Addison Biermer's disease. Addison-Birmer disease (pernicious anemia, pernicious anemia, β12 deficiency anemia)

Such a subtle structure of the nail bed interested Hippocrates, who described the phenomenon of fingers resembling drumsticks in a patient with congenital heart disease in the 4th century BC. This phenomenon appears as wide, somewhat thickened, smooth-surfaced and excessively protruding nails that resemble watch glasses. His medical specialists called "Hippocrates".

Etiological factors

Similar characteristics are observed in patients with a diagnosis of pathology of the cardiovascular system, congenital heart defects, endocarditis. This condition is associated with a lack of oxygen intake into the body.
Observed in chronic pulmonary tuberculosis, lung cancer.
With a circulatory disorder in the extremities, the nails sometimes acquire a bluish tint or, on the contrary, become yellow, typical transverse or longitudinal grooves appear on their surface. In some embodiments, the nails are separated from the nail bed near the free edge and form subungual pockets or completely move away from the finger.
They are greatly altered in scarlet fever. 7 weeks after the infection, grooves, pits and scallops form across and longitudinally near the base of the nails. With cirrhosis of the liver, the plate becomes flat, it is dotted with longitudinal grooves, pigmentation is disturbed: it turns white (like an opal stone) or a shade of frosted glass appears. Holes in such nails are difficult to distinguish.
Kidney pathology also contributes to the formation of subtleties: white and brown transverse stripes.
At endocrine disorders nails are generally able to separate from the bed.
A pale shade is a symptom of iron deficiency anemia.
A change in color can also occur while taking certain medications. Change the shade antimalarials, tetracyclines, drugs from silver, arsenic, mercury, phenolphthalein.
Longitudinal scallops, like chains of beads, elevations on the nail plane often occur with polyarthritis.
Excessive skin size and transverse splitting of the plate often indicates the presence of lichen planus.
serious nail changes and changes in the skin around the bed are formed during. Point impressions are formed on the surface (starting from the hole). With multiple formation of the latter, like a thimble, the nail looks like rough and pockmarked. In some cases, the horny plate is separated from the bed. In other cases, the nails change shade (to dull, dull white), shape, and thickening occurs.
Small dotted white spots that appear in the areas of exfoliation from the skin of the nail indicate that there are problems in the body that are associated with a metabolic disorder, it lacks any vitamins. Reception vitamin complexes leads to the disappearance of granular spots when a new part of the nail grows.
In the female body during menopause, restructuring is observed. This also affects the nails, because a disorder occurs in it. calcium metabolism. Taking a special complex of vitamins and minerals leads to the disappearance of such manifestations.
Thinning and stratification of the horny plates also occurs in pregnant women during lactation.
Frequently visiting public baths and pools are often found with fungal infections of the nail plates. Cracks and wounds on the skin, a decrease in the body's immune abilities contribute to the penetration of the fungus, which is suitable for humid microclimatic conditions. Basically, the initial manifestations are turbidity from the outer edge of the nail plate, under which clusters of a white or yellow tint with an unpleasant odor appear, the plate turns yellow, thickens, exfoliates. There is an impossibility of cutting nails, because they crumble a lot. Medications prescribed by a dermatologist help get rid of the fungus. And in order to prevent infection, doctors recommend covering the horn plate with a specific varnish. In a public shower, it is recommended to use rubber slippers, avoid walking along channels with dirty water, and wipe your feet and interdigital areas dry.
The desire to cover one's hands so as not to show off the nails worries the neurologist, since the habit of biting nails is a sign of some neurological diseases. For "rodents" found artificial legs made of plastic material, they are glued to loosened nails. In some cases, finger massage and the use of a warm bath help.
Sometimes "hippocratic" nails are hereditary or congenital, which are not associated with any pathological forms.

Have you ever seen such unusual fingers? It looks like thickening of the fingertips and rounding of the nails. At the same time, it seems to the touch that the nail does not hold well and “floats” a little. This - finger-drum sticks or, as they are also called, "watch glasses". In English literature, the most common term is "clubbing". Their historical name is "fingers of Hippocrates". You've probably seen them in older men, but sometimes they occur in younger people as well. 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 such a 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, reverse development in this case, there is practically no (even after the cure of the underlying disease).

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

Heart defects . But not minor developmental anomalies, such as an open foramen ovale, but real serious malformations, 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 it is chronic smoker's bronchitis or another variant of COPD (chronic obstructive pulmonary disease). But, if fingers appear, then this indicates that it is high time to start treatment, including inhalation therapy, etc. This also includes all types of lung cancer, interstitial diseases, including alveolitis.

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

Cirrhosis.

Hyperthyroidism.

HIV.

Hypertrophic osteoarthropathy.

And a long list of rare reasons.

For many diseases, a natural question arises: where is 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 illness. Therefore, the detection of this symptom requires a good diagnosis and identification of the real cause!

And finally, a small case from personal practice.

Already being a cardiologist, at one of the family feasts, I noted the presence of fingers in the form of drumsticks from one of my relatives. He was known to have undergone 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 birth defect"blue" color, which should be closed in a short time.

Everything came together in my head! Short stature, low muscle mass, blue lips, fingers like 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, after the operation, echocardiography was never performed. And for some reason, the boy was not registered with a cardiologist.

IN complete confidence that there would be something bad on the echocardiography, I sent him for research ... And nothing! No residual defect, no residual effects, the vice is well closed and the heart looks great!

However, further examination revealed another pathology - severe COPD against the background of a long smoking history.

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

Watch glass symptom (Hippocratic nail)- a characteristic deformation of the nail plates in the form of watch glasses with a flask-shaped thickening of the terminal phalanges of the fingers and toes in chronic diseases of the heart, lungs, liver. At the same time, the angle that makes up the posterior nail fold and the nail plate, when viewed from the side, exceeds 180°. 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. In a patient with a symptom of watch glasses, when the nails of opposite hands are compared together, the gap between them disappears (Shamroth's symptom).

This symptom, apparently, was first described by Hippocrates, which explains one of the names of the symptom of watch glasses - Hippocrates' nail.

Clinical Significance

When this symptom appears, a complete and thorough examination of the patient is necessary to determine the cause of its occurrence.

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Literature

Strutynsky A. V., Baranov A. P., Roitberg G. E., Gaponenkov Yu. P. Fundamentals of semiotics of diseases internal organs. - M .: MEDpress-inform, 2004. - S. 66-67. - ISBN 5-98322-012-8.
Trakhtenberg A. Kh. , Chissov V. I. Clinical onco-pulmonology. - M .: GEOTAR MEDICINE, 2000. - S. 109. - ISBN 5-9231-0017-7.
Chernorutsky M.V. Diagnosis of internal diseases. - Fourth edition, revised and expanded. - L. : MEDGIZ, 1954. - S. 279. - 50,000 copies.

An excerpt characterizing the Symptom of watch glasses

- Well, now the declamation! - said Speransky, leaving the office. - Amazing talent! - he turned to Prince Andrei. Magnitsky immediately struck a pose and began to speak French humorous verses, composed by him on some famous people of St. Petersburg, and was interrupted several times by applause. Prince Andrei, at the end of the poems, went up to Speransky, saying goodbye to him.
- Where are you going so early? Speransky said.
I promised tonight...
They were silent. Prince Andrei looked closely into those mirrored eyes that did not let himself through, and it became funny to him how he could expect anything from Speransky and from all his activities associated with him, and how he could attribute importance to what Speransky was doing. This neat, sad laughter did not cease to sound in the ears of Prince Andrei for a long time after he left Speransky.
Returning home, Prince Andrei began to recall his Petersburg life during these four months, as if something new. He recalled his troubles, searches, the history of his draft military regulations, which was taken into account and about which they tried to keep silent solely because another work, very bad, had already been done and presented to the sovereign; remembered the meetings of the committee, of which Berg was a member; I recalled how diligently and at length everything relating to the form and process of committee meetings was discussed in these meetings, and how diligently and briefly everything related to the essence of the matter was dealt with. He remembered his legislative work, how he anxiously translated articles of the Roman and French code into Russian, and he felt ashamed of himself. Then he vividly imagined Bogucharovo, his activities in the countryside, his trip to Ryazan, remembered the peasants, Drona the headman, and applying to them the rights of persons, which he divided into paragraphs, he wondered how he could have been engaged in such idle work for so long.

The next day, Prince Andrei went on visits to some houses where he had not yet been, including the Rostovs, with whom he renewed his acquaintance at the last ball. In addition to the laws of courtesy, according to which he needed to be with the Rostovs, Prince Andrei wanted to see at home this special, lively girl, who left him a pleasant memory.

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

Fingers, similar to drum sticks, mostly form on both limbs, but in some cases, the pathology can only affect the hands or feet separately. Such an election is typical for heart disease in a 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:

beak of a parrot;
watch glasses;
real drumsticks.

triggers

This pathology develops in the presence of the following diseases:

lung diseases of various origins;
endocarditis;
congenital defects;
ailments of the gastrointestinal tract;
cystic fibrosis;
Graves' disease;
trichuriasis;
Marie-Bamberger syndrome.

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

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

Causes

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

Constant 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 growth connective tissue, which is located between the nail and the bone. It should be noted that there is a relationship between the level of hypoxia and external changes in the shape of the nail bed.

Studies have shown that in the presence of a chronic inflammatory disease in the intestine, 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 in 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, basically does not provoke the appearance of pain. For this reason, the patient cannot notice this change in time.

The main signs of the symptom:

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

bone pain
changes in the characteristics of the skin in the pretibial region;
elbows, wrists and knees have changes very similar to arthritis;
the skin in some areas begins to coarsen;
develops paresthesia, excessive sweating.

Diagnostics

Most often, a symptom that manifests itself 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, a pencil is applied 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 symptom of Shamroth.
Feeling the finger to determine elasticity. To do this, click on upper part fingers and immediately release. If the nail is immersed in the tissue, and after a sharp springback, then a disease can be assumed, a symptom of which is glass nails. Elderly patients have the same effect, but it is the norm 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 a normal state, this indicator does not exceed 0.895. If the symptom is present, that score 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.

Important in diagnosing why the nail becomes "glassy" is to identify the main cause of the development of this symptom. For this you need:

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

Treatment

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

antibiotics;
medicines to boost immunity.

Also, it will not be superfluous to review the diet. It is important to consult with a nutritionist and find out the list of prohibited foods for this disease.

Forecast

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

even in antiquity, 25 centuries ago, Hippocrates described changes in the shape distal phalanges fingers that 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 - the fingers of Hippocrates (PG) (digiti Hippocratici).

Hippocratic finger syndrome includes two signs: "hour glasses" (Hippocratic nails - ungues Hippocraticus) and clavate deformity terminal phalanges of the fingers of the type "drumsticks" (Finger clubbing).

Currently, PG is considered the main manifestation of hypertrophic osteoarthropathy (GOA, 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 most early sign 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 "drum sticks", the ratio is reversed: C - D becomes longer than A - B (Fig. 2).

Another important sign of PG is the value 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 the paraneoplastic syndrome of Marie - Bamberger, periostitis appears in the region of the terminal sections of the long tubular bones(usually forearms and shins), 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, with x-ray examination a double cortical layer is detected, 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 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 distinguishing features this syndrome in non-tumor diseases, there is a long-term (over the course of years) development of characteristic changes in the osteoarticular apparatus, while in malignant neoplasms this process is calculated in weeks and months. After a radical surgical treatment of cancer, Marie-Bamberger 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 GHG with chronic diseases lungs, accompanied by prolonged endogenous intoxication and respiratory failure (RD), are 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).

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 characterized mainly by the symptom of "watch glasses", 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, testify in favor of an unfavorable prognosis in ELISA, reflecting, in particular, the prevalence of active damage to the alveoli (ground glass areas detected during computed tomography) and the severity of proliferation of vascular smooth muscle cells in the foci 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.

At diffuse diseases connective tissue 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 have observed more than a thousand patients with intrathoracic sarcoidosis. lymph nodes and lungs, including those with skin manifestations, and in no case did the formation of PH occur. 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 GOA is characteristic of 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 disease lungs, especially long experience disease and in the absence clinical signs activity of lung damage 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 case of damage to 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 frequency of detection of GHGs on morphological form lung cancer: reaching 35% with a non-small cell variant, with a small cell this figure is only 5%.

The development of GOA in lung cancer is associated with hyperproduction of growth hormone and prostaglandin E2 (PGE-2) tumor cells. partial pressure of oxygen in peripheral blood while it may remain normal. It was found that in the blood of patients lung cancer with the symptom of PH, 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 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 area, and may even precede the first clinical manifestations malignant tumors. Their formation is described in a malignant tumor of the thymus, cancer of the esophagus, colon, gastrinoma, characterized by a 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 "drum sticks" 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 ischemic stroke embolic origin, which 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 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 stenosis of the tricuspid valve, 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 elimination 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. infective endocarditis(IE) . The frequency of changes in the distal phalanges of the fingers according to the type of "drumsticks" in IE can exceed 50%. In favor of IE in a patient with PH is evidenced by high fever with chills, increased ESR, leukocytosis; 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, as a rule, is combined with cutaneous telangiectasias, often forming "fields 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 its transplantation into childhood, including congenital atresia bile ducts.

Repeated attempts have been made to decipher the mechanisms of development of changes in the distal phalanges of the fingers 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 was detected, as well as vascular factor growth. 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 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, 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 (with ulcerative colitis they are not characteristic), in which a change in the fingers according to the type of "drumsticks" may precede the actual intestinal manifestations of the disease.

Number probable causes, causing a 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 adverse 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 lesions of 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 according to the type 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, often having 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, excessive 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 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 this clinical phenomenon occurring in other diseases (Crohn's disease, HIV infection), in which it can occur much earlier than specific symptoms.

Literature1. Kogan E.A., Kornev B.M., Shukurova R.A. Idiopathic fibrosing alveolitis and bronchiolo-alveolar cancer // Arch. Pat. - 1991. - 53 (1). - 60-64.2. Taranova M.V., Belokrinitskaya O.A., Kozlovskaya L.V., Mukhin N.A. "Masks" of subacute infective endocarditis // Ter. arch. - 1999. - 1. - 47-50.3. Fomin V.V. Hippocratic fingers: clinical significance, differential diagnosis. Klin. honey. - 2007. - 85, 5. - 64-68.4. Shukurova R.A. Modern ideas about the pathogenesis of fibrosing alveolitis // Ter. arch. - 1992. - 64. - 151-155.5. Atkinson S., Fox S.B. Vascular endothelial growth factor (VEGF)-A and platelet-derived growth factor (PDGF) play a central role in the pathogenesis of digital clubbing // J. Pathol. - 2004. - 203. - 721-728.6. Augarten A., Goldman R., Laufer J. et al. Reversal of digital clubbing after lung transplantation in cystic fibrosis patients: a clue to the pathogenesis of clubbing // Pediatr. Pulmonol. - 2002. - 34. - 378-380.7. Baughman R.P., Gunther K.L., Buchsbaum J.A., Lower E.E. Prevalence of digital clubbing in bronchogenic carcinoma by a new digital index // Clin. Exp. Rheumatol. - 1998. - 16. - 21-26.8. Benekli M., Gullu I.H. Hippocratic fingers in Behcet's disease // Postgrad. Med. J. - 1997. - 73. - 575-576.9. Bhandari S., Wodzinski M.A., Reilly J.T. Reversible digital clubbing in acute myeloid leukaemia // Postgrad. Med. J. - 1994. - 70. - 457-458.10. Boonen A., Schrey G., Van der Linden S. Clubbing in human immunodeficiency virus infection // Br. J. Rheumatol. - 1996. - 35. - 292-294.11. Campanella N., Moraca A., Pergolini M. et al. Paraneoplastic syndromes in 68 cases of resectable non-small cell lung carcinoma: can they help in early detection? // Med. oncol. - 1999. - 16. - 129-133.12. Chotkowski L.A. Clubbing of the fingers in heroin addiction // N. Engl. J. Med. - 1984. - 311. - 262.13. Collins C.E., Cahill M.R., Rampton D.S. Clubbing in Crohn's disease // Br. Med. J. - 1993. - 307. - 508.14. Courts I.I., Gilson J.C., Kerr I.H. et al. Significance of finger clubbing in asbestosis // Thorax. - 1987. - 42. - 117-119.15. Dickinson C.J. The aetiology of clubbing and hypertrophic osteoarthropathy // Eur. J.Clin. Invest. - 1993. - 23. - 330-338.16. Dominik J., Knnes P., Sistek J. et al. Iatrogenic clubbing of the fingers // Eur. J. Cardiothorac. Surg. - 1993. - 7. - 331-333.17. Falkenbach A., Jacobi V., Leppek R. Hypertrophic osteoarthropathy as an indicator for bronchial carcinoma // Schweiz. Rundsch. Med. Prax. - 1995. - 84. - 629-632.18. Fam A.G. Paraneoplastic rheumatic syndromes // Bailliere's Best Pract. Res. Clin. Rheumatol. - 2000. - 14. - 515-533.19. Glattki G.P., Maurer C., Satake N. et al. Hepatopulmonary syndrome // Med. Klin. - 1999. - 94. - 505-512.20. Grathwohl K.W., Thompson J.W., Riordan K.K. et al. Digital clubbing associated with polymyositis and interstitial lung disease // Chest. - 1995. - 108. - 1751-1752.21. Hoeper M.M., Krowka M.J., Starassborg C.P. Portopulmonary hypertension and hepatopulmonary syndrome // Lancet. - 2004. - 363. - 1461-1468.22. Kanematsu T., Kitaichi M., Nishimura K. et al. Clubbing of the fingers and smooth-muscle proliferation in fibrotic changes in the lung in patients with idiopathic pulmonary fibrosis // Chest. - 1994. - 105. - 339-342.23. Khousam R.N., Schwender F.T., Rehman F.U., Davis R.C. Central cyanosis and clubbing in an 18-year-old postpartum woman presenting with a stroke // Am. J. Med. sci. - 2005. - 329. - 153-156.24. Krowka M.J., Porayko M.K., Plevak D.J. et al. Hepatopulmonary syndrome with progressive hypoxemia as an indication for liver transplantation: case reports and literature review // Mayo Clin. Proc. - 1997. - 72. - 44-53.25. Levin S.E., Harrisberg J.R., Govendrageloo K. Familial primary hypertrophic osteoarthropathy in association with congenital cardiac disease // Cardiol. Young. - 2002. - 12. - 304-307.26. Sansores R., Salas J., Chapela R. et al. Clubbing in hypersensitivity pneumonitis. Its prevalence and possible prognostic role // Arch. Intern. Med. - 1990. - 150. - 1849-1851.27. Sansores R.H., Villalba-Cabca J., Ramirez-Venegas A. et al. Reversal of digital clubbing after lung transplantation // Chess. - 1995. - 107. - 283-285.28. Silveira L.H., Martinez-Lavin M., Pineda C. et al. Vascular endothelial growth factor and hypertrophic osteoarthropathy // Clin. Exp. Rheumatol. - 2000. - 18. - 57-62.29. Spicknall K.E., Zirwas M.J., English J.C. Clubbing: an update on diagnosis, differential diagnosis, pathophysiology, and clinical relevance // J. Am. Acad. Dermatol. - 2005. - 52. - 1020-1028.30. Sridhar K.S., Lobo C.F., Altraan A.D. Digital clubbing and lung cancer // Chest. - 1998. - 114. - 1535-1537.31. The ESC Task force. ESC Guidelines on prevention, diagnosis and treatment of infective endocarditis // Eur. Heart J. - 2004. - 25. - 267-276.32. Toepfer M., Rieger J., Pfiuger T. et al. Primary hypertrophic osteoarthropathy (Touraine-Solente-Gole syndrome) // Dtsch. Med. Wschr. - 2002. - 127. - 1013-1016.33. Vandemergel X., Decaux G. Review on hypertrophic osteoarthropathy and digital clubbing // Rev. Med. Brux. - 2003. - 24. - 88-94.34. Yancey J., Luxford W., Sharma O.P. Clubbing of the fingers in sarcoidosis // JAMA. - 1972. - 222. - 582.35. Yorgancioglu A., Akin M., Demtray M., Derelt S. The relationship between digital clubbing and serum growth hormone level in patients with lung cancer // Monaldi Arch. Chest dis. - 1996. - 51. - 185-187.