Nail Abnormalities

Nail Abnormalities

Q. 1

Digital clubbing is seen in all except

 A >Endocarditis
 B >Pulmonary arteriovenous fistula
 C >Tricuspid atresia
 D >Aortic dissection
Q. 1

Digital clubbing is seen in all except

 A >Endocarditis
 B >Pulmonary arteriovenous fistula
 C >Tricuspid atresia
 D >Aortic dissection
Ans. D

Explanation:

Aortic dissection 

Causes of clubbing

Remember

  • Acute endocarditis does not cause clubbing, clubbing is caused by subacute endocarditis.



Q. 2 Onycholysis is seen in all of the follo­wing, except:
 A Allergic dermatitis
 B Psoriasis
 C Antineoplastic therapy
 D Nephrotic syndrome
Q. 2 Onycholysis is seen in all of the follo­wing, except:
 A Allergic dermatitis
 B Psoriasis
 C Antineoplastic therapy
 D Nephrotic syndrome
Ans. D

Explanation:

Nephrotic syndrome


Q. 3

A 60-year-old woman complains to a physician because several of her toe nails are discolored. Physical examination demonstrates crumbling, friable nails with distal-lateral separation from the nail bed. Hyperkeratotic debris is present under the affected part of the nail. Which of the following is the most likely pathogen?

 A

Aspergillus

 B

Candida

 C

Mucor

 D

Trichophyton

Q. 3

A 60-year-old woman complains to a physician because several of her toe nails are discolored. Physical examination demonstrates crumbling, friable nails with distal-lateral separation from the nail bed. Hyperkeratotic debris is present under the affected part of the nail. Which of the following is the most likely pathogen?

 A

Aspergillus

 B

Candida

 C

Mucor

 D

Trichophyton

Ans. D

Explanation:

The patient has a fungal nail infection.

These infections are seen most commonly in the elderly, and are usually caused by dermatophyte infection, typically Trichophyton rubrum, Trichophyton mentagrophytes, or Epidermophyton floccosum. Some of the more superficial lesions can be removed by simply scraping the fungus off the nail. Systemic fungal therapy (notably terbinafine) of months duration (because nails are grown so slowly) may be required for deeper nail lesions.

Aspergillus (1st Choice) may be a lung saprophyte or cause invasive disease.

Candida (2nd Choice) is a rare cause of fungal nail infection.

Associate Mucor (3rd Choice) with sinonasal infection.

 

 


Q. 4

A 60-year-old woman complains to a physician because several of her toenails are discolored. Physical examination demonstrates crumbling, friable nails with distal-lateral separation from the nail bed. Hyperkeratotic debris is present under the affected part of the nail. Which of the following is the most likely pathogen?

 A

Aspergillus

 B

Candida

 C

Mucor

 D

Trichophyton

Q. 4

A 60-year-old woman complains to a physician because several of her toenails are discolored. Physical examination demonstrates crumbling, friable nails with distal-lateral separation from the nail bed. Hyperkeratotic debris is present under the affected part of the nail. Which of the following is the most likely pathogen?

 A

Aspergillus

 B

Candida

 C

Mucor

 D

Trichophyton

Ans. D

Explanation:

The patient has a fungal nail infection.

These infections are seen most commonly in the elderly, and are usually caused by dermatophyte infection, typically Trichophyton rubrum, Trichophyton mentagrophytes, or Epidermophyton floccosum.

Some of the more superficial lesions can be removed by simply scraping the fungus off the nail.

Systemic fungal therapy (notably terbinafine) of months duration (because nails are grown so slowly) may be required for deeper nail lesions.

Aspergillus may be a lung saprophyte or cause invasive disease.
Candida is a rare cause of fungal nail infection.
Associate Mucor with sinonasal infection.
Ref: Ray C.G., Ryan K.J. (2010). Chapter 44. Dermatophytes, Sporothrix, and Other Superficial and Subcutaneous Fungi. In C.G. Ray, K.J. Ryan (Eds), Sherris Medical Microbiology, 5e.

Q. 5

True about Dyskeratosis congenita –

 A

Pancytopenia

 B

Nail dystrophy

 C

Hyperkeratosis

 D

a and b

Q. 5

True about Dyskeratosis congenita –

 A

Pancytopenia

 B

Nail dystrophy

 C

Hyperkeratosis

 D

a and b

Ans. D

Explanation:

Ans. is ‘a’ i.e pancytopenia, ‘b’ i.e nail dystrophy

Dyskeratosis congenita

  • It is characterised by mucous membrane leukoplakia, dystrophic nails, reticular hyperpigmentation and the development of aplastic anemia during chidhood.

o The X-linked variety is due to mutations in the DKC I (dyskeratin) gene; the more unusual autosomal dominant

type is due to the muatation in hTERC, which encodes an RNA template, and hTERT, which encodes the catalytic

reverse transcriptase, telomerase; these gene products cooperate in a repair complex to maintain telomere length. o Clinical features associated with dyskeratosis congenita are :-

  • Skin pigmentary abnormalities                     Nail dystrophy                                    Leukoplakia

          Epiphora                                                    Cognitive/develpomemt delay        Pulmonay disease

          Short stature                                              Dental carries/tooth loss                Esophageal stricture

          Hair loss/grey hair / sparse eyelashes           Hyperhydrosis                               Intrauterine growth retardation

          Gastrointestinal disorders                            Ataxia                                           Hypogonadism/undescended testis

          Microcephaly                                              Uretheral stricture/phimosis              Deafness

a Osteoporois/aseptic necosis/scoliosis q Bone marrow failure                        Malignancy

         Pancytopenia with hypocellular marrow


Q. 6

Nails is formed in which week of IUL –

 A

0 – 6 week

 B

10 – 12 week

 C

14 -18 week

 D

20 – 24 week

Q. 6

Nails is formed in which week of IUL –

 A

0 – 6 week

 B

10 – 12 week

 C

14 -18 week

 D

20 – 24 week

Ans. B

Explanation:

Ans. is ‘b’ i.e., 10 – 12 week

  1. Age of fetus                                                               

End of Ist month                  Important changes

  • Length -1 cm, weight -21/2 gm
  • Eyes are seen as two dark spots and mouth as a cleft
  • Nucleated RBCs begin to form in placenta

End of 2nd month           

  • Length -4 cm, weight – 10 gm
  • First ossification center appears in clavicle (4-5 weeks)
  • The anus is seen as dark spot

End of 3rd month          

  • Length -9 cm, weight – 30 gm
  • Nails appear and neck is formed

End of 4th month          

  • Length -16 cm, weight – 120 gm
  • Sex can be recognized
  • Lanugo hair is seen
  • Meconium is found in duodenum
  • Convolution begins to develop in brain

End op’ month           

  • Length -25 cm, weight – 400 gm
  • Nails are distinct and soft
  • Meconium appears in beginning of large intestine
  • Light hair appear on head
  • Skin is covered with vernix caseosa

End of 6th month          

  • Length -30 cm, weight – 700 gm
  • Eyebrows and eyelashes appear
  • Testes are seen close to kidney
  • Meconium in transverse colon

End of 7`” month          

  • Length -35 cm, weight – 900 to 1200 gm
  • Meconium in entire large intestine
  • Tests are found at external inguinal ring
  • Eyelids open and pupillary membrane disappear

End of 8th month          

  • Length -40 cm, weight – 1.5-2 kg
  • Nails reach the tips of fingers
  • Left testis is present in scrotum

End of 9th month          

  • Length -45 cm, weight – 2.2-3.0 kg
  • Scrotum contains both testes
  • Meconium is seen at the end of large intestine

End of Ir month         

  • Length -48-52 cm, weight – 2.5-5 kg

(full tenn child)                

  • Six fontanels are present
  • Surface of brain shows convolution and grey matter begins to form
  • Lanugo is absent except on shoulders.
  • Skin is pale and covered with vernix caseosa
  • The nails project beyond the tip of fingers, but reach only the tip of the toes
  • Cartilages have formed in nose and ears.

Q. 7

Wrong statement is:

 A

Mees line in Arsenic poisoning

 B

Pterygium of nails in Lichen Planus

 C

Oncholysis in Psoriasis

 D

Koilonychia in Megaloblastic Anemia (B12 def.)

Q. 7

Wrong statement is:

 A

Mees line in Arsenic poisoning

 B

Pterygium of nails in Lichen Planus

 C

Oncholysis in Psoriasis

 D

Koilonychia in Megaloblastic Anemia (B12 def.)

Ans. D

Explanation:

D i.e. Koilonychia in megaloblastic anemia (B12 def) 


Q. 8

Pitting of nails is seen in :

 A

Lichen planus

 B

Psoriasis

 C

Phemphigus

 D

Arsenic poisoning

Q. 8

Pitting of nails is seen in :

 A

Lichen planus

 B

Psoriasis

 C

Phemphigus

 D

Arsenic poisoning

Ans. B

Explanation:

B. i.e. Psoriasis


Q. 9

Which of the following is wrong statements:

 A

Koilonychia in Vit B12 deficiency

 B

Oncholysis in Psoriasis

 C

Mees lines in Arsenic poisoning

 D

Pterygium of nailis in Lichen Planus

Q. 9

Which of the following is wrong statements:

 A

Koilonychia in Vit B12 deficiency

 B

Oncholysis in Psoriasis

 C

Mees lines in Arsenic poisoning

 D

Pterygium of nailis in Lichen Planus

Ans. A

Explanation:

Ans: A i.e. Koilonychia in Vit B12 deficiency.

Koilonychia (Spoon nail)

  • The nail is concave with raised edges.
  • Seen in Iron Deficiency Anemia,Hypothyroidism,Lichen Planus.



Q. 10

Tinea ungum effects

 A

Nail fold

 B

Nail plate

 C

Joints

 D

Inter digital space

Q. 10

Tinea ungum effects

 A

Nail fold

 B

Nail plate

 C

Joints

 D

Inter digital space

Ans. B

Explanation:

B i.e. Nail plate


Q. 11

A patient presented with scarring alopecia, thinned nails, hypopigmented macular lesions over the trunk and oral mucosa. The diagnosis is

 A

Psoriasis

 B

Leprosy

 C

Lichenplanus

 D

Pemphigus

Q. 11

A patient presented with scarring alopecia, thinned nails, hypopigmented macular lesions over the trunk and oral mucosa. The diagnosis is

 A

Psoriasis

 B

Leprosy

 C

Lichenplanus

 D

Pemphigus

Ans. C

Explanation:

C i.e. Lichen Planus


Q. 12

Characterstic nail finding in lichen planus

 A

Pitting

 B

Pterygium

 C

Beau’s Lines

 D

Hyperpigmentation of nails

Q. 12

Characterstic nail finding in lichen planus

 A

Pitting

 B

Pterygium

 C

Beau’s Lines

 D

Hyperpigmentation of nails

Ans. B

Explanation:

B i.e. Pterygium


Q. 13

10 year old chid has violaceous papule and pterygium of nails. The diagnosis is

 A

Psoriasis

 B

Pemphigus

 C

Pemphigoid

 D

Lichen Planus

Q. 13

10 year old chid has violaceous papule and pterygium of nails. The diagnosis is

 A

Psoriasis

 B

Pemphigus

 C

Pemphigoid

 D

Lichen Planus

Ans. D

Explanation:

D i.e. Lichen planus


Q. 14

Koenen’s periungual fibromas are seen in > 50% of cases with :

 A

Tuberous sclerosis

 B

Sturge weber syndrome

 C

Alaxia telangiectasia

 D

Neurofibroatosis

Q. 14

Koenen’s periungual fibromas are seen in > 50% of cases with :

 A

Tuberous sclerosis

 B

Sturge weber syndrome

 C

Alaxia telangiectasia

 D

Neurofibroatosis

Ans. A

Explanation:

A i.e. Tuberous sclerosis


Q. 15

Cardiovascular causes of digital clubbing include all of the following Except:

 A

Infective Endocarditis

 B

Arteriovenous Fistulos

 C

Tricuspid Atresia

 D

Aortic Dissection

Q. 15

Cardiovascular causes of digital clubbing include all of the following Except:

 A

Infective Endocarditis

 B

Arteriovenous Fistulos

 C

Tricuspid Atresia

 D

Aortic Dissection

Ans. D

Explanation:

Answer is D (Aortic Dissection)

Aortic Dissection is not a known cause for digital clubbing:

Digital clubbing results from long standing conditions that take months to develop. It is not associated with acute event like aortic dissection

Cardiovascular causes of Digital clubbing (Ultra medicine (2005)/285)

  • Subacute Bacterial Endocarditis(SBE)
  • Cyanotic congenital Heart Disease

–         Tetralogy of Fallot (TOF)

–         Transposition of Great vessels (TGV)

–         Total Anomolous pulmonary venous circulation (TAPVC)

–         Ebstein’s Anomaly

–         Tricuspid Atresia

  • Atrial Myxoma
  • Arterio venous malformations (Brochial arteriovenous fistula)
  • Axillary artery Aneurysms

Clubbing is a feature of Subacute Bacterial Endocarditis (SBE) and is not seen in Acute Bacterial Endocarditis Acute endocarditis is a fitIminant event while clubbing takes months to develop. Acute bacterial endocarditis is not associated with clubbing.


Q. 16

Nail and half nail sign, seen in uremia is

 A

Due to melanin deposition

 B

Increased capillary density at the distal half of nails

 

 C

Hypoproteinemia

 D

Circulating toxin

Q. 16

Nail and half nail sign, seen in uremia is

 A

Due to melanin deposition

 B

Increased capillary density at the distal half of nails

 

 C

Hypoproteinemia

 D

Circulating toxin

Ans. B

Explanation:

Answer is B (Increased capillary density at distal half of nails):

The increase in capillary density of nail bed accounts for the band of discolouration–Oxford Text book of Clinical Nephrologv

Half and Half Nail: Typical nail sign in Uraemia

  • In half-and half nail, two portions can be distinguished separated almost horizontally by a clear line of demarcation.
  • Proximally the nail has a dull whitish ground glass appearance Distally the nail bed, is red. pink or brown (occupies 20-60% of total nail length)
  • When pressure is applied, the discolouration does not fade completely
  • Change can affect single nails or all nails of the hands, feet or both

Pathology /Histology

  • The disorder is believed to result from increase in capillary density of the nail bed
  • The number of capillaries under the nail plate is increased, with remarkable thickening of the capillary walls
  • The histology of the nail plate itself shows no change and it contains no melanin.

Q. 17

Clubbing is least common in:

 A

Squamous cell carcinoma

 B

Adenocarcinoma

 C

Small cell carcinoma of lung

 D

Mesothelioma

Q. 17

Clubbing is least common in:

 A

Squamous cell carcinoma

 B

Adenocarcinoma

 C

Small cell carcinoma of lung

 D

Mesothelioma

Ans. C

Explanation:

Answer is C (Small cell Ca of Lung):

`Skeletal connective tissue syndromes including clubbing is usually seen in no n small cell carcinomas ‘H-1 6th Clubbing is thus least common with small cell carcinoma of lung


Q. 18

Causes of unilateral clubbing include all of the following, Except

 A

Congenital cyanotic heart disease

 B

Panicoast tumor

 C

Aortic Ancurym

 D

Brachial AV fistulas

Q. 18

Causes of unilateral clubbing include all of the following, Except

 A

Congenital cyanotic heart disease

 B

Panicoast tumor

 C

Aortic Ancurym

 D

Brachial AV fistulas

Ans. A

Explanation:

Answer is A (Congenital Cyanotic Heart Disease) :

Congenital cyanotic heart disease is a cause for bilateral clubbing

Causes of Unilateral Clubbing

  • Aneurysm of Aorta, innonimate artery, suhclavian artery or axillary artery
  • Brachial AV fistulas / malformations
  • Infected arterial grafts
  • Pancoast tumors
  • Unilateral Elythromelalgia

Q. 19

Which of the following poisoning presents with abdominal pain, diarrhea, Mees line on nails and myelosuppression:

September 2011

 A

Lead

 B

Arsenic

 C

Alcohol

 D

Mercury

Q. 19

Which of the following poisoning presents with abdominal pain, diarrhea, Mees line on nails and myelosuppression:

September 2011

 A

Lead

 B

Arsenic

 C

Alcohol

 D

Mercury

Ans. B

Explanation:

Ans. B: Arsenic

In chronic arsenic poisoning, a classical state of ill health results are represented by 4 stages. First stage of nutritional and gastrointestinal disturbances (diarrhoea is common)

Third stage (of skin rashes) shows white bands known as Mees line crossing the nail of fingers and toes

In addition to this, there may be evidence of liver damage, kidney damage and bone marrow depression at some stage Arsenic poisoning

  • Increased levels of the element arsenic in the body.
  • Arsenic interferes with cellular longevity by allosteric inhibition of an essential metabolic enzyme.
  • Symptoms of arsenic poisoning include headache, confusion, convulsion, diarrhea, vomiting, and in severe case coma and death
  • Routes of exposure include contaminated water, air, and food.
  • Occupational exposure to arsenic may occur with copper or lead smelting and wood treatment and among workers involved in the production or application of pesticides
  • Symptoms of arsenic poisoning begin with headaches, confusion, severe diarrhea, and drowsiness.
  • As the poisoning develops, convulsions and changes in fingernail pigmentation called leukonychia may occur.
  • When the poisoning becomes acute, symptoms may include diarrhea, vomiting, blood in the urine, cramping muscles, hair loss, stomach pain, and more convulsions.
  • The organs of the body that are usually affected by arsenic poisoning are the lungs, skin, kidneys, and liver.
  • Chronic arsenic exposure can remain in the body systems for a longer period of time than a shorter term or more isolated exposure and can be detected in a longer time frame after the introduction of the arsenic, important in trying to determine the source of the exposure.
  • Hair is a potential bioindicator for arsenic exposure due to its ability to store trace elements from blood.
  • Incorporated elements maintain their position during growth of hair.
  • Thus for a temporal estimation of exposure, an assay of hair composition needs to be carried out with a single hair
    which is not possible with older techniques requiring homogenization and dissolution of several strands of hair.
  • This type of biomonitoring has been achieved with newer microanalytical techniques like Synchroton radiation based X ray fluorescence (SXRF) spectroscopy and Microparticle induced X ray emission (PIXE).
  • Dimercaprol and dimercaptosuccinic acid are chelating agents which sequester the arsenic away from blood proteins and are used in treating acute arsenic poisoning.
  • The most important side effect is hypertension.
  • Dimercaprol is considerably more toxic than succimer

Q. 20

A middle aged man presented with paraesthesia of hands and feet. Examination revealed presence of ‘Mees’ lines in the nails and raindrop pigmentation in the hands. The most likely diagnosis is:

AIIMS 08, 09, 11

 A

Lead poisoning

 B

Arsenic poisoning

 C

Thallium poisoning

 D

Mercury poisoning

Q. 20

A middle aged man presented with paraesthesia of hands and feet. Examination revealed presence of ‘Mees’ lines in the nails and raindrop pigmentation in the hands. The most likely diagnosis is:

AIIMS 08, 09, 11

 A

Lead poisoning

 B

Arsenic poisoning

 C

Thallium poisoning

 D

Mercury poisoning

Ans. B

Explanation:

Ans. Arsenic poisoning


Q. 21

Muehrcke lines in nails are seen in

 A

Nephrotic syndrome

 B

Barrter syndrome

 C

Nail patella syndrome

 D

Acute tubular necrosis

Q. 21

Muehrcke lines in nails are seen in

 A

Nephrotic syndrome

 B

Barrter syndrome

 C

Nail patella syndrome

 D

Acute tubular necrosis

Ans. A

Explanation:

Ans. is ‘a’ i.e., Nephrotic syndrome


Q. 22

A 60-year old male presented with discoloration, thickening and tunneling of 2 fingernails and one toe­nail. Which of the following will clinch the diagnosis at the earliest

 A

Wood’s lamp examination

 B

KOH mount

 C

Slit smear (split skin smear)

 D

Gram stain

Q. 22

A 60-year old male presented with discoloration, thickening and tunneling of 2 fingernails and one toe­nail. Which of the following will clinch the diagnosis at the earliest

 A

Wood’s lamp examination

 B

KOH mount

 C

Slit smear (split skin smear)

 D

Gram stain

Ans. B

Explanation:

Ans. b. KOH mount

Discoloration, thickening and tunneling of two fingernails and one toenail is suggestive of onychomycosis or Tinea unguum. The most important test to diagnose this is nail scraping for KOH

Tinea unguum (Onychomycosis)

  • Tinea unguum is the ringworm of nail, usually caused by T rubrum.
  • It causes yellowish discoloration of the nails along with thickening of the nails.
  • The most important test to diagnose this is a nail scraping for KOH.
Type Affected body part Causative agent

Tinea carporis (glabrosa)

Skin of body or limbs(usually non hairy)

T. verrucosumQ
Tinea cruris (Dhobi/jack itch) Groin, perineum, thighs, scroturn (least and late involvement)

Trichophyton rubrumQ

E. floccosum

Tinea capitis Scalp

Microsporum canis (MC)Q

T. schoenleini, T. tonsurans

Tinea pedis (Athelete foot) Feet, MC 4th web space

T. rubrumQ

T. mentagrophyte, E. floccosum

Tinea manuum Palms T. rubrumQ
Tinea unguum (Onychomycosis) Nail plate >nail bed°

T. rubrumQ

T. mentagrophyte, E. floccosum


Q. 23

A patient p lited with Hat topped violaceous papules, thinning of nails and onychyloysis. What is the -,icroscopic finding observed in this patient?

 A

Prominent necrotic cell

 B

Suprabasal split

 C

Basal cell degeneration

 D

Acantholysis

Q. 23

A patient p lited with Hat topped violaceous papules, thinning of nails and onychyloysis. What is the -,icroscopic finding observed in this patient?

 A

Prominent necrotic cell

 B

Suprabasal split

 C

Basal cell degeneration

 D

Acantholysis

Ans. C

Explanation:

Ans. c. Basal degeneration


Q. 24

Thimble pitting of nails is seen in 

 A

Psoriasis

 B

Pemphigus

 C

Lichen planus

 D

Alopecia areata

Q. 24

Thimble pitting of nails is seen in 

 A

Psoriasis

 B

Pemphigus

 C

Lichen planus

 D

Alopecia areata

Ans. A

Explanation:

Ans. is ‘a’ i.e., Psoriasis


Q. 25

Lovibond profile sign is seen in ‑

 A

Koilonychia

 B

Platynochia

 C

Clubbing

 D

Onycholysis

Q. 25

Lovibond profile sign is seen in ‑

 A

Koilonychia

 B

Platynochia

 C

Clubbing

 D

Onycholysis

Ans. C

Explanation:

Ans. is ‘c’ i.e., Clubbing

Clinical indicators of clubbing are Lovibond profile sign and curth’s modified profile sign”.

  • Lovibond angle is the angle located at the junction between the nail plate and proximal nail fold. It is normally less than 160°. In clubbing, the angle exceeds 180° (Lovibond profile sign).

Q. 26

40 yr old with koilonychias, iron deficiency & dysphagia, diagnosis is ‑

 A

Plummer Vinson syndrome

 B

Achalasia cardia

 C

7ES

 D

None

Q. 26

40 yr old with koilonychias, iron deficiency & dysphagia, diagnosis is ‑

 A

Plummer Vinson syndrome

 B

Achalasia cardia

 C

7ES

 D

None

Ans. A

Explanation:

Ans. is ‘a’ i.e., Plummer Vinson syndrome 

Plummer-Vinson syndrome

  • Plummer-Vinson syndrome, also known as Brown-Kelly-Paterson syndrome or sederopenic dysphagia, seen in middle aged edentulous women.
  • The plummer Vinsion Paterson Brown Kelly Syndrome is characterized by : –
  • Dysphagia
  • Chronic iron deficiency anemia
  • Atrophic oral mucosa and glossitis
  • Brittle, spoon-shaped fingernails (Koilonychia)
  • The cause of dysphagia is usually a cervical esophageal web, but abnormal pharyngeal and esophageal motility may play a role.
  • The syndrome characterstically occurs in middle aged edentulous (without teeth) women.
  • It is a premalignant lesion. Approximately 10% of patient develop squamous cell Ca of esophagus, oral cavity or the hypopharynx.
  • As iron-deficiency anemia is a common finding, it is also known as sideropenic dysphagia.
  • Carcinoma develops in post-cricoid region.


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