Page 26 - Delaware Medical Journal July 2015
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CASE REPORT
TABLE 3. Rosenberg-Patterson Criteria for Allergic Bronchopulmonary Aspergillosis
MAJOR CRITERIA:
Asthma
Roentgenographic fleeting pulmonary opacities
Skin test positive for Aspergillus
Eosinophilia
Precipitating serum antibodies (IgG)
Elevated serum IgE
Central bronchiectasis
Aspergillus fumigatus-specific serum IgG, IgE
MINOR CRITERIA:
Presence of sputum Aspergillus
Expectoration of dark mucus plugs
Delayed skin reaction to Aspergillus antigen
DISCUSSION
Yellow nail syndrome is a rare immunocompromised state caused by vascular damage and a subsequently impaired lymphatic system — leading to recurrent infections primarily of the upper respiratory tract. It is a rare clinical diagnosis, characterized by slow-growing yellowed nails, lymphedema, and pleural effusions which
manifest with respiratory symptoms. We suspect that our patient’s vascular damage, as smoking has been known to impair peripheral circulation.2 His history of asthma and suspected emphysematous changes predisposed him to not only the development of recurrent upper respiratory tract infections, but also to a heightened his respiratory symptom burden and prompting his diagnosis of allergic bronchopulmonary aspergillosis.
3 Pulmonary colonization of Aspergillus fumigatus in patients with poor mucociliary clearance triggers an immediate-type cutaneous hypersensitivity reaction predominantly involving eosinophils, wheezing, hemoptysis, or cough productive of dark mucous plugs. Positive Aspergillus skin testing, elevated total serum IgE levels, (Table 3) symptomatic presentation, asymptomatic remission, exacerbation, Our patient’s acute presentation precipitated by his vacation to Costa Rica later remitted with management involves addressing antifungal agents as well as glucocorticoid therapy.
While thickened, yellowed nails may seem innocuous in the
to ensure appropriate management of underlying infections
and further evaluation for associated conditions contributing to vascular dysfunction. (Table 2) Smoking cessation counseling served as a key component of our interactions with the patient. We also reminded him that while his nails and lungs may clear for a period of time after successful initiation of antifungal and antibiotic therapy, his inherently immunocompromised state
may precipitate recurrent infections in the future. The patient was instructed to alert his doctor should he experience any nail changes, peripheral edema, or respiratory symptoms for which he
CONTRIBUTING AUTHORS
■ ANITA MODI is completing her fourth year at Sidney Kimmel Medical College in Philadelphia, Penn. and will continue her training as an Internal Medicine Resident at Jefferson University Hospital in Philadelphia, Penn.
■ JOHN F. REINHARDT, MD is an Infectious Disease and Internal Medicine Physician at Christiana Care Medical System in Newark, Del.
REFERENCES
1. Maldonado F, Ryu JH. Yellow nail syndrome. Curr Opinion Pulmonary Med. 2009:15;371-375.
2. Aboyans V., et al. Risk factors for progression of peripheral arterial disease in large and small vessels. Circulation. 2006:22;2623-2629.
3. Agarwal R. Allergic bronchopulmonary aspergillosis. Chest. 2009:135;805-826.
218 Del Med J | July 2015 | Vol. 87
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