Why does cyanosis cause clubbing

Sign In. Advanced Search. Search Menu. Article Navigation. Close mobile search navigation Article Navigation. Volume Article Contents. Differential clubbing and cyanosis: a pathognomonic finding in cardiology. Federico Moccetti , Federico Moccetti. Division of Cardiology.

Oxford Academic. Google Scholar. Beat A. Select Format Select format. Clubbing has been described to occur in different stage [ Table 1 ]. On palpation, it gives a spongy sensation. Eventually, the depth of distal phalanx increases and distal inter-phalangeal joint may become hyper-extensible. At this stage, finger develops a clubbed appearance. Finally, the nail and peri-ungual skin appear shiny and nail develops longitudinal ridging. This whole process usually takes years but in certain conditions, clubbing may develop sub-acutely e.

Although different grading of clubbing has been described, it has no clinical significance. Clubbing may be associated with various clinical conditions [ Table 2 ]; 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. However, contrary to this classical view, Findik and Baughman et al.

Most studies did notice a male predominance of clubbing in lung cancer patients[ 26 ] except Sridhar et al. Hirakata et al. There are few case reports of digital clubbing occurrence in malignant mesothelioma, pleural fibroma, and metastatic osteogenic sarcoma. 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.

Vandemergel et al. 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. 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. Kanematsu et al. It is more commonly noted among male patients. Ryu et al. Asbestosis is another ILD where clubbing is commonly seen. Coutts et al. 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.

Kittis et al. Collins et al. 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.

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.

Vasculitis of digital vasculature by impairing endothelial functions promote platelet aggregation and may cause clubbing. Digital clubbing is mainly reported in biliary cirrhosis[ 52 ] but has also been described in other liver diseases,[ 53 ] such as portal cirrhosis,[ 54 ] secondary hepatic amyloidosis, alcoholic cirrhosis, and biliary atresia.

Clubbing has been reported in few endocrine conditions: Thyroid acropachy, hyperparathyroidism. It is characterized by clubbing and swelling of the fingers and toes, with or without periosteal reaction of the distal bones.

The typical features of clubbing and periostitis seen in thyroid acropachy are often different from other causes of clubbing:. In acropachy, periosteal reaction can be asymmetric but in pulmonary osteoarthropathy, periosteal reaction usually is symmetric. In thyroid acropachy, radiographs show a characteristic subperiosteal spiculated, frothy, or lacy appearance, whereas in classic pulmonary osteoarthropathy, there is laminal periosteal proliferation.

Autoimmune phenomena, increased glycosaminoglycan and fibroblast proliferation explain the pathological changes of clubbing in thyroid acropachy[ 61 , 62 ]. Thyroid acropachy less commonly involve proximal long bones and periarticular areas, which occurs in rheumatoid arthritis and metabolic disorders including hyperthyroidism[ 57 ]. 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. 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. Infective endocarditis usually causes a milder form of clubbing, whereas in congenital cyanotic heart disease, gross, drumstick appearance may be seen. 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.

Henry et al. Clubbing is generally bilateral, but in some conditions it may occur unilaterally [ Table 3 ]. Unilateral clubbing is usually associated with local vascular lesions of the arm, axilla, and thoracic outlet and with hemiplegia. It may be explained by the different methods use to elicit clubbing. Incidence of clubbing increases with the duration of stroke and Siragusa noticed development of clubbing months after the stroke.

Hypertrophy and edema of the soft tissues may be responsible for the obliteration of the nail angle in hemiplegic patients. Several theories have been put forward to explain it. Different causes of unilateral clubbing[ 76 — 78 ]. A vasoactive compound, endotoxin, or some other substance produced by bacteria adherent or adjacent to the graft. Chronic infection of the arterial graft may also lead to formation of platelet clumps within vessels with secondary release of PDGF into the circulation leading to clubbing formation.

Clubbing may also involve single digit only in case of digital mucoid cyst, osteoid osteoma, myxochondroma, and enchondromas. Occasionally, clubbing may occur selectively in lower limbs, sparing the upper limbs. This is known as differential clubbing.

Differential clubbing may occur in patient with patent ductus arteriosus associated with pulmonary artery hypertension and right to left shunt. In this condition, deoxygenated blood from the right ventricle enters aorta distal to the origin of left subclavian artery, thereby sparing the upper extremities. It may also occur in infected abdominal aortic aneurysm. Chronic obstructive pulmonary disease COPD per se does not cause clubbing, but if clubbing is present in COPD, underlying lung cancer and bronchiectasis must be ruled out.

Clubbing can be assessed by physical examination. However, it is subjective and often unreliable, particularly in mild cases. It was objectively measured by material brass templates[ 80 ] with arcs of various sizes, plethysmography,[ 81 ] digital casts,[ 82 ] and shadowgraph[ 83 ] technique. All these methods are relatively crude and cannot be accepted as standard as they do not provide easy quantification.

Recently, digital cameras and computerized analysis[ 1 ] have been used to objectively assess clubbing. It is an easy, rapid and relatively inexpensive method to study finger clubbing. It was proposed by Lovibond[ 84 ] in the year and is also popularly known as Lovibond's angle. It is defined by the angle made by nail as it exists from the proximal nail fold. It is constructed by drawing a line from distal digital crease to the cuticle and another line from the cuticle to hyponychium which is the thickened stratum corneum of epidermis lying under the free edge of the nail.

It also correlates strikingly with the subjective assessment of clubbing. It is defined by the ratio of digit's depth measured at the junction between skin and nail nail bed and at the distal interphalangeal joint. Normally, the depth at distal interphalangeal joint is more than the depth at nail bed.

In clubbing fingers, connective tissue deposition expands the pulp in the terminal phalanx and the ratio becomes reversed. This ratio is also independent of age, sex, and ethnicity of population. While performing this measurement with calipers, it should be ensured that the calipers must not compress the tissues during measurement. It is usually measured at the index finger. The phalangeal depth ratio is shown in Figure 2. Differential Clubbing and Cyanosis.

N Engl J Med ; 7 Moccetti F, Kaufmann B a. Differential clubbing and cyanosis: A pathognomonic finding in cardiology. Eur Heart J ;35 21 Watch this video to get a first-person perspective of the Examination of the Hand with Abraham Verghese. In this session, we shared our experiences with teaching the physical exam at the bedside. Our participants got into groups and came up with their own bedside teaching example to share with everyone.

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