Development of Terry’s nails after a gastrointestinal bleed

Abstract

Terry’s nails are characterized by white opacification of the nails with effacement of the lunula and distal sparing. Described originally in 1954 by Dr. Richard Terry as a common fingernail abnormality in patients with hepatic cirrhosis, Terry’s nails are now a known sequelae of other conditions such as congestive heart failure, chronic kidney disease, diabetes mellitus, and malnutrition. Often all nails of the hands are affected. Treatment of the underlying disease may result in resolution. We present a case of a 77-year-old man who developed Terry’s nails following an acute gastrointestinal bleed and subsequent hemorrhagic shock. The development of Terry’s nails after a gastrointestinal bleed has not been previously reported.

Terry’s nails, a type of apparent leukonychia, is a sign of systemic disease characterized by ground-glass opacity of nearly the entire nail with a narrow band of normal pink or brown nail bed at the distal plate.¹ Nail involvement is often bilaterally symmetrical.^1,2 Terry’s nails were first described in 1954 by Richard Terry in patients with hepatic cirrhosis.³ Subsequent studies have demonstrated this nail abnormality to be associated with congestive heart failure, chronic kidney disease, diabetes mellitus, and malnutrition.^1,2,4 Because Terry’s nails may signify underlying disease, a careful clinical exam is essential in every patient encounter. We report a case of a 77-year-old man who developed Terry’s nails following an acute gastrointestinal bleed and subsequent hemorrhagic shock.

CASE DESCRIPTION

A 77-year-old white man presented to the clinic with recent development of white fingernails affecting both hands. The white nail beds were indistinguishable from the lunula, and a band of normal pink at the distal border of each nail was appreciated (Figure 1). Three months prior to his visit, the patient’s nail findings were normal. His past medical history was remarkable for coronary artery disease, atrial fibrillation on apixaban, stage 3B chronic kidney disease, myasthenia gravis, and hypothyroidism. There was no known history of hepatitis B and C, cirrhosis, diabetes mellitus, or alcohol use. Over the past 10 months, he had also lost 10% of his body weight. Two months earlier, the patient had been admitted to the hospital for epigastric bleeding and subsequent hemorrhagic shock. Laboratory values on admission were notable for a low hemoglobin and hematocrit, hypoalbuminemia, and elevated creatinine. Liver function tests and electrolytes were within normal limits. After epigastric artery embolization and three blood transfusions, he became stable over the course of 3 days and was discharged home.

Figure 1.

(a) Our patient’s fingernails in the upper half revealing whitening or ground-glass opacity of nearly the entire nail bed of each fingernail, indistinguishable from the lunula, with a narrow band of normal pink nail bed at the distal border consistent with Terry’s nails. Normal fingernails at the bottom half are for comparison. (b) A closer view of Terry’s nails in our patient.

DISCUSSION

As described by Terry,³ Terry’s nails are evident as bilaterally symmetrical whitening of the fingernails involving nearly the entire nail bed with a 1 to 2 mm distal band of normal pink. However, Terry’s criteria were later revised in 1984 denoting that the distal band width may be between 0.5 and 3 mm and may be pink or brown in color, which represents normal nail bed tissue.⁴ Longitudinal ridging of the nail plate and nail bed thickening may also be seen with the condition.³ Terry’s nails are a type of apparent leukonychia, as the ground-glass appearance of the nail is secondary to underlying defects in the nail bed.¹ The pathophysiology is unknown but may involve changes in nail bed vascularity due to an overgrowth of connective tissue.

The differential diagnoses for Terry’s nails include Lindsay’s (half and half) nails, Muehrcke’s nails, and true leukonchyia.¹ Although both Terry’s nails and Lindsay’s nails are associated with chronic kidney disease and characterized by ground-glass opacities, the proximal nail bed whiteness in Terry’s nails occupies approximately 80% of nail while only about half of the proximal nail bed is opacified in Lindsay’s nails.^1,4 In Muehrcke’s nails, transverse white lines run parallel to the lunula and are separated by areas of normal pink nail bed color. They are often seen in association with hypoalbuminemia (e.g., from nephrotic syndrome, liver diseases, malnutrition) and chemotherapy.⁵ True leukonychia may mimic Terry’s nails, but true leukonychia involves the nail plate instead of the nail bed. Thus, a true leukonychia will grow out with the nail while Terry’s nails retain the proximal nail discoloration as the nail grows out.¹

The physical exam is important in every clinical encounter, as nail changes characteristic of Terry’s nails can indicate systemic disease that may have otherwise been missed. Common associations with Terry’s nails include cirrhosis, congestive heart failure, chronic kidney disease, diabetes mellitus, and malnutrition.^1–4 Other associations include rheumatoid arthritis, tuberculosis, leprosy, and systemic sclerosis.³ Our patient did have a history of stage 3B chronic kidney disease and gradual weight loss (malnutrition), but he presented soon after a recent acute gastrointestinal bleed and hemorrhagic shock that led to hospital admission. The cause of his new-onset Terry’s nails could be multifactorial, but the timing favors the acute gastrointestinal bleed as the more likely cause. This case report highlights the development of Terry’s nails shortly following a gastrointestinal bleed, an association that has not been previously described in the literature.