Visual Diagnosis: Abnormal Nails in an Infant

Abstract

1. Natalie P. Cunningham* 2. Peter J. Green, FRCP† 1. *Dalhousie University, Halifax, NS, Canada. 2. †Department of Medicine (Dermatology), Capital District Health Authority and Dalhousie University, Halifax, NS, Canada. * Abbreviations: ACE: : angiotensin-converting enzyme NPS: : nail patella syndrome A dermatologist has been following a 3-year-old girl for unusually shaped fingernails noted at birth. Her history is as follows. At age 6 months, the patient’s primary care physician referred her to the dermatology service after the child’s adoptive mother expressed concern about her daughter’s small, misshapen fingernails. The infant was born after a pregnancy complicated by maternal smoking. She was induced at term due to failure to progress and eventually required vacuum extraction, weighing 2.405 kg at birth with Apgar scores of 9 and 9 at 1 and 5 minutes, respectively. There had been no concerns with her growth or development, and she was an active and happy child. She took no medications and had no known allergies. Her family history included a biological mother with attention-deficit/hyperactivity disorder and substance abuse and a healthy maternal half-brother. Little was known about the biological father, but the biological mother indicated that the father had abnormal nails. Physical examination at 6 months revealed an alert, well-appearing infant in no acute distress. Vital signs were within normal limits for her age, and she was growing between the 50th and 75th percentiles for height, weight, and head circumference. She was normal in appearance. There were no dysmorphic features on her head, face, or torso. Her fingers were slightly tapered with normal creases. The nails of her fingers on both hands were small and unusually shaped with longitudinal grooving, most pronounced on her thumbnails and less so on the nails of the fifth digits. Her toenails were unaffected. Given the nonspecific nail features, the dermatologist recommended seeing the infant 1 year later. At age …