Digital Clubbing Research Articles

Digital Index of The Fingers with Digital Clubbing: An objective measurement to diagnose clubbed finger.

Introduction: Digital clubbing can often be found as a clinical sign in patients with various underlying diseases. However, early signs of clubbing are often overlooked. To determine the Digital Index values from the fingers with clinical features of clubbing of varies conditions background.
 Method: This was a prospective, case-series, investigator-initiated observation by morphometry, conducted in Kuching, Malaysia along 6 months duration. Participants were 46 patients with varies stage of clubbing of varies conditions and diseases. We measured the finger at the circumference of the Nail Fold and Distal Interphalangeal joint which determined the value of the Digital Index of a population with finger clubbing.
 Results: The value of the Digital Index of finger clubbing in this study was 9.89±0.68 (Mean±SD) for male and 9.87±0.39 (Mean±SD) for female. The value of the Digital Index of finger clubbing for all subjects together was 9.88±0.56 (Mean±SD) with a range of 8.43 to 11.26.
 Conclusion: Early clubbing often be overlooked. To avoid such condition, the physician should examine the fingers as a routine procedure. Measurement of DI can be recommended to detect early clubbing. (J Respir Indo. 2019; 39(3):196-204)

Hipocratismo digital: conociendo sus causas. Reporte de caso

Introducción. El hipocratismo digital es un signo clínico que afecta principalmente los dedos de las manos y se caracteriza por deformidad en uñas con abombamiento en vidrio de reloj. Puede presentarse en pacientes con cáncer diseminado, enfermedad pulmonar preexistente y dolor óseo, por lo cual es importante considerar esta entidad para un diagnóstico y un tratamiento oportunos.Presentación del caso. Paciente masculino de 86 años con hipocratismo digital, tabaquista en abstinencia, quien ingresa a urgencias por cuadro clínico de 2 meses de evolución consistente en fiebre y pérdida de 19kg de peso. Al examen físico presentaba disminución de ruidos respiratorios en base pulmonar derecha, dedos en palillo de tambor y deformidad ungüeal en manos. La radiografía de tórax mostró opacidad a nivel parahiliar derecho bien definida de 5cm. La tomografía computarizada de tórax mostró masas de bordes irregulares a nivel parahiliar derecho y en segmento apical del lóbulo inferior del pulmón derecho, y derrame pleural ipsilateral. La biopsia guiada por tomografía documentó adenocarcinoma pulmonar bien diferenciado.Conclusiones. El hipocratismo digital plantea un desafío en medicina debido a que puede ser difícil llegar a un diagnóstico etiológico y se pueden requerir muchos estudios para su confirmación.

CLINICAL, HISTOPATHOLOGICAL, AND MOLECULAR CHARACTERIZATION OF CARVAJAL SYNDROME WITH ORAL MANIFESTATIONS

Introduction Carvajal syndrome is characterized by woolly hair, striated palmoplantar keratoderma and left-sided ventricular cardiomyopathy. It is inherited as an autosomal recessive disorder due to a homozygous mutation in the gene coding for desmoplakin, which truncates the C-terminal of the protein and maps to chromosome 6p24. Signs and symptoms of Carvajal syndrome include: woolly hair that is present from birth, palmoplantar keratoderma that develops after infancy, follicular keratoses on elbows, knees, face, abdomen and lower limbs, clubbing of fingers and rarely mucosal lesions. The desmoplakin (DSP) abnormality can result in arrhythmogenic ventricular cardiomyopathy. Clinical Presentation A 2 month old male of Ecuadorian descent presented with oral ulcerations and poor feeding as reported by his mother. The oral lesions were noted at 2 weeks of age. Bilateral dorsal tongue and palatal erosions with sloughing were noted on oral examination. Skin excoriations were noted at sites of electrocardiogram leads. It was also noted that the child had sparse woolly hair that extended on to the forehead and had a hoarse cry. Intervention and Outcome Biopsies of the anterior dorsal tongue, lingual epiglottis, and duodenal, gastric, esophageal and rectosigmoid mucosa were performed. The tongue and epiglottis surface epithelium consisted of discohesive squamous epithelial cells with interspersed inflammation and bacterial colonies. Esophageal biopsy showed suprabasilar separation from underlying lamina propria. Direct immunofluorescence studies were negative. Whole Exome Sequence Analysis revealed patient was compound heterozygous for the c.7623delT and c.7623delG pathogenic variants in the DSP gene. Conclusion The mucosal lesions of this syndrome can present intraorally, and have a rather unique histopathology characterized by dyskeratosis and discohesion. Patients with this syndrome require regular cardiac evaluations as the cardiac issues are of paramount importance.

Clinical characteristics and outcomes of hypersensitivity pneumonitis: a population-based study in China.

Backgrounds:Hypersensitivity pneumonitis (HP) is an immune-mediated interstitial lung disease (ILD) that develops in response to the inhalation of various antigens. The clinical pathologies are very complex and undetermined. The clinical features and outcomes of HP have not been fully elucidated. The aim of this study was to analyze the incidence, clinical features, and outcomes of HP patients and construct a simple clinical model for diagnosing chronic HP (CHP).Methods:The cohort study included 101 patients with HP admitted to the Nanjing Drum Tower Hospital from January 2009 to December 2017. The patients were categorized into acute HP (AHP, n = 72) and CHP (n = 29) groups according to the updated international criteria. The clinical, imaging, treatment, and follow-up data were retrospectively reviewed. All patients were followed up until December 31, 2017. Statistical analysis was performed, and a clinical scoring system for CHP was constructed by SPSS 20.0 software.Results:The incidence of HP was 2.4% in ILD inpatients in our center. Patients in the CHP group were older (t = −2.212, P = 0.029), had more smokers (χ2 = 8.428, P = 0.004), and longer duration of symptoms (t = −4.852, P < 0.001) than those in the AHP group. Weight loss, crackles, digital clubbing, and cyanosis were more common in the CHP group than those in the AHP group (χ2 = 5.862, P < 0.001; χ2 = 8.997, P = 0.003; χ2 = 11.939, P = 0.001; and χ2 = 4.025, P = 0.045, respectively). On chest high-resolution computed tomography (HRCT), reticular patterns, traction bronchiectasis, and accompanying honeycombing were more common in CHP cases than those in AHP cases (χ2 = 101.000, P < 0.001; χ2 = 32.048, P < 0.001; and χ2 = 36.568, P < 0.001, respectively). The clinical scoring system for CHP was established based on the clinical variables (age [A], duration of symptoms [D], smoking history [S], unidentified exposure [U], and chest HRCT [C]; ADSUC) (area under the curve 0.935, 95% confidence interval: 0.883–0.987, P < 0.001). Eleven patients (15.3%) in the AHP group developed CHP, and unidentified exposure was an independent risk factor for the progression of disease (P = 0.038). The survival of patients with CHP, smoking history, unidentified antigens and fibrosis on Chest HRCT were significantly worse (P = 0.011, P = 0.001, P = 0.005, and P = 0.011, respectively) by Kaplan-Meier analysis. Cox multivariate regression analysis revealed that unidentified exposure and total lung volume (TLC pred%) were independent prognostic predictors for HP patients (P = 0.017 and P = 0.017, respectively).Conclusions:The clinical features and outcomes of the CHP patients differ from those of the AHP patients. ADSUC is a simple and feasible clinical model for CHP. Unidentified exposure is an independent risk factor for the progression of AHP to CHP. Unidentified exposure and a low baseline TLC pred% are independent predictors for survival in HP patients.

The first case of primary hypertrophic osteoarthropathy with soft tissue giant tumors caused by HPGD loss-of-function mutation.

BackgroundPrimary hypertrophic osteoarthropathy (PHO) is a rare genetic multi-organic disease characterized by digital clubbing, periostosis and pachydermia. Two genes, HPGD and SLCO2A1, which encodes 15-hydroxyprostaglandin dehydrogenase (15-PGDH) and prostaglandin transporter (PGT), respectively, have been reported to be related to PHO. Deficiency of aforementioned two genes leads to failure of prostaglandin E2 (PGE2) degradation and thereby elevated levels of PGE2. PGE2 plays an important role in tumorigenesis. Studies revealed a tumor suppressor activity of 15-PGDH in tumors, such as lung, bladder and breast cancers. However, to date, no HPGD-mutated PHO patients presenting concomitant tumor has been documented. In the present study, we reported the first case of HPGD-mutated PHO patient with soft tissue giant tumors at lower legs and evaluated the efficacy of selective COX-2 inhibitor (etoricoxib) treatment in the patient.MethodsIn this study, we summarized the clinical data, collected the serum and urine samples for biochemical test and analyzed the HPGD gene in our patient.ResultsA common HPGD mutation c.310_311delCT was identified in the patient. In addition to typical clinical features (digital clubbing, periostosis and pachydermia), the patient demonstrated a new clinical manifestation, a giant soft tissue tumor on the left lower leg which has not been reported in HPGD-mutated PHO patient before. After 6-month treatment with etoricoxib, the patient showed decreased PGE2 levels and improved PHO-related symptoms. Though the soft tissue tumor persisted, it seemed to be controlled under the etoricoxib treatment.ConclusionThis finding expanded the clinical spectrum of PHO and provided unique insights into the HPGD-mutated PHO.

Touraine–Solente–Gole syndrome: Clinical manifestation with bilateral true eyelid ptosis

Touraine–Solente–Gole syndrome (pachydermoperiostosis [PDP] or primary idiopathic hypertrophic osteoarthropathy [HOA]) is a rare hereditary disorder that is characterized by a triad of manifestations that consists of skin changes (pachydermia), abnormal bone and joint manifestations (periostosis and/or artritis), and digital clubbing (acropachia). Here, we report the case of 24-year-old male who presented with severe bilateral true eyelid ptosis. Physical examination revealed severe ptosis with poor function of the levator palpabrae superioris muscle, thickening of and deep grooves in facial skin (especially at the frontal region), and abnormal appearance of the scalp with accentuating folds and deep furrows (cutis verticis gyrata). Abnormal bone enlargement of the hands, knees, and feet was also observed. Frontal rhytidectomy and levator resection and advancement were performed to alleviate symptoms. At the short-term follow-up, the patient described being satisfied with the outcome of treatment. This patient will be routinely followed over the long term to evaluate disease progression. Although the cause of ptosis in most PDP is mechanical process or dysfunction, this case of PDP had bilateral true eyelid ptosis due to poor levator palpabrae superioris muscle excursion with coexisting signs and symptoms of complete form PDP. This finding highlights the need to investigate for bilateral true eyelid ptosis caused by abnormal levator palpabrae superioris muscle function in patients diagnosed with PDP.

Sindrom Hepatopulmoner

Hepatopulmonary syndrome (HPS) is an important complication of liver disease on pulmonary organ; characterized by the triad of liver disease, pulmonary vascular dilatation, and oxygenation defect. Clinical signs and symptoms include dyspnea, platypnea, orthodeoxia, cyanosis, and clubbing finger. The underlying patophysiology involves abnormal vasodilation and angiogenesis in the pulmonary vascular bed, which leads to ventilation-perfusion mismatch, diffusion limitation to oxygen exchange, and arteriovenous shunting. This disorder is thought to be linked to liver cell injury, which stimulates release of endothelin-1 and results in increased expression of endothelin receptors on pulmonary endothelial cells, leading to upregulation of endothelial-nitric-oxide-synthase (eNOS) and subsequent increased production of nitric oxide (NO), ultimately causing vasodilation. Laboratory studies to establish diagnosis includes blood gas analysis and echocardiography, supported by radiology and pulmonary vascular cathetherization. Despite accumulated knowledge about the pathogenesis of HPS, currently there is still no established medical therapy, and liver transplantation remains the definitive treatment for this syndrome. Supportive therapy consists oflong term oxygen administration to prevent desaturation and alleviate dyspnea.

Evaluation and management of Idiopathic Pulmonary Fibrosis.

Idiopathic Pulmonary Fibrosis (IPF) is a most common progressive interstitial lung disease (ILD) of unknown etiology, although majority of patients are elderly male smokers. The main pathogenesis is aberrant recovery of epithelial injury and collagen deposition. Fibrotic nonspecific interstitial pneumonia, connective tissue disease (CTD) especially rheumatoid arthritis (RA) associated ILD, and chronic hypersensitivity pneumonia(CHP) are important differential diagnosis. Main symptoms are non-productive cough and progressive exertional dyspnea. Crucial physical findings are scalene muscle hypertrophy, bibasilar fine crackles, and finger clubbing. The serum markers such as lactate dehydrogenase (LDH) and Krebs von den Lungen-6 (KL-6) are sensitive for ILD detection and activity. Both pulmonary function test (PFT) and the 6-minute walk test (6MWT) are useful tool for evaluation of disease progression of IPF. Serial changes of forced vital capacity (FVC) and 6MWT distance predict mortality in IPF effectively. Recently published international IPF guidelines highlight the importance of chest high resolution computed tomography (HRCT) findings such as honeycombing, traction bronchiectasis (TBE), and sub-pleural reticular opacity. IPF is chronic and progressive; therefore, tracking disease behavior is crucial. Unifying clinical, physiological, and imaging information over time is useful. With regard to its management, two anti-fibrotic drugs such as pirfenidone and nintedanib have been available. These drugs can slow the decline of FVC and prevent acute exacerbation (AE). In this review, I outline the clinical characteristics of IPF, physiological, imaging, pathological findings and review diagnosis process and management.

Digital Clubbing: A Patient With Hypertrophic Osteoarthropathy and the Presence of Acro-osteolysis

Digital Clubbing: A Patient With Hypertrophic Osteoarthropathy and the Presence of Acro-osteolysis

Nail clubbing in laxative abuse: case report and review of the literature

BackgroundThe link between clubbing and laxative abuse has been reported several times in the literature, in all cases in young females. The nature of this relationship is not understood.CaseA young female, with no history of hepatic, pulmonary or malignant disease was found to have nail clubbing in the context of laxative abuse. A literature review revealed several similar cases.ConclusionLaxative abuse is an important consideration in the assessment of clubbing in populations at risk of eating disorders, to prevent over-investigation and facilitate management of the eating disorder itself. This case highlights a new clinical presentation of an eating disorder.CaseA 36-year-old woman was being reviewed by a renal specialist for renal impairment and electrolyte disturbances, in the context of a background of multiple renal calculi 4 years prior, hypokalaemia and hypercalcaemia. The attending nephrologist brought attention to her nails, which demonstrated clubbing. She stated that she had had clubbing for 10 years, and that it was of gradual onset and not associated with any pain. There was no history of hepatic, cardoipulmonary or malignant disease.

Hypoxia due to intrapulmonary vascular dilatation in a toddler with a congenital portacaval shunt: case report

BackgroundThe term hepatopulmonary syndrome typically applies to cyanosis that results from “intrapulmonary vascular dilatation” due to advanced liver disease. Similar findings may result from a congenital portosystemic shunt without liver disease. An adverse consequence of such shunts is intrapulmonary vascular dilatation, which affects the microvascular gas exchange units for oxygen.Case presentationHere, we describe a toddler with chronic cyanosis, exercise intolerance, and finger clubbing due to a malformation shunt between the portal vein and the inferior vena cava. A transcatheter embolization of the shunt resulted in resolution of his findings.ConclusionsCongenital portosystemic shunts need to be considered in the differential diagnosis of cyanosis.

P775 Finger clubbing and Crohn's disease: higher frequency in patients with upper GI lesions in a prospective study

P775 Finger clubbing and Crohn's disease: higher frequency in patients with upper GI lesions in a prospective study

Ischemic Stroke In infant With Tetralogy of Fallot

Objectives: Although stroke is often viewed as occurring primarily in the elderly, it also strikes infants, children, young adults. Stroke in children are rare but increasingly important conditions due to the severity of their complications and diverse diagnostic differentials. It is not yet clearly understood and with multifactorial etiologies. When it comes to stroke, children are not just little adults. Stroke risk factors, symptoms, prevention efforts, and treatment are often different in children than in adults. Up to 80 % of children with ischemic stroke have cardiovascular disease. Case report: RS, An infant, aged two and half years old was admitted to DR. M. Djamil hospital Padang, with right hemiplegy and developed aphasia after activity. One year ago, he had history of cyanotic skin but neglected by his parents and never sought medical treatment. Physical findings on this patient are cyanosis and clubbing fingers. Cardiac auscultation revealed a pansystolic murmur grade III-IV best heard at the upper left sternal border. Chest radiograph showed a characteristic “bootshaped” heart, which is a reflection of Right Ventricular (RV) hypertrophy. The ECG showed right axis deviation. Brain CT Scan revealed a large hypodense lesion on the left cerebral hemisphere suggested as large brain infarction. Echocardiogram revealed tetralogy of fallot with a larged malaligned ventricular septal defect (VSD) with 60 % aortic override. Patient was managed conservatively. After two weeks of admission, patient was discharged with improvement.Conclusion : Ischemic stroke in this infant with tetralogy of fallot occurred via paradoxical embolism mechanism.

Management of tetralogy of Fallot with Blalock–Taussig shunt alone in a low-resource setting

The outcomes of management of Tetralogy of Fallot (TOF) in children with only BT shunts have not been widely reported. Therefore, we present a 29-year-old man with complaints of progressive easy fatigability and effort intolerance. He was diagnosed with TOF in infancy and had both left- and right-sided BT shunts without corrective surgery. Examination revealed an asthenic young man with conjunctival plethora, cyanosis, digital clubbing, and hypertension. Chest X-ray, electrocardiography, and echocardiography revealed the typical anomalies of TOF. He has been referred for corrective surgery. Despite two previous BT shunts, the investigations still revealed the structural anomalies of TOF; this confirms BT shunt is not the definitive treatment but a palliative measure. Total corrective surgery remains the definitive treatment of TOF. Patients and their caregivers should be counseled on this and on the need for early corrective surgery.

A Clinical Triad of Digital Clubbing, “Arthritis” and Ossifying Periostitis in a Man: Case Report

A 49 year old gentleman presented with intermittent bilateral knee swelling for the past 37 years and was eventually diagnosed as primary hypertrophic osteoarthropathy after secondary forms were excluded. This case illustrates that the disease can present during childhood with an insidious onset and progressively become more severe and that is when medical attention is sought. Furthermore, the patient did not voluntarily report his skin changes as he considered the slow progressive changes as normal. We report a case of primary hypertrophic osteoarthropathy, its clinical presentation, imaging findings and therapeutic treatment. It is a rare differential diagnosis for chronic joint pain and swelling.

Standardized clinical criteria and sweat test combined as a tool to diagnose Cystic Fibrosis

ContextCF is under-diagnosed in Ecuador; one out of every 11,252 live births born in Ecuador could have CF. AimTo analyze the clinical findings, based on previously established criteria, with the results of the sweat test, in circumstances where we do not have the routine molecular study. MethodsEpidemiological, observational, analytic, cross-sectional study. It analyzed 180 patients clinically suspected of CF. Inclusion criteria: children of both sexes older than 30 days and younger than 12 years, who meet at least three clinical criteria suggestive for CF, outpatient and referred by a specialist physician who made a preliminary diagnosis. This is a pilot study. ResultsThe combination of criteria pneumonia, chronic cough and chronic obstructive bronchial syndrome is the most frequent, with not a significant relationship with a positive sweat test. On the contrary, a significant relationship was found between the clinical combinations of pneumonia with cough and rhinosinusitis; pneumonia with cough; presence of Pseudomonas aeruginosa; and pneumonia with digital cough and clubbing, so it is recommended to perform the test in all these associations. The most frequent clinical criterion for the reference and performance of the electrolyte test in sweat is pneumonia to repeat for two or more episodes. ConclusionClinical combinations of pneumonia with cough and rhinosinusitis; pneumonia with cough; presence of Pseudomonas aeruginosa; and pneumonia with digital cough and clubbing are pathognomonic for CF and indication for the sweat test. The predictive performance in CF diagnosis, defined as compatible clinical presence plus high values of chloride in sweat test, was 91.1%.

Touraine-Solente-Gole syndrome with acne vulgaris successfully treated with isotretinoin

Touraine Solente Gole syndrome or pachydermoperiostosis is a rare genodermatosis affecting skin bones and connective tissue characterized by the triad of pachydermia periostosis and digital clubbing The authors report the case of a year old man presenting the dermato rheumatic symptoms that characterize the complete form of the syndrome He also manifested palpebral ptosis and severe acne treated with isotretinoin in addition to exuberant polyarticular arthritis Other causes of hypertrophic osteoarthropathy were investigated and not found

Safety and efficacy of cyclooxygenase-2 inhibition for treatment of primary hypertrophic osteoarthropathy: A single-arm intervention trial

BackgroundPrimary hypertrophic osteoarthropathy (PHO) is a rare disease involving joint, bone and skin. Two underlying genes responsible for this disease—hydroxyprostaglandin dehydrogenase (HPGD) and solute carrier organic anion transporter family, member 2A1 (SLCO2A1)—are both associated with aberrant accumulation of prostaglandin E2 (PGE2). Cyclooxygenase-2 (COX-2) is a key enzyme in PGE2 synthesis. This study was intended to evaluate the safety and efficacy of COX-2 inhibitor in the treatment of PHO. MethodsWe recruited patients presenting to Peking Union Medical Hospital between January 2009 and December 2016 who were diagnosed with PHO. Participants were given the COX-2 inhibitor etoricoxib (60 mg once daily) and followed up for 9 months. Gene analysis was performed at baseline. The following data were collected at baseline and during treatment: visual analogue score (VAS), volume of the distal middle finger (VDMF), knee joint circumference (KJC), serum and urinary levels of prostaglandin E2 (PGE2) and PGE metabolite (PGE-M) and serum levels of inflammatory markers. ResultsA total of 27 patients were recruited, including seven patients with PHO type I (PHOAR1) carrying HPGD gene mutations and 20 patients with PHO type II (PHOAR2) carrying SLCO2A1 gene mutations. After treatment with etoricoxib, the majority of patients experienced resolution of symptoms including pachydermia (60.9%), joint swelling (100%), digital clubbing (74.1%) and hyperhidrosis (55.0%). In both the PHO subtypes, serum and urinary levels of PGE2 were elevated at baseline and declined sharply upon treatment. For PHOAR1 patients, serum and urinary PGE-M levels were relatively low and demonstrated minimal response to COX-2 inhibition. Among PHOAR2 patients, mean serum and urinary levels of PGE-M presented at a high level at baseline and were normalized after 3 months of treatment. No severe adverse effects were reported during the study period. ConclusionsWe found COX-2 inhibitor to be safe and effective for the treatment of PHO in our cohort. The translational potential of this articleThe underlying genes responsible for PHO suggest COX inhibitor as potential therapy, and our study demonstrates the efficacy and safety of this treatment.

Failure to Thrive in Infants and Toddlers

Failure to thrive (FTT) is a broad term that is used to document an abnormal pattern of weight gain over time. There is no single definition for FTT, but all proposed definitions use anthropometric parameters such as weight gain or weight for length. The term FTT has been falling out of favor, and the term weight/growth faltering is becoming more common to describe this clinical entity. The underlying problem in FTT is inadequate usable calories. The primary mechanisms leading to FTT are impaired absorption, increased metabolic demands, and inadequate caloric intake. Inadequate caloric intake is the most common of these mechanisms, although FTT is often a combination of the three. The diagnostic evaluation of FTT must take into account the multifactorial nature of this clinical sign. A comprehensive history is essential for diagnosis and should include specific questions about the child’s living situation and feeding habits. The physical examination must include accurate weight and length measurements. Clinicians should look for signs of abuse or neglect, dysmorphic features, abnormal skin or nail findings, digital clubbing, or other signs of chronic disease. Laboratory investigations are rarely revealing in FTT but should be considered if there is a high index of suspicion for underlying disease. Treatment in FTT favors a multidisciplinary approach. The primary goal of treatment is restoration of normal growth velocity. Children with FTT are at increased risk for growth and cognitive problems in later childhood, although the clinical significance of these findings is not well understood. The mainstay of treatment is increasing calories in the diet. Enteral feeding, orally or via a tube, is always preferred over parenteral feeding due to a better safety profile, ease of feeding, and lower cost. Parenteral nutrition is an acceptable way to meet caloric needs in infants and children when enteral nutrition is not possible. Children with FTT and malnutrition should be monitored closely for refeeding syndrome, which results from fluid and electrolyte shifts in malnourished children. In general, FTT can be treated on an outpatient basis with close follow-up. Indications for hospitalization include severe malnutrition/dehydration and concern for child endangerment. This review contains 7 figures, 8 tables and 26 references Key words: enteral feeding, failure to thrive, growth charts, nutrition, parenteral nutrition, poor weight gain, tube feeding, weight loss

A SINGULAR CLUBBED DIGIT INDICATING SARCOIDOSIS

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