Case of Classical Koilonychia in Iron-Deficiency Anemia

Dr Samad Ghaffari at Tabriz University of Medical Sciences, Tabriz, Iran and colleagues have reported a Case of Classical Koilonychia in Iron-Deficiency Anemia. The case study has appeared in NEJM.

According to the history, a 54-year-old woman presented to the primary care clinic with fatigue and a 7-year history of intermittent hemorrhoidal bleeding. When examined, she appeared pale and had spoon-shaped nails (koilonychia) on the second and third finger and the thumb of both hands.

Koilonychia can be hereditary, acquired or idiopathic. Acquired causes are common which include inflammatory dermatoses like psoriasis or lichen planus, onychomycosis, secondary to anaemia and traumatic or occupational. Koilonychia occurs in 5.4% of the patients with iron deficiency. It is thought to occur due to the upward deformation of the lateral and distal portions of pliable iron deficient nail plates under mechanical pressure. Nail matrix changes due to blood flow abnormalities were also proposed as a pathomechanism.

Her laboratory evaluation showed a haemoglobin level of 7.8 g per deciliter (normal value, 12 to 15), a mean corpuscular volume of 66 fl (normal value, 80 to 95), a platelet count of 550,000 per microliter (normal value, 150,000 to 400,000), an iron level of 23 μg per deciliter (normal value, 40 to 155), a ferritin level of 3 ng per milliliter (normal value, 12 to 150), and a total iron-binding capacity of 470 μg per deciliter (normal value, 250 to 400).

Courtesy NEJM
The findings of patient on upper gastrointestinal endoscopy and colonoscopy were normal, except for the presence of haemorrhoids. Because bleeding from haemorrhoids does not typically cause this degree of anaemia, further evaluation for other causes of iron deficiency was undertaken. Stool examination for ova and parasites and laboratory testing for celiac disease were negative, and results on abdominal ultrasonography were normal.

Koilonychia is associated with iron-deficiency anemia and may also be hereditary, idiopathic, or associated with nail trauma or solvent exposure. The first three digits may be preferentially affected. The patient was treated with oral iron supplementation. At the 3-month follow-up, her fatigue had lessened, and her haemoglobin level had increased to 11.2 g per deciliter; however, her nails appeared unchanged.