Watch glasses and drumsticks syndrome. Drum fingers

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 “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 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 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(DN), is considered obvious: their formation is especially often observed in pulmonary abscesses - 70–90% (within 1–2 months), bronchiectasis - 60–70% (within 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 “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 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 ELISA, also associated with a decrease in their survival.

For 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 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 intrathoracic sarcoidosis lymph nodes and lungs, including with 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 organ pathologies chest(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 GOA is characteristic of 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 similar 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. 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 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 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, sarcoma pulmonary artery.

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 causes of PG is considered birth defects hearts, 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 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 a small atrial septal defect. 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 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, 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 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 “fields of spider veins» .
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 “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 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, 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 diseases lungs, primarily ELISA, is 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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Hippocrates' fingers (drumstick symptom) is a characteristic symptom of many diseases. This pathology is also called “watch glass”, since the fingers of the limbs acquire irregular shape. They become convex at the end areas, thicken, and the nail plate is rounded. Most often, fingers - drumsticks - can be seen in older people, but the development of the disease is not related to the age of the patient.

The key mechanism is hypoxia, that is, oxygen deficiency in tissues. The phenomenon is painless and does not cause discomfort, but it is almost impossible to return the fingers to their usual shape. Even if treatment of the underlying disease is successful, reverse development does not occur.

Definition and general information

The syndrome is named after the doctor who first described it and associated it with the development of diseases of the respiratory system: tuberculosis, empyema, abscesses and various neoplasms. Changes in the shape of the phalanges of the fingers accompanied the main symptoms of the disease or preceded their development. Today, Hippocrates' fingers are considered a sign of hypertrophic osteoarthropathy - a disease in which the mechanisms of formation of the periosteum are disrupted, and a large amount of bone tissue intensively grows on it.

The diagnosis can be made if two symptoms are present simultaneously:

“watch glasses” - the nail plate becomes round and increases in size;
“drumsticks” - thickening of the distal phalanges of the fingers.

Hippocrates' fingers can form within a few weeks. This process can be stopped by treating the underlying pathology, but reverse development is almost never achieved.

Causes and mechanism of development

The main trigger for the formation of Hippocratic fingers is considered to be hypoxia, that is, a lack of oxygen in the tissues. It was not possible to study it in detail, but doctors have several assumptions. Thus, a decrease in the rate of blood supply to the periosteum and insufficient supply of nutrients causes its deformation. During hypoxia, compensatory reactions are activated, expansion occurs small vessels. This provokes accelerated division of connective tissue cells, which underlies the formation of Hippocrates’ fingers.

The disease is more often diagnosed simultaneously on the upper and lower limbs, but its symptoms appear only on the arms or legs. It is believed that the rate of development of the disease depends on the level of deficiency of vital gases, including oxygen: the lower its supply to the tissues, the faster the deformation of the phalanges of the fingers occurs.

Initially, the causes of the pathology were considered to be chronic pulmonary infections, which occur with symptoms of purulent inflammation and general hypoxia. However, today a large number of diseases have been discovered that can manifest as a symptom of drumsticks. They are usually classified according to the location of the affected organ.

Diseases of the respiratory system that provoke the appearance of Hippocrates' fingers are serious pathologies that are life-threatening for the patient. These include cancer, chronic progressive purulent processes, tuberculosis, the formation of bronchiectasis (local dilation of the bronchi), abscesses, empyema (accumulation of pus in pleural cavity) and others. All of them are also manifested by respiratory failure, general hypoxia, painful sensations V chest cavity And general deterioration well-being.
Diseases of the heart and blood vessels are another group of pathologies that occur with symptoms of hypoxia. Hippocrates' fingers may be signs of congenital heart defects of the blue type. They get their name because patients experience a bluish discoloration of the skin (Fallot's disease, tricuspid atresia, pulmonary venous drainage, transposition of the mitral vessels, common truncus arteriosus). And also the syndrome can accompany sluggish inflammatory diseases infectious membranes of the heart.
Diseases of the gastrointestinal tract may also underlie the development of Hippocrates' fingers. These include cirrhosis of the liver, ulcerative colitis (inflammation of the mucous membrane of the large intestine), Crohn's disease (an inflammatory process of autoimmune origin that can manifest itself in any part of the digestive tract), and various enteropathies.

Other pathologies have been discovered that are characterized by changes in the shape of the distal phalanges of the fingers of the upper and lower extremities. They are not associated with infectious pathogens or hypoxia phenomena. These include:

Normally, there should be a gap between the base of the two nails, at the level of the cuticle - its absence indicates drumstick syndrome.

Hippocratic fingers in most cases appear on the upper and lower extremities simultaneously. However, in some cases one can notice their one-sided formation. This may be due to several phenomena:

Pancoast tumor is a specific neoplasm that is localized in the upper part of the lung;
lymphangitis - inflammatory processes in the walls of lymphatic vessels;
atriovenous fistula - a connection between an artery and a vein, can be formed artificially to purify the blood through hemodialysis for patients with severe forms of renal failure.

Hypocrates' fingers are often one of the symptoms of the Marie-Bamberger complex. This is a syndrome that manifests itself nearby characteristic features. In patients, periosteum grows simultaneously in several areas; the distal phalanges of the fingers and toes are most often affected. And inflammatory reactions are also observed in the area of the terminal sections of long tubular bones (tibia, ulna and radius), which is manifested by a pain reaction. The causes of Marie-Bamberger syndrome are considered to be diseases of the lungs, heart and blood vessels, digestive tract and other specific pathologies. With radical (surgical) removal of the root cause of the disease, there is a possibility of reverse development. In some cases, the condition of the periosteum returned to normal within a few months.

Symptoms

Hippocrates' fingers can be recognized already at the initial examination. Since changes are visible to the naked eye, diagnosis is aimed at clarifying the cause of the symptom. The process of formation of fingers resembling drumsticks is not accompanied by painful sensations and occurs gradually, so many patients skip the first stages of its development.

In the future, the diagnosis can be made based on several characteristic signs:

compaction and proliferation of connective tissue on the distal phalanges of the fingers, this leads to the disappearance of the Lovibond angle (it is formed by the base of the nail and the surrounding tissues);
Shamroth's symptom - the absence of a gap between the bases of two nails, if they are applied to each other;
overgrowth of the nail plate;
soft tissues located at the base of the nail bed become too soft and loose;
Ballooning of the nail - when pressure is applied to the nail plate, it becomes elastic and shock absorbent.

All measurements can be carried out at home. It is worth understanding that the appearance of Hippocrates' fingers - dangerous symptom and accompanies diseases that threaten the patient’s life. If you suspect one of the characteristic signs, you should urgently contact medical care for urgent diagnosis and treatment, despite the painlessness of the process.

Forms of the disease

The shape of the digital phalanges depends on the type of hypoxia and the individual characteristics of the patient. More often, changes occur symmetrically and affect both the upper and lower extremities. Unilateral damage is typical for specific pathologies of the heart and lungs, in which only one half of the body suffers from hypoxia. Thus, there are several types of Hippocrates’ fingers depending on their appearance:

“parrot beak” - associated with the growth of the upper sections of the terminal phalanges of the fingers;
“hour glasses” - are formed when the connective tissue grows around the nail plate, as a result of which it becomes round and wide;
“drumsticks” - the distal phalanges uniformly thicken and increase in volume.

Thickening of the fingers is a painless process, but pathological changes may lead to inflammatory changes and pain in the periosteum area.

Diagnostic methods

The diagnosis of Hippocratic fingers can be made by simple examination. Primary diagnosis includes confirmation of the main signs of the syndrome. If it occurs in isolation from the Marie-Bamberger complex, the following aspects must be established:

absence of a normal Lovibond angle - this can be checked by leaning the front part of the digital phalanx against any flat surface, as well as by diagnosing Schamroth’s symptom;
increased elasticity of the nail plate - when you press on the top of the nail, it sinks into the soft tissue and then gradually levels out;
an increase in the ratio between the volume of the terminal phalanx of the finger in the cuticle area and the interphalangeal joint, but this sign does not appear in all patients.

To determine the cause of the appearance of Hippocratic nails, a full examination is carried out. It includes radiography of the lungs, ultrasound of the heart and abdominal organs, clinical and biochemical tests blood and urine. If necessary, you can examine the conditions individual organs on MRI or CT - these diagnostic methods are considered the most reliable.

You can determine the appearance of Hippocrates’ fingers yourself, but more detailed diagnosis and treatment must be carried out only in a medical institution.

Treatment and prognosis

Therapy methods are selected individually, depending on the cause of the appearance of Hippocratic fingers. These may include antibiotic therapy, specific agents that suppress autoimmune reactions, anti-inflammatory drugs and other medications. In some cases it is shown surgical intervention(removal of tumors). The prognosis depends on the success of treatment of the underlying disease, the patient’s age and individual characteristics.

Hippocrates' fingers are a symptom that may first appear in adulthood. It may progress slowly and not bother the patient for several years, but in some cases it occurs quickly. It is possible to make a diagnosis, including at home, but the cause of this symptom can only be determined based on additional research. Further treatment also differs and depends on the results of a complete diagnosis.

The first mention of such a problem as drumstick fingers was found in the writings of Hippocrates, which is why the disease is also called “Hippocrates’ fingers.” He identified a similar deviation in a patient with empyema - an accumulation of pus in any organ. The symptom and its causes were described in more detail at the beginning of the 20th century, but in those days doctors considered the disease solely a sign of chronic infections.

Drumstick syndrome

Drum fingers, or the symptom of drumsticks, is a flask-shaped painless thickening of the first (terminal) phalanges on the hands and feet. At the same time, a specific deformation of the nail plates occurs, which is called “watch glass nails.” The ICD-10 code for this pathology is R68.3.

With advanced lesions of the fingers and nails, it is difficult not to notice external signs. The tissue between the nail plate and the bone becomes spongy, so the nail takes on a convex shape, and when you press on it, there is a feeling of mobility. Drum fingers do not become an independent pathology; they are inherent in a variety of serious diseases of internal organs or the immune system.

Forms of the disease

Typically, the fingers become like drumsticks on the upper and lower extremities at the same time. Much less often, thickenings occur only on the arms or isolated on the legs, which can only happen with special forms of circulatory disorders (when one of the halves of the body is poorly supplied with blood).

Based on appearance, the following forms of symptoms are distinguished:

“parrot’s beak” - the patient’s proximal part of the terminal phalanx of the fingers thickens and becomes deformed;
“watch glasses” - changes are noticeable mainly on the nails - at the base the nail plates grow greatly;
“classical” form - the fingers thicken along the entire circumference of the terminal phalanx.

Symptoms of drumsticks and watch glasses

Not all patients immediately pay attention to the ongoing pathological changes, because drum fingers do not cause pain or other discomfort. But upon careful examination, it is possible to identify violations in the form of the following signs even at the initial stage:

visually and to the touch a noticeable increase in soft tissue in size - while the phalanx becomes wider, more voluminous, and the natural angle between the base of the finger and its fold disappears;
smoothing the gap between the nails when matching the corresponding fingers on the right and left hand and foot;
increasing curvature and convexity of the nail, growth of the nail bed, excessive softness of the area at the base of the nail;
Balloting of the nail - gaining strength and specific elasticity.

In the vast majority of cases, the fingers begin to change at a serious stage of the underlying disease, so its symptoms also appear. Many patients have already been diagnosed, but some still do not know about the disorders occurring in the body. If the disease affects the lungs, the person suffers from chronic cough, there is sputum that is difficult to separate, and mucus and blood appear.

Often found and systemic disease joints – hypertrophic pulmonary osteoarthropathy. In this case, tympanic fingers with periostosis are diagnosed - a non-inflammatory change in the periosteum in the form of a layering of osteoid tissue on the cortical layer of the tubular bones. As a result, bone calcification occurs, as well as a number of degenerative processes. Osteoarthropathy is characteristic of lung cancer metastases to the bones, as well as cystic fibrosis and chronic empyema. In this case, the symptoms are varied:

constant pain in the bones - mild or more severe, aching and twitching;
pain when feeling bones;
symmetrical joint damage;
coarsening of soft tissues in the area of the hands, feet, and, less often, the face;
increased sweating of the hands and feet, decreased sensitivity.

After surgery or therapeutic treatment, all symptoms decrease or disappear completely (if the disease has not reached a severe stage).

Causes of pathology

Most often, the symptom of tympani fingers is caused by diseases of the lungs and heart. Among pulmonary diseases, there are acute and chronic ones, and in the first case, thickening of the fingers is possible already after 7-10 days from the development of the main pathology. Chronic pulmonary diseases can cause drumstick fingers:

cancer of the lung, bronchi, pleura, diaphragm;
lymphoma, lymphogranulomatosis;
metastases to the bronchi, lungs;
chronic bronchiectasis;
cystic fibrosis in cystic fibrosis;
alveolitis of various forms;
purulent diseases;
COPD;
altitude sickness;
silicosis, asbestosis and other occupational diseases of the respiratory system.

Their heart and vascular diseases in the etiology of the symptom are played by various congenital defects, especially the blue type - tetralogy of Fallot, TMS, pulmonary atresia. Fingers can change shape after suffering inflammation of the valves - endocarditis. Very rarely does a symptom become a consequence long-term use antihypertensive drugs based on losartan and its analogues.

At neglected form celiac disease (without following a diet), with Crohn's disease and ulcerative colitis, cirrhosis of the liver, the shape of the fingers may also change. Similar signs are observed when the body is infected with whipworms and trichuriasis. Less common causes of pathology are erythremia, diffuse toxic goiter and hyperthyroidism, HIV and AIDS, diffuse diseases connective tissue. If the fingers are affected on only one side, the problem may be caused by:

hemodialysis;
lymphangitis;
apical lung cancer.

In the presence of these diseases, abnormal growth of the connective tissue of the phalanges occurs. The reasons are a violation of humoral regulation, the development of chronic oxygen starvation of tissues, and compensatory dilation of blood vessels in the fingers.

Diagnostics

You can notice external changes and establish the presence of a symptom using a number of physical tests:

smoothing of the Lovibond angle, determined by applying a pencil and identifying a small gap between the base of the nail and the surrounding skin (normally less than 180 degrees);
Shamroth's symptom - when the bent index fingers Normally, a diamond-shaped lumen is visible with nails, but with disease it disappears;
balloting - when you press on the skin above the nail, the finger seems to sink into it, and when released, the nail springs back;
measurement of the phalanges - the ratio of the thickness of the distal phalanx in the cuticle area and the thickness of the interphalangeal joint increases (normally it is about 0.895).

As for the last test, in people with severe lung diseases the indicator may be 1 or more, for example, with cystic fibrosis, this problem is found in the vast majority of children.

To find the cause of the disease, additional examinations must be carried out:

CT scan of the lungs or radiography;
Ultrasound of the heart, ECG;
Ultrasound of internal organs;
bone radiography or scintigraphy;
blood biochemistry, etc.

Treatment and prognosis

Since the cause of the pathology is developing underlying diseases, treatment is aimed at their correction or elimination. For heart defects and tumors, operations are performed (if possible). Cancerous tumors require radiation and chemotherapy. With endocarditis, purulent diseases They also operate on the patient and administer an intensive course of antibiotic treatment. In parallel, for any reason for finger lesions, therapy with immunomodulators, vitamins, and a balanced diet are recommended.

The prognosis depends on the type and stage of the underlying disease. When running cancerous tumors the prognosis is disappointing; for cystic fibrosis it is serious; for diseases of the gastrointestinal tract and thyroid gland, long-term remissions or complete cure are possible.

Hippocrates also described fingers that looked like drumsticks when studying empyema. For this reason, this pathology of the fingers and nails is named after the fingers of Hippocrates. German doctor Eugene Bamberger and French doctor Pierre Marie described hypertrophic osteoarthropathy back in the 19th century and pointed to the presence of fingers with glass-shaped nails in the disease. And already in 1918, doctors began to recognize this symptom as a sign of a chronic infection.

Fingers, similar to drumsticks, are mainly formed on both limbs, but in some cases the pathology can affect only the arms or legs separately. This selection is typical for heart defects in the cyanotic form, which developed in the womb, when blood with oxygen enters only one part of the body.

Fingers that look like drumsticks vary in what they look like:

parrot beak;
watch glasses;
real drum sticks.

Triggers

This pathology develops in the presence of the following diseases:

lung diseases of various origins;
endocarditis;
birth defects;
gastrointestinal ailments;
cystic fibrosis;
Graves' disease;
trichocephalosis;
Marie-Bamberger syndrome.

The reasons why a lesion develops on only one side may be:

Pancoast tumor (formed when cancer first segment of the lung);
diseases of the vessels through which lymph flows;
use of a fistula during hemodialysis;
taking drugs from the angiotensin II blocker group.

Causes

The reasons for the development of the syndrome, in which the fingers become like drum sticks, have not been identified to this day. What is known is that this pathology develops in the presence of circulatory problems. In this case, tissue oxygen supply is disrupted.

Permanent oxygen starvation provokes an expansion of the lumen of the vessels located in the phalanges of the fingers, which provokes an increase in blood flow to this area.

The result of this process is a significant proliferation of connective tissue, which is located between the nail and the bone. It is worth noting that there is a relationship between the level of hypoxia and external changes in the shape of the nail bed.

Studies have shown that in the presence of a chronic inflammatory disease in the intestines, oxygen starvation is not observed, but a change in the shape of the fingers and the appearance of a specific nail plate in the form of a watch glass not only develops with Crohn's disease, but may also be the first sign of this disease.

Symptoms

The manifestation in which the nails take on the appearance of watch glasses generally does not cause pain. For this reason, the patient cannot notice this change in time.

Main signs of the symptom:

If the patient has bronchiectasis, cystic fibrosis, lung abscess, chronic empyema, the main symptom may be accompanied by osteoarthropathy of the hypertrophic type, which is characterized by:

bone pain;
changes in the characteristics of the skin in the pretibial area;
elbows, wrists and knees have changes very similar to arthritis;
the skin in some areas begins to become rough;
Paresthesia and excessive sweating develop.

Diagnostics

Most often, the symptom that appears with nails in the form of watch glasses signals the presence of Marie-Bamberger syndrome. If this diagnosis is not confirmed, then the doctor relies on compliance with the following criteria:

The Lovibond angle is measured. To do this, apply a pencil along the finger to the nail. If there is no gap between the nail and the pencil, then it can be said without a doubt that the patient has a symptom of drumsticks. Also, a decrease in the angle or its complete disappearance is determined by studying the Shamroth symptom.
Feeling with your finger to determine elasticity. To do this, press on the top of the finger and immediately release. If you observe the nail sinking into the tissue, and then a sharp springing back, then you can assume a disease, the symptom of which is glass nails. The same effect occurs in elderly patients, but it is normal and does not indicate the presence of manifestations of drumsticks.
The doctor checks the ratio of the thickness of the TDF and the interphalangeal joint. For a normal state, this figure does not exceed 0.895. If a symptom is present, that indicator increases to 1 or even more. This indicator is considered the most specific for this manifestation.

If there is a suspicion of a combination of hypertrophic osteoarthropathy with a symptom of drumsticks, then the doctor decides to give the patient an x-ray or scintigraphy.

It is important in diagnosing why the nail becomes “glassy” is to identify the main cause of development this symptom. To do this you need:

study anamnesis;
do ultrasonography lungs, heart and liver;
study the results of a chest x-ray;
the doctor prescribes a computed tomography and electrocardiogram;
the function of external respiration is examined;
the patient is required to donate blood to determine its gas composition.

Treatment

Therapy for nails in the form of watch glasses begins with the treatment of the underlying ailment. To do this, the doctor recommends that the patient take:

antibiotics;
medicines to boost immunity.

It would also be a good idea to review your diet. It is important to consult a nutritionist and find out the list of prohibited foods for this disease.

Forecast

The prognosis of how watch glass-like nails will look directly depends on what caused this pathology. If everything has already been cured of the underlying disease, then the symptoms will decrease and the fingers will look normal.