanent oxygen starvation provokes an expansion of the lumen of the vessels located in the phalanges of the fingers, which provokes an increase in blood flow to this area.

The result of this process is a significant proliferation of connective tissue, which is located between the nail and the bone. It is worth noting that there is a relationship between the level of hypoxia and external changes nail bed shapes.

Studies have shown that in the presence of a chronic inflammatory disease in the intestines, oxygen starvation is not observed, but a change in the shape of the fingers and the appearance of a specific nail plate in the form of a watch glass not only develops with Crohn's disease, but may also be the first sign of this disease.

Symptoms

The manifestation in which the nails take on the appearance of watch glasses generally does not provoke pain. For this reason, the patient cannot notice this change in time.

Main signs of the symptom:

If the patient has bronchiectasis, cystic fibrosis, lung abscess, chronic empyema, the main symptom may be accompanied by osteoarthropathy of the hypertrophic type, which is characterized by:

bone pain;
changes in the characteristics of the skin in the pretibial area;
elbows, wrists and knees have changes very similar to arthritis;
the skin in some areas begins to become rough;
Paresthesia and excessive sweating develop.

Diagnostics

Most often, the symptom that appears with nails in the form of watch glasses signals the presence of Marie-Bamberger syndrome. If this diagnosis is not confirmed, then the doctor relies on compliance with the following criteria:

The Lovibond angle is measured. To do this, apply a pencil along the finger to the nail. If there is no gap between the nail and the pencil, then it can be said without a doubt that the patient has a symptom of drumsticks. Also, a decrease in the angle or its complete disappearance is determined by studying the Shamroth symptom.
Feeling with your finger to determine elasticity. To do this, click on top part finger and immediately release. If there is a sinking of the nail into the tissue, and then a sharp springing back, then we can assume a disease, the symptom of which is glass nails. The same effect occurs in elderly patients, but it is normal and does not indicate the presence of manifestations of drumsticks.
The doctor checks the ratio of the thickness of the TDF and the interphalangeal joint. For normal condition this figure does not exceed 0.895. If a symptom is present, that indicator increases to 1 or even more. This indicator is considered the most specific for this manifestation.

If there is a suspicion of a combination of hypertrophic osteoarthropathy with a symptom of drumsticks, then the doctor decides to give the patient an x-ray or scintigraphy.

It is important in diagnosing why the nail becomes “glassy” is to identify the main cause of the development of this symptom. To do this you need:

study anamnesis;
do an ultrasound examination of the lungs, heart and liver;
study the results of a chest x-ray;
the doctor prescribes a computed tomography and electrocardiogram;
the function of external respiration is examined;
the patient is required to donate blood to determine its gas composition.

Treatment

Therapy for nails in the form of watch glasses begins with the treatment of the underlying ailment. To do this, the doctor recommends that the patient take:

antibiotics;
medicines to boost immunity.

It would also be a good idea to review your diet. It is important to consult a nutritionist and find out the list of prohibited foods for this disease.

Forecast

The prognosis of how watch glass-like nails will look directly depends on what caused this pathology. If everything has already been cured of the underlying disease, then the symptoms will decrease and the fingers will look normal.

Resume

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, and also 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 Hippocrates' fingers often precedes more specific symptoms, and therefore the correct interpretation of this clinical sign, supplemented by the results of laboratory research methods, allows a timely establishment of a 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.

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 “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 a period 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.

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 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 (“ 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. 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.

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

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 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 “drumstick”-type changes in the distal phalanges of the fingers 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.

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 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 has been successful is a likely indication of tumor recurrence.

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. 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 extra-organ, 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 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.

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 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 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 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.

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.

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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 probably could see 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 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 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 is chronic bronchitis of 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. 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 is closed late and pulmonary hypertension remains, 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! 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.