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Nail pathology

Discussion in 'General Issues and Discussion Forum' started by bstarkey, Nov 8, 2011.

  1. bstarkey

    bstarkey Member

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    Hi Folks,

    I have a 34 yr old female patient with bilateral white nails. She came to see me this morning c/o ingrowing nails, which turned out to be minor distal o/c.

    the bigger problem is the colour of the nails and state. All toenails are affected, with both hallux nails the worst affected. There is a white discolouration to the nail plates with thickening and involution. The distal ends of all toes are red and appear inflammed.

    There is no apparent sepsis, the patient has had this problem for approximately 3.5 years (coincides with birth of 1st child), with no previous treatment. She has had 4 children, the first born in July 2008, and the last born 8 months ago. No history of cardiac or respiratory problems, patient was unsure regarding liver function. She is not any specific diet and believes she eats healthily. She has no known allergies and is taking Eglinol for breastmilk production and Pregnavit - multivitamin pre and post pregnancy.

    Any ideas ???? is it as simple as leukonychia?

    i've attached some pics. the big toenails look rough and pitted, this is due to the patient roughing it with sandpaper after nail varnish removal.


    Byron Starkey

    Attached Files:

  2. G Flanagan

    G Flanagan Active Member

    Might just be my simplistic brain, but they just look mycotic to me

  3. blinda

    blinda MVP

    Hi Byron,

    Nicely presented :drinks

    I agree with George, they do appear mycotic, (although the discolouration could be nail varnish stain). But, they are also ever-so-slightly clubbed with onycholysis.

    You say she`s unsure of any liver dysfunction? I would recommend blood tests for anything systemic e.g. anaemia, hypoalbuminaemia, liver problems, protein malabsorption, etc.

    Then again, most leukonychia is classified `idiopathic` .

  4. Elizabeth Humble-Thomas

    Elizabeth Humble-Thomas Active Member

    They do look a bit mycotic. Have you checked that her shoes/stockings are long enough . During pregnancy shoe size often/usually increases. That would explain the nail thickening due to back pressure on the nail matrix and the slight involution of the nails from footwear pressure, also the slight inflammation of the distal part of the toes, also the under-riding fifth.
  5. W J Liggins

    W J Liggins Well-Known Member

    I suspect that there are a number of conditions demonstrated here.

    I would guess that it is more likely to be leukonychia totalis than a mycotic infection. If this is the case then there will definitely be a family history. The problem is that there are many false negatives produced by histological analysis, so scrapings may not be helpful. All of the nails seem to be affected by onychophosis and involution which may account for the distal hyperaemia of the toes. The digital parabola also looks unusual.

    Not very helpful I know, but let us know the outcome following t/t.

    All the best

  6. bstarkey

    bstarkey Member

    thank you everyone for your comments and insight. I think I'll be sending the patient for blood tests, but not sure when that'll happen as the patient is having surgery tomorrow for another issue.

    Thanks again,

  7. blinda

    blinda MVP

    Without compromising anonymity...what surgery is she scheduled to have? Could have a bearing on podiatric presentation.

    BTW, what are her finger nails like?
  8. RobinP

    RobinP Well-Known Member

    Off thread but 4 kids since July 2008 - impressive
  9. blinda

    blinda MVP

    Miracle babies

    Can beat that. 4 kids yet i've never given birth.
  10. RobinP

    RobinP Well-Known Member

    Show off ;)
  11. bstarkey

    bstarkey Member

    Hi Bel,

    She is having a genital prolapse procedure and her fingernails looked completely normal. Footwear is also not an issue, She's a stay at home mom, and wears open sandals, as do most women in South Africa.

  12. blinda

    blinda MVP

    I agree, the nail plates do not look traumatised through footwear (open toe shoes = lekker ;))

    Actually, Robin made an unintentional pertinent point here. Bound to be some hormonal changes in someone who has been pregnant that often in such a short period of time. So, previous pregnancy/hormonal imbalance could be a factor for acquired leukonychia. Taken from the article below;

    The nails in the pregnant patient are also affected by pregnancy, with occasional findings of transverse grooving (Beau's lines), brittleness, leukonychia, softening, subungual keratoses, and distal onycholysis.



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