Dyschromic Nails, Exertional Dyspnea, and Lower Extremity Edema | Dermatology | JN Learning | AMA Ed Hub [Skip to Content]
[Skip to Content Landing]

Dyschromic Nails, Exertional Dyspnea, and Lower Extremity Edema

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 70-year-old man with a history of hypertension and obstructive sleep apnea presented with a 2-year history of nasal congestion, persistent rhinorrhea, postnasal drip, and chronic cough. Over the same period, he also developed thickened, brittle, and discolored fingernails and toenails. More recently, he developed progressive exertional dyspnea and edema of both lower extremities. He had no joint pain or swelling and no chest pain. He was taking amlodipine (5 mg daily) and ipratropium bromide nasal spray twice daily.

Please finish quiz first before checking answer.

You answered correctly!

Read the answer below and download your certificate.

You answered incorrectly.

Read the discussion below and retake the quiz.

Yellow nail syndrome

C. Order a thoracic CT scan

The key to the correct diagnosis in this patient is the triad of yellow thickened nails, sinopulmonary manifestations, and lymphedema, which point to a diagnosis of yellow nail syndrome. Onychomycosis (option A) would not explain the other manifestations described in this case. Although dystrophic nails can be seen in psoriasis, looking for evidence of psoriatic arthritis (option B) in the absence of joint symptoms would not be justified. Additionally, the other manifestations described in this case would not be explained by psoriasis. In the of setting of yellow thickened nails, sinopulmonary manifestations, and lymphedema, exertional shortness of breath is likely related to serositis, bronchiectasis, or both, and therefore the next step to evaluate these pulmonary manifestations of yellow nail syndrome would be to obtain a thoracic CT scan (option C). Severe iron deficiency (option D) can be associated with koilonychia (spooning of nails, in which nails lose their convexity and become flat or even concave in shape) but not with yellow dystrophic nails. It would also be unlikely in the absence of anemia. Although ANA testing was positive and C3 complement level was low, in the absence of antibodies to extractable nuclear antigens and double-stranded DNA, these laboratory findings are nonspecific and not diagnostic for systemic lupus erythematosus.

Survey Complete!

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

Article Information

Corresponding Author: Soumya Chatterjee, MD, MS, Orthopaedic and Rheumatologic Institute, Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, 9500 Euclid Ave, Desk A50, Cleveland, OH 44195 (chattes@ccf.org).

Published Online: October 22, 2020. doi:10.1001/jama.2020.14648

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for providing permission to share his information.

References
1.
Vignes  S , Baran  R .  Yellow nail syndrome: a review.   Orphanet J Rare Dis. 2017;12(1):42. doi:10.1186/s13023-017-0594-4PubMedGoogle ScholarCrossref
2.
Preston  A , Altman  K , Walker  G .  Yellow nail syndrome.   Proc (Bayl Univ Med Cent). 2018;31(4):526-527. doi:10.1080/08998280.2018.1487662PubMedGoogle ScholarCrossref
3.
Valdés  L , Huggins  JT , Gude  F ,  et al.  Characteristics of patients with yellow nail syndrome and pleural effusion.   Respirology. 2014;19(7):985-992. doi:10.1111/resp.12357PubMedGoogle ScholarCrossref
4.
Norton  L .  Further observations on the yellow nail syndrome with therapeutic effects of oral alpha-tocopherol.   Cutis. 1985;36(6):457-462.PubMedGoogle Scholar
5.
Ali  MS , Ghori  UK , Musani  AI .  Orphan lung diseases.   Med Clin North Am. 2019;103(3):503-515. doi:10.1016/j.mcna.2018.12.009PubMedGoogle ScholarCrossref
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_LoginSubscribe_Purchase
Close
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_LoginSubscribe_Purchase
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
Close
With a personal account, you can:
  • Track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
jn-learning_Modal_SaveSearch_NoAccess_Purchase
Close

Lookup An Activity

or

Close

My Saved Searches

You currently have no searches saved.

Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close