Onycholysis an early indicator of thyroid disease

Onycholysis is also referred to plummer's nails is a dermatological nail disorder characterized by spontaneous distal separation of the nail plate from the free margin and progressively proximally. We discuss a case of the 38-year-old man with onycholysis associated with hyperthyroidism due to Graves' disease. In this case review, we will discuss an association of onycholysis with thyroid disease and its diagnostic prognosis. Any unexplained onycholysis should prompt the clinician to investigate the client for asymptomatic hyperthyroidism.


Introduction
Ugly nails can be a source of stress for some people especially women despite them not giving any clinical symptomatic problems apart from being 'ugly' cosmetically. Onycholysis is a dermatological nail disorder which runs a chronic course. It is characterized by spontaneous distal separation of the nail plate from the free margin and progressively proximally [1]. Onycholysis is also referred to Plummer's Nails when it occurs in setting of hyperthyroidism [2,3].
Epidemiologically, onycholysis is not well documented but it affects persons of all races. The pathophysiology of onycholysis broadly may be idiopathic, traumatic, or secondary to nail bed disorders. It is associated with multifactorial causes: systemic conditions like Thyroid diseases (both hypo and hyperthyroidism) [2, 4], psoriasis, [5] drugs-especially anticancer agents like paclitaxel, [6] other chemical agents and in the case of PATEO syndrome [7]. Infective causes have been associated or compounding factors in the progression of onychomycosis like fungal infections [8] and bacterial infections like Pseudomonas aeruginosa, [1] trauma to nail, [9] and it can also be caused by any local problem, such as periungual warts as documented by Fawcett et al. Onycholysis depending on the cause is treatable as evidenced by Li et al in which they described a case of onychomadesis associated with chemotherapy in a 72-yearold woman [6]. In this case review, will discuss an association of onycholysis with thyroid disease and its diagnostic prognosis.

Patient and observation
History: A 38-year-old West African married man, employed as an information technology specialist on a working workshop to Wuhan, Hubei province, P.R China presents at the out-patient department of Zhongnan Hospital of Wuhan University with long standing complaints of generalized body weakness, severe sweating even in conducive environmental temperatures, occasional palpitations of the heart for over slightly one year. However, these symptoms got worse 2 days prior presentation to our hospital. He denies any history of headache, fever, fainting episodes, joint pains or swellings, cough, chest pains. He had normal urinary and bowel habitus. He gives a positive history of nail changes about 7 years ago prior the about symptoms. The nail changes firstly involved the fingers of the hands and he was treated as fungal nail infections (onychomycoses) for over 6 months with the condition worsening and the nail changes spread to the toes and other fingers. He denies any history of skin rash or use of any lotion or corrosives agents or ingestion of any drugs prior initiation of these nail changes. He is not diabetic, coronary heart disease, hypertensive but he has had history isolated elevated blood pressure, not treated.
HIV/AIDS serological test was negative and so was hepatitis B, C and Syphilis. He has no significant past medical history. No known drug or food allergies and he has not been on any medications in the recent months. He does not smoke cigarettes nor drink alcohol and use of any illicit drugs.  Table 1.

Thyroid Emission Computed Tomography (ECT):
The thyroid scan showed diffuse enlargement of both lobes of the thyroid gland with significant enhancement of 99mTc04 in whole gland, which is highly considerable of Hyperthyroidism.
Electrocardiogram: Normal sinus rhythm with PR-elongation. The renal functions and cardiac enzymes tests were unremarkable.
Management: A multidisplinary approach was followed in the management of patient and we followed the treatment guidelines or protocols for management of endocrine patients in the department.
He was managed as a case of thyrotoxicosis in Graves' disease with Page number not for citation purposes 3 hyperthyroidism induced onycholysis. He was immediately started on a cocktail of the following drugs: thiamazole tablet 10mg three times a day, Inosine 0.2g three times a day, Leucogenum 20mg three times a day, potassium chloride 0.5g twice daily and recombinant human granulocyte colony-stimulating factor (rhG-CSF) 50µg intravenously every after three days until the neutropenia improves. The client showed much improvement with regards to resolving of the symptoms while in admission and was discharge after 7 days of admission. His condition was explained to him and a detailed treatment plan offered to the patient as he travelled back to his home country-Gambia for continued care.  [17]. The pathogenesis of hyperthyroidism associated onycholysis is still unknown but from most of the literature search, its observed that any unexplained onycholysis should prompt the clinician to investigate the client for asymptomatic hyperthyroidism [12,[15][16][17].

Conclusion
Onycholysis is associated with thyroid disease especially hyperthyroidism. Even if the pathogenesis of this association is still elusive, any client with unexplained onycholysis should be evaluated for asymptomatic thyroid disease and an endocrinologist should be involved soonest. Thus, the author is of the view that a large-scale prospective study should be conducted to validate this causal Page number not for citation purposes 4 association between onycholysis and hyperthyroidism, its incidence, pathogenesis and natural course of onycholysis in thyroid disease.

Competing interests
The authors declares competing interests. Acknowledgements I wish to express my sincere gratitude to our client for willingly allowing us to use his pictures for this case study.   There was no pitting nor pterygium formation on nails   There was no pitting nor pterygium formation on nails