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Polishing Over Yellow Nails
cutaneous signs 01 cardlonulmonary disease Polishing Over Yellow Nails* Glenn D. Goldstein, M.D.; and Marvin I. Dunn, M.D., FC.C.P.
N 86-year-old caucasian man was admitted to the
hospital for evaluation of recurrent respiratory difficulty. He noted that over the past several months his fingernails and toenails became thicker, grew more slowly, and had changed to a yellowish-brown color *From the Divisions of Cardiology and Dermatology, Department of Medicine, University of Kansas College of Health Sciences and Hospital, Kansas City. Reprint requests: Dr. Dunn, University of Kansas Medical Center, 39th and Rainbow, Kansas City, KS 66103
FIGURE
786
(Fig 1). His upper and lower extremities were mildly edematous. Fungal cultures of his nails were negative. What findings might you expect to see on his chest roentgenogram? a) Pleural effusion b) Bronchiectasis c) Bronchopneumonia d) Malignancy e) All of the above
1
Cutaneous Signs of Cardiopulmonary Disease (Goldstein, Dunn)
Answer: e) All of the above The classic triad of the yellow nail syndrome (YNS) consists of yellow nails, lymphedema, and pulmonary complications. 1 The etiology of the syndrome is unknown, but has been attributed to impaired lymphatic drainage. 2 The affected nails are yellowish-brown in color, slow growing, and have an increased transverse curvature. The nail changes may precede other clinical respiratory difficulties. 3 The YNS has also been reported in patients with underlying malignancy. 4 Other diseases that have yellow nails include rheumatoid arthritis, hypothyroidism, nephrotic syndrome, immunodeficiencies, persistent hypoalbuminemia and Raynaud's disease. 5 Treatment with oral vitamin E has resulted in significant improvement in some patients. The pulmonary findings that have been associated with the YNS include pleural effusions, bronchiectasis, bronchopneumonia, frequent upper respiratory tract infections, and sinusitis. Respiratory infections that impair lymphatic drainage in the pleura may result in persistent effusions. The predominant symptom in one series of YNS was chronic cough. Severity of the dyspnea depended upon the size of the pleural effusion or the severity of the bronchiectasis. There was no diagnostic significance associated with various abnormalities of pulmonary function .6 This elderly man was admitted to the hospital for recurrent pleural effusions of unknown etiology. Review of symptoms was significant for cough, orthopnea, paroxysmal nocturnal dyspnea, decreased appetite, and a 30-pound weight loss over the preceding two months. On physical examination, his vital signs were stable with blood pressure of 130170 mm Hg and a pulse rate of 80. There was no jugular venous pressure elevation. Result of cardiovascular examination was normal. Auscultation of his chest demonstrated dullness to percussion, decreased fremitus and absent breath sounds in the right base. Hands and feet had slight non-pitting edema, but no cyanosis or clubbing. His finger and toenails were yellow, markedly thickened, and had ceased growing over the past six months. The chest roentgenogram (Fig 2) showed a large right-sided pleural effusion which was not due to heart failure. Findings on electrocardiogram were normal except for low voltage in the frontal leads. Recent laboratory data included a hemoglobin level ofll.l gldl
FIGURE
2
and a white blood count of 8,400/cu mm with a slight left shift in the differential. His arterial blood gas levels on 2 liters of oxygen by nasal cannula were pH= 7.46, Pco 2 = 43 mm Hg, and Pco 2 = 93 mm Hg. His thyroid studies were normal. In view of his dramatic weight loss, a search for an occult malignancy was undertaken. Results of computerized axial tomography of his chest and abdomen and a gallium scan were not diagnostic. Thoracocentesis revealed an exudate. No malignant cells were noted on cytologic examination, and cultures for atypical mycobacteria were negative. Pleural and open lung biopsies were negative for neoplasm . After thorough evaluation, no malignancy was detected. The patient was treated symptomatically and discharged to an extended care facility. REFERENCES 1 Venecie PY, Dicken CH. Yellow nail syndrome: Report of five cases. JAAD 1984; 10:187-92 2 Muller RP. Peters PE, Echternacht-Happle K, Happle R. Roentgenographic and clinical signs in yellow nail syndrome. Lymphology 1979; 12:257-61 3 Pavlidakey GP, Hashimoto K, Blum D. Yellow nail syndrome. JAAD 1984; 11:509-12 4 Guin JD, Elleman JH. Yellow nail syndrome, possible association with malignancy. Arch Dermatol 1979; 115:734-35 5 Mattingly PC, Bossingham DH . Yellow nail syndrome in rheumatoid arthritis: report of three cases. Ann Rheum Dis 1979; 38:475-78 6 Hiller E, Rosenow EC, Olsen AM . Pulmonary manifestations of the yellow nail syndrome. Chest 1972; 61 :452-58
CHEST I 90 I 5 I NOVEMBER. 1986
767
N 86-year-old caucasian man was admitted to the
hospital for evaluation of recurrent respiratory difficulty. He noted that over the past several months his fingernails and toenails became thicker, grew more slowly, and had changed to a yellowish-brown color *From the Divisions of Cardiology and Dermatology, Department of Medicine, University of Kansas College of Health Sciences and Hospital, Kansas City. Reprint requests: Dr. Dunn, University of Kansas Medical Center, 39th and Rainbow, Kansas City, KS 66103
FIGURE
786
(Fig 1). His upper and lower extremities were mildly edematous. Fungal cultures of his nails were negative. What findings might you expect to see on his chest roentgenogram? a) Pleural effusion b) Bronchiectasis c) Bronchopneumonia d) Malignancy e) All of the above
1
Cutaneous Signs of Cardiopulmonary Disease (Goldstein, Dunn)
Answer: e) All of the above The classic triad of the yellow nail syndrome (YNS) consists of yellow nails, lymphedema, and pulmonary complications. 1 The etiology of the syndrome is unknown, but has been attributed to impaired lymphatic drainage. 2 The affected nails are yellowish-brown in color, slow growing, and have an increased transverse curvature. The nail changes may precede other clinical respiratory difficulties. 3 The YNS has also been reported in patients with underlying malignancy. 4 Other diseases that have yellow nails include rheumatoid arthritis, hypothyroidism, nephrotic syndrome, immunodeficiencies, persistent hypoalbuminemia and Raynaud's disease. 5 Treatment with oral vitamin E has resulted in significant improvement in some patients. The pulmonary findings that have been associated with the YNS include pleural effusions, bronchiectasis, bronchopneumonia, frequent upper respiratory tract infections, and sinusitis. Respiratory infections that impair lymphatic drainage in the pleura may result in persistent effusions. The predominant symptom in one series of YNS was chronic cough. Severity of the dyspnea depended upon the size of the pleural effusion or the severity of the bronchiectasis. There was no diagnostic significance associated with various abnormalities of pulmonary function .6 This elderly man was admitted to the hospital for recurrent pleural effusions of unknown etiology. Review of symptoms was significant for cough, orthopnea, paroxysmal nocturnal dyspnea, decreased appetite, and a 30-pound weight loss over the preceding two months. On physical examination, his vital signs were stable with blood pressure of 130170 mm Hg and a pulse rate of 80. There was no jugular venous pressure elevation. Result of cardiovascular examination was normal. Auscultation of his chest demonstrated dullness to percussion, decreased fremitus and absent breath sounds in the right base. Hands and feet had slight non-pitting edema, but no cyanosis or clubbing. His finger and toenails were yellow, markedly thickened, and had ceased growing over the past six months. The chest roentgenogram (Fig 2) showed a large right-sided pleural effusion which was not due to heart failure. Findings on electrocardiogram were normal except for low voltage in the frontal leads. Recent laboratory data included a hemoglobin level ofll.l gldl
FIGURE
2
and a white blood count of 8,400/cu mm with a slight left shift in the differential. His arterial blood gas levels on 2 liters of oxygen by nasal cannula were pH= 7.46, Pco 2 = 43 mm Hg, and Pco 2 = 93 mm Hg. His thyroid studies were normal. In view of his dramatic weight loss, a search for an occult malignancy was undertaken. Results of computerized axial tomography of his chest and abdomen and a gallium scan were not diagnostic. Thoracocentesis revealed an exudate. No malignant cells were noted on cytologic examination, and cultures for atypical mycobacteria were negative. Pleural and open lung biopsies were negative for neoplasm . After thorough evaluation, no malignancy was detected. The patient was treated symptomatically and discharged to an extended care facility. REFERENCES 1 Venecie PY, Dicken CH. Yellow nail syndrome: Report of five cases. JAAD 1984; 10:187-92 2 Muller RP. Peters PE, Echternacht-Happle K, Happle R. Roentgenographic and clinical signs in yellow nail syndrome. Lymphology 1979; 12:257-61 3 Pavlidakey GP, Hashimoto K, Blum D. Yellow nail syndrome. JAAD 1984; 11:509-12 4 Guin JD, Elleman JH. Yellow nail syndrome, possible association with malignancy. Arch Dermatol 1979; 115:734-35 5 Mattingly PC, Bossingham DH . Yellow nail syndrome in rheumatoid arthritis: report of three cases. Ann Rheum Dis 1979; 38:475-78 6 Hiller E, Rosenow EC, Olsen AM . Pulmonary manifestations of the yellow nail syndrome. Chest 1972; 61 :452-58
CHEST I 90 I 5 I NOVEMBER. 1986
767