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Case based discussions
Case-based discussion from North Tyneside General Hospital: somatostatin analogues in yellow nail syndrome associated with recurrent pleural effusions
  1. Kristian G Brooks1,
  2. Carlos Echevarria1,2,
  3. David Cooper1,
  4. Stephen C Bourke1,2
  1. 1Department of Respiratory Medicine, North Tyneside General Hospital, North Shields, UK
  2. 2Newcastle University, Institute of Cellular Medicine, Newcastle-upon-Tyne, UK
  1. Correspondence to Dr Stephen C Bourke, Department of Respiratory Medicine, North Tyneside General Hospital, Rake Lane, North Shields, Tyne and Wear NE29 8NH, UK; Stephen.bourke{at}nhct.nhs.uk

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Kristian Brooks (KB): A 77-year-old man presented to accident and emergency with a 1-month history of progressive breathlessness and reduced exercise tolerance. He had no chest pain, cough or wheeze, but had bilateral leg swelling and 4 kg weight loss. He had long-standing nail dystrophy and, following presentation with recurrent lower respiratory tract infections several years previously, bronchiectasis had been confirmed on high-resolution CT. He was a lifelong non-smoker, but had significant occupational asbestos exposure. There was no relevant family history. Chest radiograph showed large bilateral pleural effusions. Blood tests, including markers of infection and inflammation, were unremarkable. An ultrasound-guided pleural tap showed a lymphocytic exudate.

Stephen C Bourke (SCB): The combination of nail dystrophy, lymphocytic pleural effusions, bronchiectasis and lymphoedema is consistent with yellow nail syndrome (YNS), but coexistent malignancy or other pathology should be excluded, particularly in view of the history of weight loss and asbestos exposure. Pleural fluid should be sent for cholesterol and triglycerides, cytology and culture, including mycobacterium TB. Thoracic CT and echocardiography should be performed. Overall, the most common causes for lymphocytic effusions are malignancy or TB. In a case series of 41 patients with YNS, around half had pleural effusions, which were predominantly lymphocyte-rich and more often bilateral than unilateral.1 Chylothorax may also occur in YNS, classically appearing milky white due to high levels of triglycerides, but may be yellow or blood stained.

KB: No malignant cells were seen in the pleural fluid, and TB stain and culture were negative. Thoracic CT showed bilateral effusions, segmental consolidation in the left lower lobe and bilateral pleural plaques, but no pulmonary masses or lymphadenopathy. Echocardiography showed normal biventricular function and no evidence of a pericardial effusion. Previous medical …

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