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StanfordMedicine25Blog|WhatIsTheSpecificCauseofThisPatientsClubbing?
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What Is The Specific Cause of This Patients

Clubbing?
June3,2015

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CARDIOLOGY(10)
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HEALTH(1)
HEMATOLOGY/ONCOLOGY(2)
HISTORY(10)

Figure1.Obviousclubbinginpatientstoes.Notetherelativeseverityinthetoes
comparedtothehands.From(1)withpermission.

NEUROLOGY(7)

Thecausesofclubbingareafavouritebedsidequestiononrounds.Theycanbe
dividedinto:

OPHTHALMOLOGY(1)

Pulmonary(commonestthinkneoplasmuntilprovenotherwise).

PULMONARY(2)

NEWS(26)

PERSPECTIVE(7)

RHEUMATOLOGY(2)

Bronchialcarcinoma
Mesothelioma
Bronchiectasis
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Cyanoticcongentialheartdisease
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StanfordMedicine25Blog|WhatIsTheSpecificCauseofThisPatientsClubbing?

IBD
Coeliacdisease
Congenital
Whichofthesecouldcausethedistributioninfigure1?Ifyouneedafurtherclue,
hereisanotherpatientwiththesamecondition.

November2014(2)
October2014(5)
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Figure2.Thesaturationintoesandfingersisdifferent,despitethepatientinspiringa
constantoxygenconcentration.Adaptedfrom(2),withpermission.
AnswerBelow

Thesearepathognomonicphysicalsigns.Ifapatientwithapatentductusarteriosus
(PDA)developsEisenmengerssyndrometherewillbearteriovenousmixingcausing
deoxygenatedblood.CruciallythisaffectsthelowerlimbsexclusivelyasthePDA
connectspulmonaryarterytoaorticarchdistaltotheleftsubclavianartery.Theexact
mechanismbywhichhypoxaemiaresultsinclubbingisnotfullyunderstood,butis
thoughttoinvolvegrowthfactorsinvascularendotheliumandplatelets(Seethis
articletolearnmoreaboutthemechanism).Henceasthelowerlimbsexperience
morehypoxaemia,theydevelopmoreclubbingandcyanosis.
Todemonstrateclubbingatthebedside,Shamrothswindowtestisperformed:

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StanfordMedicine25Blog|WhatIsTheSpecificCauseofThisPatientsClubbing?

Figure3.Shamrothswindowtestshowingobliterationofnailfoldangle(no
rhomboidvisible)whenclubbednailsareopposed.
Formoreexamplesofhowimportantthehandisinphysicaldiagnosis,refertothe
Stanford25pageonthehand.
TakeHomeMessage:
Clubbingandcyanosisthatisworseinthelowerlimbsthanupperlimbscan
onlybeexplainedbyapatientwithEisemengerssyndromesecondtoPDA.
Bonusquestion:
Whatcardiovascularexaminationfindingswouldyouexpectinthispatient?
(AnswerBelow)

Cardiacauscultationrevealedaleftparasternalheave,apalpablesecondheart
sound,singleandloudS2andasoftpansystolicmurmuroftriscupid
regurgitation.
Clinicaltips:
OnceEisemengersdevelopsthereisnoflowmurmuracrossPDAasthepressurein
rightandleftheartareequal.ThismeansasingleloudS2,whichmaybepalpable
andsignsofRVhypertrophy.Oftentheremaybeassociatedflowmurmurs,butnot
thecharacteristiccontinuousmachinerymurmurofaPDA.
References:
1.AnoopT,GeorgeK.DifferentialClubbingandCyanosis.NEnglJMed
2011364(7):666.
2.MoccettiF,KaufmannBa.,ToblerD.Differentialclubbingandcyanosis:A
pathognomonicfindingincardiology.EurHeartJ201435(21):1410.
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