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Table of Contents
PICTORIAL CME
Year : 2021  |  Volume : 9  |  Issue : 2  |  Page : 134-135

Pulmonary arteriovenous malformation causing pan digital clubbing


Department of Internal Medicine, JIPMER, Puducherry, India

Date of Submission24-Dec-2020
Date of Decision28-Feb-2021
Date of Acceptance10-Mar-2021
Date of Web Publication21-Apr-2021

Correspondence Address:
Dr. S R Sruthi Meenaxshi
Plot No. 9, Door No 7, Third Street, P and T Nagar, Madurai - 625 017, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajim.ajim_112_20

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How to cite this article:
Sruthi Meenaxshi S R, Premnath V, Subrahmanyam D K. Pulmonary arteriovenous malformation causing pan digital clubbing. APIK J Int Med 2021;9:134-5

How to cite this URL:
Sruthi Meenaxshi S R, Premnath V, Subrahmanyam D K. Pulmonary arteriovenous malformation causing pan digital clubbing. APIK J Int Med [serial online] 2021 [cited 2021 Jun 12];9:134-5. Available from: https://www.ajim.in/text.asp?2021/9/2/134/314193



Digital clubbing was first described by Hippocrates in 400 BC in a patient with empyema. Hippocrates held the belief that illnesses were not a divine contrive but had a physical and rational explanation, thus laying the foundations of scientific medicine. He was the first to document digital clubbing as a sign of disease. As he described, “water accumulates; the patient has fever and cough; the respiration is fast; the feet become edematous; the nails appear curved and the patient suffers as if he had pus inside. If you put your ear against the chest you can hear it see the inside like sour wine.” This is the reason digital clubbing is also known by the eponym “Hippocratic finger” and is regarded to be the oldest clinical sign in medicine.[1]

In 1938, Lovibond described the “profile” sign which, if >180°, indicates true clubbing of the fingers (the normal angle between the nail bed and the proximal nail fold is 160°.). In addition, there are periungual edema and softening of the nail bed.[2] Digital clubbing may occur as isolated finding or is often part of the syndrome of hypertrophic osteoarthropathy which is characterized by periostosis of the long bones and occasional painful joint enlargement.

In 1944, Paul Dudley White said, Clubbing of the fingers and toes associated with cyanosis is found in certain congenital cardiovascular defects (the morbus cæruleus).[3] Clubbing without cyanosis is found in subacute bacterial endocarditis. However, it must be remembered that clubbed fingers are often found with noncardiac conditions, most commonly of all in pulmonary diseases.[4] Leo Schamroth, South African Electrophysiologist who himself a patient suffered three episodes of infective endocarditis, observed that the normal diamond-shaped window created by placing the back surfaces of the opposite terminal phalanges together was obliterated in clubbing.[5]

In 1961, Rice and Rowland described the ratio of the distal phalangeal to interphalangeal depth of more than 1:1 as a sign of clubbing.[6] This unique examination finding can provide a clue that a serious underlying condition may exist.

Here, we present a 19-year-old female who had marked swelling of the terminal digits [Figure 1], [Figure 2], [Figure 3]. No other family members had this finding. She presented with cyanosis, pan digital clubbing, and dyspnea on exertion. Her room air saturation was 60%. Her laboratory findings were normal. Computed tomography (CT) pulmonary angiography was diagnostic of pulmonary AV malformation [Figure 4]. Pulmonary AV malformation is uncommon clinical problem. The incidence of pulmonary AV malformation is 2–3 per 100,000 population.[7] The classic triad clubbing, cyanosis, and dyspnea on exertion should apprise the clinician the likelihood of pulmonary AV malformation. 80% are associated Osler–Weber–Rendu syndrome or hereditary hemorrhagic telangiectasia.[8] Therefore, all patients with pulmonary arteriovenous malformation should be screened for cerebral arteriovenous malformation by contrast-enhanced head CT or magnetic resonance imaging.
Figure 1: Clubbing in all finger nails

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Figure 2: Clubbing in all toenails

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Figure 3: Clubbing in all digits

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Figure 4: Computed tomography angiography of the thorax revealed pulmonary arteriovenous malformation in the posterior segment of the right upper lobe, with the feeding vessels all arising from the upper lobe branch of the right pulmonary artery and draining to the right superior pulmonary vein

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hippocrates. Prognostic. In: Jones WHS,Withington E T,Paul Potter,Wesley D Smith. Hippocrates. 1st ed, Vol II. London: Loeb Classical Library, No. 148, William Heinemann ltd; 1923. p. 7-55.  Back to cited text no. 1
    
2.
Lovibond J. Diagnosis of clubbed fingers. Lancet 1938;1:363-4.  Back to cited text no. 2
    
3.
White PD. Heart Disease. 3rd ed. New York: The Macmillan Company; 1944.  Back to cited text no. 3
    
4.
Spicknall KE, Zirwas MJ, English JC 3rd. Clubbing: An update on diagnosis, differential diagnosis, pathophysiology, and clinical relevance. J Am Acad Dermatol 2005;52:1020-8.  Back to cited text no. 4
    
5.
Schamroth L. Personal experience. S Afr Med J 1976;50:297-300.  Back to cited text no. 5
    
6.
Myers KA, Farquhar DR. The rational clinical examination. Does this patient have clubbing? JAMA 2001;286:341-7.  Back to cited text no. 6
    
7.
Mansour KA, Hatcher CR Jr, Logan WD Jr., Abbott OA. Pulmonary arteriovenous fistula. Am Surg 1971;37:203-8.  Back to cited text no. 7
    
8.
Hodgson CH, Kaye RL. Pulmonary arteriovenous fistula and hereditary hemorrhagic telangiectasia: A review and report of 35 cases of fistula. Dis Chest 1963;43:449-55.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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