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Figure1.Obviousclubbinginpatientstoes.Notetherelativeseverityinthetoes
comparedtothehands.From(1)withpermission.
NEUROLOGY(7)
Thecausesofclubbingareafavouritebedsidequestiononrounds.Theycanbe
dividedinto:
OPHTHALMOLOGY(1)
Pulmonary(commonestthinkneoplasmuntilprovenotherwise).
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StanfordMedicine25Blog|WhatIsTheSpecificCauseofThisPatientsClubbing?
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Congenital
Whichofthesecouldcausethedistributioninfigure1?Ifyouneedafurtherclue,
hereisanotherpatientwiththesamecondition.
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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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