Yellow nail syndrome following multiple orthopedic surgeries: a case report.

BACKGROUND: Yellow nail syndrome is a rare condition associated with a triad of symptoms: yellow nails, lung lesions, and lymphedema. We report a case of yellow nail syndrome caused by titanium exposure from multiple artificial joint replacements. CASE PRESENTATION: A 78-year-old Asian woman presented to our outpatient department with chief complaints of cough, fever, and nausea. The patient was hospitalized for observation because of the presence of hypoxemia and bilateral pleural effusion. Her medical history included knee joint replacement and two spinal fusion surgeries. Her physical examination conducted following hospitalization revealed yellow nails on both hands and feet. This finding, combined with the observation of bilateral pleural effusion, raised suspicion for yellow nail syndrome. Blood analysis yielded negative results, as did the tests for sputum culture, interferon liberation, pleural effusion culture, and pleural effusion cytology. Pleural histopathological analysis and imaging yielded negative results. Considering the possibility of titanium exposure from artificial joints based on the patient's medical history, we examined a chest radiograph obtained before the second spinal fusion surgery; however, no pleural effusion was observed. Pleural effusion was observed, however, following the surgery. On the basis of these findings, the patient was diagnosed with yellow nail syndrome due to titanium exposure. CONCLUSIONS: Clinicians should examine the nails of patients with unexplained pleural effusion. Moreover, they should inquire about titanium exposure when obtaining the patient's medical history.

Hyperplasia of Lymphoid Follicles and Lymphangiectasia in the Parietal Pleura in Bucillamine-induced Yellow Nail Syndrome.

Yellow nail syndrome (YNS) pleurisy is often difficult to control, and pathological examinations have rarely been reported. We herein report a case of bucillamine-induced YNS in which histopathology of the parietal pleura revealed hyperplasia of the lymphoid follicles and lymphangiectasia. Even after the discontinuation of bucillamine, the pleurisy and lymphedema showed no change. Based on the histopathological findings showing similarity to rheumatoid pleurisy, we administered corticosteroid treatments, and both the pleurisy and lymphedema improved. The findings in the present case suggest that, in bucillamine-induced YNS, pleurisy may be related to inflammation caused by rheumatoid arthritis in addition to abnormalities in lymphatic vessels.

Titanium Dioxide in Toothpaste Causing Yellow Nail Syndrome.

Yellow nail syndrome (YNS) is an uncommon disorder, the classic triad of which consists of yellow nails, lymphedema, and respiratory symptoms. Few pediatric cases have been reported. We report a 9-year-old girl with yellowish nail discoloration for 1 year accompanied by respiratory symptoms, including chronic cough, recurrent pneumonia, bronchiectasis, and chronic sinusitis. The patient was diagnosed with YNS. Knowing that a relationship between YNS and titanium has been reported, we collected her nail clippings and detected titanium in them by energy dispersive radiograph fluorescence. This patient's titanium exposure may have come from her habit of swallowing children's toothpaste. With meticulous avoidance of swallowing toothpaste, she had amelioration of her yellow nail discoloration as well as diminution of her respiratory symptoms. We reevaluated her nail clippings for titanium 3 years later, and no titanium was detected. This observation suggests that avoiding titanium exposure could alleviate the symptoms of YNS. This is the first report of YNS in a pediatric patient that demonstrates a relationship between YNS and titanium. We review the previous reports of pediatric patients with YNS.

Bucillamine-induced yellow nail in Japanese patients with rheumatoid arthritis: two case reports and a review of 36 reported cases.

Yellow nail syndrome is an idiopathic condition characterized by a triad consisting of yellow nail, lymphedema, and pulmonary manifestations. Thiol compounds such as D-penicillamine have been reported to be the major cause of drug-induced yellow nail syndrome in patients with rheumatoid arthritis (RA). We recently experienced two Japanese cases with RA who developed yellow nail under treatment with bucillamine, a thiol-containing anti-rheumatic drug developed and approved in Japan. We reviewed the literature for similar cases and identified 36 RA cases with bucillamine-induced yellow nail, mostly in Japanese medical journals. Most of these cases (90.3%) showed improvement of yellow nail after discontinuation of bucillamine, whereas lymphedema and pulmonary manifestations improved only in 30.8 and 35.0% of the patients, respectively.

Yellow nails as an adverse reaction to the topical use of 5-fluorouracil for the treatment of nail psoriasis.

Three patients affected with nail psoriasis of the fingers in whom the use of topical 5-fluorouracil (5-FU) led to yellow nail discoloration are reported. Based on the fact that yellow nails are associated with a slow nail growth rate, nail growth in these patients ('bad responders') and in two individuals, both affected with psoriasis, who had previously responded favorably ('good responders') to topical 5-FU for their nail condition were compared. The results of nail growth measurement revealed that mean longitudinal growth in 'bad responders' was lower than that in 'good responders'. In conclusion, although topical application of 5-FU is an effective treatment for nail psoriasis, we suggest its use in those patients in whom nail growth is not significantly impaired. For that reason an observational period to evaluate nail growth prior to treatment with topical 5-FU would be an adequate means of patient recruitment.