Acknowledgments. We thank Lee Cook, Lillian Himes, and Scott Wendler for their help from the Eisenberg Medical Library and from Sinai Medical. Photography.
0021-972X/05/$15.00/0 Printed in U.S.A.
The Journal of Clinical Endocrinology & Metabolism 90(4):2428 Copyright © 2005 by The Endocrine Society doi: 10.1210/jc.2004-2439
IMAGE IN ENDOCRINOLOGY: Dirty Nails Hans K. Ghayee, John Q. A. Mattern III, and David S. Cooper Department of Medicine (H.K.G., J.Q.A.M., D.S.C.), Division of Endocrinology and Metabolism (D.S.C.), Johns Hopkins University/Sinai Hospital, Baltimore, Maryland 21215
A
42-YR-OLD MAN presented with symptoms and signs of hyperthyroidism, including a large symmetrical goiter with a bruit, tachycardia, brisk reflexes, and fingernail changes consistent with onycholysis (Plummer’s nails), shown in Fig. 1. After thyroidectomy, he has remained well with normal thyroid function tests. A photograph of his fingernails after 18 months of follow-up is shown in Fig. 2. The patient’s fingernails are examples of Plummer’s nails, first described by Henry Stanley Plummer in 1918 (1), in a patient with hyperthyroidism. His findings were first described in Oxford Medicine by Boothby and Plummer in 1937 (1, 2). Plummer’s nails represent a separation of the distal nail body from the nail bed. This separation, or onycholysis, is characteristically concave, and the hyponichium commonly traps dirt, giving the nail a dark appearance. The detachment is probably a result of thyrotoxic catabolism and/or the rapid growth of the nail body (3). For unknown reasons, onycholysis most commonly occurs on the fourth finger (3). With progressive disease, most other fingernails become affected (1). One study reported a 5.2% prevalence of onycholysis in hyperthyroidism (4). Onycholysis is not specific to thyrotoxicosis. The differential diagnosis of onycholysis includes psoriatic arthritis, lung cancer, sarcoidosis, bronchiectasis, trauma,
FIG. 2. Resolution of onycholysis in the same patient 18 months later.
chronic arthritis, and syphilis (1, 5). Medications that may induce onycholysis are tetracyclines, fluoroquinolones, chloramphenicol, and chemotherapeutic agents such as bleomycin, paclitaxel, and 5-fluorouracil (www.emedicine.com/ DERM/topic299.htm). Paradoxically, onycholysis can also occur in hypothyroidism (5). Acknowledgments We thank Lee Cook, Lillian Himes, and Scott Wendler for their help from the Eisenberg Medical Library and from Sinai Medical Photography. Received December 13, 2004. Accepted January 5, 2005. Address all correspondence to: David S. Cooper, M.D., Sinai Hospital, Division of Endocrinology and Metabolism, 2401 West Belvedere Avenue, Baltimore, Maryland 21215.
References 1. Luria MN, Asper Jr SP 1958 Onycholysis in hyperthyroidism. Ann Int Med 49:102–108 2. Boothby WM, Plummer WA 1937 Diseases of the thyroid. In: Christian’s Oxford Medicine, Chapter XV-A. New York: Oxford University Press 3. Leonhardt JM, Heymann WR 2002 Thyroid disease and the skin. Dermatol Clin 3:473– 481 4. Caravati Jr CM, Richardson DR, Wood BT, Cawley EP 1969 Cutaneous manifestations of hyperthyroidism. South Med J 62:1127–1130 5. Heymann WR 1992 Cutaneous manifestations of thyroid disease. J Am Acad Dermatol 26:885–906
FIG. 1. Onycholysis in a patient with hyperthyroidism.
JCEM is published monthly by The Endocrine Society (http://www.endo-society.org), the foremost professional society serving the endocrine community.
2428
