The harlequin nail. A marker for smoking cessation: CASE REPORTS

26 Mar
2011

Case 1

A 71-year-old man was brought to the VA Medical Center, Johnson City, by his family, who stated that he had a one-week history of fever, chills, and cough productive of yellow sputum. Prior VA records showed that the patient was a long-term smoker, smoking 1 to 2 packs/day for more than 30 years, and had COPD. The patient was unable to give a lucid history, and records from another hospital where he had been recently treated were not available. On physical examination, the patient had a blood pressure of 120/60 mm Hg, a heart rate of 88 beats/min, and a temperature of 37.7°C. The patient was poorly nourished and ill-looking. The neurologic examination demonstrated a dense left hemiparesis, left cranial nerve 7 weakness, and a positive Babinski reflex on the left side. The patient was able to speak but was not oriented to place or person. The left index fingernail revealed a curious distribution of pigmentation, with the distal nail being yellow and nicotine stained and the proximal portion being pink and pearly. A line of demarcation separated the two halves (Fig 1).

The distance between the line of demarcation and the proximal nail fold was 5 mm; we inferred that the patient probably was unable or not allowed to smoke once he became bedridden from the stroke. We estimated that the cva was between four and ten weeks old (based on a nail growth rate of 0.5 to 1.2 mm/week). a call to the hospital from which the patient was transferred revealed that the stroke had occurred six weeks prior to our seeing the patient. The wife later confirmed that the patient had not been allowed to smoke subsequent to the stroke.
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Ficuae 1 Case 1 Note line

FIGURE 1: Case 1: Note line of demarcation between distal nicotine- stained nail and proximal pink (new) nail (original magnification x5).

Case 2

A 70-year-old with a 100 pack-year smoking history and inoperable squamous cell cancer of the lung (diagnosed two months prior to admission) presented for radiation therapy. The extremities revealed bilateral clubbed nails and nicotine staining confined to the distal half of the nail plate of the right hand. (Fig 2). a line of demarcation was clearly seen 3 to 4 mm distal to the proximal nail fold.
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FIGURE 2 Case 2 Nicotine

FIGURE 2: Case 2: Nicotine staining and line of demarcation involving several fingers (original magnification x3). The finger is also clubbed.

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