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Requests for reprints should be addressed to Fikret Er, MD, Department of Internal Medicine III, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
Despite the enormous involvement of imaging tools in medicine, a focused physical examination still plays a pivotal role in all medical fields. During and after taking history, a detailed inspection and examination of the patient will direct to further key diagnostic tools. A wealth of information can be gained from shaking hands and examining the hands at the same time. This part of the examination, and in particular the examination of the nails, is often neglected, although it is simple to notice if the hands are warm and well perfused or sweaty and to examine the color of the nails. In some cases, nail shapes are directive for the diagnosis, such as clubbed fingers in pulmonary or cardiovascular disorders. This short report describes 2 patients with different systemic diseases but developing similar nail changes. The early recognition of this nail abnormality could have led to earlier treatment.
Clinical Summary
Case 1
A 71-year-old male retiree presented with a severe aortic valve stenosis. On examination, he had typical heart failure symptoms, and measurement of the ankle-brachial index revealed arterial occlusive disease.
Incidentally, he asked if the aortic valve stenosis may explain his nail color changes (Figure 1A-D). The condition involved all fingernails uniformly, sparing the foot nails, and did not change shape under pressure. The red to brownish distal lines ran parallel to the distal part of the nail-bed. This nail discoloration with apparent leukonychia was first noticed approximately 5 years ago without pursuing further diagnostics.
Figure 1A-D, Transverse red to brownish band of the distal edge of all nails with ground-glass colored proximal parts indicating Terry's nails.
A 62-year-old man was admitted with prosthetic valve endocarditis. Examination of the patient revealed an end-stage renal disease and striking nail changes (Figure 2A-C). The nails had an opaque, ground-glass-like white color obscuring the lunula. The distal brownish bands did not obscure by venous congestion, indicating a nail-bed abnormality rather than a disease of the nail itself. The nail-bed changes were observed before his renal impairment had been diagnosed.
Figure 2A-C, Terry's nails with leukonychia of the proximal and brownish bands at the distal area of all fingernails.
Terry's nails were first described by the British physician Richard Terry, who investigated this nail-bed abnormality in 82 of 100 consecutive patients with hepatic cirrhosis.
In more than 90% of those patients, the cirrhosis was due to alcohol abuse. The nail changes were composed of a discoloration, which stops suddenly 1 to 2 mm from the distal edge of the nail, leaving a red to brownish transverse band of 0.5 to 3 mm width and nearly always corresponding to the onychodermal transition.
He presumed that red half-moons result from abnormal adhesion of the nail-bed to the nail, but until now a generally accepted pathophysiologic explanation has been missing. The biochemical circumstances leading to Terry's nails are rather related to the underlying disease and not causally associated to the nail disorder. Histopathologic findings from patients with Terry's nails demonstrated changes in vascularity, in particular distal telangiectasias.
Other colleagues disclosed further systemic disorders that are highly associated with Terry's nails, such as adult-onset diabetes mellitus, chronic renal failure, pulmonary tuberculosis, and Reiter's syndrome.
However, Terry`s nails simply might reflect an age-related phenomenon. The most important differential diagnosis of Terry's nails are the uremic half-and-half nails, also known as Lindsay's nails, which are typically seen in chronic renal diseases.
A precise clinical differentiation of both nail-bed abnormalities can at times be difficult, but the transverse band in Lindsay's nails commonly occupies up to 60% of the nail length.
In our 2 patients, Terry's nails might have reflected an early sign of a developing underlying systemic disease. Thus, it is presumable that most likely congestive heart failure and chronic renal disease gradually led to a nail manifestation in cases 1 and 2, respectively. Although there is no absolute proof that an early diagnosis of Terry's nails would have led to earlier treatment in these patients, it might be speculated that the recognition of unspecific fingernail changes could have improved the awareness of the responsible physician for systemic disorders.
Conclusions
Terry's nails are associated with a red to brownish transverse band of the distal fingernail-bed. Their occurence is strongly associated with hepatic cirrhosis, congestive heart failure, and chronic renal diseases. In daily patient contact, the examination of the hand easily delivers important information. The recognition of characteristic nail patterns, such as Terry's nails, may be a helpful herald for early diagnosis of systemic diseases.
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