Article ID: CJ-18-0154
One month after coronary artery bypass grafting (CABG) with no complications, a 76-year-old man noticed yellow discoloration of the fingernails, although he remained otherwise asymptomatic. Two months later, he was readmitted to hospital for leg edema and marked bilateral accumulation of pleural effusion (Figure A).
Chest X-ray, finger- and toenails and pleural effusion (A–C) before and (D,E) after treatment with vitamin E supplements. (B) Note the yellow, thickened nail plates with notable bulge (arrows). (E) Arrowheads, recovery of normal nail growth.
Signs of pitting edema and yellow, thickened nails were evident on all four extremities (Figure B). Pleural effusion was yellow-tinged, with serous exudate (Figure C). Culture was negative. Cardiac catheterization showed no evidence of obstruction of the bypass graft, heart failure or constrictive pericarditis. Finally, we reached a clinical and exclusive diagnosis of yellow nail syndrome (YNS) on the basis of examination,1 including the lack of longitudinal growth of the yellow thickened nails, and the presence of a notable bulge (Figure B). Medical treatment with vitamin E was initiated on the basis of this clinical diagnosis. Three months later, pleural effusion had decreased (Figure D), although the diuretic dose had not been increased. The color of the nails started to normalize and the rate of outgrowth had recovered, particularly in the hands (Figure E). Recently the patient trimmed his nails for the first time in 1 year.
YNS is a rare entity characterized by yellow nails, chronic pleural effusion and an abnormal lymphatic network.1 The etiology of YNS is unclear, and, to the best of our knowledge, this represents the first report of YNS occurring after cardiac surgery.
The Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, received research grants from Bristol-Myers Squibb, MSD K.K., Biotronic, Takeda Pharmaceutical Co., Ltd., Astellas Pharma Inc., Daiichi Sankyo Pharmaceutical Co., Ltd., Shionogi & Co., Ltd., and Otsuka Pharmaceutical Co., Ltd. M.I. received lecture fees from Daiichi Sankyo Pharmaceutical Co., Ltd., Mochida Pharmaceutical Co., Ltd., Mitsubishi Tanabe Corporation, Bayer Yakuhin, Ltd. and Takeda Pharmaceutical Co., Ltd.
