Case Presentation:
A 70-year Sudanese female, diabetic and hypertensive with a past history of ischemic stroke 7 years ago resulted in residual right-side weakness; presented complaining of fever and altered level of consciousness for 2 days with history of recurrent productive cough and recurrent right lower limb swelling for months. There is no family history of similar condition, or connective tissue disease. The patient is neither a smoker nor alcohol consumer. Her current medications included Glimepiride 4 mg and Losartan 50 mg.
Clinical examination revealed awake, confused patients (GCS 14/15) , otherwise clear neurological examination, BP 150/90 mmhg, pulse was 80 beats per minute, SPo2 on 99% of room air. There was yellowish discoloration of her nails in both upper and lower extremities associated with separation from the nail beds (Figure 1 and 2). Chest examination revealed a right-side stony dullness, decreased air entry and diminished vocal resonance. Also, a pitting right lower limb oedema.
Laboratory investigations showed random blood glucose of 44 mg/dl, positive Blood Film for Malaria, normal Renal and Liver function tests. Chest radiograph revealed a moderate right sided pleural effusion (Figure 3). Therapeutic thoracentesis was done with 2 litres of a straw-coloured fluid removed, sent for microscopic examination which showed a hemorrhagic background pleural fluid, that’s made of mixed mononuclear inflammatory cells with lymphocytic predominance and it was containing 3.0 g/dl proteins and 57.5 mg/dl glucose.
Diagnosis of yellow nail syndrome with pleural effusion and complicating pneumonia was made.
The patient managed with Quinine infusion 600 mg T.D.S, 3rd generation cephalosporin, vitamin E and prophylactic dose of heparin, however the condition deteriorate progressively and the patient passed away on the fifth day of admission due to acute respiratory distress syndrome (ARDS).