Fingernail Findings in Liver Disease

Submitted by Emily Vancor and Naseema Merchant
Published October 5, 2019

A 61 year old man with alcoholic cirrhosis presented with worsening ascites, dyspnea, and unsteadiness of five months duration.  On exam, he had a distended abdomen, dilated periumbilical vessels and a positive fluid wave test. Figure A shows the patient’s fingernails which have an opaque white nailbed that extends to 1-3 mm from the distal nail edge. With this ground-glass-like discoloration, the border of the lunula cannot be seen.  The distal 1-2 mm of each of the patient’s nails are a red-brown color. After 6 L of ascitic fluid was removed via large volume paracentesis, the patient’s dyspnea and unsteadiness improved.

Questions:

The patient’s fingernail physical exam findings are most consistent with which condition?

1. Lindsay’s Nails
2. Terry’s Nails
3. Splinter hemorrhages
4. Paronychia

This condition, which is commonly seen in chronic diseases including cirrhosis, congestive heart failure, nephrotic syndrome, and diabetes, is thought to be caused by: 

1. Hypoalbuminemia and changes in nail bed vascularity
2. Hypoperfusion of the nail bed
3. Hypertension
4. Malnutrition

Answers and Discussion:

The nail findings are called Terry's Nails and are caused by hypoalbuminemia and changes in nail bed vascularity.

The proximal ground-glass discoloration of this patient’s fingernails which obscures the border of the lunula and the red-brown horizontal bands on the patient’s distal fingernail tips are characteristic of Terry’s nails. Terry nails are commonly seen in patients with liver cirrhosis, as well as in patients with other chronic diseases including congestive heart failure, nephrotic syndrome, and diabetes mellitus. Although the pathophysiology behind Terry’s nails is not well understood, possible explanations include hypoalbuminemia, increased connective tissue between the nailbed and the growth plate, and altered steroid metabolism(1). Histopathologic studies of Terry’s nails have also shown changes in nailbed vascularity with distal telangiectasias in the upper dermis(2). This case highlights the importance and utility of inspecting patients’ hands and fingernails, which can reveal early signs of systemic disease.

References:

1. Terry R. White nails in hepatic cirrhosis. Lancet. 1954;266(6815):757-759. doi:10.1016/S0140-6736(54)92717-8.
2. Holzberg M, Walker HK. Terry’s Nails: Revised Definition and New Correlations. Lancet. 1984;323(8382):896-899. doi:10.1016/S0140-6736(84)91351-5.

Authors:

Emily Vancor is a medical student at the Yale School of Medicine.

Dr. Naseema Merchant is an attending physician at the Yale School of Medicine Department of Internal Medicine.