A 65 years old female admitted to the ICU with Urosepsis. Past history of anemia and Interstitial Lung Disease. Please describe is there are any pathological changes in the nails ?



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.

I was not expecting the answer could be so well elaborated. I mean, Dr. Hussain has elaborated the findings so well with all the possible differentials, this answer could be published for general medicine topic on emedicine. Brilliant!

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parrot beak nails/picer nails & lindsays half and half nails indicating either end stage renal disease due to DM,or hemodialysis and/bladder ca


Respected Dr Kazi sir,very well explained in detail!thnxs sir!

Thank you revered Sir for your valuable input.

Parrot beak nail, Longitudinal ridges , There is also dystrophy setting kn

Parrot beak appearance. Grade 3 CLUBBING

Wonderful analytical explanations about bilateral nail clubbing. My hearty congratulations. Dr Abdul Majeed

Clubbing with brittle nails.

Nothing more to add but still one point I would say It takes 2 to 3 weeks for clubbing to occur.

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

Might be some fungal infection.

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