A case of orange-brown chromonychia in a patient with kawasaki disease.

Abstract

Dear Editor: Kawasaki disease (KD) is an acute inflammatory syndrome of middle-sized arteries such as the coronary artery, and its pathogenesis and etiology remain unclear1. The diagnosis of classic KD is based on the presence of fever lasting longer than 5 days and four of five specific clinical criteria, including bilateral nonpurulent conjunctival injection, oral mucosal changes, redness and swelling of the hands and feet, skin rash, and cervical lymphadenopathy1. Among the cutaneous features of KD, typical nail changes have previously been described, such as transverse leukonychia, onychomadesis, and pincer nails2,3. In addition, Pal and Giri4 reported that patients with KD may show transverse orange-brown chromonychia and suggested to incorporate it as add-on clinical finding of KD. A 5-year-old Korean girl presented with transverse orange-brown discoloration of the finger and toe nails with periungual desquamation. There was no evidence of any other disease or use of drugs that could lead to chromonychia. Ten days previously, she was found to have KD, and was then treated with aspirin at a local hospital. On her visit, she showed orange-brown discoloration at the distal portion of the nail (Fig. 1). Conjunctival hyperemia, cracking of the lips, and strawberry tongue were also observed (Fig. 2). On the basis of the clinical findings, we diagnosed her nail discoloration as orange-brown chromonychia that occurred with KD on the basis of the clinical findings. Two weeks later, the almost transverse orange-brown discoloration disappeared with other symptoms. Fig. 1 (A) Orange-brown discoloration at the distal portion of the nail. (B) Closer view. Fig. 2 (A) Conjunctival hyperemia. (B) Cracking of the lips. (C) Strawberry tongue. A variety of nail abnormalities have been reported in KD. Ciastko2 reported onychomadesis in a boy with KD, that started 6 weeks after a fever. Pincer nail deformity and Beau's lines in KD were also reported2,3. These nail abnormalities commonly develop in the chronic phase and spontaneously resolve. Otherwise, Lindsley5 was the first to describe red transverse nail-bed lines in four KD patients during the acute phase. He considered that chromonychia may be related to localized vasculitis or nail-bed hyperemia, because the lines occurred during active inflammation. Thereafter, Pal amd Giri4 studied about the typical transverse orange-brown discoloration of the nails observed in KD patients, and reported that it was present in almost 75% of the patients (29 of 40). Also, they recognized that this orange-brown chromonychia started appearing between the fifth and eight day of the onset of fever and slowly faded away with time. Therefore, they suggested to include orange-brown chromonychia as an additional clinical feature in the diagnosis of KD, differently to other nail changes. Chromonychia is described after the use of antineoplastic drugs, including adriamycin, cyclophosphamide, and vincristine. In addition, thermal injury, contact exposure to elemental iron, angiotensin-receptor blockage therapy, use of a nail hardener, systemic lupus erythematosus, and hyperbilirubinemia may cause these changes. In summary, we report a case of orange-brown chromonychia in a KD patient, and suggest that it should be considered as a reference of in the diagnosis of KD, based on the basis of its appearance in the acute phase.