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Yellow Nails

      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.
      Figure thumbnail gr1
      Figure 1Yellow discoloration of all fingernails, with increased curvature.
      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).
      Figure thumbnail gr2
      Figure 2Coronal sinus computed tomography scan demonstrates complete opacification of the left frontal sinus (red arrow), moderate mucosal thickening in the right frontal sinus (blue arrow), and mild to moderate mucosal thickening in the right maxillary sinus (yellow arrow).
      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.
      • Vignes S.
      • Baran R.
      Yellow nail syndrome: a review.
      ,
      • Hiller E.
      • Rosenow E.C.
      • Olsen A.M.
      Pulmonary manifestations of the yellow nail syndrome.
      Yellow nail syndrome can also be associated with malignancy or autoimmune conditions or can be idiopathic.
      • Maldonado F.
      • Tazelaar H.D.
      • Wang C.-W.
      • Ryu J.H.
      Yellow nail syndrome: analysis of 41 consecutive patients.
      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.
      • Kurin M.
      • Wiesen J.
      • Mehta A.C.
      Yellow nail syndrome: a case report and review of treatment options.
      One study demonstrated that improvement of nail manifestations correlates with better control of recurrent sinopulmonary disease.
      • Maldonado F.
      • Tazelaar H.D.
      • Wang C.-W.
      • Ryu J.H.
      Yellow nail syndrome: analysis of 41 consecutive patients.

      Acknowledgment

      We thank Dr. Vance T. Lehman, Division of Neuroradiology, Mayo Clinic, who supplied the CT image and accompanying figure legend.

      References

        • Vignes S.
        • Baran R.
        Yellow nail syndrome: a review.
        Orphanet J Rare Dis. 2017; 12: 42
        • Hiller E.
        • Rosenow E.C.
        • Olsen A.M.
        Pulmonary manifestations of the yellow nail syndrome.
        Chest. 1972; 61: 452-458
        • Maldonado F.
        • Tazelaar H.D.
        • Wang C.-W.
        • Ryu J.H.
        Yellow nail syndrome: analysis of 41 consecutive patients.
        Chest. 2008; 134: 375-381
        • Kurin M.
        • Wiesen J.
        • Mehta A.C.
        Yellow nail syndrome: a case report and review of treatment options.
        Clin Respir J. 2017; 11: 405-410