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A 57-year-old man presented with a 1-year history of yellowish discoloration and increased brittleness affecting his fingernails and toenails, with spontaneous avulsion of left toenail. On review of systems, he reported a history of progressive shortness of breath, fatigue, and chronic cough of 2 years duration, with unintentional weight loss. He denied use of tobacco or other drugs. Dermatological examination revealed diffuse yellow discoloration of all fingernails and toenails (Figure 1). Nail clipping sent for Grocott-Gömöri silver (GMS) staining showed negative results for fungal hyphae, excluding onychomycosis. The patient had no clinical lower-limb edema, a finding confirmed by normal lymphoscintigraphy studies.
A maxillofacial computed tomography (CT) scan showed severe bilateral frontal and ethmoid disease as well as mild maxillary sinus disease. Chest CT showed multifocal endobronchial plugging, tree-in-bud nodules, and bronchial-wall thickening, as well as bronchiectasis (Figure 2).
Based on yellow discoloration involving all nails, coupled with chronic sinusitis and bronchiectasis, the patient was diagnosed with yellow nail syndrome.
Yellow nail syndrome is a rare disorder characterized by at least 2 of the following characteristics: yellowed, dystrophic nails; lymphedema; and sinopulmonary complications including pleural effusion, bronchiectasis, and chronic sinusitis.
The precise etiology remains unclear, although the entity has been linked to lymphatic abnormalities or protein leakage. It has been postulated that the yellow color could be due to the deposition of lipofuscin pigment, a product derived from lipid oxidation of free radicals. Management entails treatment of associated conditions, along with nail-specific treatments including oral vitamin E, oral biotin, or systemic antifungal azoles. Compression stockings can improve any associated lower-limb lymphedema.