Original article
Prevalence, aetiologies and significance of clubbing in a department of general internal medicine

https://doi.org/10.1016/j.ejim.2007.05.015Get rights and content

Abstract

Background

Clubbing remains an amazing clinical sign. Its strong association with serious disease is still a clinical enigma. Moreover, the significance of diagnosing clubbing is not well established. The aim of our study was to evaluate prevalence, aetiology and clinical significance of clubbing in a department of general internal medicine.

Patients and methods

During one year (1511 admissions), all patients with digital clubbing assessed by determining ratio of the distal phalangeal depth (DPD) to the interphalangeal depth (IPD) and with the presence of Swamroth sign were included. Fifteen patients were diagnosed with clubbing (10 males and 5 females). They underwent complete physical examination, pulmonary CT-scan, bone scintigraphy, blood gas analysis and were compared with 86 matched controls.

Results

Aetiology were renal cell carcinoma, pulmonary arteriovenous malformation, AIDS, inflammatory pseudo-tumour of the lung, adenocarcinoma of unknown origin in one case and in one case, Pet-scan suspected neoplasia but histology was not obtained. In 9 cases, no aetiology was found. Bone scan was normal in 14 cases and revealed periostitis in one case (idiopathic clubbing). Compared to control group, there was no difference in blood gas analysis but emphysema was more often present in patients with clubbing (p < 0.01). No patient without aetiology developed cancer in the one year follow-up.

Conclusion:

Clubbing is present in 1% of admission in a department of general internal medicine and is associated in nearly 40% with serious disease. In 60% of cases, aetiology is not identified but follow-up do not disclosed cancer.

Introduction

Digital clubbing (DC) is a focal, bulbous swelling of digital connective tissue that develops on the dorsal surface of terminal phalanges [1]. Initially described by Hippocrates over 2500 years ago [2], DC is associated with a variety of diseases including cystic fibrosis, bronchiectasis, cirrhosis, cyanotic congenital heart disease and cancer [1]. The concurrent presence of periostitis, arthritis and fully developed DC forms an entity called hypertrophic osteoarthropathy syndrome (HOA). Other minor signs, such as pachydermia, synovial effusion, seborrhoea, folliculitis or hypertrophic gastropathy are sometimes present. Rarely, autonomic disorders such as flushing can also be noted [3], [4].

Despite the well-known prevalence of DC in certain disorders (current estimations mention an incidence of 24% in primary biliary cirrhosis patients [5] and 30% in bronchogenic carcinoma patients [6]), neither its prevalence in general internal medicine in-patients, nor its significance are known. Our study's dual aim is to assess clubbing prevalence and aetiology in such patients and analyse its significance.

Section snippets

Patients and methods

During one year (February 2006–February 2007), all patients admitted to our general internal medicine ward were assessed for digital clubbing. The unit includes 45 beds allocated to non oncological patients. Clubbing assessment was based on the ratio of distal phalangeal depth (DPD; measured at the cuticle of the index) to distal interphalangeal joint depth (IPD) (Fig. 1). A DPD/IPD ratio superior to 1 is indicative of clubbing and by the presence of Schamroth's sign (Fig. 2) (disappearance of

Results

During the study period, clubbing was diagnosed in 15 of our 1511 patients (0.99% of admissions). Mean age was 67 years (range: 47–85). None of these patients had noticed the changes in their fingers. Mean DPD/IPD ratio was 1.209 ±0.08. Patients characteristics are reported in Tables 1 and 2. Ten of the patients were male and 5 were female.

One 79-year old patient was admitted to the hospital for hematuria. Clinical examination revealed the presence of digital clubbing (DPD/IPD ratio: 1.3). An

Discussion

Although clubbing has been recognised since 400 BC, when it was described by Hippocrates in a patient with empyema, its clinical relevance still remains obscure [2]. Alternately referred to as Hippocratic fingers, watch-glass nails or drumstick fingers [7], digital clubbing is a feature of the hypertrophic osteoarthropathy syndrome which is characterized by periostosis of the long bones, joint pain and arthritis [3]. Clubbing has been described as occurring in stages [8]. From a histological

Learning points

  • One percent of the patients admitted to a general internal medicine ward presented with digital clubbing.

  • Clubbing is associated in nearly 40% with serious disease and in the remaining cases follow-up do not disclosed cancer.

  • No statistically significant mean PaO2 difference was found between the patients with clubbing and the controls.

  • Periostitis, component of hypertrophic osteoarthropathy is found in only one case.

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