Case and Research Letter
Digital Clubbing: Ultrasound Findings
Ecografía de acropaquia digital
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"apellidos" => "Fernandez-Quiroga" "email" => array:1 [ 0 => "drafernandezquiroga@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "F." "apellidos" => "Alfageme-Roldán" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "G." "apellidos" => "Roustan-Gullón" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad de Dermatología, Hospital General de Agudos Carlos G. Durand, Ciudad Autónoma de Buenos Aires, Argentina" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Ecografía de acropaquia digital" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1137 "Ancho" => 2978 "Tamanyo" => 339672 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(a) High-frequency ultrasound showing a normal nail in the longitudinal plane. (b) Similar image of the distal phalanx. Note the thickened nail bed and increased vascularization.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Digital clubbing refers to focal enlargement of connective tissue at the distal phalanges of fingers or toes. It is particularly prominent on dorsal surfaces and is often bilateral. Clinically, it is characterized by an increased Lovibond angle, which is the angle made by the proximal nail fold and the nail plate and normally measures 160° or less (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>a). In clubbing, it is larger than 180°, forming what is known as the Schamroth sign. The most common causes of digital clubbing are pulmonary (75%–80% of cases), cardiac (10%–15%), gastrointestinal (5%–10%), and thyroid (among others).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Ultrasound is a useful tool for evaluating the anatomy and structures of the nail unit as these show different degrees of echogenicity. In addition, Doppler measurements are helpful for assessing the vascularization of the nail matrix and nail bed. Ultrasound imaging has been used to characterize abnormalities observed in nail psoriasis and tumors of the nail and surrounding tissues, as well as nail changes in patients with autoimmune, infectious, and inflammatory diseases.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">1–4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In this report, we describe ultrasound findings observed in a patient with digital clubbing.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 46-year-old male smoker presented with hand eczema of 2 weeks’ duration and paronychia secondary to onychophagia. The physical examination revealed clubbing (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>b), which the patient said had been present since childhood; he denied a family history of nail abnormalities and reported no pain or mechanical symptoms.</p><p id="par0025" class="elsevierStylePara elsevierViewall">We studied the nail unit using high-frequency ultrasound with a 10–22<span class="elsevierStyleHsp" style=""></span>MHz linear probe connected to an Esaote MyLab Class C system. The longitudinal view revealed an enlarged nail bed, with a diameter of 3<span class="elsevierStyleHsp" style=""></span>mm (normal measurements are ≤<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>mm [<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>a]), and increased vascularization through the full thickness of the bed. No alterations were observed in the bone surface of the distal phalanx (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>b).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Comment</span><p id="par0030" class="elsevierStylePara elsevierViewall">The most widely accepted pathophysiologic hypothesis to explain clubbing is proliferation of vascular connective tissue due to platelets and platelet-derived growth factors (PDGFs). In the case of pulmonary diseases, it is assumed that circulating megakaryocytes cross from venous blood to arterial blood and are delivered to the extremities, where they release growth factors such as PDGFs. Normally, megakaryocytes do not fragment until they are trapped in the pulmonary capillaries, which is why clubbing is mainly associated with pulmonary diseases.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">5–7</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Clubbing must be distinguished from pachyperiostitis, which is clinically characterized by subperiosteal bone neoformation associated with pain (hypertrophic osteoarthropathy), polyarthritis, cutis verticis gyrata, pachydermia, seborrhea, and hyperhidrosis.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">8,9</span></a> None of these features were observed in our patient. Ultrasound findings in pachyperiostitis include echogenic tissue surrounding the long bones, reflecting the presence of edema and inflammation. Doppler imaging shows increased vascularization on the surface of some superficial bony structures.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">10,11</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Cutaneous ultrasound is an inexpensive, rapidly accessible, noninvasive tool for exploring the anatomy of the nail unit. In addition, it is useful for distinguishing between clubbing and pachyperiostitis without the need for ionizing radiation. Underlying disease must always be ruled out in such cases.</p><p id="par0045" class="elsevierStylePara elsevierViewall">This is the first case in the literature to describe ultrasound findings in a patient with digital clubbing.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Comment" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 799 "Ancho" => 2105 "Tamanyo" => 165340 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(a) Normal nail, Lovibond angle <160°. (b) Digital clubbing.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1137 "Ancho" => 2978 "Tamanyo" => 339672 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(a) High-frequency ultrasound showing a normal nail in the longitudinal plane. (b) Similar image of the distal phalanx. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 21 | 16 | 37 |
| 2024 October | 137 | 55 | 192 |
| 2024 September | 148 | 47 | 195 |
| 2024 August | 154 | 63 | 217 |
| 2024 July | 121 | 49 | 170 |
| 2024 June | 117 | 66 | 183 |
| 2024 May | 121 | 42 | 163 |
| 2024 April | 90 | 35 | 125 |
| 2024 March | 90 | 49 | 139 |
| 2024 February | 88 | 37 | 125 |
| 2024 January | 73 | 39 | 112 |
| 2023 December | 54 | 21 | 75 |
| 2023 November | 77 | 36 | 113 |
| 2023 October | 78 | 34 | 112 |
| 2023 September | 75 | 31 | 106 |
| 2023 August | 50 | 17 | 67 |
| 2023 July | 79 | 32 | 111 |
| 2023 June | 66 | 20 | 86 |
| 2023 May | 59 | 31 | 90 |
| 2023 April | 47 | 19 | 66 |
| 2023 March | 52 | 28 | 80 |
| 2023 February | 47 | 31 | 78 |
| 2023 January | 67 | 58 | 125 |
| 2022 December | 69 | 37 | 106 |
| 2022 November | 53 | 50 | 103 |
| 2022 October | 70 | 47 | 117 |
| 2022 September | 75 | 55 | 130 |
| 2022 August | 91 | 68 | 159 |
| 2022 July | 84 | 50 | 134 |
| 2022 June | 110 | 68 | 178 |
| 2022 May | 75 | 50 | 125 |
| 2022 April | 17 | 31 | 48 |
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