SLR - January 2021 - Samuel R. Gorelik

Dyschromic Nails, Exertional Dyspnea, and Lower Extremity Edema

Reference: Chatterjee S, Dasenbrook EC. Dyschromic Nails, Exertional Dyspnea, and Lower Extremity Edema. JAMA. Published online October 22, 2020. doi:10.1001/jama.2020.14648

Level of Evidence: Level V

Scientific Literature Review

Reviewed By: Samuel R. Gorelik, DPM
Residency Program: Saint Vincent Hospital – Worcester, MA

Podiatric Relevance: Along with the surgical aspect of a Podiatrist’ career, many consults may come due to an irregular appearance of the lower extremities. Although appearing as simply onychomycotic on the surface, “yellow nail syndrome” can be seen with a triad of yellow thickened nails, chronic sinopleuropulmonary manifestations, and lymphedema of the lower extremities. This triad differentiates the abnormal nail appearance from the more common onychomycosis that Podiatrists see in their offices. This article was evaluating how “yellow nail syndrome” presents and how it can be treated. 

Methods: This article was a level V case study on a 70 year old male who presented with yellow nail syndrome. They were presenting how they treated someone who had symptoms of dyschromic nails, exertional dyspnea, and lower extremity edema. After medical history was taken and he was evaluated clinically, labs were drawn. A chest radiograph was performed, along with an ECG, an echocardiogram, and a CT of the sinuses. This was followed by a thoracic CT scan. Patient required a thoracentesis done, followed by pericardiocentesis and a pericardial window. Cultures were taken of the fluid. The patient was finally treated with Vitamin E and furosemide. He required further thoracenteses, along with knee-high graduated compression stockings and regular manual lymph drainage. He continued to follow-up for two years.

Results: Patient initially presented with sinus issues, discolored fingernails and toenails, exertional dyspnea and bilateral lower extremity edema. He had stable vitals. He showed diminished breath sounds at lung bases. Antinuclear antibody was positive but testing of antibodies to nuclear antigens and double-stranded DNA were negative. Chest radiograph, CBC, CMP, thyrotropin level, ECG, and Echocardiogram were all normal. A CT scan of his sinuses showed bilateral sinusitis. A thoracic CT scan showed bronchiectasis, bilateral pleural effusions and a large pericardial effusion. On thoracentesis over a liter of fluid was drained from right pleural space. Pleural and pericardial fluids were nonchylous, exudative and had many lymphocytes. Bacterial and fungal cultures were negative. No sign of malignancy was seen in the fluid. 

Conclusions: This article was presenting an important triad of symptoms to be noticed for yellow nail syndrome: yellow thickened nails, sinopulmonary manifestations, and lymphedema. Each of these by themselves can have a multitude of etiologies. By noticing this triad, the physicians were able to more efficiently diagnose and treat this patient. They treated the yellow thickened nails with vitamin E. The sinopulmonary issues required interventional radiology, along with pericardiocentesis and a pericardial window. Lymphedema was treated with compression and manual lymph drainage. It does not appear to me that the authors’ treatment was that effective. Discolored nails are often left untreated without harm to patient, and it can be treated with Vitamin E or antifungal treatment. Knowing this triad did not appear to help them treat the patient’s symptoms, as they still treated the symptoms individually. Podiatrist are often being consulted for nail discoloration, we should consider other issues the patient may have like swelling and pulmonary issues.

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