A SINGULAR CLUBBED DIGIT INDICATING SARCOIDOSIS

Abstract

SESSION TITLE: Signs and Symptoms of Chest Disease SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: First described by Hippocrates, digital clubbing is a classic physical exam finding associated primarily with pulmonary disease. Clubbing also has well established associations with suppurative lung infection, bronchogenic carcinoma, bronchiectasis, pleural tumors, idiopathic pulmonary fibrosis, cirrhosis, endocarditis, and cyanotic heart disease among others.[1-3] However, isolated clubbing of a solitary digit most often is related to a neoplastic condition such as osteoid osteoma or enchondroma. We report the rare case of a patient presenting with classic findings of sarcoidosis whose heralding symptom was isolated digital clubbing of a single finger. CASE PRESENTATION: A 47 year-old man was referred to our clinic with worsening dyspnea on exertion, fatigue and intermittent dry cough. His vital signs were normal: temperature 36.4°c, respirations 14/min, pulse 66/min, blood pressure 131/82 mmHg and SpO2 97% on room air. His examination was unremarkable apart from prominent digital clubbing of a solitary finger; all other fingers and toes were normal (Fig 1). He was a nonsmoker without history of prior hand injury. There was no family history of rheumatologic or pulmonary disease. Hand x-ray (Fig. 2) revealed moth-eaten appearance with acroosteolysis of the distal phalanx, but no other regions of boney destruction. Chest x-ray (Fig 3) showed bilateral bulky hilar lymphadenopathy along with reticular and nodular opacities within the lungs. Bone biopsy from the distal phalanx (Fig. 4) demonstrated non-caseating granulomatous inflammation, but no malignancy. Acid-fast, fungal, and bacterial cultures of the biopsy were all sterile. DISCUSSION: Less frequently, sarcoidosis has also been associated with digital clubbing, but described cases have been bilateral and typically with involvement of all fingers.[4] Our presented case is unique in that a single finger was clubbed with complete sparing of all other fingers and toes. Typically, the differential diagnosis for a single clubbed finger includes osteoid osteoma, enchondroma, myxochondroma, digital mucoid cyst or glomus tumor. Less frequently, chondrosarcoma, Ewing’s sarcoma, and subungual squamous cell carcinoma have also been described arising from the distal phalanx. Accordingly, cases of isolated single digit clubbing should undergo biopsy because of their malignant potential. CONCLUSIONS: Our case highlights a unique presentation of sarcoidosis with osseous involvement causing a single Hippocratic finger. Digital clubbing found in any patient may herald a variety of significant underlying medical conditions and should prompt further evaluation. Reference #1: 1. Martinez-Lavin, M, Exploring the cause of the most ancient clinical sign of medicine: finger clubbing. Semin Arthritis Rheum, 2007. 36(6): p. 380-5.2. Rutherford, JD, Digital clubbing. Circulation, 2013. 127(19): p. 1997-9. Reference #2: 3. Spicknall, K.E., Zirwas MJ, and English JC. Clubbing: an update on diagnosis, differential diagnosis, pathophysiology, and clinical relevance. J Am Acad Dermatol, 2005. 52(6): p. 1020-8. Reference #3: 4. Yancey J, Luxford W, and Sharma OP, Clubbing of the fingers in sarcoidosis. JAMA, 1972. 222(5): p. 582. DISCLOSURES: No relevant relationships by Kevin Davidson, source=Web Response No relevant relationships by Andrew Levy, source=Web Response