Drumsticks. "Watch glasses": causes of nail deformation Club-shaped fingers

Drum stick syndrome is not an independent disease, but rather an informative sign of other diseases and pathological symptoms.

The reasons

The true reasons why fingers in the form of drumsticks develop in long-term smokers, in those suffering from pulmonary and cardiac pathologies, are not yet clear. It is assumed that the causes lie in the violation of humoral regulation under the influence of provoking factors, including chronic hypoxia. The provocateurs of the development of this symptom can be pulmonary diseases: lung cancer, chronic pulmonary intoxication, bronchiectasis, lung abscess, fibrosis.

Often drumsticks are found in those suffering from cirrhosis of the liver, Crohn's disease, with tumors of the esophagus, esophagitis. Lymphoma, myeloid leukemia, infective endocarditis, heart defects, and hereditary causes can also cause the fingers to look like drumsticks.

Symptoms

The symptom of fingers - drumsticks proceeds at first unnoticed by the patient, since it does not cause pain, and it is not so easy to notice changes. First, soft tissues thicken on the terminal phalanges of the fingers (more often than the hands). Bone tissue is not changed. As the distal phalanges increase, the fingers become more and more like drumsticks, and the nails take on the appearance of watch glasses.

If you press on the base of the nail, you will get the impression that the nail is about to come off. In fact, a layer of supple spongy tissue has formed between the nail and the bone of the phalanx, which creates a feeling of looseness of the nail plate. In the future, the changes become more noticeable and coarser, and when the fingers are brought together, the so-called “Shamroth window” disappears.

Diagnosis and treatment

X-ray and bone scintigraphy will help to clarify whether these are really fingers in the form of drumsticks, and not congenital hereditary osteoarthropathy.

When this symptom appears, a complete and thorough examination of the patient is necessary in order to determine the source of this symptom. Etiotropic treatment may be different - depending on the cause that led to the development of drumstick fingers.

Forecast

It depends solely on the reason that led to its development. If the fingers of the drumsticks have developed due to a disease that can be cured or transferred to the stage of stable remission, then the reverse development of symptoms is possible, including the fingers of the drumsticks and nails - watch glasses.

Drum stick fingers are a fairly typical symptom that develops in people suffering from chronic lung diseases, including those that occur in a latent form. It is rare that anyone notices the appearance of this symptom, since the fingers are the part of the body that a person sees daily. Drum stick syndrome is not an independent disease, but rather an informative sign of other diseases and pathological symptoms.

Causes of fingers in the form of drumsticks

Pulmonary diseases can be provocateurs of the development of this symptom:

lung cancer,
chronic pulmonary intoxication,
bronchiectasis,
lung abscess,
fibrosis.

Often drum sticks are found in those suffering from cirrhosis of the liver, Crohn's disease, with tumors of the esophagus, esophagitis. , myeloid leukemia, infective endocarditis, heart defects and hereditary causes can also cause the fingers to take on the appearance of drumsticks.

X-ray and bone scintigraphy will help to clarify whether these are really fingers in the form of drumsticks, and not congenital hereditary osteoarthropathy. When this symptom appears, a complete and thorough examination of the patient is necessary in order to determine the source of this symptom. Etiotropic treatment may be different - depending on the cause that led to the development of drumstick fingers.

Hippocrates' fingers (a symptom of drumsticks) is a characteristic symptom of many diseases. This pathology is also called "watch glass", because the fingers of the limbs become irregular in shape. They become convex in the final sections, 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 associated with the age of the patient.

The key mechanism is hypoxia, that is, oxygen deficiency in the 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 the treatment of the underlying disease is successful, the reverse development does not occur.

Definition and general information

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

Diagnosis can be made when two symptoms are present at the same time:

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

Hippocratic 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 hypoxia, that is, a lack of oxygen in the tissues. It was not possible to study it in detail, but doctors have several assumptions. So, a decrease in the rate of blood supply to the periosteum and insufficient intake of nutrients causes its deformation. During hypoxia, compensatory reactions are activated, and small vessels expand. This provokes an accelerated division of connective tissue cells, which underlies the formation of Hippocratic 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.

Initially, the causes of the pathology were considered to be chronic pulmonary infections that occur with symptoms of 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 Hippocratic fingers are severe pathologies that are life-threatening for the patient. These include cancer, chronic progressive purulent processes, tuberculosis, the formation of bronchiectasis (local extensions of the bronchi), abscesses, empyema (accumulation of pus in the pleural cavity) and others. All of them are also manifested by respiratory failure, general hypoxia, pain in the chest cavity and a general deterioration in well-being.
Diseases of the heart and blood vessels are another group of pathologies that occur with hypoxia. Hippocratic fingers may be a sign of congenital heart defects of the blue type. They got their name because patients have a bluish tint to the skin (Fallot's disease, tricuspid valve atresia, pulmonary venous drainage, mitral transposition, truncus arteriosus). And also the syndrome can accompany sluggish inflammatory diseases of the membranes of the heart of an infectious nature.
Diseases of the gastrointestinal 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.

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

Hippocratic fingers in most cases appear on the upper and lower extremities at the same time. However, in some cases, one-sided formation can be seen. This may be due to several things:

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

Hippocratic fingers are often one of the symptoms of the Marie-Bamberger complex. This is a syndrome that is manifested by a number of characteristic signs. In patients, there is an increase in the periosteum simultaneously in several areas, most often the distal phalanges of the fingers and toes are affected. And inflammatory reactions are also observed in the region of the final sections of long tubular bones (tibia, ulna and radius), which is manifested by a pain reaction. The causes of the Marie-Bamberger syndrome are diseases of the lungs, heart and blood vessels, digestive tract and other specific pathologies. With a radical (surgical) removal of the root cause of the disease, there is a possibility of reverse development. In some cases, the state of the periosteum returned to normal in a few months.

Symptoms

You can recognize the fingers of Hippocrates already at the initial examination. Since the changes are visible to the naked eye, the diagnosis is aimed at clarifying the cause of the symptom. The process of forming 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 on the basis of several characteristic features:

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 surrounding tissues);
symptom of Shamroth - the absence of a gap between the bases of two nails, if you attach them to each other;
growth of the nail plate;
soft tissues located at the base of the nail bed become too soft and loose;
nail balloting - when pressed on the nail plate, it becomes elastic and absorbs.

All measurements can be taken at home. It should be understood that the appearance of Hippocratic fingers is a dangerous symptom and accompanies diseases that threaten the patient's life. If you suspect one of the characteristic signs, you should urgently seek medical help for urgent diagnosis and treatment, despite the painlessness of the process.

Forms of the disease

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

"Parrot's beak" - associated with the growth of the upper sections of the terminal phalanges of the fingers;
"watch 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 evenly thicken and increase in volume.

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

Diagnostic methods

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

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

To determine the cause of the appearance of Hippocratic nails, a complete examination is carried out. It includes radiography of the lungs, ultrasound of the heart and abdominal organs, clinical and biochemical blood and urine tests. If necessary, you can examine the condition of individual organs on MRI or CT - these diagnostic methods are considered the most reliable.

You can determine the appearance of Hippocratic fingers on your own, but more detailed diagnostics and treatment should be carried out only in a medical institution.

Treatment and prognosis

The methods of therapy are selected individually, depending on the cause of the appearance of Hippocratic fingers. These may include antibiotic therapy, specific drugs that suppress autoimmune reactions, anti-inflammatory drugs, and other drugs. In some cases, surgical intervention (removal of neoplasms) is indicated. The prognosis depends on the success of the treatment of the underlying disease, the age of the patient and individual characteristics.

Hippocratic toes is a symptom that may first appear as an adult. It may progress slowly and not disturb the patient for several years, but in some cases it occurs quickly. It is possible to make a diagnosis, including at home, but it is possible to determine the cause of this symptom only on the basis of additional studies. Further treatment also differs and depends on the results of a complete diagnosis.

Summary

Changes in the distal phalanges of the fingers in the form of "drumsticks" and nails in the form of "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 as well as malignant tumors. At the same time, one should take into account the possibility of manifestation of this clinical syndrome in other diseases (Crohn's disease, HIV infection, etc.).

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

Keywords

Fingers of Hippocrates, 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 pathologies (abscess, tuberculosis, cancer, pleural empyema), and called them "drumsticks". Since then, this syndrome has been called by his name - the fingers of Hippocrates (PG) (digiti Hippocratici).

Hippocratic finger syndrome includes two signs: "hour glass" (Hippocratic nails - ungues Hippocraticus) and club-shaped deformity of the terminal phalanges of the fingers like "drumsticks" (Finger clubbing).

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

Mechanisms for the development of GHGs are currently not fully understood. However, it is known that the formation of PG occurs as a result of microcirculation disorders, accompanied by local tissue hypoxia, impaired periosteal trophism and autonomic innervation against the background of prolonged endogenous intoxication and hypoxemia. In the process of PG formation, the shape of the nail plates (“watch glasses”) first changes, then the shape of the distal phalanges of the fingers changes in a club-like or cone-shaped form. The more pronounced endogenous intoxication and hypoxemia, the coarser the terminal phalanges of the fingers and toes are modified.

There are several ways to establish a change in the distal phalanges of the fingers according to the type of "drumsticks".

It is necessary to identify the smoothing of the normal 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 the back surfaces to each other, is the earliest sign of thickening of the terminal phalanges. The angle between the nails normally does not extend upwards more than half the length of the nail bed. With thickening of the distal phalanges of the fingers, the angle between the nail plates becomes wide and deep (Fig. 1).

On unchanged fingers, the distance between points A and B should exceed the distance between points C and D. With "drumsticks" the ratio is reversed: C - D becomes longer than A - B (Fig. 2).

Another important sign of 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 the paraneoplastic Marie-Bamberger syndrome, periostitis appears in the region of the terminal sections of long tubular bones (often the forearms and lower legs), as well as the bones of the hands and feet. In places of periosteal changes, pronounced ossalgia or arthralgia and local palpation soreness can be noted, an 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 neoplasms of the lungs, pleural mesothelioma, teratoma, mediastinal lipoma). Occasionally, this syndrome occurs in cancer of the gastrointestinal tract, lymphoma with metastases to the lymph nodes of the mediastinum, lymphogranulomatosis. At the same time, the 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 distinguishing features of this syndrome in non-tumor diseases is the long-term (over the years) development of characteristic changes in the osteoarticular apparatus, while in malignant neoplasms this process is calculated in weeks and months. After a radical surgical treatment of cancer, Marie-Bamberger's syndrome may regress and completely disappear within a few months.

At present, the number of diseases in which changes in the distal phalanges of the fingers are described as “drumsticks” and nails as “watch glasses” have increased significantly (Table 1). The appearance of PG often precedes more specific symptoms. It is especially necessary to remember the "ominous" connection of this syndrome with lung cancer. Therefore, the identification of signs of PH requires the correct interpretation and implementation of instrumental and laboratory examination methods for the timely establishment of a reliable diagnosis.

The relationship of PH with chronic lung diseases, accompanied by prolonged endogenous intoxication and respiratory failure (RD), 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).

With 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 mainly characterized by the symptom of "watch glasses", thickening, hyperemia and cyanosis of the nail fold (" gentle "fingers of Hippocrates - 60-80%, Fig. 5).

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

In diffuse connective tissue diseases involving the lung 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. B. Holcomb et al. revealed changes in the distal phalanges of the fingers in the form of "drumsticks" and nails in the form of "watch glasses" in 5 out of 11 examined patients with pulmonary veno-occlusive disease.

As lung lesions progress, PG appear in at least 50% of patients with exogenous allergic alveolitis. It should be emphasized that a persistent decrease in the partial pressure of oxygen in the blood and tissue hypoxia in the development of GOA in patients with chronic lung diseases should be emphasized. 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 fingers and nails.

There are isolated reports of the appearance of PG in bone sarcoidosis (J. Yancey et al., 1972). We observed more than a thousand patients with sarcoidosis of the intrathoracic lymph nodes and lungs, including those with skin manifestations, and in no case did we reveal the formation of PH. 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 in the form of "drumsticks" and nails in the form of "watch glasses" are often recorded in occupational diseases that involve the pulmonary interstitium. Relatively early appearance of GOA is typical for patients with asbestosis; this feature is indicative of 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 PH, the probability of death in them increased by at least 2 times.
GHGs were detected in 42% of the surveyed coal mine workers suffering from silicosis; in some of them, along with diffuse pneumosclerosis, foci of active alveolitis were found. Changes in the distal phalanges of the fingers in the form of "drumsticks" and nails in the form of "watch glasses" are described in match factory workers who were in contact with the rhodamine used in their manufacture.

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

The appearance of PH in a patient with interstitial lung disease, especially with a long history of the disease and in the absence of clinical signs of lung injury activity, requires a persistent search for a malignant tumor in the 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 lesions of the pulmonary interstitium without signs of neoplastic transformation, it is detected more rarely - in 63% of patients.

The rapid development of changes in the distal phalanges of the fingers in the form of "drumsticks" is one of the indications for the development of lung cancer even in the absence of precancerous diseases. In such a situation, clinical signs of hypoxia (cyanosis, shortness of breath) may be absent and this sign develops according to the laws of paraneoplastic reactions. W. Hamilton et al. demonstrated that the probability of a patient having PH increased 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 detection rate of PG on the morphological form of lung cancer has been shown: reaching 35% in the non-small cell variant, this figure is only 5% in the small cell variant.

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 lung cancer patients with PH symptoms, 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 as 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 “drum stick” changes in the distal phalanges of the fingers is clearly demonstrated by the disappearance of this clinical phenomenon after successful resection of a lung tumor. In turn, the reappearance of this clinical sign in a patient in whom lung cancer treatment was successful is a likely indication of tumor recurrence.

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

The possibility of PH formation in malignant tumors of the mammary gland, pleural mesothelioma, which was not accompanied by the development of DN, has been repeatedly demonstrated.

PG is detected in lymphoproliferative diseases and leukemias, 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. with 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 for lymphogranulomatosis.

Thus, PH, along with various types of arthritis, erythema nodosum, and migrating thrombophlebitis, are among the frequent extraorganic, nonspecific manifestations of malignant tumors. The paraneoplastic origin of changes in the distal phalanges of the fingers in the form of "drumsticks" can be assumed with their rapid formation (especially in patients without DN, heart failure and in the absence of other causes of hypoxemia), as well as in combination with other possible extraorganic, nonspecific signs of a malignant tumor - an increase in ESR, changes in the picture of peripheral blood (especially thrombocytosis), persistent fever, articular syndrome and recurrent thrombosis of various localization.

One of the most common causes of PH is considered congenital heart defects, especially the "blue" type. Among 93 patients with pulmonary arteriovenous fistulas, observed in the Mauo clinic for 15 years, such changes in the fingers were registered in 19%; they outnumbered hemoptysis (14%), but were inferior to murmurs over the pulmonary artery (34%) and shortness of breath (57%).

R. Khousam et al. (2005) described an ischemic stroke of embolic origin that developed 6 weeks after delivery in an 18-year-old patient. The presence of characteristic changes in the fingers and hypoxia, which required respiratory support, led to the 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 heart to the right, including those formed as a result 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, a complication of which was a small atrial septal defect. During the period that has passed since the operation, its hemodynamic significance has increased significantly due to the fact that the patient also developed rheumatic tricuspid valve stenosis, after the correction of which these symptoms completely disappeared. J. Dominik et al. noted the appearance of PH 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 erroneously directed to the left atrium.

PG is considered one of the most typical non-specific, so-called non-cardiac, clinical signs of infective endocarditis (IE). The frequency of changes in the distal phalanges of the fingers in the form of "drumsticks" in IE can exceed 50%. In favor of IE in a patient with PH, high fever with chills, an increase in ESR, and leukocytosis testify; anemia, a transient increase in the serum activity of hepatic aminotransferases, and various variants 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 PH phenomenon 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 relationship has been established between the formation of GOA in liver cirrhosis and previous alcohol abuse. In patients with cirrhosis of the liver without concomitant hypoxemia, PG, as a rule, is not detected. This clinical phenomenon is also characteristic of primary cholestatic liver lesions requiring transplantation in 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 in the form of "drumsticks" in diseases, including those mentioned above (chronic lung diseases, congenital heart defects, IE, cirrhosis of the liver 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 nails of the fingers. 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 the decrease in the partial pressure of oxygen in the arterial blood is considered the most obvious. Also, in patients with PH, a significant increase in the expression of factors of type 1a and 2a induced by hypoxia is found.

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

The number of probable reasons for the change in the distal phalanges of the fingers according to the type of "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, the 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 damage to the pulmonary vascular bed were not detected in him. The formation of PGs is also described in Behcet's disease, although it cannot be completely ruled out that their appearance in this disease was accidental.
PG is considered among the possible indirect markers of drug use. In some of these patients, their development may be associated with a variant of lung damage or IE that is characteristic of drug addicts. Changes in the distal phalanges of the fingers in the form of "drumsticks" are described in users of not only intravenous, but also inhaled drugs, for example, in hashish smokers.

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

The so-called primary form of GOA, not associated with diseases of the internal organs, is known, which often has a family character (Touraine-Solanta-Gole syndrome). It is diagnosed only with the exclusion of 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 altered phalanges, increased sweating. R. Seggewiss et al. (2003) observed primary GOA involving the fingers of the lower extremities only. At the same time, when stating the presence of PG in members of the same family, it is necessary to take into account the possibility of their having inherited congenital heart defects (for example, non-closure of the ductus arteriosus). The formation of characteristic changes in the fingers can continue for about 20 years.

Recognition of the causes of changes in the distal phalanges of the fingers according to the type of "drumsticks" 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 disease, primarily ELISA, is one of the most common causes of PH; the severity of this clinical phenomenon can be used to assess the activity of the lung lesion. The rapid formation or increase in the severity of GOA necessitates the search for lung cancer and other malignant tumors. At the same time, one should take into account the possibility of the appearance of this clinical phenomenon in other diseases (Crohn's disease, HIV infection), in which it can occur much earlier than specific symptoms.

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LESSON 21-7 SYMPTOM OF DRUG STICKS Symptom of drumsticks (fingers of Hippocrates) - a flask-shaped thickening of the terminal phalanges of the fingers of the hands less often than the toes of the feet in chronic diseases of the heart, lungs, liver with a characteristic deformation of the nail plates in the form of watch glasses. The tissue between the nail and the underlying bone acquires a spongy character, due to which, when pressed on the base of the nail, there is a feeling of mobility of the nail plate. Such a thickening accompanies various diseases, often ahead of more specific symptoms of the disease. It is especially necessary to remember the connection of this symptom with lung cancer. The symptom of drum sticks is not an independent disease, but is a rather informative sign of other diseases, pathological processes and proceeds imperceptibly at first, since it does not cause pain. Thickening of the terminal phalanges can develop over many years, and in some diseases for several months (lung abscess). CAUSES One of the main reasons for the formation of a symptom of drumsticks 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 dilation of the vessels of the nail phalanges of the 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 with inhalation of 100% oxygen (O2). The right-to-left shunt can be intracardiac or intrapulmonary. Intracardiac shunting of blood from right to left - a direct hit of blood from the right heart to the left, most characteristic of congenital cyanotic heart defects (atrial septal defect, ventricular septal defect, 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 disseminated microatelectasis - collapse of the pulmonary alveoli due to compression of the lung, blockage of the bronchus (for example, mucus, tumor), and also 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 shunting 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 commonly found in the lungs. REFLECTION OF THE SYMPTOM OF DRUM STICKS Fig. 76a, a 31-year-old man. Hereditary hemorrhagic telangiectasia, recurrent nosebleeds, a symptom of drumsticks in the initial stage of the disease. Fig. 76b, male, cyanotic heart disease, a symptom of drumsticks 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), as a result of which multiple angiomas and telangiectasias (capillary anomalies) form on different parts of the skin and mucous membranes of the lips, mouth, and internal organs. ) that bleed. Congenital inferiority of the vessels of the 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 heart diseases. SYMPTOM OF DRUG STICKS - indicates a low oxygen content in the tissues (hypoxia) and the development of pulmonary heart diseases, the cause of which in this case is hemorrhagic telangiectasia. With a symptom of drum sticks, 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 violation of calcium metabolism in the body. Sometimes the hole increases only on one finger. One of the main reasons for the increase in holes on the nails is magnesium deficiency (Fig. 75). Link to Fig.75.