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What's the difference?
European Journal of Internal Medicine 25 (2014) e89–e90
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Internal Medicine Flashcard
What's the difference? David Itskoviz ⁎, Maya Alaluf, Rafael Hirsch Department of Medicine D, Rabin Medical Center, Petah Tikva, Israel
a r t i c l e
i n f o
Article history: Received 11 May 2014 Received in revised form 20 May 2014 Accepted 13 June 2014 Available online 10 July 2014
1. Introduction A 40 year old female was admitted to our department due to hemoptysis. Her medical history was remarkable for patent ductus arteriosus, which was diagnosed several years earlier while she was investigated for progressive dyspnea. An echocardiography performed several months prior to her admission was suggestive of pulmonary hypertension. What is the diagnosis?
⁎ Corresponding author.
http://dx.doi.org/10.1016/j.ejim.2014.06.009 0953-6205/© 2014 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
e90
D. Itskoviz et al. / European Journal of Internal Medicine 25 (2014) e89–e90
2. Discussion Physical examination on her admission revealed clubbing of the fingers limited to her lower limbs — a physical sign named “differential clubbing”. This finding indicates the development of Eisenmenger syndrome in the presence of a significant patent ductus arteriosus [1]. Failure of the ductus arteriosus to close within the first days of life causes a left-to-right shunt. When the shunt is significant, pulmonary hypertension develops as time progresses resulting in Eisenmenger syndrome, as the shunt direction is reversed to right-to-left shunt. The anatomical location of the patent ductus arteriosus distal to the brachiocephalic arteries in the setting of right-to-left shunt causes deoxygenated blood to be delivered mainly to the lower limbs. As a result, clubbing is noted predominantly in the lower limbs. Our patient was treated with a conservative approach and the hemoptysis gradually resolved. Differential clubbing is a pathognomonic, uncommonly presented sign on physical examination and serves as an indication for patent ductus arteriosus with Eisenmenger syndrome [2,3].
3. Conflict of interests The authors state that they have no conflicts of interest.
References [1] Srinivans SK, Manjunath CN. Differential clubbing and cyanosis: classic signs of patent ductus arteriosus with Eisenmenger syndrome. Mayo Clin Proc Sep 2013;88(9):e 105–6. [2] Anoop TM, George KC. Images in clinical medicine. Differential clubbing and cyanosis. N Engl J Med Feb 17 2011;364(7):666. [3] Diller GP, Dimopoulos K, Broberq CS, Kaya MG, Nakhotra US, Uebing A, et al. Presentation, survival prospects, and predictors of death in Eisenmenger syndrome: a combined retrospective and case–control study. Eur Heart J Jul 2006;27(14):1737–42.
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Internal Medicine Flashcard
What's the difference? David Itskoviz ⁎, Maya Alaluf, Rafael Hirsch Department of Medicine D, Rabin Medical Center, Petah Tikva, Israel
a r t i c l e
i n f o
Article history: Received 11 May 2014 Received in revised form 20 May 2014 Accepted 13 June 2014 Available online 10 July 2014
1. Introduction A 40 year old female was admitted to our department due to hemoptysis. Her medical history was remarkable for patent ductus arteriosus, which was diagnosed several years earlier while she was investigated for progressive dyspnea. An echocardiography performed several months prior to her admission was suggestive of pulmonary hypertension. What is the diagnosis?
⁎ Corresponding author.
http://dx.doi.org/10.1016/j.ejim.2014.06.009 0953-6205/© 2014 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
e90
D. Itskoviz et al. / European Journal of Internal Medicine 25 (2014) e89–e90
2. Discussion Physical examination on her admission revealed clubbing of the fingers limited to her lower limbs — a physical sign named “differential clubbing”. This finding indicates the development of Eisenmenger syndrome in the presence of a significant patent ductus arteriosus [1]. Failure of the ductus arteriosus to close within the first days of life causes a left-to-right shunt. When the shunt is significant, pulmonary hypertension develops as time progresses resulting in Eisenmenger syndrome, as the shunt direction is reversed to right-to-left shunt. The anatomical location of the patent ductus arteriosus distal to the brachiocephalic arteries in the setting of right-to-left shunt causes deoxygenated blood to be delivered mainly to the lower limbs. As a result, clubbing is noted predominantly in the lower limbs. Our patient was treated with a conservative approach and the hemoptysis gradually resolved. Differential clubbing is a pathognomonic, uncommonly presented sign on physical examination and serves as an indication for patent ductus arteriosus with Eisenmenger syndrome [2,3].
3. Conflict of interests The authors state that they have no conflicts of interest.
References [1] Srinivans SK, Manjunath CN. Differential clubbing and cyanosis: classic signs of patent ductus arteriosus with Eisenmenger syndrome. Mayo Clin Proc Sep 2013;88(9):e 105–6. [2] Anoop TM, George KC. Images in clinical medicine. Differential clubbing and cyanosis. N Engl J Med Feb 17 2011;364(7):666. [3] Diller GP, Dimopoulos K, Broberq CS, Kaya MG, Nakhotra US, Uebing A, et al. Presentation, survival prospects, and predictors of death in Eisenmenger syndrome: a combined retrospective and case–control study. Eur Heart J Jul 2006;27(14):1737–42.