A 74 y.o. woman presents with SOB. Her nails are discolored
what condition is she likely to have?
Hint: she is a non smoker
Our patient had half and half nails. This is seen in 20-50% of patients with chronic kidney disease but may also occur in Crohn’s disease, Behcet’s disease, Kawasaki disease and cirrhosis. The proximal white band is caused by chronic anemia secondary to increased wall thickness of capillaries with reduction in blood to the subpapillary plexus. The distal brown band is caused by melanin deposits. Hemodialysis does not cause improvement in the nail changes but they can disappear after a kidney transplant. Another important cause of half and half nails is chemotherapy.
benign melanonychia
In studies nail changes due to chemotherapy are observed in 37% of patients. Melanonychia is most common followed by half and half nails.
Melanonychia describes a longtitudinal streak of the nail plate due to increased activity of melanocytes in the nail matrix. It can be physiologic in individuals with darkly pigmented skin and is noted in other causes of melanocytic activation like pregnancy or trauma. This must be distinguished from nail melanoma and melanocytic nevus. Subungual melanomas account for 50% of melanomas in patients with dark skin.
IT IS IMPORTANT TO RECOGNIZE SUBUNGUAL MELANOMA AS DISTINCT FROM MELANONYCHIA. THIS IS MELANOMA
Mees lines-are horizontal lines across the nail associated with renal failure and arsenic/ heavy metal poisoning. They have also been reported after chemotherapy.
Mees lines
Beau lines- are deep grooves across the width of the nail which indicate the nails has stopped growing for a time. This can happen with chemotherapy.
Pitted nails- can occur with psoriasis. It is also associated with atopic dermatitis and alopecia areata.
Interruption of nail growth occurs with chemo.
Our patient also had another interesting diagnosis. She had Meig’s syndrome.She had a R pleural effusion associated with an ovarian tumor. It was originally reported with benign ovarian fibromas ( also granulosa cell tumors) and can cause ascites and hydrothorax. It is important to think of this when a woman presents with a pleural effusion because it has an excellent prognosis if the ovarian tumor is removed.
Meig’s syndrome
Trivedi M, Mehta R, Rekha S. Nail changes caused by chemotherapy amoung cancer patients: a cross-sectional study of northwest Rajasthan. Indian Dermatology Online JJ. 2020 Nov-Dec ;11(6):953-958.
Oanta, Iliescscu, Tarean S. Half and half nails in a healthy person. Case Reports Acta Dermatovenerol Croat. 2017 Dec 25(4):303-304.
Kortekaas K, Pelikan H. Hydrothorax, ascites and an abdominal mass: not always signs of a malignancy-three cases of Meigs’ syndrome. J Radiol Case Rep 2018 Jan;12(1):17-26.
Tully A, Trayes K, Studdiford J. Evaluation of nail abnormalities. Am Fam Physician2012;85(8):779-787.