Yellow nail syndrome: a review

Palliative Subcutaneous Needle Drainage for a Rare Cause of Refractory Lymphedema: Yellow Nail Syndrome

Yellow nail syndrome (YNS) presents a therapeutic challenge due to its elusive etiology and lack of effective treatments. We present a case of a 77-year-old female with YNS-associated lymphedema who experienced significant symptomatic relief with subcutaneous drainage therapy, a novel intervention not previously described in YNS. Despite prior failed conventional therapies, she achieved remarkable weight loss, improved mobility, and stable biochemical parameters. Subcutaneous drainage therapy, though traditionally utilized in cancer-associated lymphedema, demonstrates promise as an alternative palliative treatment for refractory cases of lymphedema to improve quality of life.

Yellow nail syndrome in anti-SSA and anti-SSB positive primary Sjögren's syndrome

Yellow nail syndrome (YNS) is a rare, acquired condition, characterised by at least two of the three clinical criteria: nail changes, respiratory tract disease and lymphoedema. Currently, the aetiology of YNS remains unknown; however, it is believed to be caused by impaired lymphatic drainage. Currently, there remain no definitive treatment options available and no prospective trials evaluating this. Management includes supportive care and symptomatic treatment. The presence of YNS has been described alongside various conditions, including autoimmune diseases, malignancies and drug exposures. To strengthen the literature on this topic, we present the case of a female patient with a history of anti-SSA and anti-SSB positive primary Sjögren's syndrome, who developed YNS in the immediate postpartum period.

A Case Report on the Trilogy of Yellow Nail Syndrome: Yellow Nails, Pleural Effusion, and Lymphedema

Yellow nail syndrome is a rare medical syndrome characterized by the combination of a triad of yellow nails, recurrent pulmonary manifestations, and lymphedema. All three features of the triad may not be present synchronously. The diagnosis is made clinically once other causes have been excluded. Typically, it occurs in individuals who are 50 years old and above. We report a case of yellow nail syndrome in a 62-year-old male who presented with recurrent episodes of difficulty breathing due to pleural effusion. Further examination revealed pitting edema of the bilateral lower extremities. In the later encounter, his nail was found to be yellowish. Excluding other diagnoses like heart failure, fungal infections, autoimmune diseases, and lung cancer, with a typical triad, a diagnosis of yellow nail syndrome was made. He was managed with pleural fluid tapping for pleural effusion, compression stockings for leg edema, and vitamin E for nail changes. The study also intends to highlight current treatment options and alert physicians of this syndrome with such typical findings.

Control of pleural effusion with prednisolone in a patient with yellow nail syndrome: A case report

Yellow nail syndrome (YNS) can induce bilateral exudative pleural effusion; however, to the best of our knowledge, no standard treatment for YNS has been established. The present study describes a patient with YNS for whom the pleural effusion was controlled by prednisolone. A 73-year-old man was referred to the University of Tsukuba Hospital (Ibaraki, Japan) complaining of shortness of breath, which was diagnosed as being due to bilateral pleural effusion. Based on the presence of yellowing and growth retardation of the toenails, lymphedema, bilateral exudative pleural fluid of unknown etiology, and lymphatic congestion on lymphoscintigraphy, the patient was diagnosed with YNS. The pleural fluid was predominantly lymphocytic and responded to systemic steroid administration [prednisolone 30 mg/day (0.5 mg/kg) for 2 weeks, with subsequent weekly tapering]. The general condition of the patient and their dyspnea also improved with treatment. These findings indicated that systemic steroid administration should be considered as one of the treatment options for patients with YNS who are reluctant to undergo chest drainage or pleurodesis due to the potential for a decrease in their ability to perform daily activities and respiratory function.

Examination of the nails: Main signs

Understanding the anatomy of the nail apparatus is a prerequisite for diagnosing and managing various nail disorders. The latter may be associated with systemic pathologies, or accompany infectious, inflammatory, tumoral, toxic or traumatic dermatoses. Before attempting to identify the cause, a rigorous clinical examination should be conducted to screen for elementary lesions that may affect general nail shape, nail surface, subungual attachments, periungual soft tissue or nail color. All of these guide differential diagnosis.

Vitamins for the Management of Nail Disease: A Literature Review

Background

Vitamins have gained popularity among physicians and patients for purported benefits to hair, skin, and nail health. Safe and efficacious therapies for nail disorders, many of which are chronic conditions, are needed.

Summary

We conducted a literature review of studies assessing the efficacy of oral, topical, and intralesional vitamin/vitamin derivatives for the treatment of nail disorders, including yellow nail syndrome, brittle nail syndrome, onychomycosis, habit-tic nail deformity, periungual/subungual verruca, and nail psoriasis. Forty-nine articles were reviewed. There is good evidence to support the use of topical tazarotene and vitamin D analogs for nail psoriasis treatment. We found overall limited evidence for treatment of other nail disorders with vitamin/vitamin derivatives, and further research is needed to support their use.

Key Messages

Besides topical tazarotene and vitamin D analogs for nail psoriasis treatment, there is limited evidence for treatment of nail disorders with topical, oral, and intralesional vitamin/vitamin derivatives.

Nail disorders to be kept in mind

Recognizing and diagnosing the most common nail diseases is essential, to be able to guide patients and provide appropriate treatment. However, uncommon nail disorders should not be neglected, in order to avoid inadequate treatment and above all to ensure that no severe underlying disorder, with severe prognosis, is overlooked.

Four-Year Follow-Up of a Case of Yellow Nail Syndrome With IgM Deficiency

Yellow nail syndrome is a rare condition occurring sporadically, with an extremely low prevalence rate. This syndrome classically presents with a triad of lower extremity edema, yellow nails, and mucosal issues such as pleural effusion and/or chronic sinusitis. Two out of the three features are deemed sufficient to diagnose a person with yellow nail syndrome. We present a rare case of yellow nail syndrome that began with chronic leg swelling and later progressed to the development of an asymptomatic pleural effusion and finally discoloration of nails. In our case, the patient did have a significant recent history of a total knee replacement with a titanium implant. Of note was the chronology of events including leg edema and asymptomatic pleural effusion which were present even before the titanium knee implant. The third feature of the hardening and yellow discoloration of the nails was found to have developed following the knee replacement. Interestingly, on further evaluation, he was found to have IgM deficiency.

Frontal Examination of the Distal Nail Unit

Clinical findings in many nail disorders are not usually pathognomonic. An accurate diagnosis therefore relies on inspection of the nail unit from different angles. We review clinical features of different nail disorders that can be observed during frontal examination of the distal edge of the nail plate and the hyponychium and correlate these with features observed when the nail is viewed from above. Frontal examination of the distal nail unit can help establish a clinical diagnosis in routine practice.

[Translated article] Frontal Examination of the Distal Nail Unit

Clinical findings in many nail disorders are not usually pathognomonic. An accurate diagnosis therefore relies on inspection of the nail unit from different angles. We review clinical features of different nail disorders that can be observed during frontal examination of the distal edge of the nail plate and the hyponychium and correlate these with features observed when the nail is viewed from above. Frontal examination of the distal nail unit can help establish a clinical diagnosis in routine practice.

A 28-Year-Old Woman With Nail Discoloration, Recurrent Bronchitis, and Left-Sided Facial Swelling

CASE PRESENTATION

A 28-year-old woman with a history of congenital hip dysplasia was referred for evaluation of recurrent bronchitis. She had undergone left hip replacement with titanium implants 11 years prior to presentation. The patient reported frequent bouts of bronchitis, sinusitis, and left-sided nontender facial swelling that started after the hip replacement surgery. She also reported nail discoloration of her left first toenail 1 year after this procedure, and nail discoloration of her right first toenail 3 years after the procedure. She was treated for onychomycosis without improvement. Review of symptoms was positive for chronic dry cough and facial tenderness but was negative for dyspnea, wheezing, or chest tightness. She previously had been diagnosed with common variable immunodeficiency based on low immunoglobulin levels, and the condition was maintained with monthly IV immunoglobulins but without any improvement or change in the frequency of sinusitis, bronchitis, or facial swelling. She did not use tobacco, and her family history was unremarkable.

Tomato Plant-Associated Xanthoderma: Case Report and Review of Exogenous Causes of Yellow Skin

The skin, hair, and nails can all present with yellow discoloration secondary to exogenous etiologies. Xanthoderma, yellow discoloration of the skin, can occur not only from exogenous sources secondary to topical contact with various substances but also from endogenous causes such as diseases from the liver and kidney, or oral medications. A 64-year-old man developed asymptomatic, yellow staining of his distal left forearm, hand, and fingertips. He was not receiving antimalarials, did not have hepatic or renal dysfunction, and had not applied any sunless tanning solutions to his skin. Prior to the appearance of his xanthoderma, he had been tending to a tomato plant in his yard; the yellow staining appeared on the areas of his left upper extremity that had contacted the stems and leaves of the tomato plant. Within two days, the yellow skin discoloration resolved spontaneously after several washings of the affected areas with soap and water. Tomato plants have trichomes that appear as hair-like structures on the stems and produce an oily substance; the trichomes not only produce the scent of the plant, but also provide protection from cold, drought, disease, and pests. Initially, when the oily substance contacts the skin, the skin appears yellow; subsequently, the skin may become black. The skin that has been stained by a tomato plant is referred to as "tomato skin" (TOMASK). In addition to reviewing the etiology of exogenous xanthoderma, this paper also summarizes the causes of exogenous yellow hair and yellow nails. Exogenous yellowing of the skin can result from various topical causes. Common topical etiologies of xanthoderma include not only contact with tomato plants, but also sunless tanning solutions (that contain dihydroxyacetone) and tobacco (that not only causes yellow staining of the white hair on men's upper lip referred to as "smoker's mustache", but also yellow staining of the nail plate and fingertips used to hold the cigarette or cigar). In summary, tomato plant-associated xanthoderma is a benign exogenous etiology of yellow staining of the skin which eventually resolves after several washings of the affected sites with soap and water.

A Practical Approach to the Diagnosis of Lymphedema: A Narrative Review

INTRODUCTION

Lymphedema often presents as progressive, unremitting swelling and skin changes that are extremely distressing to patients. Hereditary lymphedema (HL) constitutes a type of primary lymphedema that is passed down through generations.

OBJECTIVES

The primary aims of this narrative review are to illustrate a framework to distinguish lymphedema from other causes of swelling and to differentiate the hereditary lymphedemas from each other.

RESULTS

A literature search was undertaken using relevant search terms. The articles were evaluated to generate a diagnostic algorithm to approach the swelling of an extremity using clinical and laboratory data. First, the stemmer sign should be evaluated. If it is negative, other causes should be considered. History and additional physical exam findings suggest either a primary or secondary cause of lymph-edema.

CONCLUSIONS

The hereditary lymphedemas have been classified by age of onset and then stratified by clinical criteria and genetic testing.

[Yellow nail syndrome. A case report with postmortem study]

Yellow nail syndrome is a rare disease of unknown aetiology. Patients with YNS have a characteristic yellowish-coloured nails, pulmonary alterations and primary lymphedema. To the best of our knowledge, only a few reports of autopsy findings in these patients have been published. Its aetiology possibly involves a primary malformation of larger lymph vessels. We describe autopsy findings not previously associated with yellow nail syndrome, such as expansion of mediastinal lymph-nodes and splenic sinusoids. The present autopsy reveals hitherto unreported findings associated with YNS, such as alterations in splenic sinusoids and mediastinal lymph-node sinuses.

Selective IgG2-deficiency in yellow nail syndrome

IgG2-deficiency increases susceptibility to recurrent pulmonary infections and the risk for bronchiectasis. Isolated IgG2-deficiency has not been previously described in Yellow Nail Syndrome (YNS).

How and when to manage respiratory infections out of hospital

Lower respiratory infections include acute bronchitis, influenza, community-acquired pneumonia, acute exacerbation of COPD and acute exacerbation of bronchiectasis. They are a major cause of death worldwide and often affect the most vulnerable: children, elderly and the impoverished. In this paper, we review the clinical presentation, diagnosis, severity assessment and treatment of adult outpatients with lower respiratory infections. The paper is divided into sections on specific lower respiratory infections, but we also dedicate a section to COVID-19 given the importance of the ongoing pandemic. Lower respiratory infections are heterogeneous entities, carry different risks for adverse events, and require different management strategies. For instance, while patients with acute bronchitis are rarely admitted to hospital and generally do not require antimicrobials, approximately 40% of patients seen for community-acquired pneumonia require admission. Clinicians caring for patients with lower respiratory infections face several challenges, including an increasing population of patients with immunosuppression, potential need for diagnostic tests that may not be readily available, antibiotic resistance and social aspects that place these patients at higher risk. Management principles for patients with lower respiratory infections include knowledge of local surveillance data, strategic use of diagnostic tests according to surveillance data, and judicious use of antimicrobials.

Amlodipine as a Suggested Cause of Yellow Nail Syndrome: A Case Report

Yellow nail syndrome (YNS) is a rare disorder initially described in 1964. It is characterized by a classical triad: yellow nails, lymphedema, and respiratory manifestations. We present a 71-year-old woman who presented with progressive dyspnea. Medical history includes hypertension treated with amlodipine. Examination showed bilateral lower extremity non-pitting edema, yellowish discoloration of nails, and bilateral pleural effusion. Thoracentesis demonstrated chylous effusion. The presumptive diagnosis was YNS. Assuming amlodipine as a cause of interstitial edema, it was stopped, and the symptoms improved gradually. After two months, amlodipine was restarted externally, and the dyspnea relapsed. Amlodipine was discontinued again. After two years of amlodipine cessation, the patient remained well without symptoms. The progression and resolution of symptoms point to amlodipine as a suggested cause of YNS. Paying attention to the prescribed drugs was the key to diagnosing and resolving serious complications.

Yellow nail syndrome accompanied by minimal-change nephrotic syndrome: A case report

BACKGROUND

In most cases of yellow nail syndrome (YNS), the classic triad of yellow nails, lymphedema and respiratory manifestations rarely manifest simultaneously. Therefore, diagnosis is delayed or frequently missed.

CASE SUMMARY

We report a 62-year-old YNS patient presenting with bilateral pleural, pericardial and peritoneal effusions who, 2 mo later, developed minimal-change nephrotic syndrome. After treatment with vitamin E, clarithromycin and prednisone for 3 mo, effusions in the chest, pericardium and abdominal cavity decreased while urine protein levels returned to within normal ranges.

CONCLUSION

Clinicians should consider the possibility of YNS for patients presenting with multiple serous effusions and nephrotic syndromes.

Yousif M, Abdelmageed I, Eljack MMF, Abbasher Hussien Mohamed Ahmed K, Tarig AbdAlla Mohamed M, Abdelkareim G. Mohammed S, B. Salih E, H. Osman D. Yellow nail syndrome in an elderly sudanese female: A case report

Yellow nail syndrome is a rare lymphatic abnormality without clear pathogenesis. Hereby, we report a 70‐year‐old Sudanese female patient who presented with recurrent cough, recurrent lower limb swelling, and yellowish nail discoloration diagnosed as yellow nail syndrome but unfortunately passed away due to acute respiratory distress syndrome (ARDS).

The co‐existence of recurrent respiratory affection and non‐pitting edema in patients of more than 40 years should raise suspicion of yellow nail syndrome even in absence of sinusitis, bronchiectasis, or positive family history.

Pericarditis With Cardiac Tamponade Mimicking Yellow Nail Syndrome in a Patient With Rheumatoid Arthritis and a Paucity of Joint Symptoms

Pericarditis is a cardiac disease that commonly manifests with rheumatoid arthritis, and its complications are related to rheumatoid arthritis disease activity. The diagnosis can be complicated in patients with multiple extra-joint complications of rheumatoid arthritis. We report a case of pericarditis in an 82-year-old woman with few joint symptoms who was admitted to the hospital due to worsening edema of the lower legs and dyspnea, which progressed to cardiac tamponade. The patient presented with gradual onset of edema of both lower limbs and bilateral pleural effusion and was initially diagnosed with yellow nail syndrome. Ultimately, the patient was diagnosed with rheumatoid pericarditis due to a rapid increase in pericardial effusion. She was treated with non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine; however, the symptoms were progressive and required pericardiocentesis. After pericardiocentesis, the patient responded well to NSAIDs and colchicine, and systemic edema was relieved. This case highlights the fact that pericarditis associated with rheumatoid arthritis is not necessarily related to the severity of joint symptoms. Moreover, it can be difficult to differentiate pericarditis from multiple other diseases, such as yellow nail syndrome, in patients with rheumatoid arthritis who mainly have extra-articular symptoms.

[Surgery for chyloptysis]

Chyloptysis is a rare disease characterized by formation of bronchial casts containing chyle and repeating bronchial tree branching. The authors report a 56-year-old woman with chyloptysis accompanied by cough and expectoration of milky bronchial casts, as well several episodes of asphyxia. Stages of diagnosis and successful treatment including thoracic duct ligation and skeletonization of the root of the left lung are described. The authors also analyze literature data on etiology, pathogenesis and feasibility of conservative and surgical treatment of these patients.

Yellow nail syndrome

Yellow nail syndrome is an extremely rare syndrome, mainly in people over 50 years of age, occurring both systemically and in isolation and requiring the most careful collection of anamnesis, since this condition has a close relationship with respiratory diseases, malignant neoplasms of internal organs and rheumatoid arthritis. Moreover, this rare disease is not sufficiently studied to fully understand its pathogenesis and effective treatment. Patients pay attention to the yellow color of the nails, associated with the deposition of melanin, bile pigments and hemosiderin in the submarginal space, slowing down the growth and thickening of the nail. It should be noted that the change in the nail plates can be observed long before the other clinical manifestations of this syndrome are detected, and probably this can in some cases serve as a harbinger of incipient changes in the lung tissue, neoplasms and changes in the lymphatic vessels. In this regard, it is extremely important to clearly differentiate this condition and refer patients to related specialists for verification of the diagnosis and further treatment.

Yellow Nail Syndrome in Which Intranodal Lymphangiography Contributed to the Diagnosis

Yellow nail syndrome (YNS) is a rare disease comprising the clinical triad of yellow nail discoloration, pleural effusion, and lower limb lymphedema. We encountered a difficult-to-treat case of YNS in which the diagnosis was finally made based on intranodal lymphangiography. An 84-year-old man was admitted to our hospital with pleural effusion and yellow-green discoloration of the nails, accompanied by onychomycosis and limb lymphedema. Intranodal lymphangiography revealed a slow contrast flow and narrowing of the thoracic duct, suggesting lymphatic duct dysplasia and leading to the diagnosis of YNS.

A 49-Year-Old Woman With Persistent Bilateral Pleural Effusions

CASE PRESENTATION

A 49-year-old woman presented to the ED with sudden onset abdominal pain, nausea, and vomiting. Her medical history included an uncomplicated gastric lap band surgery 9 years ago and subsequent removal of lap band after 6 years. She had a Roux-en-Y gastric bypass and cholecystectomy 5 months prior to the current presentation. The patient had been diagnosed with asthma and was prescribed an inhaled corticosteroid that she used only as needed. The patient denied smoking and heavy alcohol consumption. She was currently employed as a scrub technician in a local surgical center.

Recurrent Pleural Effusions, Lymphedema, and Abnormal Nails in a 61 Year Old Man

A 61 year old man with history of hypertension, coronary artery disease (CAD) with prior stent placement, and chronic obstructive pulmonary disease (COPD) presented with a four month history of recurrent pleural effusions and progressive diffuse edema. Four months prior to hospital presentation, the patient began to notice new onset dyspnea on exertion, fatigue, and chest pain. Initial evaluation with troponin and EKG were negative. A chest x-ray (CXR) was done which revealed a moderate sized left pleural effusion. He did not have a history of pleural effusions or heart failure. Therefore, he underwent diagnostic thoracentesis and fluid studies were consistent with an exudative pleural effusion without malignant cells or microbial growth.

A Rare Cause of Exudative Pleural Effusion in a Female

Yellow nail syndrome is an extremely rare syndrome that presents with a clinical triad of thickened yellow nails, lymphedema, and recurring pulmonary manifestations (pleural effusion, chronic cough, or bronchiectasis), usually in the population above the age of 50 years. We describe a case of yellow nail syndrome in a 48-year-old lady who presented with the typical classical triad of this syndrome.

Yellow nail syndrome with massive chylothorax after esophagectomy: A case report

Yellow nail syndrome (YNS) is a rare condition characterized by the triad of yellow nails, lymphedema, and respiratory manifestations. Diuretics and thoracic drainage are often not effective in YNS, and the most effective treatments are pleurodesis and decortication/pleurectomy. A 66-year-old man was admitted to our hospital for YNS after esophagectomy with gastric tube reconstruction for esophageal cancer. The patient presented with yellow nails and lymphedema. Chest X-rays and computed tomography showed massive pleural effusions and ascites that were both chylous. The patient was considered to have YNS that became apparent after surgery. He recovered with diuretics and a low-fat diet without pleurodesis and decortication/pleurectomy. Thoracic surgery can exacerbate the functional impairment of lymphatic drainage in patients with asymptomatic and undiagnosed YNS, and can lead to further development of YNS-related clinical symptoms. Despite relatively massive chylothorax following thoracic surgery, chylothorax related to YNS could be successfully controlled with conservative treatment without pleurodesis and decortication/pleurectomy.

Nails in systemic disease

A change in colour, size, shape or texture of finger- and toenails can be an indicator of underlying systemic disease. An appreciation of these nail signs, and an ability to interpret them when found, can help guide diagnosis and management of a general medical patient. This article discusses some common, and some more rare, nail changes associated with systemic disease.

Nail is Systemic Disorders: Main Signs and Clues

Describing and listing all nail symptoms and signs in systemic disorders has already been widely detailed in dedicated textbooks. To be tutorial, this article described most common nails signs and the systemic disorders one may encounter in routine dermatologic consultation. Capsule summaries are presented for each section.

Yellow nail syndrome: a genetic Disorder?

BACKGROUND

Yellow nail syndrome is a very rare disorder. The classic clinical presentation includes a triad involving yellow nail discoloration, chronic pulmonary manifestations and lower limb lymphedema. Its etiology remains unknown and the genetic disorder is still controversial.

OBSERVATION

We report a case of a young man diagnosed with this syndrome and for who the same affection was found in several members of his family Conclusion: The diagnosis of yellow nail syndrome in several members of the same family supports the fact that it is a genetic disorder.

Unusual presentation of a man with recurrent chylous ascites

We describe an interesting case of a 77-year-old man presenting with refractory chylous ascites of unknown aetiology. After extensive diagnostic workup, unifying diagnosis of an intriguing condition of yellow nail syndrome was reached. This case is unusual as it describes a rare cause of chylous ascites in this age group. Despite refractory ascites and the need for recurrent paracentesis, this patient has a good prognosis with no significant impact on overall mortality.

Cutaneous Paraneoplastic Syndromes with Nail Involvement

The cutaneous paraneoplastic syndromes are rare and intrinsically devoid of any neoplastic nature. The manifestations on the skin and the nails are due to various mechanisms caused by the tumor, either due to production of bioactive substances or in response to it. These disorders evolve in parallel to the malignancy, in that, they regress when the tumor is removed and reappear in the case of tumor recurrence. The aim of this article is to aid with the early recognition of the signs, leading to the early detection of cancer and therefore to better clinical outcomes for the patients.

Pulmonary Manifestations of Skin Disorders in Children

Systemic diseases often manifest with cutaneous findings. Many pediatric conditions with prominent skin findings also have significant pulmonary manifestations. These conditions include both inherited multisystem genetic disorders such as yellow-nail syndrome, neurofibromatosis type 1, tuberous sclerosis complex, hereditary hemorrhagic telangiectasia, Klippel-Trénaunay-Weber syndrome, cutis laxa, Ehlers-Danlos syndrome, dyskeratosis congenita, reactive processes such as mastocytosis, and aquagenic wrinkling of the palms. This overview discusses the pulmonary manifestations of skin disorders.

An autopsy case report of yellow nail syndrome coincided with primary biliary cholangitis

Yellow nail syndrome (YNS) is a rare entity characterized by thickened yellowish nails, lymphedema and respiratory manifestations such as pleural effusion. Lymphatic dysfunction is considered as a cause of YNS. However, evidence of systemic dilatation/hyperplasia of lymphatics based on autopsy in YNS is not available. In this report, autopsy revealed dilatation and hyperplasia of lymphatic vessels in lungs, visceral and parietal pleurae, and intestines. We identified the direct opening of lymphatic vessels of the visceral pleura to the pleural cavity, which indicated the pathophysiology of uncontrollable pleural effusion in YNS. The current case was compromised with primary biliary cholangitis (PBC). The onset of PBC seemed to be related with the progression of YNS.

Nontraumatic Chylothorax: Nonenhanced MR Lymphography

Chylothorax is a rare cause of pleural effusion, secondary to accumulation of lymph in the pleural space. Diagnosis is based on the triglyceride and cholesterol content of pleural fluid obtained with thoracentesis. Because the lymphatic system plays an essential role in fat absorption and immune response, lymphatic leak associated with chylothorax may cause life-threatening malnutrition and immunodeficiency. Chylothorax is usually described as traumatic or nontraumatic. The main cause of chylothorax is traumatic, typically postsurgical, secondary to iatrogenic direct puncture of the thoracic duct during thoracic surgery. Causes of nontraumatic chylothorax include a wide range of differential diagnoses. Lymphoma and thoracic malignancies are the most common causes and are responsible for chylothorax by extrinsic compression or invasion of the thoracic duct. Other rare causes include primary and secondary diffuse lymphatic diseases, responsible for chylothorax by lymphatic vessel wall dysfunction. Imaging the lymphatic system remains a challenge in the days of modern imaging. Nonenhanced MR lymphography is a noninvasive technique based on heavily T2-weighted sequences, thus enabling visualization of the lymphatic circulation. This technique allows diagnosis and differential diagnosis, evaluation of disease severity, and guidance of therapeutic management in nontraumatic chylothorax. Furthermore, it may offer radiologic classification of primary lymphatic diseases on the basis of morphologic features of lymphatic vessels. The authors describe the anatomy and physiology of the thoracic lymphatic system, present the technique of nonenhanced MR lymphography, and discuss pathophysiologic mechanisms and imaging features in different causes of nontraumatic chylothorax. ^©RSNA, 2020.

Inactivation Kinetics and Membrane Potential of Pathogens in Soybean Curd Subjected to Pulsed Ohmic Heating Depending on Applied Voltage and Duty Ratio

The aim of this research was to investigate the efficacy of the duty ratio and applied voltage in the inactivation of pathogens in soybean curd by pulsed ohmic heating (POH). The heating rate of soybean curd increased rapidly as the applied voltage increased, although the duty ratio did not affect the temperature profile. We supported this result by verifying that electrical conductivity increased with the applied voltage. Escherichia coli O157:H7, Salmonella enterica serovar Typhimurium, and Listeria monocytogenes in soybean curd were significantly (P < 0.05) inactivated by more than 1 log unit at 80 Vrms (root mean square voltage). To elucidate the mechanism underlying these results, the membrane potential of the pathogens was examined using DiBAC4(3) [bis-(1,3-dibutylbarbituric acid)trimethine oxonol] on the basis of a previous study showing that the electric field generated by ohmic heating affected the membrane potential of cells. The values of DiBAC4(3) accumulation increased under increasing applied voltage, and they were significantly (P < 0.05) higher at 80 Vrms, while the duty ratio had no effect. In addition, morphological analysis via transmission electron microscopy showed that electroporation and expulsion of intracellular materials were predominant at 80 Vrms Moreover, electrode corrosion was overcome by the POH technique, and the textural and color properties of soybean curd were preserved. These results substantiate the idea that the applied voltage has a profound effect on the microbial inactivation of POH as a consequence of not only the thermal effect, but also the nonthermal effect, of the electric field, whereas the duty ratio does not have such an effect.IMPORTANCE High-water-activity food products, such as soybean curd, are vulnerable to microbial contamination, which causes fatal foodborne diseases and food spoilage. Inactivating microorganisms inside food is difficult because the transfer of thermal energy is slower inside than it is outside the food. POH is an adequate sterilization technique because of its rapid and uniform heating without causing electrode corrosion. To elucidate the electrical factors associated with POH performance in the inactivation of pathogens, the effects of the applied voltage and duty ratio on POH were investigated. In this study, we verified that a high applied voltage (80 Vrms) at a duty ratio of 0.1 caused thermal and nonthermal effects on pathogens that led to an approximately 4-log-unit reduction in a significantly short time. Therefore, the results of this research corroborate database predictions of the inactivation efficiency of POH based on pathogen control strategy modeling.

Drug reactions affecting hair and nails

Drug-induced changes of hair and nails have been observed with a variety of different pharmaceutical agents, both topical and systemic. These compounds or their metabolites may interfere with hair cycling and texture, nail matrix, nail bed, nail folds, and microvasculature. Phototoxic reactions may also occur. Before initiating treatment, physicians and patients should be aware of possible adverse events to hair and nails and should be aware of the preventive measures, if available, as quality of life can be reduced, and adherence and compliance to treatment may be impaired.