Download An Unusual Cause of Pleural Effusion: Yellow Nails Syndrome – A

Southern Medical Association
An Unusual Cause of Pleural Effusion: Yellow
Nails Syndrome – A Case Report
P-1
The following abstract will be presented at the Southern Medical Association Annual Scientific Assembly, November 3-5, 2016, in Chattanooga, TN.
Author and
Co-Authors
Emad Alkhankan, MD, Internal Medicine1; Hani Alkhankan, MD, Nephrology2; Fadi Alkhankan,
MD, Pulmonary Medicine1; Mohammed Al-Ourani, MD, Pulmonary Medicine1; 1Marshall University,
Huntington, WV; 2University of Kentucky, Lexington, KY.
Upon completion of the presentation, learners should be better prepared to:
Objectives
1) Discuss Yellow nails syndrome as a rare cause of pleural effusion. Diagnosis is based on the
clinical findings and treatment is effective and targeted the respiratory manifestations of the
disease like chemical pleuradesis and decortication in the case of pleural effusion.
Abstract
Introduction: Yellow nails syndrome is a rare disease develops in adulthood and can cause
several pulmonary complications includingpleural effusions. Slow growing yellow nails discoloration is
essential to the diagnosis. Pleural effusions usually require multiple procedures and interventions.
Case Report: A 53 years old female started to have shortness of breath in addition to fatigue
and a productive cough of a clear sputum. She started to have yellow discoloration and thickening her
nails a 3 years ago. Initial Chest X Ray showed large pleuraleffusions more on the right side. CT scan of
the chest revealed bilateral pleural effusions without mediastinal lymphadenopathy or other abnormal
findings. Initial thoracentesis showed exudative fluid with WBC of 446, RBC 601, neutrophils 7,
lymphocytes 73%, macrophages 20, amylase 18, glucose 119, LDH 64, and protein 3.4. Fluid cytology
was negative for malignancy. The patient underwent Pleuroscopy with Pleural Biopsy which was
negative for malignancy and showed chronic inflammation. Patient had placement of Pleurx Catheter as
the fluid accumulate quickly.
Patient continued to have pleural effusion without improvements she had another pleuroscopy
with biopsy which showed fibro-adipose tissue with chronic inflammation and rare admixed acute
inflammatory cells at that time chemical pleuradesis with doxycycline was attempted.
Overall conditions did not improve and she came back with effusion which became loculated.
After the chemical pleuradesis she had another chest tube bilaterally and at this time she underwent
bilateral decortication which resulted in improvement in her shortness of breath and pleural effusions.
Discussion: This patient presented with chronic effusion and yellow nails which is the hallmark
of this condition Yellow nails syndrome. It is rare and consists of a triad of yellow nails dystrophy,
chronic lymphedema and pleural effusions which is usually bilateral and lymphocytic predominant
exudative effusion based on Light’s criteria. Despite it has been considered inherited disease; most of
cases are sporadic and have no family history of the disease as in our case. The mechanism of the disease
is not well established, but there is a suggestion in the literature of the development of lymphatic system
abnormalities which was documented via lymphoscintigraphy. The abnormality in the lymphatic system
is functional rather than anatomical. Pleural effusion occurs due to decrease the drainage of
the pleural spaces and usually pleural biopsies will show chronic inflammation as is our case. The
diagnosis is established based on clinical symptoms. Lymphedema is present in 80% of the cases and it
was absent in our case. Pulmonary complication is common. Cough and shortness of breath is the most
common symptoms and effusion is presented in 40% of cases. Chylothorax, recurrent pneumonias,
bronchiectasis and chronic sinusitis are other respiratory complications that have been reported.
Treatment usually targeted to the complications of the disease. pleural effusion can be treated effectively
with chemical pleuradesis. Decortication sometimes is needed as in our case.
Conclusion: Yellow nails syndrome is a rare cause of pleural effusion. Diagnosis is based on
the clinical findings and treatment is effective and targeted the respiratory manifestations of the disease.
Disclosure
Emad Alkhankan, MD – No Relevant Financial Relationships to Disclose
Fadi Alkhankan, MD – No Relevant Financial Relationships to Disclose
Hani Alkhankan, MD – No Relevant Financial Relationships to Disclose
Mohammed Al-Ourani, MD – No Relevant Financial Relationships to Disclose