E-page Original Images: Differential clubbing in an adult patient with patent ductus arteriosus and small ventricular septal defect

A 27-year-old male patient was admitted to our clinic with advancing fatigue and dyspnea since last six months. On physical examination he was asthenic in appearance. No significant murmurs were heard on cardiac auscultation and lungs were clear. There was prominent clubbing of toes compared with fingers (Fig.1, 2). Oxygen saturation was 96-98% on fingers and 84-85 % on toes. Electrocardiography showed sinus rhythm with P pulmonale and huge R wave in V1 (Fig. 3). On echocardiography, left chambers were normal in size and function. Right atrium, right ventricle and pulmonary artery were dilated. Estimated systolic pulmonary artery pressure (SPAP) was 110 mmHg while simultaneous systemic pressure was 110 mmHg. Suprasternal images were not diagnostic for patent ductus arteriosus (PDA).