Problem-based Learning Case 1 Respiratory System Module wnafifah Construction Worker with Blood in his Sputum __________________________________________________________________________________ CLUBBING

NG OF THE FINGER NAILS

Definition : Clubbing is a thickening of the flesh under the toenails and fingernails (gives them an abnormal rounded appearance). The nail curves downward. Clubbing of the fingernail. The above line shows the outline of a clubbed nail.

Clubbing develops in 5 steps : 1. Fluctuation and softening of the nail bed (increase ballotability) 2. Loss of the normal <160 Lovibond angle 3. Increase convexity of the nail fold 4. Thickening of the end part of finger (drumstick) 5. Shiny & striation of the nail and skin TEST FOR CLUBBING NAIL 1. Schamroths test or Schamroths window test A small diamond-shaped window is normally apparent between the nailbeds. If this window is obliterated, the test is positive and clubbing is present

2.

Look across the nail and nail bed at the nail bed angle normally obtuse but disappears in early finger clubbing Place your thumbs under the pulp of the terminal phalanx and attempt to move the nail within the nail bed using your index fingers A spongy feel confirms nail bed fluctuation

3.

PATHOPHYSIOLOGY The specific pathophysiologic mechanism of digital clubbing remains unknow n. (mechanism unclear). 1. 2. An increase in distal digital vasodilation (unknown cause) increase blood flow under the nail bed Secretion of growth factors (platelet-derived GF) from lungs fragments are large enough to lodge in the vascular beds of fingertips -increase capillary permeability connective tissue hypertrophy.

DISEASE ASSOCIATIONS Respiratory system diseases Bronchiectasis Cystic fibrosis Lung abscess Lung cancer Pulmonary fibrosis Tuberculosis Digestive system diseases Celiac disease Cirrhosis Crohns disease Ulcerative colitis Cardiovascular system diseases Cyanotic congenital heart disease Bacterial endocarditis Aortic valve disease Congestive heart failure Other conditions Graves disease Dysentery Cancer (liver, GIT, Hodgkins lymphoma) osteoarthropathy

Problem-based Learning Case 1 Respiratory System Module wnafifah Construction Worker with Blood in his Sputum __________________________________________________________________________________ GRANULOMA IN TUBERCULOSIS Definition :
1. A focus of chronic inflammation consisting of a microscopic aggregation of macrophages that are transformed into epithelial-like cell (epitheliod) surrounded by a collar of lymphocytes and occasional plasma cells. Seen in immunologically mediated, infectious & non-infectious conditions.

2.

Foreign body granulomas

- inert foreign body (eg. IV drug abuse, sutures @ fibres)

Granuloma

Immune granulomas - poorly degradable or insoluble particle, microbes that are capable of inducing cell mediated immune response

MECHANISM OF GRANULOMA

Poorly degradable @ particulate antigen (Mycobacterium Tuberculosis)

Macrophages engulf foreign protein antigen, process it (Sequestration within APC)

Present peptides to antigen specifi T-lymphocyte activate (APC-T cell interaction) Activate other T-cells

-activating other macrophages -transform them into epitheliod & multinucleated giant cell

T cell produce cytokines

IL-2
IFN-

IFN-
Epitheliod granuloma

Caseating granuloma
Necrosis = cell death Appears cheese-like to unaided eye Typically a feature of the granuloma of TB Tend to have infectious causes Just pink, no purple Loss of cellular details (no nucleus, outline)

Non-caseating granuloma
No necrosis present Does not appear cheese-like to unaided eye Purple amongst the pink Can see the cellular details (outline) Chrome diseases other than TB (Leprosy, Syphilis)