CASE 722 Published on 16.08.2001

Yellow nail syndrome

Section

Chest imaging

Case Type

Clinical Cases

Authors

T. Boehm, P. Hilfiker , K. Stoop, E. Russi, D. Weishaupt

Patient

74 years, male

Categories
No Area of Interest ; Imaging Technique CT
Clinical History
Patient presenting with yellowish discoloured nails in the hands and feet and long-standing respiratory disorders with recurrent bronchitis and pneumonias
Imaging Findings
This is a previously healthy 74-years-old man who stopped smoking 15 years ago. He noticed a yellow discoloration of his finger nails and toe nails during the past 2 years. At the same time he started to suffer from chronic rhinorrhea and a chronic productive cough. He experienced two episodes of fever that promptly responded to antibiotics. Physical examination : Physical examination was remarkable for a yellow discoloration with trophic changes of the finger nails and the toe nails. Breath sounds were normal. No peripheral edema was noted. Pulmonary function tests were normal for dynamic and static lung volumes and for CO diffusion capacity. In sputum cultures did not grow acid fast bacilli, Nocardia or Gram-negative bacteria. Imaging findings : A recent chest X-ray examination performed by the referring physician was of only intermediate quality and showed no pathology. Chest CT (4x2.5 mm collimation, pitch 5, 120 ml contrast media, 2 ml/ sec flow, delay 45 sec, VolumeZoom, Siemens, Erlangen, Germany) including HR-CT (4x1mm, single slice, 20 mm slice distance) were performed to exclude bronchiectasis as a reason for the recurrent bronchitic episodes. CT showed bronchiectasis in the left lower lobe with adjacent patchy consolidations. Mild bronchiectasis and tree-in-bud phenomenon were seen in the lingula. A small consolidation or subsegmental atelectasis was present in the right medial middle lobe. No pleural effusion and no lymphedema were present to date. Yellow nail syndrome was diagnosed based on the dystrophic changes of the nails and the extensive manifestation of bronchiectasis with consecutive bronchial mucus impaction.
Discussion
Yellow nail syndrome is a rare disorder featuring the classical trias yellow nails, lymphedema, pleural effusion. It was first discribed in 1964 by Samman and White(5). However, first clinical reports without considering it a "syndrome" were published much earlier beginning in 1894 (for complete history see Ref. 4). Recently a further diagnostic criterium has been added : bronchiectasis (2,4). Nordkild et. al give an extensive overview over the history and the 97 case reports until 1986. The etiology of the syndrome is still unknown. The diagnosis is justified if 2 of the 4 criteria are fulfilled (4,1). Symptoms may appear not simultaneously but in different order and severity. Yellow nails are the most stable symptom observed in 89% of the patients (4). Most frequent age of presentation is middle or older age. In the present case bronchiectasis and yellow nails were present whereas no pleural effusion or lymphedema were detected. Tree in bud sign represent the imaging manifestation of peripheral bronchial mucus impaction. Moore proximal mucus impaction resulted in small atelectasis. Clinical course as well as physical examination and imaging findings together suggested Yellow nail syndrome as a reason for the patients complaints. Differential diagnosis would be bronchiectasis of other origin such as chronic endobronchial infection (M. avium etc.). Hence, bronchoscopy did not reveal such clinical condition.
Differential Diagnosis List
Yellow nail syndrome
Final Diagnosis
Yellow nail syndrome
Case information
URL: https://www.eurorad.org/case/722
DOI: 10.1594/EURORAD/CASE.722
ISSN: 1563-4086