Yellow nail syndrome associated with rheumatoid arthritis, thiol-compound therapy and early gastric cancer
- Correspondence to Dr Hirofumi Taki,
Yellow nail syndrome (YNS) was first described in 1964 by Samman and White, who noted the association of nail discolouration and leg oedema.1 Emerson added pleural effusion as the third element of YNS.2 Hiller et al reported that the respiratory manifestations are diverse and include pleural effusion, bronchiectasis, rhinosinusitis, chronic cough and recurrent lung infections.3 He also reported that the presence of two of three elements, namely yellow nails, lymphoedema and one the aforementioned respiratory manifestations, has been judged sufficient for diagnosis.3 Males and females are equally affected and typically present between the fourth and sixth decades of life.4 In the present case, bronchiectasis preceded the appearance of yellow nails (figure 1) and lymphoedema of the legs (figure 2). The triad of yellow nails, lymphoedema and lung involvement is present in only a quarter of patients with YNS. Furthermore, all three criteria are present in 40% to 60% of patients with YNS.4 The most common conditions associated with YNS include malignancies, connective tissue diseases, endocrine disorders and drugs, including thiol compounds.4 The present patient had three conditions, namely rheumatoid arthritis,5 thiol-compound therapy and early gastric cancer. The thiol compound was withdrawn, and endoscopic segment dissection of the gastric cancer was performed, resulting in resolution of the yellow nails (figure 3).
▶ Diagnosis of YNS requires two of the following three criteria: yellowish nails, lymphoedema and a respiratory manifestation.
▶ Yellow nails, lymphoedema and lung involvement are simultaneously present in only a quarter of patients.
▶ YNS is associated with connective tissue diseases, malignancies, and thiol-compound drugs.
▶ Reversal of nail colour may be observed after treatment of malignancies or withdrawal of associated drugs.