Drum fingers. Drumsticks

Poteyko P.I., Kharkovskaya medical Academy Postgraduate Education, Department of Phthisiology and Pulmonology

Even in ancient times, 25 centuries ago, Hippocrates described changes in the shape of the distal phalanges of the fingers, which occurred in chronic pulmonary pathology (abscess, tuberculosis, cancer, pleural empyema), and called them “drum sticks.” Since then, this syndrome has been called by his name - Hippocratic fingers (Hippocratic fingers) (digiti Hippocratici).

Hippocrates' finger syndrome includes two signs: “hour glasses” (Hippocrates' nails - ungues Hippocraticus) and club-shaped deformation of the terminal phalanges of the fingers like “drumsticks” (Finger clubbing).

Currently, PG is considered the main manifestation of hypertrophic osteoarthropathy (HOA, Marie-Bamberger syndrome) - multiple ossifying periostosis.

The mechanisms of development of PG are currently not fully understood. However, it is known that the formation of PG occurs as a result of microcirculation disturbances, accompanied by local tissue hypoxia, disruption of periosteal trophism and autonomic innervation against the background of prolonged endogenous intoxication and hypoxemia. In the process of formation of PG, the shape of the nail plates (“hour glasses”) first changes, then the shape of the distal phalanges of the fingers changes into a club-shaped or flask-shaped shape. The more pronounced the endogenous intoxication and hypoxemia, the more severely the terminal phalanges of the fingers and toes are modified.

Changes in the distal phalanges of the fingers according to the “drumstick” type can be established in several ways.

It is necessary to identify a smoothing of the normally existing angle between the base of the nail and the nail fold. The disappearance of the “window”, which is formed when the distal phalanges of the fingers are juxtaposed with their dorsal surfaces facing each other, is the earliest sign of thickening of the terminal phalanges. The angle between the nails does not normally extend upward more than half the length of the nail bed. As the distal phalanges of the fingers thicken, the angle between the nail plates becomes wide and deep (Fig. 1).

On unmodified fingers, the distance between points A and B should exceed the distance between points C and D. With “drumsticks” the relationship is the opposite: C - D becomes longer than A - B (Fig. 2).

Another important sign PG is the value of the angle ACE. On a normal finger this angle is less than 180°; with “drumsticks” it is more than 180° (Fig. 2).

Along with the “Hippocrates fingers”, in paraneoplastic Marie-Bamberger syndrome, periostitis appears in the area of ​​the end sections of the long tubular bones(usually the forearms and legs), as well as the bones of the hands and feet. In places of periosteal changes, severe ossalgia or arthralgia and local palpation tenderness may be observed; X-ray examination reveals a double cortical layer, due to the presence of a narrow dense strip separated from the compact bone substance by a light gap (symptom of “tram rails”) (Fig. 3). It is believed that Marie-Bamberger syndrome is pathognomonic for lung cancer; less often it occurs in other primary intrathoracic tumors ( benign neoplasms lungs, pleural mesothelioma, teratoma, mediastinal lipoma). Occasionally, this syndrome occurs in cancer of the gastrointestinal tract, lymphoma with metastases to the mediastinal lymph nodes, and lymphogranulomatosis. At the same time, Marie-Bamberger syndrome also develops in non-oncological diseases - amyloidosis, chronic obstructive pulmonary disease, tuberculosis, bronchiectasis, congenital and acquired heart defects, etc. One of the distinctive features of this syndrome in non-tumor diseases there is a long-term (over the course of years) development of characteristic changes in the osteoarticular apparatus, while in malignant neoplasms this process is calculated in weeks and months. After radical surgical treatment Cancer Marie-Bamberger syndrome can regress and completely disappear within a few months.

Currently, the number of diseases in which changes in the distal phalanges of the fingers are described as “drumsticks” and nails as “watch glasses” has increased significantly (Table 1). The appearance of PG often precedes more specific symptoms. We especially need to remember the “sinister” connection of this syndrome with lung cancer. Therefore, identifying signs of PG requires correct interpretation and instrumental and laboratory methods examinations for timely establishment of a reliable diagnosis.

Relationship between GHG and chronic diseases lungs, accompanied by prolonged endogenous intoxication and respiratory failure(DN), is considered obvious: their formation is especially often observed when pulmonary abscesses- 70–90% (within 1–2 months), bronchiectasis - 60–70% (within several years), pleural empyema - 40–60% (within 3–6 months or more) (“rough” fingers Hippocrates, Fig. 4).

In tuberculosis of the respiratory organs, PGs are formed in the case of a widespread (more than 3–4 segments) destructive process with a long or chronic course(6–12 months or more) and are characterized mainly by the “watch glass” symptom, thickening, hyperemia and cyanosis of the nail fold (“delicate” Hippocratic fingers - 60–80%, Fig. 5).

In idiopathic fibrosing alveolitis (IFA), PG occurs in 54% of men and 40% of women. It has been established that the severity of hyperemia and cyanosis of the nail fold, as well as the very presence of PG, indicate an unfavorable prognosis with ELISA, reflecting, in particular, the prevalence of active damage to the alveoli (ground-glass zones detected with computed tomography) and the severity of proliferation of vascular smooth muscle cells in areas of fibrosis. PG is one of the factors that most reliably indicates a high risk of the formation of irreversible pulmonary fibrosis in patients with ELISA, also associated with a decrease in their survival.

At diffuse diseases connective tissue with the involvement of the pulmonary parenchyma, PH always reflect the severity of DN and are an extremely unfavorable prognostic factor.

For other interstitial lung diseases, the formation of PG is less typical: their presence almost always reflects the severity of DN. J. Schulze et al. described this clinical phenomenon in a 4-year-old girl with rapidly progressive pulmonary histiocytosis X. V. Holcomb et al. revealed changes in the distal phalanges of the fingers like “drumsticks” and nails like “watch glasses” in 5 out of 11 patients examined with pulmonary veno-occlusive disease.

As lung lesions progress, PGs appear in at least 50% of patients with exogenous allergic alveolitis. It should be emphasized the leading importance of a persistent decrease in the partial pressure of oxygen in the blood and tissue hypoxia in the development of HOA in patients suffering from chronic lung diseases. Thus, in children with cystic fibrosis, the values ​​of partial pressure of oxygen in arterial blood and forced expiratory volume in 1 second were the smallest in the group with the most pronounced changes distal phalanges of fingers and nails.

There are isolated reports of the appearance of PG in bone sarcoidosis (J. Yancey et al., 1972). We observed more than a thousand patients with intrathoracic sarcoidosis lymph nodes and lungs, including skin manifestations, and in no case was the formation of PG detected. Therefore, we consider the presence/absence of PG as a differential diagnostic criterion for sarcoidosis and other pathologies of the chest organs (fibrosing alveolitis, tumors, tuberculosis).

Changes in the distal phalanges of the fingers like “drum sticks” and nails like “watch glasses” are often recorded when occupational diseases occurring with the involvement of the pulmonary interstitium. Relatively early appearance GOA is characteristic of patients with asbestosis; this sign is in favor of high risk of death. According to S. Markowitz et al. , during a 10-year follow-up of 2709 patients with asbestosis, with the development of PG, their probability of death increased by at least 2 times.
PGs were detected in 42% of the examined coal mine workers who suffered from silicosis; in some of them, along with diffuse pneumosclerosis, foci of active alveolitis were found. Changes in the distal phalanges of the fingers like “drum sticks” and nails like “watch glasses” have been described in workers of factories producing matches who were in contact with rhodamine used in their production.

The connection between the development of PH and hypoxemia is confirmed by the repeatedly described possibility of the disappearance of this symptom after lung transplantation. In children with cystic fibrosis, characteristic changes in the fingers regressed during the first 3 months. after lung transplantation.

The appearance of PG in a patient with interstitial lung disease, especially with a long history of the disease and in the absence of clinical signs of active lung damage, requires a persistent search for a malignant tumor in lung tissue. It has been shown that in lung cancer that develops against the background of ELISA, the frequency of GOA reaches 95%, while in cases of damage to the pulmonary interstitium without signs of neoplastic transformation, it is found more rarely - in 63% of patients.

The rapid development of changes in the distal phalanges of the fingers like “drumsticks” is one of the indications for the development of lung cancer even in the absence of precancerous diseases. In such a situation, clinical signs of hypoxia (cyanosis, shortness of breath) may be absent and this sign develops according to the laws of paraneoplastic reactions. W. Hamilton et al. demonstrated that the likelihood of a patient having PG increases by 3.9 times.

GOA is one of the most common paraneoplastic manifestations of lung cancer; its prevalence in this category of patients can exceed 30%. The dependence of the frequency of detection of PG on morphological form lung cancer: reaching 35% with the non-small cell variant, with the small cell variant this figure is only 5%.

The development of HOA in lung cancer is associated with hyperproduction of growth hormone and prostaglandin E2 (PGE-2) by tumor cells. Partial pressure of oxygen in peripheral blood however, it may remain normal. It was found that in the blood of patients with lung cancer with a symptom of PG, the level of transforming growth factor β (TGF-β) and PGE-2 significantly exceeds that of patients without changes in the distal phalanges of the fingers. Thus, TGF-β and PGE-2 can be considered relative inducers of PG formation, relatively specific for lung cancer; Apparently, this mediator is not involved in the development of the discussed clinical phenomenon in other chronic pulmonary diseases with DN.

The paraneoplastic nature of the “drumstick” type changes in the distal phalanges of the fingers is clearly demonstrated by the disappearance of this clinical phenomenon after successful resection lung tumors. In turn, the reappearance of this clinical sign in a patient in whom treatment for lung cancer was successful is a likely indication of tumor recurrence.

PG can be a paraneoplastic manifestation of tumors localized outside the lung area, and may even precede the first clinical manifestations malignant tumors. Their formation is described in malignant tumors of the thymus, cancer of the esophagus, colon, gastrinoma, characterized by clinically typical Zollinger-Ellison syndrome, and pulmonary artery sarcoma.

The possibility of PG formation in malignant breast tumors and pleural mesothelioma, which is not accompanied by the development of DN, has been repeatedly demonstrated.

PGs are detected in lymphoproliferative diseases and leukemia, including acute myeloblastic, in which they were noted on the arms and legs. After chemotherapy, which stopped the first attack of leukemia, the signs of GOA disappeared, but reappeared after 21 months. in case of tumor recurrence. In one of the observations, regression of typical changes in the distal phalanges of the fingers was stated with successful chemotherapy and radiation therapy lymphogranulomatosis.

Thus, PG, along with various types of arthritis, erythema nodosum and migratory thrombophlebitis are among the frequent extraorgan, nonspecific manifestations of malignant tumors. The paraneoplastic origin of changes in the distal phalanges of the fingers like “drumsticks” can be assumed when they form quickly (especially in patients without DN, heart failure and in the absence of other causes of hypoxemia), as well as when combined with other possible extra-organ, nonspecific signs of a malignant tumor - an increase in ESR, changes in the peripheral blood picture (especially thrombocytosis), persistent fever, articular syndrome and recurrent thrombosis of various locations.

One of the most common reasons The appearance of PG is considered to be congenital heart defects, especially the “blue” type. Among 93 patients with pulmonary arteriovenous fistulas observed at the Mauo Clinic for 15 years, similar changes in the fingers were recorded in 19%; they exceeded hemoptysis in frequency (14%), but were inferior to noises over pulmonary artery(34%) and shortness of breath (57%).

R. Khouzam et al. (2005) described ischemic stroke embolic origin, which developed 6 weeks after birth in an 18-year-old patient. The presence of characteristic changes in the fingers and hypoxia, which required respiratory support, led to a search for an anomaly in the structure of the heart: transthoracic and transesophageal echocardiography revealed that the inferior vena cava opened into the cavity of the left atrium.

PGs can “discover” the existence of pathological shunting from the left side of the heart to the right, including that formed as a consequence of cardiac surgery. M. Essop et al. (1995) observed characteristic changes in the distal phalanges of the fingers and increasing cyanosis for 4 years after balloon dilatation of rheumatic mitral stenosis, the complication of which was small defect interatrial septum. During the period that has passed since the operation, its hemodynamic significance has increased significantly due to the fact that the patient also developed rheumatic stenosis of the tricuspid valve, after correction of which indicated symptoms completely disappeared. J. Dominik et al. noted the appearance of PG in a 39-year-old woman 25 years after successful elimination atrial septal defect. It turned out that during the operation the inferior vena cava was mistakenly directed to left atrium.

PG is considered one of the most typical nonspecific, so-called extracardiac, clinical signs infective endocarditis(IE). The frequency of changes in the distal phalanges of the fingers like “drumsticks” in IE can exceed 50%. Evidence in favor of IE in a patient with PG high fever with chills, increase in ESR, leukocytosis; Anemia, a transient increase in serum activity of hepatic aminotransferases, and various types of kidney damage are often observed. To confirm IE, transesophageal echocardiography is indicated in all cases.

According to some clinical centers, one of the most common causes of the phenomenon of PG is cirrhosis of the liver with portal hypertension and progressive dilatation of the vessels of the pulmonary circulation, leading to hypoxemia (the so-called pulmonary-renal syndrome). In such patients, GOA is usually combined with cutaneous telangiectasias, often forming “spider vein fields”.
A connection has been established between the formation of HOA in liver cirrhosis and previous alcohol abuse. In patients with liver cirrhosis without concomitant hypoxemia, PG is usually not detected. This clinical phenomenon is also characteristic of primary cholestatic liver lesions requiring liver transplantation. childhood, including when congenital atresia bile ducts.

Repeated attempts have been made to decipher the mechanisms of development of changes in the distal phalanges of the fingers like “drumsticks” in diseases, including those mentioned above (chronic lung diseases, congenital heart defects, IE, liver cirrhosis with portal hypertension), accompanied by persistent hypoxemia and tissue hypoxia. Hypoxia-induced activation of tissue growth factors, including platelet growth factors, plays a leading role in the formation of changes in the distal phalanges and fingernails. In addition, in patients with PH, an increase in the serum level of hepatocyte growth factor, as well as vascular growth factor, was detected. The connection between the increase in the activity of the latter and a decrease in the partial pressure of oxygen in arterial blood is considered the most obvious. Also, in patients with PH, a significant increase in the expression of hypoxia-inducible factors type 1a and 2a is found.

In the development of changes in the distal phalanges of the fingers of the “drumstick” type, endothelial dysfunction associated with a decrease in the partial pressure of oxygen in arterial blood may have a certain significance. It has been shown that in patients with GOA, the serum concentration of endothelin-1, the expression of which is induced primarily by hypoxia, is significantly higher than that in healthy people.
The mechanisms of PG formation in chronic diseases are difficult to explain. inflammatory diseases intestines, for which hypoxemia is not typical. At the same time, they are often found in Crohn’s disease (they are not typical in ulcerative colitis), in which changes in the fingers like “drumsticks” may precede the actual intestinal manifestations diseases.

The number of probable reasons causing changes in the distal phalanges of the fingers according to the “watch glass” type continues to increase. Some of them are very rare. K. Packard et al. (2004) observed the formation of PG in a 78-year-old man who took losartan for 27 days. This clinical phenomenon persisted when losartan was replaced by valsartan, which allows us to consider it undesirable reaction for the entire class of angiotensin II receptor blockers. After switching to captopril, changes in the fingers completely regressed within 17 months. .

A. Harris et al. found characteristic changes in the distal phalanges of the fingers in a patient with primary antiphospholipid syndrome, while no signs of thrombotic damage to the pulmonary vascular bed were detected. The formation of PGs has also been described in Behçet's disease, although it cannot be completely ruled out that their appearance in this disease was accidental.
PGs are considered among possible indirect markers of drug use. In some of these patients, their development may be associated with a variant of lung damage or IE characteristic of drug addicts. Changes in the distal phalanges of the fingers like “drum sticks” are described in users of not only intravenous, but also inhaled drugs, for example, hashish smokers.

With increasing frequency (at least 5%), PG is registered in HIV-infected people. Their formation may be based on various forms of HIV-associated pulmonary diseases, but this clinical phenomenon is observed in HIV-infected patients with intact lungs. It has been established that the presence of characteristic changes in the distal phalanges of the fingers in HIV infection is associated with a lower number of CD4-positive lymphocytes in the peripheral blood; in addition, interstitial lymphocytic pneumonia is more often recorded in such patients. In HIV-infected children, the appearance of PG is a likely indication of pulmonary tuberculosis, which is possible even in the absence of Mycobacterium tuberculosis in sputum samples.

The so-called primary form of GOA, not associated with diseases of the internal organs, is known, often having a familial nature (Touraine-Solant-Gole syndrome). It is diagnosed only after excluding most of the causes that can cause the appearance of PG. Patients with the primary form of GOA often complain of pain in the area of ​​the changed phalanges, increased sweating. R. Seggewiss et al. (2003) observed primary GOA involving only the fingers of the lower extremities. At the same time, when establishing the presence of PH in members of the same family, it is necessary to take into account the possibility that they have inherited congenital heart defects (for example, patent ductus botallus). The formation of characteristic changes in the fingers can continue for about 20 years.

Recognizing the causes of changes in the distal phalanges of the fingers according to the “drumstick” type requires differential diagnosis various diseases, among which the leading position is occupied by those associated with hypoxia, i.e. clinically manifested DN and/or heart failure, as well as malignant tumors and subacute IE. Interstitial lung diseases, primarily ELISA, are one of the most common causes of PG; the severity of this clinical phenomenon can be used to assess the activity of lung damage. The rapid formation or increase in the severity of GOA necessitates the search for lung cancer and other malignant tumors. At the same time, one should take into account the possibility of the appearance of this clinical phenomenon in other diseases (Crohn's disease, HIV infection), in which it can occur much earlier than specific symptoms.

Poteyko P.I., Kharkov Medical Academy of Postgraduate Education, Department of Phthisiology and Pulmonology

Even in ancient times, 25 centuries ago, Hippocrates described changes in the shape of the distal phalanges of the fingers, which occurred in chronic pulmonary pathology (abscess, tuberculosis, cancer, pleural empyema), and called them “drum sticks.” Since then, this syndrome has been called by his name - Hippocratic fingers (Hippocratic fingers) (digiti Hippocratici).

Hippocrates' finger syndrome includes two signs: “hour glasses” (Hippocrates' nails - ungues Hippocraticus) and club-shaped deformation of the terminal phalanges of the fingers like “drumsticks” (Finger clubbing).

Currently, PG is considered the main manifestation of hypertrophic osteoarthropathy (HOA, Marie-Bamberger syndrome) - multiple ossifying periostosis.

The mechanisms of development of PG are currently not fully understood. However, it is known that the formation of PG occurs as a result of microcirculation disturbances, accompanied by local tissue hypoxia, disruption of periosteal trophism and autonomic innervation against the background of prolonged endogenous intoxication and hypoxemia. In the process of formation of PG, the shape of the nail plates (“hour glasses”) first changes, then the shape of the distal phalanges of the fingers changes into a club-shaped or flask-shaped shape. The more pronounced the endogenous intoxication and hypoxemia, the more severely the terminal phalanges of the fingers and toes are modified.

Changes in the distal phalanges of the fingers according to the “drumstick” type can be established in several ways.

It is necessary to identify a smoothing of the normally existing angle between the base of the nail and the nail fold. The disappearance of the “window”, which is formed when the distal phalanges of the fingers are juxtaposed with their dorsal surfaces facing each other, is the earliest sign of thickening of the terminal phalanges. The angle between the nails does not normally extend upward more than half the length of the nail bed. As the distal phalanges of the fingers thicken, the angle between the nail plates becomes wide and deep (Fig. 1).

On unmodified fingers, the distance between points A and B should exceed the distance between points C and D. With “drumsticks” the relationship is the opposite: C - D becomes longer than A - B (Fig. 2).

Another important sign of PG is the size of the ACE angle. On a normal finger this angle is less than 180°; with “drumsticks” it is more than 180° (Fig. 2).

Along with the “fingers of Hippocrates,” in paraneoplastic Marie-Bamberger syndrome, periostitis appears in the area of ​​the end sections of long tubular bones (usually the forearms and legs), as well as the bones of the hands and feet. In places of periosteal changes, severe ossalgia or arthralgia and local palpation tenderness may be observed; X-ray examination reveals a double cortical layer, due to the presence of a narrow dense strip separated from the compact bone substance by a light gap (symptom of “tram rails”) (Fig. 3). It is believed that Marie-Bamberger syndrome is pathognomonic for lung cancer; less often it occurs with other primary intrathoracic tumors (benign lung neoplasms, pleural mesothelioma, teratoma, mediastinal lipoma). Occasionally, this syndrome occurs in cancer of the gastrointestinal tract, lymphoma with metastases to the mediastinal lymph nodes, and lymphogranulomatosis. At the same time, Marie-Bamberger syndrome also develops in non-oncological diseases - amyloidosis, chronic obstructive pulmonary disease, tuberculosis, bronchiectasis, congenital and acquired heart defects, etc. One of the distinctive features of this syndrome in non-tumor diseases is the long-term (over the course of years) development of characteristic changes in the osteoarticular apparatus, while in case of malignant neoplasms this process is calculated in weeks and months. After radical surgical treatment of cancer, Marie-Bamberger syndrome can regress and completely disappear within a few months.

Currently, the number of diseases in which changes in the distal phalanges of the fingers are described as “drumsticks” and nails as “watch glasses” has increased significantly (Table 1). The appearance of PG often precedes more specific symptoms. We especially need to remember the “sinister” connection of this syndrome with lung cancer. Therefore, identifying signs of PG requires correct interpretation and implementation of instrumental and laboratory examination methods for the timely establishment of a reliable diagnosis.

The relationship between PG and chronic lung diseases, accompanied by long-term endogenous intoxication and respiratory failure (RF), is considered obvious: their formation is especially often observed in pulmonary abscesses - 70–90% (within 1–2 months), bronchiectasis - 60–70% (for several years), pleural empyema - 40–60% (for 3–6 months or more) (“rough” fingers of Hippocrates, Fig. 4).

In tuberculosis of the respiratory organs, PGs are formed in the case of a widespread (more than 3–4 segments) destructive process with a long or chronic course (6–12 months or more) and are characterized mainly by the “clock glass” symptom, thickening, hyperemia and cyanosis of the nail fold (“ tender" fingers of Hippocrates - 60–80%, Fig. 5).

In idiopathic fibrosing alveolitis (IFA), PG occurs in 54% of men and 40% of women. It has been established that the severity of hyperemia and cyanosis of the nail fold, as well as the very presence of PG, indicate an unfavorable prognosis in ELISA, reflecting, in particular, the prevalence of active damage to the alveoli (ground glass areas detected on computed tomography) and the severity of proliferation of vascular smooth muscle cells in foci of fibrosis. PG is one of the factors that most reliably indicates a high risk of the formation of irreversible pulmonary fibrosis in patients with IFA, which is also associated with a decrease in their survival.

In diffuse connective tissue diseases involving the pulmonary parenchyma, PG always reflects the severity of DN and is an extremely unfavorable prognostic factor.

For other interstitial lung diseases, the formation of PG is less typical: their presence almost always reflects the severity of DN. J. Schulze et al. described this clinical phenomenon in a 4-year-old girl with rapidly progressive pulmonary histiocytosis X. V. Holcomb et al. revealed changes in the distal phalanges of the fingers like “drumsticks” and nails like “watch glasses” in 5 out of 11 patients examined with pulmonary veno-occlusive disease.

As lung lesions progress, PGs appear in at least 50% of patients with exogenous allergic alveolitis. It should be emphasized the leading importance of a persistent decrease in the partial pressure of oxygen in the blood and tissue hypoxia in the development of HOA in patients suffering from chronic lung diseases. Thus, in children with cystic fibrosis, the values ​​of partial pressure of oxygen in arterial blood and forced expiratory volume in 1 second were the smallest in the group with the most pronounced changes in the distal phalanges of the fingers and nails.

There are isolated reports of the appearance of PG in bone sarcoidosis (J. Yancey et al., 1972). We observed more than a thousand patients with sarcoidosis of the intrathoracic lymph nodes and lungs, including skin manifestations, and in no case did we detect the formation of PG. Therefore, we consider the presence/absence of PG as a differential diagnostic criterion for sarcoidosis and other pathologies of the chest organs (fibrosing alveolitis, tumors, tuberculosis).

Changes in the distal phalanges of the fingers like “drumsticks” and nails like “watch glasses” are often recorded in occupational diseases involving the pulmonary interstitium. Relatively early appearance of GOA is typical for patients with asbestosis; this sign indicates a high risk of death. According to S. Markowitz et al. , during a 10-year follow-up of 2709 patients with asbestosis, with the development of PG, their probability of death increased by at least 2 times.
PGs were detected in 42% of the examined coal mine workers who suffered from silicosis; in some of them, along with diffuse pneumosclerosis, foci of active alveolitis were found. Changes in the distal phalanges of the fingers like “drum sticks” and nails like “watch glasses” have been described in workers of factories producing matches who were in contact with rhodamine used in their production.

The connection between the development of PH and hypoxemia is confirmed by the repeatedly described possibility of the disappearance of this symptom after lung transplantation. In children with cystic fibrosis, characteristic changes in the fingers regressed during the first 3 months. after lung transplantation.

The appearance of PG in a patient with interstitial lung disease, especially with a long history of the disease and in the absence of clinical signs of active lung damage, requires a persistent search for a malignant tumor in the lung tissue. It has been shown that in lung cancer that develops against the background of ELISA, the frequency of GOA reaches 95%, while in cases of damage to the pulmonary interstitium without signs of neoplastic transformation, it is found more rarely - in 63% of patients.

The rapid development of changes in the distal phalanges of the fingers like “drumsticks” is one of the indications for the development of lung cancer even in the absence of precancerous diseases. In such a situation, clinical signs of hypoxia (cyanosis, shortness of breath) may be absent and this symptom develops according to the laws of paraneoplastic reactions. W. Hamilton et al. demonstrated that the likelihood of a patient having PG increases by 3.9 times.

GOA is one of the most common paraneoplastic manifestations of lung cancer; its prevalence in this category of patients can exceed 30%. The dependence of the frequency of detection of PG on the morphological form of lung cancer is shown: reaching 35% in the non-small cell variant, in the small cell variant this figure is only 5%.

The development of HOA in lung cancer is associated with hyperproduction of growth hormone and prostaglandin E2 (PGE-2) by tumor cells. The partial pressure of oxygen in the peripheral blood may remain normal. It was found that in the blood of patients with lung cancer with a symptom of PG, the level of transforming growth factor β (TGF-β) and PGE-2 significantly exceeds that of patients without changes in the distal phalanges of the fingers. Thus, TGF-β and PGE-2 can be considered relative inducers of PG formation, relatively specific for lung cancer; Apparently, this mediator is not involved in the development of the discussed clinical phenomenon in other chronic pulmonary diseases with DN.

The paraneoplastic nature of the “drumstick” type changes in the distal phalanges of the fingers is clearly demonstrated by the disappearance of this clinical phenomenon after successful resection of the lung tumor. In turn, the reappearance of this clinical sign in a patient in whom treatment for lung cancer was successful is a likely indication of tumor recurrence.

PG can be a paraneoplastic manifestation of tumors located outside the lung area, and may even precede the first clinical manifestations of malignant tumors. Their formation is described in malignant tumors of the thymus, cancer of the esophagus, colon, gastrinoma, characterized by clinically typical Zollinger-Ellison syndrome, and pulmonary artery sarcoma.

The possibility of PG formation in malignant breast tumors and pleural mesothelioma, which is not accompanied by the development of DN, has been repeatedly demonstrated.

PGs are detected in lymphoproliferative diseases and leukemia, including acute myeloblastic, in which they were noted on the arms and legs. After chemotherapy, which stopped the first attack of leukemia, the signs of GOA disappeared, but reappeared after 21 months. in case of tumor recurrence. One observation showed regression of typical changes in the distal phalanges of the fingers with successful chemotherapy and radiation therapy for lymphogranulomatosis.

Thus, PG, along with various types of arthritis, erythema nodosum and migratory thrombophlebitis, are among the frequent extraorgan, nonspecific manifestations of malignant tumors. The paraneoplastic origin of changes in the distal phalanges of the fingers like “drumsticks” can be assumed when they form quickly (especially in patients without DN, heart failure and in the absence of other causes of hypoxemia), as well as when combined with other possible extra-organ, nonspecific signs of a malignant tumor - an increase in ESR, changes in the peripheral blood picture (especially thrombocytosis), persistent fever, articular syndrome and recurrent thrombosis of various locations.

One of the most common causes of PH is considered to be congenital heart defects, especially the “blue” type. Among 93 patients with pulmonary arteriovenous fistulas observed at the Mauo Clinic for 15 years, similar changes in the fingers were recorded in 19%; they exceeded the frequency of hemoptysis (14%), but were inferior to murmurs over the pulmonary artery (34%) and shortness of breath (57%).

R. Khouzam et al. (2005) described an ischemic stroke of embolic origin that developed 6 weeks after birth in an 18-year-old patient. The presence of characteristic changes in the fingers and hypoxia, which required respiratory support, led to a search for an anomaly in the structure of the heart: transthoracic and transesophageal echocardiography revealed that the inferior vena cava opened into the cavity of the left atrium.

PGs can “discover” the existence of pathological shunting from the left side of the heart to the right, including that formed as a consequence of cardiac surgery. M. Essop et al. (1995) observed characteristic changes in the distal phalanges of the fingers and increasing cyanosis for 4 years after balloon dilatation of rheumatic mitral stenosis, the complication of which was a small atrial septal defect. During the period since the operation, its hemodynamic significance increased significantly due to the fact that the patient also developed rheumatic stenosis of the tricuspid valve, after correction of which these symptoms completely disappeared. J. Dominik et al. noted the appearance of PG in a 39-year-old woman 25 years after successful repair of an atrial septal defect. It turned out that during the operation the inferior vena cava was mistakenly directed to the left atrium.

PG is considered one of the most typical nonspecific, so-called extracardiac, clinical signs of infective endocarditis (IE). The frequency of changes in the distal phalanges of the fingers like “drumsticks” in IE can exceed 50%. High fever with chills, increased ESR, and leukocytosis testify in favor of IE in a patient with PG; Anemia, a transient increase in serum activity of hepatic aminotransferases, and various types of kidney damage are often observed. To confirm IE, transesophageal echocardiography is indicated in all cases.

According to some clinical centers, one of the most common causes of the phenomenon of PH is cirrhosis of the liver with portal hypertension and progressive dilatation of the vessels of the pulmonary circulation, leading to hypoxemia (the so-called pulmonary-renal syndrome). In such patients, GOA is usually combined with cutaneous telangiectasias, often forming “spider vein fields”.
A connection has been established between the formation of HOA in liver cirrhosis and previous alcohol abuse. In patients with liver cirrhosis without concomitant hypoxemia, PG is usually not detected. This clinical phenomenon is also characteristic of primary cholestatic liver lesions requiring liver transplantation in childhood, including congenital bile duct atresia.

Repeated attempts have been made to decipher the mechanisms of development of changes in the distal phalanges of the fingers like “drumsticks” in diseases, including those mentioned above (chronic lung diseases, congenital heart defects, IE, liver cirrhosis with portal hypertension), accompanied by persistent hypoxemia and tissue hypoxia. Hypoxia-induced activation of tissue growth factors, including platelet growth factors, plays a leading role in the formation of changes in the distal phalanges and fingernails. In addition, in patients with PH, an increase in the serum level of hepatocyte growth factor, as well as vascular growth factor, was detected. The connection between the increase in the activity of the latter and a decrease in the partial pressure of oxygen in arterial blood is considered the most obvious. Also, in patients with PH, a significant increase in the expression of hypoxia-inducible factors type 1a and 2a is found.

In the development of changes in the distal phalanges of the fingers of the “drumstick” type, endothelial dysfunction associated with a decrease in the partial pressure of oxygen in arterial blood may have a certain significance. It has been shown that in patients with GOA, the serum concentration of endothelin-1, the expression of which is induced primarily by hypoxia, is significantly higher than that in healthy people.
The mechanisms of PG formation in chronic inflammatory bowel diseases, for which hypoxemia is not typical, are difficult to explain. At the same time, they are often found in Crohn’s disease (they are not typical in ulcerative colitis), in which changes in the fingers like “drum sticks” may precede the actual intestinal manifestations of the disease.

The number of probable reasons causing changes in the distal phalanges of the fingers according to the “watch glass” type continues to increase. Some of them are very rare. K. Packard et al. (2004) observed the formation of PG in a 78-year-old man who took losartan for 27 days. This clinical phenomenon persisted when losartan was replaced by valsartan, which allows us to consider it an undesirable reaction to the entire class of angiotensin II receptor blockers. After switching to captopril, changes in the fingers completely regressed within 17 months. .

A. Harris et al. found characteristic changes in the distal phalanges of the fingers in a patient with primary antiphospholipid syndrome, while no signs of thrombotic lesions of the pulmonary vascular bed were identified in him. The formation of PGs has also been described in Behçet's disease, although it cannot be completely ruled out that their appearance in this disease was accidental.
PGs are considered among possible indirect markers of drug use. In some of these patients, their development may be associated with a variant of lung damage or IE characteristic of drug addicts. Changes in the distal phalanges of the fingers like “drum sticks” are described in users of not only intravenous, but also inhaled drugs, for example, hashish smokers.

With increasing frequency (at least 5%), PG is registered in HIV-infected people. Their formation may be based on various forms of HIV-associated pulmonary diseases, but this clinical phenomenon is observed in HIV-infected patients with intact lungs. It has been established that the presence of characteristic changes in the distal phalanges of the fingers in HIV infection is associated with a lower number of CD4-positive lymphocytes in the peripheral blood; in addition, interstitial lymphocytic pneumonia is more often recorded in such patients. In HIV-infected children, the appearance of PG is a likely indication of pulmonary tuberculosis, which is possible even in the absence of Mycobacterium tuberculosis in sputum samples.

The so-called primary form of GOA, not associated with diseases of the internal organs, is known, often having a familial nature (Touraine-Solant-Gole syndrome). It is diagnosed only after excluding most of the causes that can cause the appearance of PG. Patients with the primary form of GOA often complain of pain in the area of ​​the changed phalanges and increased sweating. R. Seggewiss et al. (2003) observed primary GOA involving only the fingers of the lower extremities. At the same time, when establishing the presence of PH in members of the same family, it is necessary to take into account the possibility that they have inherited congenital heart defects (for example, patent ductus botallus). The formation of characteristic changes in the fingers can continue for about 20 years.

Recognizing the causes of changes in the distal phalanges of the fingers according to the “drumstick” type requires differential diagnosis of various diseases, among which the leading position is occupied by those associated with hypoxia, i.e. clinically manifested DN and/or heart failure, as well as malignant tumors and subacute IE. Interstitial lung diseases, primarily ELISA, are one of the most common causes of PG; the severity of this clinical phenomenon can be used to assess the activity of lung damage. The rapid formation or increase in the severity of GOA necessitates the search for lung cancer and other malignant tumors. At the same time, one should take into account the possibility of the appearance of this clinical phenomenon in other diseases (Crohn's disease, HIV infection), in which it can occur much earlier than specific symptoms.

Watch glass symptom (Hippocrates nail)- characteristic deformation of the nail plates in the form of watch glasses with flask-shaped thickening of the terminal phalanges of the fingers and toes in chronic diseases of the heart, lungs, and liver. In this case, the angle between the posterior nail fold and the nail plate, when viewed from the side, exceeds 180°. The tissue between the nail and the underlying bone acquires a spongy character, due to which, when pressing on the base of the nail, there is a feeling of mobility of the nail plate. In a patient with the watch glass symptom, when the nails of opposite hands are placed together, the gap between them disappears (Shamroth's symptom).

This symptom was apparently first described by Hippocrates, which explains one of the names for the watch glass symptom, Hippocrates' fingernail.

Clinical significance

When this symptom appears, a complete and thorough examination of the patient is necessary to determine the cause of its occurrence.

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Literature

• Strutynsky A.V., Baranov A.P., Roitberg G.E., Gaponenkov Yu.P. Fundamentals of semiotics of diseases of internal organs. - M.: MEDpress-inform, 2004. - P. 66-67. - ISBN 5-98322-012-8.
• Trakhtenberg A. Kh., Chissov V. I. Clinical oncopulmonology. - M.: GEOTAR MEDICINE, 2000. - P. 109. - ISBN 5-9231-0017-7.
• Chernorutsky M.V. Diagnosis of internal diseases. - Fourth edition, revised and expanded. - L.: MEDGIZ, 1954. - P. 279. - 50,000 copies.

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Excerpt characterizing the Symptom of watch glasses

The next day, Prince Andrei went on visits to some houses where he had not yet been, including the Rostovs, with whom he renewed his acquaintance at the last ball. In addition to the laws of politeness, according to which he needed to be with the Rostovs, Prince Andrei wanted to see at home this special, lively girl, who left him with a pleasant memory.

Even in ancient times, 25 centuries ago, Hippocrates described changes in the shape of the distal phalanges of the fingers, which were found in chronic pulmonary pathology (abscess, tuberculosis, cancer, pleural empyema), and called them “drum sticks.” Since then, this syndrome has been called by his name - Hippocratic fingers (Hippocratic fingers) (digiti Hippocratici).

Hippocrates' finger syndrome includes two signs: “hour glasses” (Hippocrates' nails - ungues Hippocraticus) and club-shaped deformation of the terminal phalanges of the fingers like “drumsticks” (Finger clubbing).

Currently, PG is considered the main manifestation of hypertrophic osteoarthropathy (HOA, Marie-Bamberger syndrome) - multiple ossifying periostosis.

The mechanisms of development of PG are currently not fully understood. However, it is known that the formation of PG occurs as a result of microcirculation disturbances, accompanied by local tissue hypoxia, disruption of periosteal trophism and autonomic innervation against the background of prolonged endogenous intoxication and hypoxemia. In the process of formation of PG, the shape of the nail plates (“hour glasses”) first changes, then the shape of the distal phalanges of the fingers changes into a club-shaped or flask-shaped shape. The more pronounced the endogenous intoxication and hypoxemia, the more severely the terminal phalanges of the fingers and toes are modified.

Changes in the distal phalanges of the fingers according to the “drumstick” type can be established in several ways.

It is necessary to identify a smoothing of the normally existing angle between the base of the nail and the nail fold. The disappearance of the “window”, which is formed when the distal phalanges of the fingers are juxtaposed with their dorsal surfaces facing each other, is the earliest sign of thickening of the terminal phalanges. The angle between the nails does not normally extend upward more than half the length of the nail bed. As the distal phalanges of the fingers thicken, the angle between the nail plates becomes wide and deep (Fig. 1).

On unmodified fingers, the distance between points A and B should exceed the distance between points C and D. With “drumsticks” the relationship is the opposite: C - D becomes longer than A - B (Fig. 2).

Another important sign of PG is the size of the ACE angle. On a normal finger this angle is less than 180°; with “drumsticks” it is more than 180° (Fig. 2).

Along with the “fingers of Hippocrates,” in paraneoplastic Marie-Bamberger syndrome, periostitis appears in the area of ​​the end sections of long tubular bones (usually the forearms and legs), as well as the bones of the hands and feet. In places of periosteal changes, severe ossalgia or arthralgia and local palpation tenderness may be observed; X-ray examination reveals a double cortical layer, due to the presence of a narrow dense strip separated from the compact bone substance by a light gap (symptom of “tram rails”) (Fig. 3). It is believed that Marie-Bamberger syndrome is pathognomonic for lung cancer; less often it occurs with other primary intrathoracic tumors (benign lung neoplasms, pleural mesothelioma, teratoma, mediastinal lipoma). Occasionally, this syndrome occurs in cancer of the gastrointestinal tract, lymphoma with metastases to the mediastinal lymph nodes, and lymphogranulomatosis. At the same time, Marie-Bamberger syndrome also develops in non-oncological diseases - amyloidosis, chronic obstructive pulmonary disease, tuberculosis, bronchiectasis, congenital and acquired heart defects, etc. One of the distinctive features of this syndrome in non-tumor diseases is the long-term (over the course of years) development of characteristic changes in the osteoarticular apparatus, while in case of malignant neoplasms this process is calculated in weeks and months. After radical surgical treatment of cancer, Marie-Bamberger syndrome can regress and completely disappear within a few months.

Currently, the number of diseases in which changes in the distal phalanges of the fingers are described as “drumsticks” and nails as “watch glasses” has increased significantly (Table 1). The appearance of PG often precedes more specific symptoms. We especially need to remember the “sinister” connection of this syndrome with lung cancer. Therefore, identifying signs of PG requires correct interpretation and implementation of instrumental and laboratory examination methods for the timely establishment of a reliable diagnosis.

The relationship between PG and chronic lung diseases, accompanied by long-term endogenous intoxication and respiratory failure (RF), is considered obvious: their formation is especially often observed in pulmonary abscesses - 70–90% (within 1–2 months), bronchiectasis - 60–70% (for several years), pleural empyema - 40–60% (for 3–6 months or more) (“rough” fingers of Hippocrates, Fig. 4).

In tuberculosis of the respiratory organs, PGs are formed in the case of a widespread (more than 3–4 segments) destructive process with a long or chronic course (6–12 months or more) and are characterized mainly by the “clock glass” symptom, thickening, hyperemia and cyanosis of the nail fold (“ tender" fingers of Hippocrates - 60–80%, Fig. 5).

In idiopathic fibrosing alveolitis (IFA), PG occurs in 54% of men and 40% of women. It has been established that the severity of hyperemia and cyanosis of the nail fold, as well as the very presence of PG, indicate an unfavorable prognosis in ELISA, reflecting, in particular, the prevalence of active damage to the alveoli (ground glass areas detected on computed tomography) and the severity of proliferation of vascular smooth muscle cells in foci of fibrosis. PG is one of the factors that most reliably indicates a high risk of the formation of irreversible pulmonary fibrosis in patients with IFA, which is also associated with a decrease in their survival.

In diffuse connective tissue diseases involving the pulmonary parenchyma, PG always reflects the severity of DN and is an extremely unfavorable prognostic factor.

For other interstitial lung diseases, the formation of PG is less typical: their presence almost always reflects the severity of DN. J. Schulze et al. described this clinical phenomenon in a 4-year-old girl with rapidly progressive pulmonary histiocytosis X. V. Holcomb et al. revealed changes in the distal phalanges of the fingers like “drumsticks” and nails like “watch glasses” in 5 out of 11 patients examined with pulmonary veno-occlusive disease.

As lung lesions progress, PGs appear in at least 50% of patients with exogenous allergic alveolitis. It should be emphasized the leading importance of a persistent decrease in the partial pressure of oxygen in the blood and tissue hypoxia in the development of HOA in patients suffering from chronic lung diseases. Thus, in children with cystic fibrosis, the values ​​of partial pressure of oxygen in arterial blood and forced expiratory volume in 1 second were the smallest in the group with the most pronounced changes in the distal phalanges of the fingers and nails.

There are isolated reports of the appearance of PG in bone sarcoidosis (J. Yancey et al., 1972). We observed more than a thousand patients with sarcoidosis of the intrathoracic lymph nodes and lungs, including skin manifestations, and in no case did we detect the formation of PG. Therefore, we consider the presence/absence of PG as a differential diagnostic criterion for sarcoidosis and other pathologies of the chest organs (fibrosing alveolitis, tumors, tuberculosis).

Changes in the distal phalanges of the fingers like “drumsticks” and nails like “watch glasses” are often recorded in occupational diseases involving the pulmonary interstitium. Relatively early appearance of GOA is typical for patients with asbestosis; this sign indicates a high risk of death. According to S. Markowitz et al. , during a 10-year follow-up of 2709 patients with asbestosis, with the development of PG, their probability of death increased by at least 2 times.
PGs were detected in 42% of the examined coal mine workers who suffered from silicosis; in some of them, along with diffuse pneumosclerosis, foci of active alveolitis were found. Changes in the distal phalanges of the fingers like “drum sticks” and nails like “watch glasses” have been described in workers of factories producing matches who were in contact with rhodamine used in their production.

The connection between the development of PH and hypoxemia is confirmed by the repeatedly described possibility of the disappearance of this symptom after lung transplantation. In children with cystic fibrosis, characteristic changes in the fingers regressed during the first 3 months. after lung transplantation.

The appearance of PG in a patient with interstitial lung disease, especially with a long history of the disease and in the absence of clinical signs of active lung damage, requires a persistent search for a malignant tumor in the lung tissue. It has been shown that in lung cancer that develops against the background of ELISA, the frequency of GOA reaches 95%, while in cases of damage to the pulmonary interstitium without signs of neoplastic transformation, it is found more rarely - in 63% of patients.

The rapid development of changes in the distal phalanges of the fingers like “drumsticks” is one of the indications for the development of lung cancer even in the absence of precancerous diseases. In such a situation, clinical signs of hypoxia (cyanosis, shortness of breath) may be absent and this symptom develops according to the laws of paraneoplastic reactions. W. Hamilton et al. demonstrated that the likelihood of a patient having PG increases by 3.9 times.

GOA is one of the most common paraneoplastic manifestations of lung cancer; its prevalence in this category of patients can exceed 30%. The dependence of the frequency of detection of PG on the morphological form of lung cancer is shown: reaching 35% in the non-small cell variant, in the small cell variant this figure is only 5%.

The development of HOA in lung cancer is associated with hyperproduction of growth hormone and prostaglandin E2 (PGE-2) by tumor cells. The partial pressure of oxygen in the peripheral blood may remain normal. It was found that in the blood of patients with lung cancer with a symptom of PG, the level of transforming growth factor β (TGF-β) and PGE-2 significantly exceeds that of patients without changes in the distal phalanges of the fingers. Thus, TGF-β and PGE-2 can be considered relative inducers of PG formation, relatively specific for lung cancer; Apparently, this mediator is not involved in the development of the discussed clinical phenomenon in other chronic pulmonary diseases with DN.

The paraneoplastic nature of the “drumstick” type changes in the distal phalanges of the fingers is clearly demonstrated by the disappearance of this clinical phenomenon after successful resection of the lung tumor. In turn, the reappearance of this clinical sign in a patient in whom treatment for lung cancer was successful is a likely indication of tumor recurrence.

PG can be a paraneoplastic manifestation of tumors located outside the lung area, and may even precede the first clinical manifestations of malignant tumors. Their formation is described in malignant tumors of the thymus, cancer of the esophagus, colon, gastrinoma, characterized by clinically typical Zollinger-Ellison syndrome, and pulmonary artery sarcoma.

The possibility of PG formation in malignant breast tumors and pleural mesothelioma, which is not accompanied by the development of DN, has been repeatedly demonstrated.

PGs are detected in lymphoproliferative diseases and leukemia, including acute myeloblastic, in which they were noted on the arms and legs. After chemotherapy, which stopped the first attack of leukemia, the signs of GOA disappeared, but reappeared after 21 months. in case of tumor recurrence. One observation showed regression of typical changes in the distal phalanges of the fingers with successful chemotherapy and radiation therapy for lymphogranulomatosis.

Thus, PG, along with various types of arthritis, erythema nodosum and migratory thrombophlebitis, are among the frequent extraorgan, nonspecific manifestations of malignant tumors. The paraneoplastic origin of changes in the distal phalanges of the fingers like “drumsticks” can be assumed when they form quickly (especially in patients without DN, heart failure and in the absence of other causes of hypoxemia), as well as when combined with other possible extra-organ, nonspecific signs of a malignant tumor - an increase in ESR, changes in the peripheral blood picture (especially thrombocytosis), persistent fever, articular syndrome and recurrent thrombosis of various locations.

One of the most common causes of PH is considered to be congenital heart defects, especially the “blue” type. Among 93 patients with pulmonary arteriovenous fistulas observed at the Mauo Clinic for 15 years, similar changes in the fingers were recorded in 19%; they exceeded the frequency of hemoptysis (14%), but were inferior to murmurs over the pulmonary artery (34%) and shortness of breath (57%).

R. Khouzam et al. (2005) described an ischemic stroke of embolic origin that developed 6 weeks after birth in an 18-year-old patient. The presence of characteristic changes in the fingers and hypoxia, which required respiratory support, led to a search for an anomaly in the structure of the heart: transthoracic and transesophageal echocardiography revealed that the inferior vena cava opened into the cavity of the left atrium.

PGs can “discover” the existence of pathological shunting from the left side of the heart to the right, including that formed as a consequence of cardiac surgery. M. Essop et al. (1995) observed characteristic changes in the distal phalanges of the fingers and increasing cyanosis for 4 years after balloon dilatation of rheumatic mitral stenosis, the complication of which was a small atrial septal defect. During the period since the operation, its hemodynamic significance increased significantly due to the fact that the patient also developed rheumatic stenosis of the tricuspid valve, after correction of which these symptoms completely disappeared. J. Dominik et al. noted the appearance of PG in a 39-year-old woman 25 years after successful repair of an atrial septal defect. It turned out that during the operation the inferior vena cava was mistakenly directed to the left atrium.

PG is considered one of the most typical nonspecific, so-called extracardiac, clinical signs of infective endocarditis (IE). The frequency of changes in the distal phalanges of the fingers like “drumsticks” in IE can exceed 50%. High fever with chills, increased ESR, and leukocytosis testify in favor of IE in a patient with PG; Anemia, a transient increase in serum activity of hepatic aminotransferases, and various types of kidney damage are often observed. To confirm IE, transesophageal echocardiography is indicated in all cases.

According to some clinical centers, one of the most common causes of the phenomenon of PH is cirrhosis of the liver with portal hypertension and progressive dilatation of the vessels of the pulmonary circulation, leading to hypoxemia (the so-called pulmonary-renal syndrome). In such patients, GOA is usually combined with cutaneous telangiectasias, often forming “spider vein fields”.
A connection has been established between the formation of HOA in liver cirrhosis and previous alcohol abuse. In patients with liver cirrhosis without concomitant hypoxemia, PG is usually not detected. This clinical phenomenon is also characteristic of primary cholestatic liver lesions requiring liver transplantation in childhood, including congenital bile duct atresia.

Repeated attempts have been made to decipher the mechanisms of development of changes in the distal phalanges of the fingers like “drumsticks” in diseases, including those mentioned above (chronic lung diseases, congenital heart defects, IE, liver cirrhosis with portal hypertension), accompanied by persistent hypoxemia and tissue hypoxia. Hypoxia-induced activation of tissue growth factors, including platelet growth factors, plays a leading role in the formation of changes in the distal phalanges and fingernails. In addition, in patients with PH, an increase in the serum level of hepatocyte growth factor, as well as vascular growth factor, was detected. The connection between the increase in the activity of the latter and a decrease in the partial pressure of oxygen in arterial blood is considered the most obvious. Also, in patients with PH, a significant increase in the expression of hypoxia-inducible factors type 1a and 2a is found.

In the development of changes in the distal phalanges of the fingers of the “drumstick” type, endothelial dysfunction associated with a decrease in the partial pressure of oxygen in arterial blood may have a certain significance. It has been shown that in patients with GOA, the serum concentration of endothelin-1, the expression of which is induced primarily by hypoxia, is significantly higher than that in healthy people.
The mechanisms of PG formation in chronic inflammatory bowel diseases, for which hypoxemia is not typical, are difficult to explain. At the same time, they are often found in Crohn’s disease (they are not typical in ulcerative colitis), in which changes in the fingers like “drum sticks” may precede the actual intestinal manifestations of the disease.

The number of probable reasons causing changes in the distal phalanges of the fingers according to the “watch glass” type continues to increase. Some of them are very rare. K. Packard et al. (2004) observed the formation of PG in a 78-year-old man who took losartan for 27 days. This clinical phenomenon persisted when losartan was replaced by valsartan, which allows us to consider it an undesirable reaction to the entire class of angiotensin II receptor blockers. After switching to captopril, changes in the fingers completely regressed within 17 months. .

A. Harris et al. found characteristic changes in the distal phalanges of the fingers in a patient with primary antiphospholipid syndrome, while no signs of thrombotic lesions of the pulmonary vascular bed were identified in him. The formation of PGs has also been described in Behçet's disease, although it cannot be completely ruled out that their appearance in this disease was accidental.
PGs are considered among possible indirect markers of drug use. In some of these patients, their development may be associated with a variant of lung damage or IE characteristic of drug addicts. Changes in the distal phalanges of the fingers like “drum sticks” are described in users of not only intravenous, but also inhaled drugs, for example, hashish smokers.

With increasing frequency (at least 5%), PG is registered in HIV-infected people. Their formation may be based on various forms of HIV-associated pulmonary diseases, but this clinical phenomenon is observed in HIV-infected patients with intact lungs. It has been established that the presence of characteristic changes in the distal phalanges of the fingers in HIV infection is associated with a lower number of CD4-positive lymphocytes in the peripheral blood; in addition, interstitial lymphocytic pneumonia is more often recorded in such patients. In HIV-infected children, the appearance of PG is a likely indication of pulmonary tuberculosis, which is possible even in the absence of Mycobacterium tuberculosis in sputum samples.

The so-called primary form of GOA, not associated with diseases of the internal organs, is known, often having a familial nature (Touraine-Solant-Gole syndrome). It is diagnosed only after excluding most of the causes that can cause the appearance of PG. Patients with the primary form of GOA often complain of pain in the area of ​​the changed phalanges and increased sweating. R. Seggewiss et al. (2003) observed primary GOA involving only the fingers of the lower extremities. At the same time, when establishing the presence of PH in members of the same family, it is necessary to take into account the possibility that they have inherited congenital heart defects (for example, patent ductus botallus). The formation of characteristic changes in the fingers can continue for about 20 years.

Recognizing the causes of changes in the distal phalanges of the fingers according to the “drumstick” type requires differential diagnosis of various diseases, among which the leading position is occupied by those associated with hypoxia, i.e. clinically manifested DN and/or heart failure, as well as malignant tumors and subacute IE. Interstitial lung diseases, primarily ELISA, are one of the most common causes of PG; the severity of this clinical phenomenon can be used to assess the activity of lung damage. The rapid formation or increase in the severity of GOA necessitates the search for lung cancer and other malignant tumors. At the same time, one should take into account the possibility of the appearance of this clinical phenomenon in other diseases (Crohn's disease, HIV infection), in which it can occur much earlier than specific symptoms.

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LESSON 21-7 SYMPTOM OF DRUMSTICKS The symptom of drumsticks (Hippocratic fingers) is a flask-shaped thickening of the terminal phalanges of the fingers of the hands, less commonly of the toes, in chronic diseases of the heart, lungs, and liver with a characteristic deformation of the nail plates in the form of watch glasses. The tissue between the nail and the underlying bone becomes spongy, causing the nail plate to feel mobile when pressure is applied to the base of the nail. This thickening accompanies various diseases, often precedes more specific symptoms of the disease. You especially need to remember the connection of this symptom with lung cancer. The symptom of drumsticks is not an independent disease, but is a rather informative sign of other diseases, pathological processes and proceeds unnoticed at first because it does not cause pain. Thickening of the terminal phalanges can develop over many years, and in some diseases within several months (lung abscess). CAUSES One of the main reasons for the formation of the drumstick symptom is the discharge of blood from right to left - getting into venous blood into the arterial bed, bypassing the lungs or ventilated areas in them, which leads to a decrease in oxygen content in the blood, the development of hypoxemia, hypoxia and, ultimately, to dilation of the vessels of the nail phalanges of the fingers. The discharge of blood is accompanied by an increase in P(A-a)O2 - the alveolar-arterial difference in the partial pressure of oxygen. The partial pressure of oxygen in arterial blood (PaO2) does not increase when inhaled with 100% oxygen (O2). The discharge of blood from right to left can be intracardiac and intrapulmonary. Intracardiac shunting of blood from right to left - direct entry of blood from the right parts of the heart to the left, most typical for congenital cyanotic heart defects (atrial septal defect, interventricular septum, tetralogy of Fallot) and infective endocarditis. Intrapulmonary shunting of blood from right to left - most often occurs in diseases accompanied by impaired ventilation with normal perfusion of the alveoli. This is due to multiple scattered microatelectasis - collapse of the pulmonary alveoli due to compression of the lung, blockage of the bronchial tube (for example, mucus, tumor), as well as due to obstruction and occlusion (impaired patency) of the pulmonary capillaries. Intrapulmonary shunting of blood from right to left occurs against the background of long-term pulmonary diseases: bronchial lung cancer, bronchiectasis, pleural empyema, lung abscess, alveolitis. Less commonly, intrapulmonary discharge of blood occurs through arteriovenous fistulas. They can be congenital (for example, hereditary hemorrhagic telangiectasia) or acquired and can occur in any organ, although they are most often found in the lungs. REFLECTION OF THE SYMPTOM OF DRUM STICKS Fig. 76a, 31 year old man. Hereditary hemorrhagic telangiectasia, recurrent nosebleeds, drumstick sign in initial stage diseases. Fig. 76b, man, cyanotic heart defect, drumstick symptom in the final stage of the disease. Link to Fig.76: https://img-fotki.yandex.ru/get/69324/39722250.2/0_14b0e0_9c7cbac9_orig Hemorrhagic telangiectasia (Osler-Weber-Rendu disease) is a disease based on the inferiority of the vascular endothelium (vascular cells), resulting in the formation of multiple angiomas and telangiectasia (capillary abnormalities) in different areas of the skin and mucous membranes of the lips, mouth, and internal organs. ), which bleed. Congenital inferiority of the vessels of internal organs is manifested by arteriovenous aneurysms, which are most often localized in the lungs, less often in the liver, kidneys, spleen and contribute to the development of pulmonary-cardiac diseases. DRUM STICK SYMPTOM - indicates reduced content oxygen in tissues (hypoxia) and the development of pulmonary-heart diseases, the cause of which is in this case is hemorrhagic telangiectasia. With the symptom of drumsticks, the holes on the nails are almost always enlarged (Fig. 76a and Fig. 76b). LARGE HOLES ON THE NAILS, as well as their absence, indicate a disturbance in calcium metabolism in the body. Sometimes the hole enlarges on only one finger. One of the main reasons for enlarged holes on the nails is magnesium deficiency (Fig. 75). Reference to Fig. 75.