Quincke Sign

Aqsa Sorathia; Michael Soos

Quincke Sign

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Definition/Introduction

The Quincke sign, also known as the Quincke pulse, represents the visualization of capillary pulsations upon light compression applied to the tip of the fingernail bed. It is an eponym associated with chronic severe aortic regurgitation.[1][2][3] On physical examination, a patient exhibiting this sign will have an alternating reddening and blanching of the nailbed with each pulsation.[4] This sign can be further enhanced with the use of illumination.[5] In addition to this sign on the nailbed, a Quincke sign has also been reported to occur on a Janeway lesion in a patient with infective endocarditis.[6]

The Quincke sign is named after Dr. Heinrich Quincke, a German physician who first coined the term in 1868.[7] Dr. Quincke also contributed to many other notable medical discoveries, including the identification of angioedema, the technique of the lumbar puncture, and the description of what is now known as idiopathic intracranial hypertension.[7]

Issues of Concern

The Quincke sign, similar to the other signs of chronic severe aortic regurgitation (AR), results from a widened pulse pressure, an increased systolic stroke volume, and a rapid decrease in arterial pressure.[8][9] The reported prevalence of the Quincke sign is not as well studied as the prevalence of aortic regurgitation. In the Framingham study, the Quincke sign was noted in 4.9% of the population, with 0.5% of the population having moderate or severe AR.[8]

The sign is not unique to or pathognomonic for aortic regurgitation.[10] A “Pseudo-Quincke pulse” has been described in a case report describing a patient with keratoderma whose manifestations were from sclerodactylous compression of the nailbed.[11] It is important to consider that certain physical exam findings can suggest a condition; supporting objective confirmation is required before proceeding with further management.[12][13][14]

Clinical Significance

The Quincke sign is one of the over 30 reported eponymous signs of severe aortic regurgitation, with flashing carotids being quoted as the 32nd.[8][15][16] Of all reported signs, the quintessential finding for aortic regurgitation is an early diastolic, decrescendo murmur best auscultated at the sternal border.[17]

Some of the other classically taught physical examination findings in patients with severe aortic regurgitation include head bobbing (de Musset sign), a bounding carotid pulse (Corrigan pulse), pistol shot sounds over the femoral artery with compression (the Duroziez murmur or Traube sign), the presence of visible pulsation of retinal arteries (Becker sign), and pulsation of the uvula (Müller sign).[18][19][20]

Traditionally the Hill sign had been one of the other classic findings of aortic regurgitation. The Hill sign has been described as when the difference of greater than 20 mm Hg between arm and foot systolic blood pressure; this is now thought to be an artifact of sphygmomanometric lower limb pressure measurement and its removal from the list of the classic diagnostic signs for aortic regurgitation has been recommended by some authors.[21] An observant clinician can quickly identify concerning signs of cardiac valvular disease on physical examination, which is confirmable with the use of transthoracic echocardiography.[22]

Nursing, Allied Health, and Interprofessional Team Interventions

The Quincke sign is an infrequently encountered physical examination finding. When this sign appears in a patient, the healthcare provider must complete a thorough physical examination with detailed attention paid to the cardiovascular exam.

Proper documentation is necessary for interprofessional communication when describing physical exam findings in an electronic medical record. Any signs and symptoms of valvular heart disease should be further evaluated by a transthoracic echocardiogram. Coordinated patient-centered care is required between the primary physician, nursing staff, cardiologist, and cardiothoracic surgeon to provide the best possible patient care.

Nursing, Allied Health, and Interprofessional Team Monitoring

Of the healthcare providers, the nursing staff has the most prolonged interaction with the patients. As a result, they can be the first to encounter new symptoms or physical examination findings, which must be communicated to the physicians. Therefore, integrated patient-centered care between healthcare providers is essential for improving patient outcomes.

Details

References

[1]

Mehta NJ, Khan IA. Original descriptions of the classic signs of aortic valve insufficiency. The Journal of emergency medicine. 2003 Jan:24(1):69-72 [PubMed PMID: 12554044]

[2]

Hsieh MT, Wu WS. Pulsation of the nailbed. Lancet (London, England). 2012 Nov 17:380(9855):1767. doi: 10.1016/S0140-6736(12)61153-2. Epub 2012 Jul 27 [PubMed PMID: 22841298]

[3]

Dewaswala N, Chait R. Aortic Regurgitation. StatPearls. 2023 Jan:(): [PubMed PMID: 32310404]

[4]

Michelena HI, Enriquez-Sarano M. Corrigan's Pulse and Quincke's Pulse. The New England journal of medicine. 2018 Aug 2:379(5):e9. doi: 10.1056/NEJMicm1715353. Epub [PubMed PMID: 30067925]

[5]

Mizuno A, Niwa K. Pocket flashlight-elicited Quincke pulse for aortic dissection diagnosis. The Korean journal of internal medicine. 2013 Sep:28(5):631. doi: 10.3904/kjim.2013.28.5.631. Epub 2013 Aug 14 [PubMed PMID: 24009465]

[6]

Cho HJ, Yu JH. Quincke's Sign of Janeway Lesion in Infective Endocarditis. American journal of respiratory and critical care medicine. 2022 May 15:205(10):e51-e52. doi: 10.1164/rccm.202110-2362IM. Epub [PubMed PMID: 35085054]

[7]

. Heinrich Ireanaeus Quincke (1842-1922--clinician of Kiel. JAMA. 1966 Jun 27:196(13):1152-3 [PubMed PMID: 5327866]

[8]

Akinseye OA, Pathak A, Ibebuogu UN. Aortic Valve Regurgitation: A Comprehensive Review. Current problems in cardiology. 2018 Aug:43(8):315-334. doi: 10.1016/j.cpcardiol.2017.10.004. Epub 2017 Nov 2 [PubMed PMID: 29174586]

[9]

Flint N, Wunderlich NC, Shmueli H, Ben-Zekry S, Siegel RJ, Beigel R. Aortic Regurgitation. Current cardiology reports. 2019 Jun 3:21(7):65. doi: 10.1007/s11886-019-1144-6. Epub 2019 Jun 3 [PubMed PMID: 31161305]

[10]

Sapira JD. Quincke, de Musset, Duroziez, and Hill: some aortic regurgitations. Southern medical journal. 1981 Apr:74(4):459-67 [PubMed PMID: 7013091]

[11]

Norton SA. Keratoderma with pseudo-Quincke's pulse. Cutis. 1998 Sep:62(3):135-6 [PubMed PMID: 9770128]

[12]

Babu AN, Kymes SM, Carpenter Fryer SM. Eponyms and the diagnosis of aortic regurgitation: what says the evidence? Annals of internal medicine. 2003 May 6:138(9):736-42 [PubMed PMID: 12729428]

[13]

Galusko V, Thornton G, Jozsa C, Sekar B, Aktuerk D, Treibel TA, Petersen SE, Ionescu A, Ricci F, Khanji MY. Aortic regurgitation management: a systematic review of clinical practice guidelines and recommendations. European heart journal. Quality of care & clinical outcomes. 2022 Mar 2:8(2):113-126. doi: 10.1093/ehjqcco/qcac001. Epub [PubMed PMID: 35026012]

Level 2 (mid-level) evidence

[14]

Bugan B, Yildirim E, Celik M, Cagdas Yuksel U. Acute Aortic Regurgitation in the Current Era of Percutaneous Treatment: Pathophysiology and Hemodynamics. The Journal of heart valve disease. 2017 Jan:26(1):22-31 [PubMed PMID: 28544828]

[15]

Choudhry NK, Etchells EE. The rational clinical examination. Does this patient have aortic regurgitation? JAMA. 1999 Jun 16:281(23):2231-8 [PubMed PMID: 10376577]

[16]

Cheng TO. Flashing carotids: the 32nd eponymous sign of aortic regurgitation. International journal of cardiology. 2007 Mar 20:116(2):271 [PubMed PMID: 16839632]

[17]

Otto CM. Heartbeat: Improving diagnosis and management of aortic valve disease. Heart (British Cardiac Society). 2018 Nov:104(22):1807-1809. doi: 10.1136/heartjnl-2018-314232. Epub [PubMed PMID: 30366931]

[18]

Ashrafian H. Pulsatile pseudo-proptosis, aortic regurgitation and 31 eponyms. International journal of cardiology. 2006 Mar 8:107(3):421-3 [PubMed PMID: 16503268]

[19]

Shako D, Kawasaki T. Becker's sign and many other eponyms in aortic regurgitation. European heart journal. Case reports. 2021 Nov:5(11):ytab421. doi: 10.1093/ehjcr/ytab421. Epub 2021 Nov 4 [PubMed PMID: 34816085]

[20]

Kawamata H, Yamano M, Kawasaki T. Duroziez's Sign. Circulation reports. 2020 Jun 2:2(7):380-381. doi: 10.1253/circrep.CR-20-0029. Epub 2020 Jun 2 [PubMed PMID: 33693257]

[21]

Kutryk M, Fitchett D. Hill's sign in aortic regurgitation: enhanced pressure wave transmission or artefact? The Canadian journal of cardiology. 1997 Mar:13(3):237-40 [PubMed PMID: 9117911]

[22]

Capoulade R, Pibarot P. Assessment of Aortic Valve Disease: Role of Imaging Modalities. Current treatment options in cardiovascular medicine. 2015 Nov:17(11):49. doi: 10.1007/s11936-015-0409-7. Epub [PubMed PMID: 26391799]