A 72-year-old man presented with progressive dysphagia for solids and liquids accompanied by asthenia and >10% weight loss for 2 months. He denied gastrointestinal blood loss or chronic medication. Physical examination was unremarkable, except for all fingernails which had a transverse brownish band occupying 50% of the nail bed distally and a dull white band proximally. On pressure over nail plates, the demarcation band did not disappear. These appeared a few weeks before the other symptoms. His blood work revealed normocytic anaemia (Hb 6,5g/dL, MGV 90.3fL, serum iron 52,4mcg/dL, total iron binding capacity 201mcg/dL, transferrin saturation 32%, ferritin 1625,3ng/mL), but all other blood tests were normal, namely his kidney function (blood urea nitrogen 82mg/dL, creatinine 0,87mg/dL). The diagnostic workup included an upper gastrointestinal endoscopy with biopsies and whole body computerized tomography to reveal a distal oesophageal adenocarcinoma (stage III), for which he started neoadjuvant chemotherapy.
Lindsay’s nails, or half-and-half nails, are a form of apparent leukonychia described as a nail bed change in which the proximal half of the nail appears white and the distal portion appears to be red–brown. The exact pathophysiology is not well understood. The proximal white band is thought to result from excessive development of connective tissue between the nail and bone reducing the quantity of blood in the subcapillary plexus, and the brown band from thickening of the capillary wall1. These features are more typically observed in patients with chronic kidney disease2, but have been described in cases of yellow-nail syndrome, Crohn´s disease, Kawasaki´s disease, Behcet´s disease, hyperthyroidism, zinc deficiency, pellagra, HIV, cirrhosis and psoriasis1.
To our knowledge this is the first case report of Lindsay nails associated with oesophageal adenocarcinoma, although it had been described in association with another type of tumour (hepatocellular carcinoma3). There is no specific therapy beyond treating the underlying condition.
Figura I
Finger nails depicting whitish and reddish-brown discolouration of the proximal and distal halves respectively.
BIBLIOGRAFIA
1) Pellegrino M, Taddeucci P, Mei S, Peccianti C, Fimiani M. Half-and-half nail in a patient with Crohn’s disease. J Eur Acad Dermatol Venereol. 2010; 24(11):1366-7.
2) Lin CJ, Wu CJ, Chen YC, Chen HH. Half and half nail secondary to chronic renal failure. South Med J 2009; 102(11):1189-90
3) Jamwal, V; Chandail, VS. Half and Half Nails: Not Always Uremia. JK Science: Journal of Medical Education & Research; 2010;12(3)161
