Muehrcke's nails

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Muehrcke's lines
Other namesApparent leukonychia striata
Muehrcke's lines.JPG

Muehrcke's nails or Muehrcke's lines (apparent leukonychia striata) are changes in the fingernail that may be a sign of an underlying medical condition. The term refers to a set of one or more pale transverse bands extending all the way across the nail, parallel to the lunula. In contrast to Beau's lines, they are not grooved (no 3-dimensional deformity), and in contrast to Mees' lines, the thumb is usually not involved. [1] [2]

Contents

Muehrcke's lines are a strong indicator of hypoalbuminemia, which can result from a variety of different causes. [3] [4]

The lines are actually in the vascular bed underneath the nail plate. As such, they do not move with nail growth, and disappear when pressure is applied to the nail (blanching the underlying nail bed): this distinguishes them from "true leukonychia striata" such as Mees' lines. [1] As in Terry's and half-and-half nails, the pattern is thought to be formed by bands of localized edema exerting pressure on the surrounding capillaries. [3] [5]

Physiology

The appearance of Muehrcke's lines is associated specifically with marked hypoalbuminemia (serum albumin ≤ 2.2 g/dL) indicating decreased protein synthesis, which may occur during periods of metabolic stress (e.g. systemic infection, trauma, AIDS, chemotherapy), or in hypoalbuminemic states such as the nephrotic syndrome or dietary protein deficiency. They are also seen in patients with end-stage kidney disease on hemodialysis, Hodgkin's disease, pellagra, and sickle cell anaemia. [3] [6] [7] [8] [9]

The lines remain visible as long as protein intake is inadequate or synthesis is impaired, and they should disappear upon return to normal function. [3]

In extreme conditions, Muehrcke's lines may also arise from physical changes in peripheral circulation: one case study reported appearance of the lines in a healthy subject following ascent to 8,848 meters (29,029 ft) on Mount Everest. [10]

History

Muehrcke's lines were described by American physician Robert C. Muehrcke (1921–2003) in 1956. In a study published in BMJ, he examined patients with known chronic hypoalbuminemia and healthy volunteers, finding that the appearance of multiple transverse white lines was a highly specific marker for low serum albumin (no subject with the sign had SA over 2.2 g/dL), was associated with severity of the underlying condition, and disappeared upon successful treatment (corticosteroids in nephrotic syndrome) or direct infusion of HSA. [4]

See also

Related Research Articles

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<span class="mw-page-title-main">Nephrotic syndrome</span> Symptoms resulting from kidney damage

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<span class="mw-page-title-main">Serum protein electrophoresis</span> Laboratory test

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<span class="mw-page-title-main">Nail (anatomy)</span> Hard keratin protection of digit

A nail is a protective plate characteristically found at the tip of the digits of all primates, corresponding to the claws in other tetrapod animals. Fingernails and toenails are made of a tough rigid protein called alpha-keratin, a polymer also found in the claws, hooves and horns of vertebrates.

<span class="mw-page-title-main">Nail disease</span> Medical condition

A nail disease or onychosis is a disease or deformity of the nail. Although the nail is a structure produced by the skin and is a skin appendage, nail diseases have a distinct classification as they have their own signs and symptoms which may relate to other medical conditions. Some nail conditions that show signs of infection or inflammation may require medical assistance.

<span class="mw-page-title-main">Nail clubbing</span> Deformity of the finger or toe nails

Nail clubbing, also known as digital clubbing or clubbing, is a deformity of the finger or toe nails associated with a number of diseases, anomalies and defects; some congenital. This is mostly of the heart and lungs. When it occurs together with joint effusions, joint pains, and abnormal skin and bone growth it is known as hypertrophic osteoarthropathy.

<span class="mw-page-title-main">Serum albumin</span> Type of globular protein produced by the liver

Serum albumin, often referred to simply as blood albumin, is an albumin found in vertebrate blood. Human serum albumin is encoded by the ALB gene. Other mammalian forms, such as bovine serum albumin, are chemically similar.

<span class="mw-page-title-main">Leukonychia</span> White spots on finger and toe nails

Leukonychia is a medical term for white discoloration appearing on nails. It is derived from the Greek words leuko 'white' and onyx 'nail'. The most common cause is injury to the base of the nail where the nail is formed.

<span class="mw-page-title-main">Beau's lines</span> Medical condition

Beau's lines are deep grooved lines that run from side to side on the fingernail or the toenail. They may look like indentations or ridges in the nail plate.

<span class="mw-page-title-main">Onycholysis</span> Medical condition

Onycholysis is a common medical condition characterized by the painless detachment of the nail from the nail bed, usually starting at the tip and/or sides. On the hands, it occurs particularly on the ring finger but can occur on any of the fingernails. It may also happen to toenails.

<span class="mw-page-title-main">Mees' lines</span> Clinical sign involving white bands across the nails

Mees' lines or Aldrich–Mees lines, also called leukonychia striata, are white lines of discoloration across the nails of the fingers and toes (leukonychia).

<span class="mw-page-title-main">Hypoalbuminemia</span> Abnormally low levels of albumin in the blood

Hypoalbuminemia is a medical sign in which the level of albumin in the blood is low. This can be due to decreased production in the liver, increased loss in the gastrointestinal tract or kidneys, increased use in the body, or abnormal distribution between body compartments. Patients often present with hypoalbuminemia as a result of another disease process such as malnutrition as a result of severe anorexia nervosa, sepsis, cirrhosis in the liver, nephrotic syndrome in the kidneys, or protein-losing enteropathy in the gastrointestinal tract. One of the roles of albumin is being the major driver of oncotic pressure in the bloodstream and the body. Thus, hypoalbuminemia leads to abnormal distributions of fluids within the body and its compartments. As a result, associated symptoms include edema in the lower legs, ascites in the abdomen, and effusions around internal organs. Laboratory tests aimed at assessing liver function diagnose hypoalbuminemia. Once identified, it is a poor prognostic indicator for patients with a variety of different diseases. Yet, it is only treated in very specific indications in patients with cirrhosis and nephrotic syndrome. Treatment instead focuses on the underlying cause of the hypoalbuminemia. Albumin is an acute negative phase respondent and not a reliable indicator of nutrition status.

<span class="mw-page-title-main">Human serum albumin</span> Albumin found in human blood

Human serum albumin is the serum albumin found in human blood. It is the most abundant protein in human blood plasma; it constitutes about half of serum protein. It is produced in the liver. It is soluble in water, and it is monomeric.

<span class="mw-page-title-main">Terry's nails</span> Medical condition

Terry's nails is a physical condition in which a person's fingernails or toenails appear white with a characteristic "ground glass" appearance without any lunula. The condition is thought to be due to a decrease in vascularity and an increase in connective tissue within the nail bed; the darker shade of the distal portion of the nail fades upon pressure, which differentiates Terry's nails from Lindsay's nails. It frequently occurs in the setting of liver failure, cirrhosis, diabetes mellitus, congestive heart failure, hyperthyroidism, or malnutrition. Eighty percent of patients with severe liver disease have Terry's nails, but they are also found in people with kidney failure, in patients with congestive heart failure and are described as a brown arc near the ends of the nails. The recognition of characteristic nail patterns, such as Terry's nails, may be a helpful herald for early diagnosis of systemic diseases. This finding was named for Richard Terry.

Glomerulonephrosis is a non-inflammatory disease of the kidney (nephrosis) presenting primarily in the glomerulus as nephrotic syndrome. The nephron is the functional unit of the kidney and it contains the glomerulus, which acts as a filter for blood to retain proteins and blood lipids. Damage to these filtration units results in important blood contents being released as waste in urine. This disease can be characterized by symptoms such as fatigue, swelling, and foamy urine, and can lead to chronic kidney disease and ultimately end-stage renal disease, as well as cardiovascular diseases. Glomerulonephrosis can present as either primary glomerulonephrosis or secondary glomerulonephrosis.

<span class="mw-page-title-main">Half and half nail</span> Medical condition

Half and half nails show the proximal portion of the nail white and the distal half red, pink, or brown, with a sharp line of demarcation between the two halves. The darker distal discoloration does not fade on pressure, which differentiates Lindsay's nails from Terry's nails. The discoloration is thought to be due to β-melanocyte–stimulating hormone. Seventy percent of hemodialysis patients and 56% of renal transplant patients have at least one type of nail abnormality. Absence of lunula, splinter hemorrhage, and half and half nails were significantly more common in hemodialysis patients, while leukonychia was significantly more common in transplant patients.

Melanonychia is a black or brown pigmentation of a nail, and may be present as a normal finding on many digits in Afro-Caribbeans, as a result of trauma, systemic disease, or medications, or as a postinflammatory event from such localized events as lichen planus or fixed drug eruption.

Pincer nails are a toenail disorder in which the lateral edges of the nail slowly approach one another, compressing the nailbed and underlying dermis. It occurs less often in the fingernails than toenails, and there usually are no symptoms.

<span class="mw-page-title-main">Onychorrhexis</span> Medical condition

Onychorrhexis, is a brittleness with breakage of finger or toenails that may result from hypothyroidism, anemia, anorexia nervosa or bulimia, or after oral retinoid therapy. It can also be seen in melanoma that involves the nail and onychomycosis.

Chromonychia is an abnormality in color of the substance or surface of the nail plate or subungual tissues.

References

  1. 1 2 Rapini, Ronald P.; Bolognia, Jean L.; Jorizzo, Joseph L. (2007). Dermatology: 2-Volume Set. St. Louis: Mosby. ISBN   978-1-4160-2999-1.
  2. Zaiac, Martin N.; Walker, Ashley (September 2013). "Nail abnormalities associated with systemic pathologies". Clinics in Dermatology. 31 (5): 627–649. doi:10.1016/j.clindermatol.2013.06.018. ISSN   1879-1131. PMID   24079592.
  3. 1 2 3 4 Singal, Archana; Arora, Rahul (2015). "Nail as a window of systemic diseases". Indian Dermatology Online Journal. 6 (2): 67–74. doi: 10.4103/2229-5178.153002 . ISSN   2229-5178. PMC   4375768 . PMID   25821724.
  4. 1 2 MUEHRCKE RC (June 1956). "The finger-nails in chronic hypoalbuminaemia; a new physical sign". Br Med J. 1 (4979): 1327–8. doi:10.1136/bmj.1.4979.1327. PMC   1980060 . PMID   13316143.
  5. Hinds, Ginette; Thomas, Valencia D. (January 2008). "Malignancy and cancer treatment-related hair and nail changes". Dermatologic Clinics. 26 (1): 59–68, viii. doi:10.1016/j.det.2007.08.003. ISSN   0733-8635. PMID   18023771.
  6. Freedberg, Irwin M.; et al., eds. (2003). Fitzpatrick's dermatology in general medicine (6th ed.). New York, NY: McGraw-Hill. p. 659. ISBN   978-0-07-138076-8.
  7. Bianchi L, Iraci S, Tomassoli M, Carrozzo AM, Nini G (1992). "Coexistence of apparent transverse leukonychia (Muehrcke's lines type) and longitudinal melanonychia after 5-fluorouracil/adriamycin/cyclophosphamide chemotherapy". Dermatology. 185 (3): 216–7. doi: 10.1159/000247451 . PMID   1446089.
  8. Chapman S, Cohen PR (April 1997). "Transverse leukonychia in patients receiving cancer chemotherapy". South. Med. J. 90 (4): 395–8. doi:10.1097/00007611-199704000-00006. PMID   9114829. S2CID   29031413.
  9. Morrison-Bryant M, Gradon JD (2007). "Muehrcke's Lines". N Engl J Med. 357 (9): 917. doi:10.1056/NEJMicm065055. PMID   17761595.
  10. Windsor, Jeremy S.; Hart, Nigel; Rodway, George W. (2009). "Muehrcke's Lines on Mt. Everest". High Altitude Medicine & Biology. 10 (1): 87–88. doi:10.1089/ham.2008.1079. ISSN   1557-8682. PMID   19278357.

Bibliography