Revered Dr. Mohammed Parvez sir, good evening.Thanks for the post. Pictures posted above show BOTH HANDS WITH BILATERAL DIGITAL CLUBBING, GRADE II/III, WITH RIGHT MIDDLE FINGER NAIL, AND TO A LESSER EXTENT RIGHT RING FINGER SHOWING FEATURES OF KOILINYCHIA WITH POSSIBLE ONYCHOMYCOSIS. History is supportive of above findings. Clubbing is also known as HIPPOCRATIC FINGERS, DRUMSTICK FINGERS or WATCH GLASS NAILS. Clubbing and its causes: Clubbing is described as a bulbous uniform swelling of the soft tissue of the terminal phalanx of a digit, with subsequent loss of the normal angle between the nail and nail bed.The first stage of clubbing is a periungual erythema and a softening of the nail bed; this is followed by an increase in the Lovibond's angle [the angle between the proximal nail fold and the nail plate]. Eventually the depth of the distal phalange increases, and the distal interphalangeal joint may become hyper-extensible.The Schamroth window test can be used to identify or confirm clubbing. If 2 opposing fingers are held back to back against each other, a diamond-shaped space should normally appear between the nail beds and the nails of the 2 fingers. In clubbing, this space (or window) is missing. CAUSES OF BILATERAL CLUBBING: A. Common causes - 1. Lung cancer, 2. Bronchiectasis, 3. Lung abscess, 4. Empyema, 5. Congenital heart disease, 6. Infective endocarditis, 7. Hypersensitivity pneumonitis (extrinsic allergic alveolitis). B. Uncommon causes- 1. Cystic fibrosis, 2. Interstitial pulmonary fibrosis, 3. Sarcoidosis, 4. Asbestosis, 5. Pleural mesothelioma, 6. Cavitating pulmonary TB, 7. Pulmonary metastases, 8. Atrial myxoma, 9. Axillary artery aneurysm, 10.Brachial malformations, 11.Thyroid acropachy, 12.Acromegaly, 13.Severe secondary hyperparathyroidism, 14.Hodgkin's lymphoma, 15.Disseminated chronic myelogenous leukaemia, 16.Ulcerative colitis, 17.Crohn's disease, 18.Primary biliary cirrhosis, 19.Cirrhosis, 20.Thyroid cancer, 21.Thymus cancer, 22.Lipoid pneumonia, 23.Pulmonary artery sarcoma, 24.Ulcerative oesophagitis, 25.Achalasia, 26.Coeliac disease, 27.Tropical sprue, 28.Leiomyoma of the oesophagus, 29.Familial clubbing, 30.Pachydermoperiostosis (primary hypertrophic osteoarthropathy), 31.Secondary hypertrophic osteoarthropathy, 32.Palmoplantar keratoderma, 33.Pregnancy, 34.Pseudo clubbing, 35.Myelofibrosis. CAUSES OF UNILATERAL CLUBBING- 1. Anomalous aortic arch, 2. Aortic or subclavian artery aneurysm, 3. Pulmonary hypertension with patent ductus arteriosus, 4. Brachial arteriovenous aneurysm or fistula, 5. Recurrent shoulder dislocation, 6. Superior sulcus (Pancoast) tumor. Unidigital clubbing: 1. Trauma, 2. Gout (tophi), 3. Sarcoidosis. Upper limb clubbing only: Heroin addicts (phlebitis) Lower limb clubbing only: 1. Infected abdominal aneurysms, 2. Patent ductus arteriosus. CAUSES OF KOILONYCHIA- 1. Iron deficiency anemia, 2. Plummer Vinson syndrome. Thank you sir.
Grade 3 clubbing requires parrot beak or drum stick appearance in addition to swelling of the distal phalanx. Here no significant swelling is appreciated and only obliteration of the lovibond angle is present, hence its Grade 2
parrot beak nails/picer nails & lindsays half and half nails indicating either end stage renal disease due to DM,or hemodialysis and/bladder ca
Wonderful analytical explanations about bilateral nail clubbing. My hearty congratulations. Dr Abdul Majeed
Parrot beak nail, Longitudinal ridges , There is also dystrophy setting kn
Grade 2 clubbing of nails..seems some fungal infection is also present
Respected Dr Kazi sir,very well explained in detail!thnxs sir!
appreciable detailed quote Dr.Kazi it's very helpful thanx.
clubbing grade III (parrot beaking) with fungal infection
Sir,are you talking about Clubbing of Nails..,?
Cases that would interest you
- Login to View the image
ABC OF : NAIL DISORDERS. ( I ). MAY BE USEFUL. *** ANONYCHIA is the absence of nails, an anomaly, which may be the result of a congenital ectodermal defect, ichthyosis, severe infection, severe allergic contact dermatitis, self-inflicted trauma, Raynaud phenomenon, lichen planus, epidermolysis bullosa, or severe exfoliative diseases....... *** PSORIASIS can also affect the fingernails and toenails, leading to thick fingernails with pitting, ridges in the nails, nail lifting away from the nail bed, and irregular contour of the nail....... *** LICHEN PLANUS of the nails can cause brittle or split nails, and the affected nails may have ridges running lengthwise....... *** FUNGAL nail infections are common infections of the fingernails or toenails that can cause the nail to become discolored, thick, and more likely to crack and break. Infections are more common in toenails than fingernails.....by some dermatophytes, Candida (Monilia) species, etc....... The technical name for a fungal nail infection is “ONYCHOMYCOSIS.”....... *** SPOON-SHAPED or spooning fingernails refers to a concavity in the fingernail itself, resulting in a depression in the nail that gives an appearance of a spoon shape to the entire nail. This growth disturbance in the nail is known as KOILONYCHIA....... In particular, koilonychias is associated with IRON DEFICIENCY. *** Fingernails are made by living skin cells....... So a skin condition such as eczema may lead to fingernail ridges. Skin dryness can also cause these ridges. If the body is low in protein, calcium, zinc.......or vitamin A, a deficiency can sometimes be revealed by ridges in the fingernails. ** HORIZONTAL RIDGES run from side to side on nails and are often referred to as BEAU'S LINES may be a sign of previous injury, underlying health conditions, or in rare cases, arsenic poisoning....... Horizontal ridges can be caused by trauma to the nail and may be deep or discolored. The can also indicate malnutrition, psoriasis or a thyroid problem....... ** VERTICAL RIDGES are usually harmless and a consequence of ageing.......nail injury, or trauma, or underlying medical conditions....... *** The ECTODERMAL DYSPLASIAS (EDs) are genetic disorders affecting the development or function of the teeth, hair, nails and sweat glands....... ** ED is not a single disorder, but a group of closely related conditions of which more than 150 different syndromes have been identified....... *** Nail CLUBBING, also known as digital clubbing, is a deformity of the finger or toe nails associated with a number of diseases, mostly of the heart and lungs. ... Hippocrates was probably the first to document clubbing as a sign of disease, and the phenomenon is therefore occasionally called "Hippocratic fingers"..... ** Lung cancer is the most common cause of clubbing. Clubbing often occurs in heart and lung diseases that reduce the amount of oxygen in the blood. ... Heart defects that are present at birth (congenital) Chronic lung infections that occur in people with bronchiectasis, cystic fibrosis, or lung abscess....... *** While the NAIL BITING and picking seems to be such a common problem, the psychological and medical research does not agree on the exact motivation for the action. However, it suggests that nail biting can be the result of STRESS, VARIOUS MEDICAL DISORDERS, LEARNED BEHAVIORS, OR JUST PLAIN HABIT....... *** SPLINTER HEMORRHAGES : They run in the direction of nail growth. They are named splinter hemorrhages because they look like a splinter under the fingernail. The hemorrhages may be caused by tiny clots that damage the small capillaries under the nails. Splinter hemorrhages can occur with infection of the heart valves (endocarditis)....... *** YELLOW TOENAILS in an infection by a fungus that attacks the nails..... or, in some cases, they may be a sign of skin cancer. The fungal infection is caused most often by dermatophytes, which eat keratin to grow....... One of the MOST COMMON CAUSES of YELLOW NAILS is a FUNGAL INFECTION. As the infection worsens, the nail bed may retract, and nails may thicken and crumble. In rare cases, yellow nails can indicate a more serious condition such as SEVERE THYROID DISEASE, LUNG DISEASE, DIABETES or PSORIASIS....... *** WHILE NAILS ( LEUKONYCHIA ) : CAUSES : Iron deficiency anemia. Cirrhosis of liver. Kidney disease. Heart failure. Diabetes. Problems with the digestion of proteins. An excessive loss of proteins in the intestines. zinc deficiency........etc....... *** RED NAILS :- CAUSES : LUPUS patients get quirky, angular blood vessels in their nail folds. PSORIASIS starts in the nails up to 10 percent of the time and CAUSES SPLITTING and PITTING of the nail bed. HEART DISEASE can turn the nail beds red....... ** If the NAIL BED is RED, it could be caused by a high content of fatty acids and cholesterol, due to an excess of dairy products, sugar and salt in the diet. This can lead to an underactive liver and blocked arteries....... To keep the system healthy by replacing refined foods with wholegrain rice and bread, and flush out the system with plenty of fresh vegetables and at least five glasses of water a day....... *** HALF PINK and HALF WHITE nails can be a sign of kidney disease....... *** BRITTLE NAILS :- CAUSES : AGING. CHEMICAL/TOXIN EXPOSURE. LONG-TERM USE OF NAIL POLISH AND POLISH REMOVE. LOW HUMIDITY ENVIRONMENT. MALNUTRITION. NAIL-PATELLA SYNDROME. PROLONGED EXPOSURE TO WATER. TRAUMA. ** B complex vitamins (especially biotin), calcium, and zinc have all been implicated. There are other medical conditions which can cause brittle nails such as ANEMIA (low blood count), THYROID DISORDERS, and skin disorders such as LICHEN PLANUS and PSORIASIS. ** ONYCHOSCHIZIA includes splitting, brittle, soft or thin nails. Onychoschizia is MORE COMMON IN WOMEN. Only VERY RARELY are INTERNAL DISEASE or VITAMIN DEFICIENCIES the reason (IRON DEFICIENCY is the MOST COMMON).......Dr. Puranjoy Saha36 Likes33 Answers
- Login to View the image
FINGER CLUBBING It is a bulbous enlargement of soft parts of the terminal phalanges with both transverse and longitudinal curving of the nails. The swelling of the terminal phalanges in clubbing occurs due to interstitial edema and dilation of the arterioles and capillaries. CLUBBING is mostly asymptomatic, but may predict the presence of some dreaded underlying diseases. Clubbing was first described by Hippocrates nearly 2500 years ago in & is regarded to be the oldest sign in clinical medicine. Digital clubbing may occur as isolated finding or is often part of the syndrome of hypertrophic osteoarthropathy. GRADES OF CLUBBING I.. Fluctuation and softening of the nail bed. II. Loss of the normal <165° angle between the nailbed and the fold. III.. Increased convexity of the nail fold IV.. Thickening of the whole distal finger (resembling a drumstick) The process usually takes years but in certain conditions like lung abscess, empyema of thorax, clubbing may develop quite fast. Grading of clubbing has no clinical significance. MECHANISM OF CLUBBING The exact MECHANISM is not known. But most acceptable hypothesis is… megakaryocyte or platelet clusters, lodged in the peripheral vessels of the digits, release platelet-derived growth factor or vascular endothelial growth factor to cause dilatation of vessels and lead to the increased vascularity, permeability, and connective tissue changes that are the hallmark of clubbing. CAUSES OF DIGITAL CLUBBING PULMONARY Bronchogenic carcinoma Lung abscess, Empyema Bronchiectasis Tuberculois with secondary infections Cystic fibrosis Diffuse fibrosing alveolitis CARDIAC Infective endocarditis Cyanotic heart disease Congenital heart disease GASTROINTESTINAL Ulcerative colitis Crohn’s disease Cholangiolitic cirrhosis Inflmmatory Bowel Disease ENDOCRINE Iatrogenic myxedema Exophthalmosis Acromegaly Miscellaneous Causes HEREDITARY Idiopathic UNILATERAL CLUBBING Pancoast tumor, subclavian and innominate artery aneurysm UNIDIGITAL CLUBBING Traumatic or gout deposit In heroin addicts due to chronic obstructive phlebitis DIFFERENTIAL CLUBBING clubbing may occur in lower limbs, sparing the upper limbs. It may occur in patient with patent ductus arteriosus with right to left shunt. CLUBBING CAUSES… EASY MNEMONIC CLUBBING C.. Cyanotic heart disease L.. Lung disease (hypoxia, lung cancer, bronchiectasis, cystic fibrosis) U.. Ulcerative Colitis /Crohn's disease B.. Biliary cirrhosis B.. Birth defect (harmless) I.. Infective endocarditis N.. Neoplasm (esp. Hodgkins) G.. GI malabsorption I hope this piece of information will be useful to most of us Dr K N PoddarDr. K N Poddar11 Likes10 Answers
- Login to View the image
What can be diagnosed with the help of the image, or put into differential?Dr. Shashiprakash Kshatriya3 Likes16 Answers
- Login to View the image
Identity the condition.Give complete D/D .young male.Dr. Parminder Singh2 Likes24 Answers
- Login to View the image
pt aged 38 c/o severe pain in extremeties o/e clubbing of finger seen,No H/o Htn ,, ptnt is diabetic . what it could be??Dr. Md.shahid Ansari4 Likes15 Answers