Differential Clubbing and Cyanosis

Abstract

A 30-year-old woman with known congenital heart disease presented to our clinic with a 1-year history of fatigue, hemoptysis, and progressive exertional dyspnea. On examination, the toes had mild cyanosis and marked clubbing, but the fingers had subtle clubbing only. She was noted to have a left parasternal heave, a palpable second heart sound, and a systolic ejection murmur audible in the pulmonic area. Contrast echocardiography showed right atrial and right ventricular dilatation, an elevated mean pulmonary-artery pressure of 68 mm Hg, and bidirectional flow through a patent ductus arteriosus. In Eisenmenger's syndrome, a long-standing systemic-to-pulmonary circulatory shunt results in . . .