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images in clinical medicine
T h e n e w e n g l a n d j o u r n a l o f medicin e
n engl j med 369;7 nejm.org august 15, 2013e8
Lindsey R. Baden, M.D., Editor
Quinckes Pulse
Andr M. Mansoor, M.D.Steven E. Mansoor, M.D., Ph.D.
Oregon Health and Science UniversityPortland,
[email protected]
A34-year-old man presented with a 6-to-8-week history of
fatigue,
malaise, fevers, and night sweats. He had a history of a
congenital quadri-
cuspid aortic valve and 16 years earlier had undergone a Ross
procedure
(during which the aortic valve was replaced by a pulmonary
autograft and the pul-
monary valve was replaced by a pulmonary homograft). On
examination, the tem-
perature was 39.2C and the blood pressure 130/50 mm Hg. A grade
3/4 diastolic
murmur was heard over the base of the heart. Alternating f
lushing and blanching
of the nail beds of several fingers in concert with the cardiac
cycle, known as
Quinckes pulse, was easily visualized (see video). Transthoracic
echocardiographyconfirmed severe insufficiency of the pulmonary
autograft and homograft in as-
sociation with vegetations. Blood cultures grew Streptococcus
milleri. The patient un-
derwent replacement of both grafts. Quinckes pulse is a physical
f inding of severe
and chronic aortic insufficiency. Regurgitant blood flow into a
dilated left ventricle
during diastole leads to a decrease in diastolic pressure and a
consequent increase
in stroke volume, resulting in blanching and f lushing,
respectively, of the nail bed.
DOI: 10.1056/NEJMicm1215624
Copyright 2013 Massachusetts Medical Society.
The New England Journal of Medicine
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