Gnarly Nails in a Four-year old Boy
This case of "gnarly nails" takes you back to Physical Diagnosis 101. Do you recall the causes of pitting, clubbing and lines?
Gnarly Nails and Thinning Hair...What Cause?
A new day, many new mysteries.
A 4-year-old child is brought in by his mother. Of note are grooves on all the child's fingernails, each groove approximately 7 mm from the periungual folds.
In response to your query about recent illnesses, the mother says that a few weeks ago, her son had strep throat with a fever of nearly 106°F for 3 days before she could get an appointment for treatment.
Note the grooves and the uniform distance from the periungual folds on each finger.
Similar grooves are noted on the child's toenails (about 5 mm from the periungual folds) and you also see some diffuse hair thinning in his scalp.
Differential diagnosis: Clubbing, koilonychia, onycholysis, nail pitting, Beau’s lines, Muehrcke’s lines, Mee’s lines, longitudinal melanonychia
You tell the mother the child has: Lupus erythematosus, a fungal infection of his nails and hair, Beau’s lines and mild telogen effluvium, possible malignancy, psoriasis with onset from strep throat, not certain and refer to dermatology
The correct answer is: The child has Beau’s lines of his nails and mild telogen effluvium (hair loss) and you give reassurance that this will resolve over time without treatment.
Beau's lines are deep grooves that run from side to side on the fingernail or the toenail. The cause is an illness that affects the entire body and is severe enough to disrupt normal nail growth.
The date of stress causing Beau's lines and other identifiable marks on nails can be estimated by measuring the distance of the ridges from the periungual folds.
Causes of Beau's lines in pediatric patients: Malnutrition, myocardial diseases, severe infections with high fever, poorly controlled diabetes, chemotherapy, after birth
The noted thinning of the boy's hair is telogen effluvium-a form of hair growth disruption that can occur simultaneously with nail growth disruption.
A 4-month old otherwise well child with telogen effluvium that appeared 2-3 months after birth.
Some causes of telogen effluvium: seizures, crash diets, anesthesia, high fever, oral contraceptives, thyroid disease, severe stress, surgery, drugs, contact dermatitis.
Telogen effluvium, known drug causes: Colchicine, thallium, antiseizure drugs (phenytoin, valproic acid, carbamazepine), anticoagulants (heparin, warfarin), retinoids
This case of a young boy with disruption in growth of his nails and hair is a good test of your physical diagnosis skills as well as a reminder of essential questions to cover in the history. What do you remember about nail abnormalities? What would you include in your differential diagnosis?Follow the clues in the slides above through Dr Jonathan Schneider's most recent diagnostic challenge.Â
