A NONCLASSIC TRIAD OF YELLOW NAIL SYNDROME

Abstract

SESSION TITLE: Systemic Diseases with Deceptive Pulmonary ManifestationsSESSION TYPE: Rapid Fire Case ReportsPRESENTED ON: 10/18/2022 12:25 pm - 01:25 pmINTRODUCTION: Yellow nail syndrome (YNS) is a rare disorder characterized by the triad of yellow nails, lymphedema, and respiratory epithelium involvement (1). The classic respiratory manifestation involves pleural effusions, but the syndrome also encompasses bronchiectasis, chronic bronchitis, and sinusitis (2). We present a case of YNS with a non-classic triad of yellow nails, lymphedema, and chronic sinusitis.CASE PRESENTATION: A 79-year-old man presented to the pulmonary clinic for follow-up of his COPD and OSA. His past medical history was also significant for chronic sinusitis and OSA. He reported a medication regimen of budesonide/formoterol BID, tiotropium QAM, and albuterol PRN. While the patient's pulmonary symptoms were controlled, his wife reported worsening yellow nail discoloration and leg swelling over the past several years (Figures 1-3). Upon further investigation, the patient denied any history of liver disease or alcohol abuse. The patient's echocardiogram and BNP levels were unremarkable. His OSA was well-controlled with CPAP. He reported recurrent episodes of nasal congestion and drainage; a sinus CT scan revealed pansinusitis. There was no evidence of bronchiectasis or pleural effusions on a CT of the chest. YNS was suspected and the patient was referred to a dermatologist. He subsequently completed an empiric course of fluconazole without improvement. A diagnosis of YNS was confirmed and the patient was started on 400mg of vitamin E TID.DISCUSSION: While the classic triad of YNS includes yellow nails, lymphedema, and pleural effusions, our case illustrates the rarer involvement of sinus disease (1,2). The etiology of YNS remains unknown; however, theories include dysfunction of the lymphatics or protein leakage in the microvascular system (3). The first mention of YNS came from Samman and Strickland in 1962 where they connected nail disorders and impaired blood supply (4). YNS typically presents in middle-aged males, although few cases have reported in females ranging in age from 25-65 (4). Current treatment options for YNS are primarily supportive. Various case reports describe clinical improvement with vitamin E; however, further investigations are needed (2,3,5).CONCLUSIONS: YNS is a disease process defined by the triad of thickened yellow nails, lymphedema, and respiratory tract involvement. Physicians should be aware of atypical presentations, which may include bronchiectasis, bronchitis, and sinusitis (1,2).Reference #1: 1. Lotfollahi, L., Abedini, A., Alavi Darazam, I., Kiani, A., & Fadaii, A. (2015). Yellow Nail Syndrome: Report of a Case Successfully Treated with Octreotide. Tanaffos, 14(1), 67–71.2. Vignes, S., Baran, R. Yellow nail syndrome: a review. Orphanet J Rare Dis 12, 42 (2017). https://doi.org/10.1186/s13023-017-0594-43. Kurin, M., Wiesen, J. and Mehta, A.C. (2017), Yellow nail syndrome: a case report and review of treatment options. The Clinical Respiratory Journal, 11: 405-410. https://doi.org/10.1111/crj.123544. Samman, P.D. and White, W.F. (1964), THE "YELLOW NAIL” SYNDROME.. British Journal of Dermatology, 76: 153-157. https://doi.org/10.1111/j.1365-2133.1964.tb14499.x5. Cheslock M, Harrington DW. Yellow Nail Syndrome. [Updated 2021 Nov 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557760/DISCLOSURES: No relevant relationships by Madeeha BanuNo relevant relationships by Sarah GreenNo relevant relationships by Hassan HashmNo relevant relationships by Frank Maldonado SESSION TITLE: Systemic Diseases with Deceptive Pulmonary Manifestations SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: Yellow nail syndrome (YNS) is a rare disorder characterized by the triad of yellow nails, lymphedema, and respiratory epithelium involvement (1). The classic respiratory manifestation involves pleural effusions, but the syndrome also encompasses bronchiectasis, chronic bronchitis, and sinusitis (2). We present a case of YNS with a non-classic triad of yellow nails, lymphedema, and chronic sinusitis. CASE PRESENTATION: A 79-year-old man presented to the pulmonary clinic for follow-up of his COPD and OSA. His past medical history was also significant for chronic sinusitis and OSA. He reported a medication regimen of budesonide/formoterol BID, tiotropium QAM, and albuterol PRN. While the patient's pulmonary symptoms were controlled, his wife reported worsening yellow nail discoloration and leg swelling over the past several years (Figures 1-3). Upon further investigation, the patient denied any history of liver disease or alcohol abuse. The patient's echocardiogram and BNP levels were unremarkable. His OSA was well-controlled with CPAP. He reported recurrent episodes of nasal congestion and drainage; a sinus CT scan revealed pansinusitis. There was no evidence of bronchiectasis or pleural effusions on a CT of the chest. YNS was suspected and the patient was referred to a dermatologist. He subsequently completed an empiric course of fluconazole without improvement. A diagnosis of YNS was confirmed and the patient was started on 400mg of vitamin E TID. DISCUSSION: While the classic triad of YNS includes yellow nails, lymphedema, and pleural effusions, our case illustrates the rarer involvement of sinus disease (1,2). The etiology of YNS remains unknown; however, theories include dysfunction of the lymphatics or protein leakage in the microvascular system (3). The first mention of YNS came from Samman and Strickland in 1962 where they connected nail disorders and impaired blood supply (4). YNS typically presents in middle-aged males, although few cases have reported in females ranging in age from 25-65 (4). Current treatment options for YNS are primarily supportive. Various case reports describe clinical improvement with vitamin E; however, further investigations are needed (2,3,5). CONCLUSIONS: YNS is a disease process defined by the triad of thickened yellow nails, lymphedema, and respiratory tract involvement. Physicians should be aware of atypical presentations, which may include bronchiectasis, bronchitis, and sinusitis (1,2). Reference #1: 1. Lotfollahi, L., Abedini, A., Alavi Darazam, I., Kiani, A., & Fadaii, A. (2015). Yellow Nail Syndrome: Report of a Case Successfully Treated with Octreotide. Tanaffos, 14(1), 67–71. 2. Vignes, S., Baran, R. Yellow nail syndrome: a review. Orphanet J Rare Dis 12, 42 (2017). https://doi.org/10.1186/s13023-017-0594-4 3. Kurin, M., Wiesen, J. and Mehta, A.C. (2017), Yellow nail syndrome: a case report and review of treatment options. The Clinical Respiratory Journal, 11: 405-410. https://doi.org/10.1111/crj.12354 4. Samman, P.D. and White, W.F. (1964), THE "YELLOW NAIL” SYNDROME.. British Journal of Dermatology, 76: 153-157. https://doi.org/10.1111/j.1365-2133.1964.tb14499.x 5. Cheslock M, Harrington DW. Yellow Nail Syndrome. [Updated 2021 Nov 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557760/ DISCLOSURES: No relevant relationships by Madeeha Banu No relevant relationships by Sarah Green No relevant relationships by Hassan Hashm No relevant relationships by Frank Maldonado