Abstract
BackgroundYellow nail syndrome is a rare condition associated with a triad of symptoms: yellow nails, lung lesions, and lymphedema. We report a case of yellow nail syndrome caused by titanium exposure from multiple artificial joint replacements.Case presentationA 78-year-old Asian woman presented to our outpatient department with chief complaints of cough, fever, and nausea. The patient was hospitalized for observation because of the presence of hypoxemia and bilateral pleural effusion. Her medical history included knee joint replacement and two spinal fusion surgeries. Her physical examination conducted following hospitalization revealed yellow nails on both hands and feet. This finding, combined with the observation of bilateral pleural effusion, raised suspicion for yellow nail syndrome. Blood analysis yielded negative results, as did the tests for sputum culture, interferon liberation, pleural effusion culture, and pleural effusion cytology. Pleural histopathological analysis and imaging yielded negative results. Considering the possibility of titanium exposure from artificial joints based on the patient’s medical history, we examined a chest radiograph obtained before the second spinal fusion surgery; however, no pleural effusion was observed. Pleural effusion was observed, however, following the surgery. On the basis of these findings, the patient was diagnosed with yellow nail syndrome due to titanium exposure.ConclusionsClinicians should examine the nails of patients with unexplained pleural effusion. Moreover, they should inquire about titanium exposure when obtaining the patient’s medical history.
Highlights
Yellow nail syndrome is a rare condition associated with a triad of symptoms: yellow nails, lung lesions, and lymphedema
Our patient had undergone joint replacement twice without the development of Yellow nail syndrome (YNS); attributing titanium exposure as the cause of YNS following the third surgery was difficult because no disease onset was observed following the initial two surgeries
Lymphedema is observed in 30–80% of patients with YNS [3]; it appears in both lower extremities, usually below the knee
Summary
Yellow nail syndrome (YNS) is a rare condition that was first identified by Samman et al in 1964. Published case reports of YNS due to titanium exposure could not confirm the number of surgeries undergone by patients. Our patient had undergone joint replacement twice without the development of YNS; attributing titanium exposure as the cause of YNS following the third surgery was difficult because no disease onset was observed following the initial two surgeries. The patient’s surgical history included knee joint replacement and two spinal fusion surgeries; the second spinal fusion had been performed 3 months before the current consultation. Bilateral pleural effusion was detected on a chest radiograph (Fig. 1). After a half-year of vitamin E administration, improvement in the thickness of the nails on the patient’s hands was observed (Fig. 5), but no effect was seen for the pleural effusion. Pleural drainage is performed if there is an increase in pleural fluid
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