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CASE REPORT
Year : 2009  |  Volume : 55  |  Issue : 4  |  Page : 270-271

Yellow nail syndrome following thoracic surgery: A new association?


Loma Linda University Medical Center, VA Loma Linda Healthcare System, Loma Linda, California, USA

Date of Submission07-Sep-2008
Date of Decision12-Jun-2009
Date of Acceptance10-Sep-2009
Date of Web Publication14-Jan-2010

Correspondence Address:
D P Banta
Loma Linda University Medical Center, VA Loma Linda Healthcare System, Loma Linda, California
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0022-3859.58931

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 :: Abstract 

An 80-year-old man presented with the characteristic triad of yellow nail syndrome (chronic respiratory disorders, primary lymphedema and yellow nails) in association with coronary artery bypass graft surgery. Treatment with mechanical pleurodesis and vitamin E resulted in near complete resolution of the yellow nails, pleural effusions, and lower extremity edema. The etiology of the yellow nail syndrome has been described as an anatomical or functional lymphatic abnormality. Several conditions have previously been described as associated with this disease. This is the first report of the association of this syndrome with thoracic surgery.


Keywords: Abnormal nails, lymphedema, pleural effusion


How to cite this article:
Banta D P, Dandamudi N, Parekh H J, Anholm J D. Yellow nail syndrome following thoracic surgery: A new association?. J Postgrad Med 2009;55:270-1

How to cite this URL:
Banta D P, Dandamudi N, Parekh H J, Anholm J D. Yellow nail syndrome following thoracic surgery: A new association?. J Postgrad Med [serial online] 2009 [cited 2020 Nov 29];55:270-1. Available from: https://www.jpgmonline.com/text.asp?2009/55/4/270/58931


We report a case of yellow nail syndrome (YNS) in an 80-year-old man who presented with chronic pleural effusions, lymphedema and yellow nails. He lacked any of the predisposing factors described so far with YNS. This case report illustrates a novel association between thoracic surgery and YNS.


 :: Case Report Top


An 80-year-old male smoker with history of diabetes and emphysema presented with dyspnea for several months. One year before presentation, he underwent uncomplicated coronary artery bypass graft surgery for three-vessel coronary artery disease. Subsequently, he was repeatedly admitted for pneumonias, recurrent pleural effusions and lower extremity edema for which he received multiple rounds of diuretics, antibiotics and thoracocenteses.

He had decreased breath sounds and dullness to percussion over the right lower chest. The nails of his fingers and toes were hard, yellow, thickened and "grew slowly" as per the patient. Onycholysis, increased longitudinal curvature, transverse ridging and loss of the lunula were also seen [Figure 1]a. He had pitting edema extending up to the knees [Figure 1]b. Chest radiograph revealed a right pleural effusion [Figure 1]c, which showed an exudative, non-chylous yellow fluid [LDH 146 U/L (normal 60-210), protein content 46 g/L, glucose content 6.327 mmol/L (114 mg/dL), triglyceride level 0.1469 mmol/L (13 mg/dL), red blood cell count of 2622/mL and white blood cell count of 1511/mL]. All cultures of the fluid were negative. Cytological examination showed no malignant cells.

Spirometry performed a month later revealed moderate obstructive lung disease with a post-bronchodilator FEV 1 of 1.51 L (46% predicted), FVC of 2.46 L (56% predicted) and FEV 1 /FVC of 61%. Trans-thoracic echocardiogram showed normal left ventricular systolic function with an estimated left ventricular ejection fraction of ,65%.

The patient underwent right video-assisted thoracoscopic surgery (VATS). Decortication and mechanical pleurodesis were performed. Cytology from a pleural biopsy showed no malignancy. Patient was then started on oral vitamin E and topical lotion containing vitamin E for his discolored nails. The patient experienced dramatic improvement with resolution of his pleural effusion and lower extremity edema. His nail beds appeared normal and there was near-resolution of his discolored, thickened nails in his fingers and toes.


 :: Discussion Top


Yellow nail syndrome is a rare condition, with over a hundred sporadic case reports published since the first description by Samman and White in 1964. Although YNS is described as a triad of yellow nails, lymphedema and respiratory tract involvement, only two of the three manifestations are required to make a clinical diagnosis. The complete triad is seen in approximately 30% of cases. [1] The diagnosis of onychomycosis was not considered in our patient because he lacked risk factors for or manifestations of onychomycosis. The simultaneous involvement of all his nails and relief of manifestations without antifungal treatment precluded this diagnosis.

The exact etiology of YNS is unknown but is generally thought to be due to an underlying anatomical or functional lymphatic abnormality. [2] Many patients with YNS have lymphangiographic abnormalities such as chylothorax and hypoplastic or dilated lymphatics. [3],[4] Although YNS has been proposed to be a genetic abnormality with variable expression, this has been widely disputed. [4],[5]

YNS is associated with several conditions including endocrine disorders such as diabetes and thyroid dysfunction, autoimmune diseases, immunodeficiency states, Guillain-Barré syndrome, obstructive sleep apnea, certain drugs, tuberculosis and malignancy (involving the breast, lung or gall bladder and lymphoma). [4],[5] Most of these associations are described in isolated case reports. This patient had a history of diabetes, but unlike previously described diabetics who suffered YNS, our patient's diabetes was well-controlled on oral hypoglycemic agents. Thus, our patient lacked any of the conditions known to be associated with YNS (including familial predisposition).

We think that YNS resulted from mechanical disruption of lymphatic vessels that occurred during thoracic surgery or a dysfunctional lymphatic system that occurred as a result of peri-operative or postoperative medications. Our hypothesis could have been proved by undertaking additional studies such as a histological investigation of the nail bed, capilloroscopy studies, and lymphangiography, which all would have provided a more detailed explanation for the patient's condition. However, the patient refused to undergo them.

A causal link between the thoracic surgery and YNS is unproven, but the close temporal association strongly supports this connection. This is the first report to make an association between thoracic surgery and YNS.

 
 :: References Top

1.Emerson PA. Yellow nails, lymphoedema, and pleural effusions. Thorax 1966;21:247-53.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]  
2.Bull RH, Fenton DA, Mortimer PS. Lymphatic function in the yellow nail syndrome. Br J Dermatol 1996;134:307-12.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]  
3.Samman PD, White WF. The "Yellow Nail" Syndrome. Br J Dermatol 1964;76:153-7.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]  
4.Maldonado F, Tazelaar HD, Wang CW, Ryu JH. Yellow nail syndrome: Analysis of 41 consecutive patients. Chest 2008;134:375-81.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]  
5.Hoque SR, Mansour S, Mortimer PS. Yellow nail syndrome: Not a genetic disorder? Eleven new cases and a review of the literature. Br J Dermatol 2007;156:1230-4.  Back to cited text no. 5      


    Figures

  [Figure 1]

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