We present the case of a 55-year-old man admitted for dyspnea, cough and edema of the legs and feet. The patient, a smoker with psoriasis at hands and feet noted the comparison, three years ago, of marked thickening and yellow discoloration of the nails. The chest X-ray showed a right-sided pleural effusion with parenchymal atelectasis. The cytologic examination of pleural fluid revealed mesothelial cells with inflammatory changes. The bacterial culture of the pleural fluid was negative and pleural biopsies revealed fibrosis. To reduce dyspnoea and formation of pleural fluid, was performed a pleurodesis by talcage. The patient was discharged with itraconazole, high dose vitamin E and zinc supplements as home therapy. The correct diagnosis was not easily achieved because the patient had symptoms and signs referable to other diseases as heart failure or venous insufficiency or psoriasis.
Samman and White [
A 55-year-old man was admitted to our ward for shortness of breath, productive cough and edema of the legs and feet. The patient was a smoker and had an history of recurrent pleurites with effusion, chronic venous insufficiency, psoriasis at palms of hands and at soles of feet. He noted the comparison, three years ago of marked thickening and yellow discoloration of the nails in hands and feet (Figures 1 and 2). During the last year he had a surgical treatment for nasal polyps. The electrocardiogram showed a left anterior hemiblock and an heart rate of 63 beats per minute (
ejection fraction and no valvular steno-insufficiency. The chest X-ray showed a right-sided pleural effusion with parenchymal atelectasis. The second day a diagnostic thoracentesis was performed, removing 2.100 ml of clear yellow fluid and a thoraco-abdominal computed tomography scan confirmed what X-ray showed, without further findings (
The diagnosis of Yellow Nail Syndrome is essentially clinical in nature and one of exclusion; is usually established by the classical triad: yellow discoloured nails, lymphedema and pleural effusion, but the presence of two of them has been judjed to be sufficient for diagnosis [
The pathogenic mechanism underlying this syndrome has not been defined, but hypoplasia of the lymphatic system as generalized phenomenon was suggested. A precipitating event is needed such as insect bites, erysipela or injury which increase the load on the already deficient lymphatics.
Individual manifestations of the syndrome can appear from birth to late adult life and no gender predominance has been noted. This syndrome has been associated with autoimmune disorders, such as thyroiditis, systemic lupus erythematosus, and rheumatoid arthritis or tuberculosis, AIDS, diabetes mellitus, myocardial infarction and with the use of certain drugs such as gold, penicillamine, griseofulvin [
There’s no well coded therapy for the yellow nail syndrome, but it improve in about one half of patients, often without therapy. Octreotide, a synthetic analogue of somatostatin, has an unclear mechanism of action; it acts by inhibiting lymph fluid excretion in the lymphatic vessels [
We think the diagnosis of Yellow Nail Syndrome is rarely achieved because symptoms are usually referred to other disease or syndromes.