Yellow nail syndrome following multiple orthopedic surgeries
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Yellow nail syndrome is a rare condition associated with a triad of symptoms: yellow nails, lung lesions, and lymphedema. A case of yellow nail syndrome caused by titanium exposure from multiple artificial joint replacements is presented.

A 78-year-old Asian woman presented to our outpatient department with chief complaints of cough, fever, and nausea. The patient was hospitalized for observation because of the presence of hypoxemia and bilateral pleural effusion. Her medical history included knee joint replacement and two spinal fusion surgeries. Her physical examination conducted following hospitalization revealed yellow nails on both hands and feet. This finding, combined with the observation of bilateral pleural effusion, raised suspicion for yellow nail syndrome. Blood analysis yielded negative results, as did the tests for sputum culture, interferon liberation, pleural effusion culture, and pleural effusion cytology. Pleural histopathological analysis and imaging yielded negative results. Considering the possibility of titanium exposure from artificial joints based on the patient’s medical history, we examined a chest radiograph obtained before the second spinal fusion surgery; however, no pleural effusion was observed. Pleural effusion was observed, On the basis of these findings, the patient was diagnosed with yellow nail syndrome due to titanium exposure.

YNS may also develop following dental treatment or titanium exposure from cardiac pacemakers or artificial joints, Previous studies have demonstrated that vitamin E supplementation, antifungal agents, and clarithromycin are effective in the treatment of YNS.

YNS, which may be caused by titanium exposure, is a rare complication of multiple joint replacement surgeries. A patient’s nails should be examined in the case of an unexplained pleural effusion, and the surgical history, particularly the number of operations the patient has undergone, should be evaluated. As the population ages and the number of patients with artificial joints increases, the incidence of YNS may also increase. Surgical intervention is effective in the treatment of pleural effusion in patients with YNS.

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