Epidemiology of Digital Clubbing and Hypertrophic Osteoarthropathy: A Systematic Review and Meta-analysis.

ABSTRACT: Digital clubbing and hypertrophic osteoarthropathy (HOA) are long-standing clinical entities, but their prevalence have not been synthesized. We aimed to estimate the prevalence of digital clubbing and HOA in people with existing medical conditions.We comprehensively searched PubMed, Embase, and Web of Science to select studies addressing HOA or digital clubbing and published through March 23, 2021. Summary estimates of the prevalence were derived through random-effects meta-analysis and narrative synthesis. The review protocol has been registered with PROSPERO, CRD42021243934.Of 3973 records, we included 142 studies. In adults, the pooled prevalence of digital clubbing was 33.4% (95% confidence interval [CI], 16.6-52.8), 31.3% (95% CI, 22.4-41.1), 27% (95% CI, 9.4-49.5), and 22.8% (95% CI, 10.8-37.6) in subjects with intestinal diseases, interstitial lung diseases, infective endocarditis, and hepatic diseases, respectively. In children and adolescents, the pooled prevalence of digital clubbing was 29.1% (95% CI, 19.4-39.9), 23% (95% CI, 9.0-41.1), 19.5% (95% CI, 4.1-42.4), and 17.1% (95% CI, 9.5-26.5) in subjects with human immunodeficiency virus infection, hemoglobinopathies, cystic fibrosis, and tuberculosis. The pooled prevalence of HOA was 10.1% (95% CI, 2.0-23.1) in adults with cancers, and 5% (95% CI, 2.5-8.2) in children and adolescents with cystic fibrosis.In conclusion, the prevalence of digital clubbing varied across disease groups in both adults and children. Full-spectrum HOA was mostly reported in adults with liver disease and cancers, and in children and adolescents with cystic fibrosis.

Skin conditions in a South African tuberculosis hospital: Prevalence, description, and possible associations.

BACKGROUND: The current pandemic of tuberculosis (TB) and human immunodeficiency virus (HIV) co-infection, the modern era of antiretroviral therapy, and the rising incidence of multidrug-resistant TB have led to a broader spectrum of skin conditions in patients hospitalized with TB. These factors also influence investigations into possible causal relationships with TB. OBJECTIVES: The aim of this study was to describe mucocutaneous conditions found in patients hospitalized with TB and to report associated factors. METHODS: A cross-sectional observational study examining the spectrum of skin manifestations found in 105 patients hospitalized with TB was conducted. All relevant demographic and clinical data were collected. Possible associations were evaluated by making use of statistical analysis. RESULTS: Seventy-four (70%) of the investigated population were HIV-positive, and 46 (44%) patients were being treated for drug-resistant TB. The most prevalent dermatosis was xerosis (n = 83, 79%), followed by oral candidiasis (n = 33, 31%) and scars (n = 33, 31%), finger clubbing (n = 31, 29%), leukonychia (n = 29, 28%), striae (n = 25, 24%), and facial hyperpigmentation (n = 22, 21%). Anemia was detected in 90 (86%) patients, and 75 (71%) were classified as being underweight. Three patients were diagnosed with cutaneous TB. CONCLUSIONS: Patients hospitalized with TB have on average four different dermatoses, but xerosis remains the leading dermatological finding, irrespective of HIV status or TB drug sensitivity. Anemia and malnutrition are associated with numerous skin conditions found in this population. The prevalence of cutaneous TB among patients hospitalized with TB remains low, despite the high rate of TB and HIV co-infection.

Extrathyroidal manifestations of Graves' disease: a 2014 update.

INTRODUCTION: Graves' orbitopathy (GO), thyroid dermopathy (also called pretibial myxedema) and acropachy are the extrathyroidal manifestations of Graves' disease. They occur in 25, 1.5, and 0.3 % of Graves' patients, respectively. Thus, GO is the main and most common extrathyroidal manifestation. Dermopathy is usually present if the patient is also affected with GO. The very rare acropachy occurs only in patients who also have dermopathy. GO and dermopathy have an autoimmune origin and are probably triggered by autoimmunity to the TSH receptor and, likely, the IGF-1 receptor. Both GO and dermopathy may be mild to severe. MANAGEMENT: Mild GO usually does not require any treatment except for local measures and preventive actions (especially refraining from smoking). Currently, moderate-to-severe and active GO is best treated by systemic glucocorticoids, but response to treatment is not optimal in many instances, and retreatments and use of other modalities (glucocorticoids, orbital radiotherapy, cyclosporine) and, in the end, rehabilitative surgery are often needed. Dermopathy is usually managed by local glucocorticoid treatment. No specific treatment is available for acropachy. PERSPECTIVES: Novel treatments are presently being investigated for GO, and particular attention is paid to the use of rituximab. It is unknown whether novel treatments for GO might be useful for the other extrathyroidal manifestations. Future novel therapies shown to be beneficial for GO in randomized studies may be empirically used for dermopathy and acropachy.

Fibrosis pulmonar idiopática: un reto para la atención primaria / Idiopathic pulmonary fibrosis: A challenge for primary care

No disponible

Hypertrophic osteoarthropathy: what a rheumatologist should know about this uncommon condition.

This article presents an updated overview of hypertrophic osteoarthropathy and digital clubbing for the practicing rheumatologist. Discussion includes a brief historical perspective, its definition, incidence and prevalence, classification, pathology and pathophysiology, clinical manifestations, demographics, findings on physical examination, imaging techniques for its detection, differential diagnosis, and treatment modalities.

Incidence of hypertrophic pulmonary osteoarthropathy associated with primary lung cancer.

BACKGROUND AND OBJECTIVE: Although the association of hypertrophic pulmonary osteoarthropathy (HPO) with lung cancer was investigated in the 1960s, the recent incidence of clinically apparent HPO is not known. Data from a large series of patients with lung cancer were analysed, in order to assess the incidence of possible HPO, based on bone scintigraphy, as well as the incidence of clinically confirmed HPO. The clinical features of confirmed HPO were also evaluated. METHODS: The medical records of patients admitted with lung cancer between January 1986 and August 2004 were reviewed. Bone scintigraphy showing symmetrical, abnormally high uptake in joints and/or long bones was considered to be suggestive of HPO. Patients who also had finger clubbing and joint pain were considered to have a confirmed diagnosis of HPO. Clinical histories and hormone levels were then investigated in these patients, to identify possible causal factors. RESULTS: Among the 1226 lung cancer patients, 55 (4.5%) demonstrated abnormally high uptake on bone scintigraphy, suggesting possible HPO. Ten (0.8%) patients had clubbed fingers and joint pain and were eventually confirmed as having HPO. Serum hormone concentrations were abnormally high in the patients with confirmed HPO. CONCLUSIONS: This retrospective study indicated that 4.5% of lung cancer patients showed findings suggestive of HPO, a frequency similar to that reported previously. However, patients with HPO rarely showed the complete triad of signs. Although increased hormone concentrations may have caused the HPO, further investigation is required to confirm this.

Digital clubbing in HIV-infected patients: an observational study.

Digital clubbing is characterized by bulbous enlargement of the distal phalanges due to an increase in soft tissue. It has been associated with a variety of conditions including cyanotic heart disease, neoplasms and infections of the lungs, bronchiectasis, liver cirrhosis, and inflammatory bowel disease. We conducted an observational study at an urban Veterans Affairs Medical Center outpatient HIV clinic to confirm our clinical impression that clubbing is common in HIV-infected patients and to identify factors that might be associated with it. Clinical, laboratory, and physical examination data including measurement of the circumference of the nail bed and distal phalanx of each finger were obtained on 78 HIV-infected patients seen for their routine care over a 3-month period. A digital index (DI), the ratio of the nail bed:distal phalanx circumference was determined for each patient. Clubbing was found in 28 patients (36%). Clubbed patients did not differ from nonclubbed patients with respect to most patient characteristics; CD4 cell counts and quantitative HIV RNA were similar in both groups. Clubbed patients had a significantly higher DI than controls (1.03 versus 0.96, p < 0.001), were younger (45 versus 49 years, p = 0.04), and had longer duration of HIV disease (48 versus, 42 months, p = 0.03). HIV infection should be considered in the differential diagnosis of acquired digital clubbing.

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

BACKGROUND: Clubbing remains an amazing clinical sign. Its strong association with serious disease is still a clinical enigma. Moreover, the significance of diagnosing clubbing is not well established. The aim of our study was to evaluate prevalence, aetiology and clinical significance of clubbing in a department of general internal medicine. PATIENTS AND METHODS: During one year (1511 admissions), all patients with digital clubbing assessed by determining ratio of the distal phalangeal depth (DPD) to the interphalangeal depth (IPD) and with the presence of Swamroth sign were included. Fifteen patients were diagnosed with clubbing (10 males and 5 females). They underwent complete physical examination, pulmonary CT-scan, bone scintigraphy, blood gas analysis and were compared with 86 matched controls. RESULTS: Aetiology were renal cell carcinoma, pulmonary arteriovenous malformation, AIDS, inflammatory pseudo-tumour of the lung, adenocarcinoma of unknown origin in one case and in one case, Pet-scan suspected neoplasia but histology was not obtained. In 9 cases, no aetiology was found. Bone scan was normal in 14 cases and revealed periostitis in one case (idiopathic clubbing). Compared to control group, there was no difference in blood gas analysis but emphysema was more often present in patients with clubbing (p<0.01). No patient without aetiology developed cancer in the one year follow-up. CONCLUSION: Clubbing is present in 1% of admission in a department of general internal medicine and is associated in nearly 40% with serious disease. In 60% of cases, aetiology is not identified but follow-up do not disclosed cancer.

Dactilitis: evaluación, implicaciones pronósticas y abordaje terapéutico / No disponible

No disponible

Digital clubbing in tuberculosis--relationship to HIV infection, extent of disease and hypoalbuminemia.

BACKGROUND: Digital clubbing is a sign of chest disease known since the time of Hippocrates. Its association with tuberculosis (TB) has not been well studied, particularly in Africa where TB is common. The prevalence of clubbing in patients with pulmonary TB and its association with Human Immunodeficiency Virus (HIV), severity of disease, and nutritional status was assessed. METHODS: A cross-sectional study was carried out among patients with smear-positive TB recruited consecutively from the medical and TB wards and outpatient clinics at a public hospital in Uganda. The presence of clubbing was assessed by clinical signs and measurement of the ratio of the distal and inter-phalangeal diameters (DPD/IPD) of both index fingers. Clubbing was defined as a ratio > 1.0. Chest radiograph, serum albumin and HIV testing were done. RESULTS: Two hundred patients (82% HIV-infected) participated; 34% had clubbing by clinical criteria whilst 30% had clubbing based on DPD/IPD ratio. Smear grade, extensive or cavitary disease, early versus late HIV disease, and hypoalbuminemia were not associated with clubbing. Clubbing was more common among patients with a lower Karnofsky performance scale score or with prior TB. CONCLUSION: Clubbing occurs in up to one-third of Ugandan patients with pulmonary TB. Clubbing was not associated with stage of HIV infection, extensive disease or hypoalbuminemia.

Assessment of digital clubbing in medical inpatients by digital photography and computerized analysis.

BACKGROUND: Digital clubbing has been associated with a large number of disorders. To overcome the limitation of subjective clinical assessment, several objective measurements have been developed among which the hyponychial angle was considered most accurate for quantification of finger clubbing. METHODS AND RESULTS: Here we investigated hyponychial angles in 123 healthy subjects and 515 medical inpatients from a tertiary hospital. Healthy subjects had a mean angle of 178.87 +/- 4.70 degrees (range: 164.78-192.10 degrees ), a finding that is well in accordance with previous results obtained using other techniques, underlining the accuracy of the chosen method of assessment. The mean angle of patients was 181.65 +/- 7.18 degrees (range: 162.22-209.19; p <0.0001 compared to healthy controls). When the upper limit of normality, i.e. 192.10 degrees, was used to define digital clubbing, the prevalence of digital clubbing in our patients was 8.9%; the percentage of clubbed fingers varied substantially among the various disease states (up to 80% in patients with cystic fibrosis). CONCLUSION: The use of digital photography with computerised analysis was found to be an easy, fast and inexpensive method for the quantification of hyponychial angles with excellent intra and inter observer reliability whilst causing no discomfort to patients. This tool may therefore be useful in further longitudinal and cross-sectional studies of finger morphology and may become an accepted standard in the diagnosis of digital clubbing.

Osteoartropatía hipertrófica pnéumica / Hypertropic pneumic osteoarthropaty

No disponible

Prevalence of digital clubbing in bronchogenic carcinoma by a new digital index.

OBJECTIVE: Clubbing can be a paraneoplastic manifestation of bronchogenic carcinoma. We assessed a new digital index of clubbing and used it to determine the prevalence of clubbing for different cell types of lung cancer. METHODS: Clubbing was assessed by measurement of the thickness of both the base of the nailbed (distal phalangeal depth--DPD) and the distal interphalangeal depth (IPD) of the index finger in a control group compared to patient groups with either chronic obstructive lung disease, or lung cancer. RESULTS: Of the 55 normal subjects, no patient had a DPD/IPD ratio of more than 1.05 on either hand, while 11% of the patients with COPD had a ratio of more than one. For the cancer patients, 33% had a ratio greater than one, with 30 of 109 (37%) having a ratio > 1.05 (chi(2) = 17.6, p < 0.0001). There was no difference in the prevalence of clubbing between the 33 squamous cell patients, the 43 adenocarcinoma patients, and the 33 small cell lung carcinoma patients included. CONCLUSIONS: Measurement of the interphalangeal and distal phalangeal distance demonstrated that one-third of patients with lung cancer had evidence of clubbing. The type of bronchogenic carcinoma did not appear to affect the proportion of patients with clubbing.

Renal ostodystrophy during the developing stage of maintenance dialysis in Transylvania. Early development of periarticular calcifications and beta 2 microglobulin amyloidosis in spite of a relatively good prevention of secondary hyperparathyroidism.

BACKGROUND: Dialysis facilities have been introduced only recently in Transylvania with many limitations, in particular a standard high calcium dialysate, Al(OH)3 as phosphate binder and pharmacological doses of native vitamin D2, but neither CaCO3 nor 1 alpha hydroxylated vitamin D. Rheumatological complaints and metastatic calcifications were frequent, leading to suspect either overt hyperparathyroidism, adynamic bone disease or beta 2 microglobulin amyloidosis. AIMS OF THE STUDY: Evaluate the prevalence of radiological osteitis fibrosa, amyloid osteoarthropathy and periarticular calcification and their link with PTH secretion, phophocalcic disorders, acidosis, bone turn over, aluminum and beta 2 microglobulin accumulation in the dialysis population of Sibiu (Transylvania). METHODS: The clinical and radiological rheumatological data of the 49 uremic patients dialyzed in Sibiu since 1990 were reviewed as well as the monthly routine monitoring of their plasma phosphocalcic parameters. Furthermore in July 1994, 36 of them had an X rays of the hands for evaluation of subperiosteal resorption of the phalanges, periarticular calcifications and carpal cysts as well as a determination of plasma concentrations of intact PTH (normal range: 10-55; optimal range: 100-200 pg/ml), osteocalcin, bone alkaline phosphatase, aluminum and 25 OH vitamin D. RESULTS: The prevalence of subperiostal resorption of the phalanges was 8% and that of severe biological hyperparathyroidism (PTH > 400 pg/ml) 22%, whereas that of a relative hypoparathyroidism (PTH < 100 pg/ml) was 31%. Mean plasma concentrations of calcium was 2.07 +/- 0.15; of phosphate 2.50 +/- 0.35; of bicarbonate 15 +/- 2.0 mmol/l, of 25 OHD 30 +/- 20 ng/ml, of aluminum 1.1 +/- 0.5 mumol/l. Plasma PTH concentrations were negatively correlated to dialysis duration, and to plasma concentrations of aluminum, calcium and 25 OH vitamin D but not to those of phosphate and bicarbonate. Multivariate analysis showed however that only duration of dialysis and plasma aluminum concentration were independently and negatively correlated to plasma PTH concentrations. The prevalence of periarticular calcifications (26%) and of carpal cysts suggestive of beta 2 microglobulin amyloidosis (10%) were relatively high considering the young age of the population (42 years) and the short duration of dialysis (2.6 years). Patients with calcifications comparatively to those without calcifications were older, had longer duration on dialysis, higher prevalence of carpal cysts and higher plasma beta 2 microglobulin concentrations, lower plasma PTH (98 versus 313 pg/ml) and higher plasma aluminum concentration (1.3 versus 0.8 mumol/l). Patients with carpal cysts comparatively to those without cyst were older, had a longer duration on dialysis and a higher prevalence of periarticular calcifications. CONCLUSIONS: a) In spite of no use of 1 alpha hydroxylated vitamin D derivatives, and poor control of hyperphosphatemia and acidosis, hyperparathyroidism declined with duration of dialysis due to the use of a high dialysate calcium concentration, Al(OH)3 as sole phosphate binder and high supplement of native vitamin D. b) Considering the relative young age and short duration on dialysis, the prevalence of periarticular calcifications and carpal cysts were high. c) Calcifications were possibly favored by relative hypoparathyroidism and moderate aluminum overload. d) The association of periarticular calcifications and subchondrial cysts suggest a causal relationship.

Clubbing--a reevaluation of its incidence and causes.

117 adult patients (age > 13 years) admitted in medical wards were studied for clubbing. 24.8% (29/117) of the patients had clubbing. Incidence of clubbing in males and females was 22.2% (26/117) and 2.6% (3/117) respectively [corrected]. Liver disease, which was seen in 27.6% cases (8/29) of clubbing, was the commonest cause of clubbing and was observed only in males. This was related to a high incidence of alcohol intake among males i.e. 34.6% (9/26) as against none among the females. Amongst the liver disease, suppurative liver disease was responsible for clubbing in 75% (6/8) of cases. Only 20.7% (6/29) of patients with clubbing had severe clubbing. 66.6% (4/6) of patients with severe clubbing had liver disease. Congenital heart disease was cause of clubbing in 2 out of 3 females (66.6%) with clubbing. Alcohol may be causally related to occurrence of clubbing in this part of the country.

Hypertrophic osteoarthropathy secondary to bronchopulmonary cancer (our experience).

During 5 years (1986-1990), 81 of the patients under our care showed bronchopulmonary cancer diagnosed by clinical, x-ray and bronchoscopic examinations. Of these, 69 (85.2) were men and 12 (14.8%) women, with a mean age of 62 years; 72 patients (90%) were moderate or heavy smokers. Four of them (4.9%) presented the classical hypertrophic osteoarthropathy (HOA) described by Bamberger and Pierre Marie, i.e., finger clubbing, ossifying periostitis of the long bones, joint pains and swelling. Other 3 patients showed only finger clubbing, while 7 of 30 cases studied by systematic x-ray examinations of the long bones presented ossifying periostitis (5 cases) or hyperostosis (2 cases). It results that almost one third (31.6%) of the patients with bronchopulmonary cancer had a complete or incomplete Bamberger-Pierre Marie syndrome. It is concluded that HOA identification before the clinical and x-ray manifestations of bronchopulmonary cancer could contribute to an early diagnosis of this malignant disease.