A case of brown and striped nails after chemotherapy

Dr Musa F. Alzahrani at King Saud University, Riyadh, Saudi Arabia has reported a case of nails turning brown and striped after chemotherapy. The case has appeared in NEJM.

Chemotherapy can have various side effects on a person's hair and nails, ranging from changes in the colour, the appearance of Grooves or ridges, brittle nails, Changes in nail shape or texture,cuticles that are red and hurt and nail splitting but in the instant case, the cancer treatment created a particularly striking pattern.

According to history a 42-year-old man Saudi Arabia presented with gastric-outlet obstruction and was diagnosed with non-Hodgkin lymphoma. He underwent four cycles of chemotherapy which had included rituximab, etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin after which he presented to the oncology clinic with changes in his fingernails.

His physical examination showed diffuse, dark brown discolouration of his fingernails called melanonychia and two types of transverse white lines that were not palpable. His serum albumin level was 2.5 g per deciliter (reference range, 3.5 to 5.0). He had opaque-appearing transverse lines (long arrow) on the fingernails which are called Mees’ lines (true leukonychia), and the more translucent-appearing lines (short arrow) that are called Muehrcke’s lines (apparent leukonychia)

After six cycles of chemotherapy, the patient had remission of the non-Hodgkin’s lymphoma. After approximately 6 months of the completion of chemotherapy, the fingernail changes resolved completely.

The brown discolouration is due to a condition called "melanonychia," which occurs when the nail has excess melanin, a dark brown or black pigment that colours the hair, skin and iris of the eye.

Mees’ lines develop as a result of injury to the nail matrix, whereas Muehrcke’s lines are related to the abnormal nail-bed vasculature. Therefore, Mees’ lines do not diminish with compression of the nail plate, and Muehrcke’s lines do. Multiple chemotherapy agents are associated with these nail changes. Muehrcke’s lines can also occur in patients with hypoalbuminemia.