LUNG CANCER IS THE MOST COMMON CAUSE OF CLUBBING. * CLUBBING has been described to occur in different stage....... GRADE 1 to GRADE 5.......Although DIFFERENT GRADING of clubbing has been described, it has NO CLINICAL SIGNIFICANCE.......This whole process ( Great 1 to Get 5 ) usually takes years but in certain conditions, clubbing may develop sub-acutely (e.g. lung abscess, empyema thorasis)....... Clubbing may be associated with various clinical conditions. HOWEVER, lung diseases are most commonly associated with clubbing and NEOPLASTIC LUNG DISEASE IS THE MOST COMMON PULMONARY CAUSE OF CLUBBING. OTHER LUNG DISEASES that can be associated with clubbing are bronchiectasis, lung abscess, interstitial lung disease, fibrous pleural tumors, mesothelioma, etc....... Other diseases are : CARDIAC CONDITIONS (namely, CYANOTIC HEART DISEASES, INFECTIVE ENDOCARDITIS) and GASTROINTESTINAL diseases namely, INFLAMMATORY BOWEL DISEASE, COELIAC DISEASE, CIRRHOSIS mostly primary biliary cirrhosis). There are also cases of CONGENITAL and IDIOPATHIC clubbing, and PSEUDO-CLUBBING..... In adults, MALIGNANT NEOPLASM OF THE LUNG is the predominant pulmonary cause of clubbing, CONTRIBUTING TO NEARLY 90% OF CASES. AMONG the DIFFERENT types of THORACIC MALIGNANCY, LUNG CANCER IS RESPONSIBLE FOR 80% CASES OF CLUBBING, whereas pleural tumors and other intrathoracic and mediastinal growth contribute to 10% and 5% cases, respectively. On the other hand, the prevalence of clubbing in lung cancer patient ranges from 5% to 15%. Clubbing in lung cancer is a paraneoplastic manifestation and is also the most common paraneoplastic syndrome in lung cancer patients. A MAJORITY of clubbing in lung cancer patient involves NON-SMALL CELL VARIETY. Clubbing is relatively uncommon in small cell lung carcinoma because of its aggressive course and poor prognosis, thereby leading to early death. HOWEVER, contrary to this classical view, Findik and Baughman et al.'s series reported similar incidence of clubbing in both SCLC and NSCLC patients. Most studies did notice a MALE PREDOMINANCE of clubbing in lung cancer patients except Sridhar et al. who found a female predominance of clubbing in lung cancer patients. The megakaryocyte/platelet hypothesis appears quite reliable in explaining digital clubbing in lung cancer patients. Hirakata et al. also reported increased serum transforming growth factor (TGF ß1) level in primary lung cancer patients with clubbing. Therefore, large megakaryocyte or platelet clumps may release TGF ß1 level locally which may increase local accumulation of extra cellular matrix protein. There are few case reports of digital clubbing occurrence in malignant mesothelioma, pleural fibroma, and metastatic osteogenic sarcoma. McGavin et al. noticed finger clubbing based on abnormal fluctuation of nail bed in 30% of the MESOTHELIOMA and 14% of benign ASBESTOS PLEURAL DISEASE, respectively. The incidence of clubbing in malignant pleural mesothelioma is high enough to be included in the list of digital clubbing. Solitary fibrous tumor of pleura is less common than malignant mesothelioma. Moreover, they are MESENCHYMAL in origin unlike MESOTHELIAL origin of mesothelioma. They often develop characteristic paraneoplastic syndrome of clubbing, HOA, and hypoglycemia, not typically seen with mesothelioma. Inflammatory pseudo-tumor is a rare benign lung tumor of uncertain etiology, occurring more commonly in younger patients. Vandemergel et al. reported the first association of inflammatory pseudo tumor with digital clubbing in an adult patient. PULMONARY METASTASES from extrathoracic neoplasms are RARE CAUSE OF CLUBBING and HPOA. Most of the reported cases have been SARCOMAS, mainly of BONE and soft TISSUES; among the rest are tumors of the nasopharynx and uterus and cervix and RENAL CELL CARCINOMA. Renal cell carcinoma has been USUALLY ASSOCIATED CLUBBING in the presence of pulmonary metastases. However, in the Vandemergel et al. series renal cell carcinoma patient with digital clubbing did not have evidence of lung metastasis. HODGKIN'S LYMPHOMA is rarely associated with digital clubbing. Characteristically, clubbing is mainly seen in the presence of intrathoracic involvement and in children and adolescents. In patients of Hodgkin's lymphoma, the presence of clubbing requires searching for an underlying intrathoracic neoplasm. INTERSTITIAL LUNG DISEASE is frequently associated with digital clubbing. AMONG DIFFERENT ILDs, digital CLUBBING is MOST COMMONLY NOTED IN IDIOPATHIC PULMONARY FIBROSIS (IPF), which is also the most common pulmonary cause of digital clubbing in developed country. Kanematsu et al. reported clubbing in 67% of the 55 patients of idiopathic pulmonary fibrosis. Ryu et al. from Mayo clinic reported digital clubbing in 45% of IPF patients younger than 50 years. Rarely, patients may develop features of HOA associated with severe pain in the distal extremities. CLUBBING RARELY occurs IN SARCOIDOSIS and is usually seen in advanced fibrotic stage. ASBESTOSIS is another ILD where clubbing is commonly seen. Coutts et al. noted finger CLUBBING IN 43% of ASBESTOSIS PATIENTS and is usually seen in patients with more severe form of disease. Digital clubbing, complicating INFLAMMATORY BOWEL DISEASE has been frequently reported in the Western country. However, its association with secondary HOA has been very rarely found. Digital clubbing is more commonly noted in CROHN'S DISEASE than in ULCERATIVE COLITIS . Kittis et al. reported digital clubbing incidence of 38% and 15% in patients with Crohn's disease and ulcerative colitis, respectively . ** Megakaryocytes or platelet or their derivatives may play a role in the pathogenesis of clubbing in inflammatory bowel disease. Collins et al. have detected increased circulating platelets aggregates as well as an increase number of platelets in patients with Crohn's disease. Normally, P-SELECTIN (a surface marker of platelet activation) expression is greater in finger tip capillary blood than in venous blood; this difference is further increased in Crohn's disease. So platelets are more susceptible to activation in the micro-circulation in Crohn's disease which could result in increased release of PDGF. Finger clubbing is more significantly associated with active disease than inactive disease in patients with IBD. Patients with Crohn's disease have shown regression of clubbing after resection of macroscopic disease. There is also a possibility that mucosal inflammatory changes and fibrosis in the gut may act as focal stimuli for vagus nerve and possibly other autonomic nerve, acting as the afferent arc of a finger clubbing reflex. BEHCETS DISEASE and HEPATO-PULMONARY SYNDROME are RARE CAUSES of clubbing. VASCULITIS of digital vasculature by impairing endothelial functions promote platelet aggregation and may cause clubbing. Digital clubbing is mainly reported in BILIARY CIRRHOSIS but has also been described in other liver diseases, such as PORTAL CIRRHOSIS, SECONDARY HEPATIC AMYLOIDOSIS, ALCOHOLIC CIRRHOSIS, and BILIARY ATRESIA. CLUBBING IN ENDOCRINE DISEASE :- Clubbing has been reported in few endocrine conditions: THYROID ACROPACHY, HYPERPARATHYROIDISM. HUMAN IMMUNODEFICIENCY VIRUS AND CLUBBING :- Human immunodeficiency virus (HIV) and clubbing is an interesting topic but STUDIES ARE WEAK. ONLY FEW CASE REPORTS are there LINKING HIV infection AND CLUBBING. However, direct linking of HIV to clubbing is STILL a matter of CONTROVERSY. In an observational study, Dever et al. reported 36% incidence of clubbing in HIV infected outpatients. Patients with digital clubbing are slightly younger in age and had history of longer duration of HIV infection. Clubbing in HIV-infected patients has generally been attributed to CONCOMITANT PULMONARY INFECTION. Ddungu et al. assert that clubbing is MORE often present IN PATIENTS WITH PRIOR tuberculosis (TB). CLUBBING AND CARDIOVASCULAR DISEASE :- INFECTIVE ENDOCARDITIS usually causes a milder form of clubbing, whereas in CONGENITAL CYANOTIC HEART DISEASE, gross, drumstick appearance may be seen. Although digital clubbing is common in patients with cyanotic congenital heart disease (CCHD), HOA is rarely reported in this condition. However, one Mexican study reported a higher frequency of HOA of 31% in congenital cyanotic heart disease. CLUBBING AND PULMONARY TUBERCULOSIS :- ALTHOUGH TB has NOT been REPORTED AS A CAUSE OF CLUBBING IN MAJOR TEXTBOOKS OF MEDICINE, there are SEVERAL CASE REPORTS of its occurrence in TB patients. Studies from endemic areas of TB have shown a 30% frequency of clubbing amongst smear-positive TB patients. ONE INDIAN STUDY also reported a very high frequency of digital clubbing (82%). MacFarlane et al. in an earlier study in Nigeria reported associations of clubbing with severity of disease, cavitary TB, and hypoalbuminemia, indicative of chronic disease. Henry et al. could not find significant association between clubbing and duration of illness, frequency of cavitation, early versus late HIV disease, and hypoalbuminemia, but it was more common among patients with a lower Karnofsky performance scale score or with prior TB......... Dear@Dr. Asv Prasad in the context of nail clubbing, I have mentioned " Lung cancer is the most common cause of clubbing often occurs in heart and lung diseases..................or lung abscess......." Please go through this, where different studies are cited, with different percentage of clubbing in different disease....... etc etc. Thanking you. Regards, Puranjoy Saha.
Dr Saha Sir, U literally 'clubbed my head' with statestics. You may perhaps agree that the literature produced says that , 'Of the pulmonary causes, ca long is the commonest cause , Which is not same as ' the commonest cause '. The literature quotes the relative incidence , say in all pulmonary cases etc studied . Here also as u have rightly pointed out, there is discrepancy among studies. One NCBI quoted study puts - ' idiopathic pulmonary fibrosis ' at an incidence of 85% where as ca lung is given 29 %. U know that the statestics vary from study to study and within the same study due to ' sample size'- which has inverse relationship with incidence !. 'Sample bias' is also there. High incidence of asbestosis is seen in population effected by that pnumoconiosis where as outside the figures might not be true. Ethnic factors also play a role. In one study nearly 1/3 of 'UGANDAN ' pts studied were reported to have clubbing. Westren books don't consider P.TB as a cause as the incidence of PT is very less there. I was embarrassed when students were indicted in exms for citing PT as a cause , taking a leaf from the clinical medicine book written by me . We live with TB yet it is not accepted here what is accepted in UGANDA. ! The real commenest incidence of a cause is found when a large scale study incuding all possible causes is conducted. However my caution was that examiners perhaps don't like the ans as Ca lung being the commonest cause of clubbing. " Afteral we have to give ans to their likings if not their 'whims and fancies'. I will end this discussion quoting my real time experience in one exm. When one student quoted from my book, pulmonary AV fistula as a cause of clubbing, the examiner exhibited ' tantrum fits'.. Parodoxically it did not sooth the situation when , I immediately opened the internet on my mobile and furnished the ' required ' evidence ! Besides students, there are innocent Curofians who might jump to the conclusion on seeing a case of cubbing as ca lung , as it is cited as ' the commonest cause. " Anything even wrong, if done for a right cause should be exonerated !- and it is precisely what I request from you Sir. Nevertheless , though none would dare to ' sit in judgement' as to the relative merits of the arguments, it is hoped that the discussion would serve a 'good feast' to those with " literary bent of mind ". Regards Sir, conceeding that al lthis ' hocus- pocus' is just for discussion sake !
Comprehence. Thanks for sharing Sir. One correction about clubbing. That it is most common in lung Cancer. This may sènd wrong signals. Grade 4 or hypertrophic pulmonary osteoarthropathy is the characteristic feature of ca. Lung.
Nice and informative sir for day to day practice.
Really Nice and informative post sir
Very nine and informative post sir.
Nice and helpful post sir
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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
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26 year old male non smoker c/o clubbing of both upper n lower limb fingers since 1 year no c/0 . kindly diagnose n how to evaluate furtherDr. Mohd Anas1 Like8 Answers