Hepatobiliary and Pancreatic: Terry's nails and liver disease

Abstract

In 1954, Dr R Terry, writing in The Lancet, described a nail abnormality characterized by a white nail bed with a distal band, 1–2 mm in length, that had a normal pink color. Associations were noted with a variety of disorders including chronic liver disease. Subsequent studies confirmed an association with cirrhosis but also showed associations with congestive cardiac failure, diabetes mellitus and advanced age. There was no apparent relationship to anemia or hypoalbuminemia. Histological studies of the nail bed have shown vascular changes (telangiectasias) in the proximal and distal bands but reasons for the color variations remain unclear. One possibility is that the proximal and distal nail bed have separate blood supplies. The disorder needs to be distinguished from leukonychia (white nails) that appear to be related to minor injuries to the nail during growth. In contrast to Terry's nails, patchy leukonychia is lost as the nail grows distally. A middle-aged male was referred to our hospital in 1997 because of minor changes in liver enzymes. He was noted to have unusual fingernails (Figure 1) and toenails (Figure 2). Apparently, these changes had been present since the age of 6 years. The proximal nail bed was white, the lunula was absent and the distal nail had a normal pink color. The features were typical of Terry's nails. He was positive for HBsAg and anti-HBe with HBV DNA levels >106 copies/ml. His serum albumin was within the reference range and he was negative for other hepatitis viruses. A liver biopsy showed mild liver inflammation without fibrosis. He was initially treated with lamivudine and subsequently with the combination of lamivudine and adefovir. Currently, he has normal liver function tests with undetectable levels of HBV DNA. A Fibroscan value was within the reference range. Terry's nails would appear to be an uncommon feature of hepatitis B and is rare in patients without cirrhosis such as the patient described above. In patients with Terry's fingernails, 50% of patients show similar changes in all nails but some have normal and abnormal nails, apparently in a random fashion. The frequency of the association between Terry's fingernails and Terry's toenails remains unclear.