Clinical Image: Clubbed with a Reminder to Test for HIV

Abstract

A previously healthy 34-year-old man was evaluated for two years of progressive digital clubbing. He denied fevers, night sweats, cardiopulmonary symptoms, travel, or unusual exposures. Physical examination demonstrated no pathologic lymphadenopathy, genital lesions or penile discharge. The patient had dramatic clubbing of all digits and erythematous nail beds (Figs. 1 and ​and22). Figure 1 Digital clubbing. Figure 2 Digital clubbing. There are many different diseases associated with clubbing. Pulmonary diseases are most commonly associated, but cardiac conditions, gastrointestinal diseases, and various infections are also found with clubbing. The patient’s evaluation included unremarkable labs for systemic diseases such as malignancy, liver disease, and inflammatory bowel disease. His cardiopulmonary evaluation included echocardiography, pulmonary function testing, polysomnography and chest computed tomography. These were also unrevealing. The patient’s PPD test and RPR were nonreactive. His HIV antibody test (with Western blot) returned positive. CD4+ lymphocyte count was 401/μL and viral load was 205,000 copies/mL.1 Digital clubbing is associated with HIV. Among one convenience sample of 76 HIV-infected patients, 28 (36 %) had objectively confirmed clubbing—thus, HIV testing is recommended as part of a diagnostic algorithm.1,2 While HIV screening is now recommended for all patients aged 15–65 years, this case highlights the need for HIV diagnostic testing in patients with digital clubbing.3