Dyspnea with chylothorax: Importance of examining the nails

Published:December 23, 2022DOI:
      A previously healthy 53-year-old man presented to our department with 2 months of dyspnea. Lung examination revealed a left-sided pleural effusion confirmed on the chest radiograph (Fig. 1A ) and CT scan. Physical examination was remarkable for dystrophic fingernails and toenails appeared 3 years ago, with yellowish discoloration, thickening of the nail plates, enhanced transverse curvature of some nails and the absence of lunula and cuticle (Fig. 1B,1C). No lymphedema was present. The pleural fluid appeared milky white with triglycerides > 110 mg/dL and the presence of chylomicrons, consistent with a chylothorax. The pulmonary magnetic resonance imaging revealed a hypoplastic thoracic duct with collateral lymphatic channels. Histopathological analysis of the matrix and the nail bed demonstrated mild fibrosis with a perivascular inflammatory infiltrate, excluding nail lichen planus. Periodic acid-Schiff (PAS) staining showed no fungal pathogens. What is the diagnosis?
      Fig. 1
      Fig. 1A) Left pleural effusion, B) Thumbnails with yellowish discoloration, dystrophy, thickening, absence of lunula and cuticle, C) Fingernails of the right hand showing, dystrophy, thickening, absence of lunula and cuticle, and transverse over curvature of some nails.


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