Terry's Nails
Patient of about 70 years, HIV positive, transplanted kidney donor cadaver in the previous 6 months, complicated with urinary infections so he received multiple antibiotic therapy schemes. During prolonged hospitalization due to diarrhea due to Clostridium difficile . On physical examination, Terry's nails are seen (see image), in addition to signs of malnutrition. Laboratory with hypoalbuminemia.
In patients with Terry's nails, the proximal two-thirds of the nail plate appear white, while the distal third is red. In his original publication in Lancet in 1954 , Richard Terry described "white nails" in 82 patients (out of a total of 100 studied) with liver cirrhosis. In his article, Terry suggested that this finding would probably be explained by an abnormal steroid metabolism since other manifestations also present in patients with cirrhosis (gynecomastia, palmar erythema, spider angiomas and skin stretch marks) were explained by this mechanism.
It is currently believed that this finding is secondary to hypoalbuminemia. However, Terry's nails are not specific to cirrhosis since they can be seen in other entities associated with hypoalbuminemia (such as nephrotic syndrome). They can also be seen in patients with renal failure, diabetes and heart failure.
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Nail Pathologies - Findings in or Near Nails
Paronychia
A superficial infection of the proximal and lateral nail folds adjacent to the nail
plate. The nail folds are often red, swollen, and tender. Represents the most
common infection of the hand, usually from Staphylococcus aureus or Streptococcus
species, and may spread until it completely surrounds the nail plate. Creates a felon
if it extends into the pulp space of the finger. Arises from local trauma due to nail
biting, manicuring, or frequent hand immersion in water. Chronic infections may
be related to Candida.
Clubbing of the Fingers
Clinically a bulbous swelling of the soft tissue at the nail base, with loss of the
normal angle between the nail and the proximal nail fold. The angle increases to
180 degrees or more, and the nail bed feels spongy or floating. The mechanism is still
unknown but involves vasodilatation with increased blood flow to the distal
portion of the digits and changes in connective tissue, possibly from hypoxia,
changes in innervation, genetics, or a platelet-derived growth factor from
fragments of platelet clumps. Seen in congenital heart disease, interstitial lung
disease and lung cancer, inflammatory bowel diseases, and malignancies.
Onycholysis
A painless separation of the whitened opaque nail plate from the pinker translucent
nail bed. Starts distally and progresses proximally, enlarging the free edge Of the
nail. Local causes include trauma from excess manicuring, psoriasis, fungal
infection, and allergic reactions to nail cosmetics. Systemic causes include diabetes,
anemia, photosensitive drug reactions, hyperthyroidism, peripheral ischemia,
bronchiectasis, and syphilis.
Terry's Nails
Nail plate turns white with a ground-glass appearance, a distal band of reddish
brown, and obliteration of the lunula. Commonly affects all fingers, although may
appear in only one finger. Seen in liver disease, usually cirrhosis, heart failure, and
diabetes. May arise from decreased vascularity and increased connective tissue in
nail bed.
White Spots (Leukonychia)
Trauma to the nails is commonly followed by nonuniform white spots that grow
slowly out with the nail. Spots in the pattern illustrated are typical of overly
vigorous and repeated manicuring. The curves in this example resemble the curve
of the cuticle and proximal nail fold.
Transverse White Bands (Mees' Lines)
Curving transverse white bands that cross the nail parallel to the lunula. Arising
from the disrupted matrix of the proximal nail, they vary in width and move
distally as the nail grows out. Seen in arsenic poisoning, heart failure, Hodgkin's
disease, chemotherapy, carbon monoxide poisoning, and leprosy.
Transverse Linear Depressions (Beau's Lines)
Transverse depressions of the nail plates, usually bilateral, resulting from temporary
disruption of proximal nail growth from systemic illness. As with Mees' lines,
timing of the illness may be estimated by measuring the distance from the line to
the nail bed (nails grow approximately 1 mm every 6 to 10 days). Seen in severe
illness, trauma, and cold exposure if Raynaud's disease is present.
Pitting
Punctate depressions of the nail plate caused by defective layering of the superficial
nail plate by the proximal nail matrix. Usually associated with psoriasis but also
seen in Reiter's syndrome, sarcoidosis, alopecia areata, and localized atopic or
chemical dermatitis.
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** GrepMed Recommended Text: Bates' Guide to Physical Examination and History Taking - https://amzn.to/2Z6LYmf
Transverse lines of the fingernails. (A) Beau’s lines (arrows) of the thumbnail. (B) Mees’ lines (arrowheads) of the thumbnail
Transverse lines of the nails can be caused by a growth arrest in the nail matrix or changes in the color of the nail itself, and may suggest underlying systemic conditions or the effects of a toxin or drug.1, 2 Beau’s lines are a typical sign of acute toxicity to nail matrix keratinocytes, resulting in a transient arrest in nail plate production. The nail develops a transverse linear depression that moves distally as the nail grows.3 In Mees’ lines, change occurs in the color of the nail without the cessation of nail matrix growth. Mees’ lines are easily differentiated from Muehrcke’s lines, which are apparent leukonychia and paired white lines caused by vascular congestion in the nail bed, because Muehrcke’s lines fade with digital compression.2, 4 An adverse reaction resulting from chemotherapeutic agents should be considered when transverse lines are seen on the nails, including Beau’s lines and Mees’ lines.
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