Page 25 - Delaware Medical Journal July 2015
P. 25
CASE REPORT
CASE DESCRIPTION
The patient is a 66-year-old man with a past medical history
disease secondary to tobacco smoking. He reports a two-year history of recurrent sinus infections, beginning upon his return to the United States from a trip to Costa Rica. His family physician
He was subsequently evaluated by an otolaryngologist with a CT moderate mucosal thickening and nasal polyposis. Multiple courses of outpatient antibiotics similarly proved unsuccessful in alleviating his recurrent symptoms. The patient later noticed the progressive color, thickening and curving with time. (Figures 1 and 2)
He was referred to a dermatologist who ruled out fungal infection via nail cultures. The patient was referred to an infectious disease specialist for further work-up. At this time, his exam sinus tenderness; increased AP diameter with prolonged expiration; yellow, opaque, curved nails involving all nails and swelling of periungal tissue; and bilateral pitting edema of the lower extremities. Blood work revealed elevated IgE levels to 898; c- and p-ANCA results were negative. Given the patient’s respiratory symptoms, a CT scan of the chest was ordered and demonstrated patchy ground-glass opacities of the right upper, right middle, and both lower lobes with centrilobular nodules. (Figure 3) A bronchoalveolar lavage was subsequently performed pneumonia and Aspergillus fumigatus.
The patient’s history of asthma, elevated IgE levels, ground-glass opacities noted on CT scan of the chest, and documented Aspergillus fumigatus on bronchoalveolar lavage all led to the diagnosis of allergic bronchopulmonary aspergillosis. He additionally met criteria for yellow nail syndrome, a clinical diagnosis. (Table 1) He was improvement of nail growth and respiratory symptoms. However,
as the pathophysiology of yellow nail syndrome would suggest,
the patient’s underlying vascular impairment and dysfunctional lymphatic system create an acquired, immunocompromised state that cannot be readily reversed. The patient was informed that he is predisposed to developing recurrent infections, which will be treated on a case-by-case basis in the future.
FIGURE 3
CT Scan of the Chest. Radiologist Read: “Emphysematous changes. Patchy ground-glass density in the Right Upper Lobe, Right Middle Lobe, both Lower Lobes with centrilobular nodules. Inflammatory or infectious etiology. Follow-up study in 8-10 weeks after therapy recommended to complete resolution.”
TABLE 1.
Diagnostic Criteria for Yellow Nail Syndrome
Yellow Nails
Peripheral Edema
Pleural Effusions
TABLE 2. Conditions associated with Yellow Nail Syndrome
Malignancies
(ie. bronchogenic carcinoma, breast cancer, endometrial carcinoma)
Immunodeficiency states
Connective tissue disorders
Endocrine disorders (ie. diabetes mellitus, thyroid dysfunction)
Obstructive sleep apnea
Tuberculosis
Del Med J | July 2015 | Vol. 87 | No. 7
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