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Abheek Sil1, Atanu Chandra2, Biswajit Banik3, Surajit Kumar Biswas4, Uddalak Chakraborty5

Author Affiliations: 

1Junior Resident, Department of Dermatology, Venereology and Leprosy, RG Kar Medical College, Kolkata, India; 2Assistant Professor, Department of Internal Medicine, RG Kar Medical College and Hospital, Kolkata, India; 3Senior Resident, Department of Gastroenterology, IPGMER and SSKM Hospital, Kolkata, India; 4Professor and HOD, Department of Dermatology, Venereology and Leprosy, RG Kar Medical College, Kolkata; 5Senior Resident, Department of Neurology, Bangur Institute of Neurosciences, IPGMER and SSKM Hospital, Kolkata, India

Correspondence to: 

Atanu Chandra, Doctor’s Quarters (RG Kar Medical College Campus), 1 Khudiram Bose Sarani, Kolkata-700004, West Bengal, India


Journal Issue: 
Volume 51: Issue 2: 2021
Cite paper as: 
J R Coll Physicians Edinb 2021; 51: 166–7




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A 55-year-old male, without any comorbidity, presented to our facility with yellowish discolouration of toenails for the last 2 years. He had been diagnosed with onychomycosis by his treating dermatologist and had received multiple courses of systemic antifungal treatment without any clinical improvement. Interestingly, his past medical history was notable for some pertinent findings. A decade ago, he had undergone functional endoscopic sinus surgery for the treatment of chronic rhinosinusitis. He was hospitalised one year ago with right-sided moderate pleural effusion (exudative with lymphocyte predominance) and was conservatively managed without any sequelae. He had no symptom suggestive of any pulmonary involvement at present, or lower limb swelling, nor was he on any regular allopathic medication. Cutaneous examination revealed longitudinal ridging, nail plate thickening, transverse overcurvature and diffuse yellow discolouration involving all toenails. The cuticle and lunula could not be visualised (Figure 1). No fungal elements were detected on a potassium hydroxide mount of toenail sample. Fungal culture from the nail did not show any growth. Other mucocutaneous sites were unaffected. Systemic examination (especially pulmonary and lymphatic evaluation) and routine biochemical analysis were unremarkable. Thyroid function test and evaluations for malignancies and autoimmune diseases did not reveal any abnormality. Based on the history of pulmonary involvement, and characteristic cutaneous finding, a diagnosis of yellow nail syndrome (YNS) was established. He was treated with oral alpha-tocopherol (1,200 IU/day) and itraconazole (400 mg/day for a week every month) for three months with moderate success.

Figure 1 Yellow discolouration involving all toenails with longitudinal ridging, transverse overcurvature and nail plate thickening; the cuticle and lunula could not be visualised due to hyperkeratosis

The term YNS was described for the first time by Samman and White in 1964.1 It is a rare condition that is based on a triad associating yellow nails, pulmonary manifestations (chronic cough, bronchiectasis, pleural effusion) and lower limb lymphedema, but only two are required for diagnosis.2 Moreover, the three components are not necessarily present simultaneously, and may appear individually and sequentially, thereby making diagnosis of YNS a challenge. The complete triad is present only in 27–60% of the patients.3 Uncommon associations include cancer, autoimmune diseases and chronic sinusitis. Although aetiology remains unknown, lymphatic impairment is regularly evoked in pathogenesis; yellow nail occurs due to altered arterial circulation and Raynaud’s disease. YNS may also develop following titanium exposure from cardiac pacemakers or artificial joints.4 Oral vitamin E alone or in combination with triazole antifungals may achieve partial or total disappearance of nail discoloration.5

All three components of YNS may manifest at different times, often appearing individually. Moreover, in India, exudative pleural effusion and lymphoedema are primarily attributed to tuberculosis and filariasis, respectively. Nail discolouration of this syndrome mimics more common nail disorders like onychomycosis and chloronychia, leading to misdiagnosis. Clinicians should be acquainted with this uncommon entity.

Evaluation of lung pathology in a patient with yellow nail discoloration is of utmost importance to avoid delay in diagnosis and unnecessary treatments.


  1. Samman PD, White WF. The ‘Yellow Nail’ Syndrome. Br J Dermatol 1964; 76: 153–7. doi: 10.1111/j.1365-2133.1964.tb14499.x.
  2. Vignes S, Baran R. Yellow nail syndrome: a review. Orphanet J Rare Dis 2017; 12: 42. doi: 10.1186/s13023-017-0594-4.
  3. Hoque SR, Mansour S, Mortimer PS. Yellow nail syndrome: not a genetic disorder? Eleven new cases and a review of the literature. Br J Dermatol 2007; 156: 1230–4. doi: 10.1111/j.1365-2133.2007.07894.x.
  4. Valdés L, Huggins JT, Gude F et al. Characteristics of patients with yellow nail syndrome and pleural effusion. Respirology 2014; 19: 985–92. doi: 10.1111/resp.12357.
  5. Luyten C, André J, Walraevens C. et al. Yellow nail syndrome and onychomycosis. Experience with itraconazole pulse therapy combined with vitamin E. Dermatology 1996; 192: 406–8. doi: 10.1159/000246433.
Financial and Competing Interests: 
No conflict of interests declared.