Thursday, 3 July 2008

Quinke Sign in the Skin !!!!

Dear Bloggers

Sorry for keeping you waiting for new updates this week.

Here is a patient from with ankylosing spondylitis who was noticed to have pulsating carotid arteries in the neck.

Examination revealed a high upstroke volume of the radial pulse followed by a collapsing quality. The carotid pulsation was the classical Corrigan Sign.

Cardiac examination revealed a low grade systolic murmur at the aortic area with radiation to the carotid arteries in the neck. There was no audible diastolic murmur.

Femoral bruits were heard and the popliteal arteries were also palpable (in normal individuals it is unusual to feel the popliteal arteries unless hyperdynamic circulation or popliteal aneurysms are present).

As can be seen from the video below, Quinke Sign is strongly positive. Usually, one sees Quinke sign in the nail bed as a change in the redness that surrounds the white part of the nail near to the nail fold. It is a bit like watching the 'tide come in and out' in the nail. However, in this patient, the regurgitation was so strong, this change in blood flow pattern could be seen in the skin !!!

This patient had suspected Aortic Regurgitation. 

Ankylosing spondylitis is associated with aortic root dilatation and may precipitate aortic regurgitation. Other causes of aortic dilatation include:
  • Marfan's Syndrome
  • Reiter's Syndrome
  • Atherosclerosis
  • Syphilis (aortitis)
  • Hypertension
Causes of Aortic Regurgitation not associated with dilatation include:
  • Rheumatic heart disease
  • Infective Endocarditis
  • Trauma
  • Bicuspid valves
  • Disproportionate cusps
As a first year doctor in the UK, I first found Quinke sign in an elderly lady with accelerated hypertension who had a wide-pulse pressure. On the ward round the next morning I mentioned to the consultant that the patient had Quinke sign. The consultant boastfully said that he had never seen it-- until he indeed checked the patient and confirmed that it was indeed Quinke sign!!

Just because you may have not seen a sign does not mean that it does not exist anymore or is somehow obsolete. I have seen Quinke sign over a dozen times or more in my career by just spending the time to look for the sign when considering the diagnosis of Aortic Regurgitation.

Things to think about at the bedside to suspect the diagnosis include:

  1. Wide Pulse Pressure
  2. Collapsing pulse and Water Hammer pulse
  3. Quinke Sign
  4. Corrigan Sign 
  5. De Mussett's Sign (head nodding with the cardiac cycle)
  6. Femoral Bruits 'Pistol Shot'-type
  7. Popliteal pulses being palpable
  8. Aortic ejection systolic flow murmur
  9. Diastolic flow murmur
Have a good day!

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