This paper reported a case of a 16 years old Nigerian girl with Plummer’s nails associated with hyperthyroid­ism (Graves’ disease). The issue of excessive weight gain after therapy for the Graves’ disease was also discussed. Following therapy, the patient gained 7 Kg over a period of 5 months. The diagnosis of hyperthyroidism due to Graves’ disease was based on increased heart rate at rest, diffuse smooth goiter, mild ophthalmopathy, low TSH (thyroid stimulating hormone) level, elevated T3 (triiodothyronine)and T4 (tetraiodothyronine) levels. The paper emphasized the need for clinicians to be alert to the possibility of nail changes in adolescents with thyroid diseases and watch out for weight gain following successful therapy

Atamah, Chinedu A.

Onyiriuka, Alphonsus N.

Onyiriuka, Louis C.

English

Aristotle University of Thessaloniki: Open Journals / ΑΡΙΣΤΟΤΕΛΕΙΟ ΠΑΝΕΠΙΣΤΗΜΙΟ ΘΕΣΣΑΛΟΝΙΚΗΣ

INTRODUCTIONIn patients with hyperthyroidism, onycholysis (sepa-ration of the nail plate from the nail bed) is referred to as ”Plummer’s nails”1,2. Plummer’s nails are unique for Graves’ disease.1,3 In Plummer’s nails, the nails of-ten exhibit a concave shape (“scoop shovel” configu-ration) and/or a distal onycholysis2. Hyperthyroidism makes the nail brittle, leading to the separation of the plate from the nail bed4.In adults, nail changes are present in 5% of cases of hyperthyroidism2. Reports of Plummer’s nails in children and adolescents with hyperthyroidism are very scarce. A survey of standard textbooks of pae-diatrics as well as paediatric endocrinology, revealed that there was no mention of nails changes in hyper-thyroidism, indicating the need to raise awareness among clinicians of its association with hyperthyroid-ism in the paediatric age group5,6. Given the assertion that Plummer’s nail is unique to Graves’ disease3, its presence might be a useful clue to the diagnosis of Graves’ disease, particularly in developing countries where availability of laboratory facilities for evalua-tion of endocrine disorders is grossly inadequate. Ab-normalities of the nail is known to provide both subtle and obvious clues to common medical problems or severe systemic diseases7. Indeed, it has been stated that the complete physician regardless of his field of specialty needs to be alert to the often significant man-ifestation of abnormal nail as a signal to important pa-thology8. In this context, Nakat Sui and Lin suggested that patients with unexplained onycholysis should be screened for asymptomatic thyroid disease3.This case report aims at stimulating the interest and raising awareness of the general paediatrician with regard to the association between abnormalities of the nail and hyperthyroidism in adolescence. CASE REPORTThe patient was a 16 years old girl who was referred from a secondary healthcare facility in a neighbour-ing state. The presenting complaints were weight loss for 17 months, cessation of menses for 10 months and neck swelling for 8 months. The immediate symptoms that prompted seeking medical help were abdominal pain, vomiting and frequent watery stools all of 4 days duration. A review of the systems revealed a positive history of increased food intake, excessive sweating, Case RepoRtPlummer’s nails (onycholysis) in an adolescent nigerian  girl with hyperthyroidism due to Graves’ disease.Dr Alphonsus N. Onyiriuka1, Dr Chinedu A. Atamah1, Dr Louis C. Onyiriuka21Department of Child Health, University of Benin Teaching Hospital, Pmb 1111, Benin City, Nigeria2School Of Medicine, College Of Medical Sciences, University Of Benin, Benin City, NigeriaABSTRACT: This paper reported a case of a 16 years old Nigerian girl with Plummer’s nails associated with hyperthyroid-ism (Graves’ disease). The issue of excessive weight gain after therapy for the Graves’ disease was also discussed. Following therapy, the patient gained 7 Kg over a period of 5 months. The diagnosis of hyperthyroidism due to Graves’ disease was based on increased heart rate at rest, diffuse smooth goiter, mild ophthalmopathy, low TSH (thyroid stimulating hormone) level, elevated T3 (triiodothyronine)and T4 (tetraiodothyronine) levels. The paper emphasized the need for clinicians to be alert to the possibility of nail changes in adolescents with thyroid diseases and watch out for weight gain following successful therapy.Key Words: Adolescence, Hyperthyroidism, Graves’ disease, Plummer’s nails, Onycholysis. Corresponding author: Dr A.N. Onyiriuka, Department of Child Health, University of Benin Teaching Hospital, Pmb 1111, Benin City, Nigeria, e-mail: alpndiony@yahoo.com, didiruka@gmail.com14 Aristotle University Medical Journal, Vol. 39, Issue 3, October 2012palpitation, sweaty palms and a slight change in hand writing. She had emotional lability. No family history suggestive of thyroid disorder. There was no positive history of acute iodine exposure or ingestion of thy-roid hormone. The patient does not do pedicure. She attained menarche at the age of 12 years and her men-strual cycle had been fairly regular until the present illness. The patient was a secondary school graduate who has just secured admission into one of the Ni-gerian universities. The patient was the youngest of four children. Her mother was 53 years old. Her father died (from “Stroke”) three years ago before the onset of her illness. Physical examination revealed an anx-ious-looking adolescent girl with fine finger tremor and mild ophthalmopathy. She weighed 44 Kg with a height of 162 cm (BMI=16.8 Kg/m2). She had a dif-fuse, smooth, non-tender thyroid swelling measuring 4x6 cm. The goiter had no nodule, bruit or differen-tial warmth. The Sexual Maturity Rating (SMR) was Tanner stage IV. The Plummer’s nails (Onycholysis) and goiter are shown in Figures 1 and 2 respectively. She had tachycardia with bounding pulse (pulse rate 124/minute at rest). The blood pressure was 110/60 mmHg with the apex beat in the 5th left intercostals space mid-clavicular line. There was no cardiac mur-mur or finger clubbing. The abdomen was flat, soft with tenderness in the lower half. Bowel sound was normal. The urea and electrolyte profile were normal. Her haematocrit value was 34%.The laboratory find-ings are displayed in Table 1 and show a low normal serum TSH and elevated T3 and T4 values. A diag-nosis of Hyperthyroidism due to Graves’ disease was considered. The gastroenteritis was also kept in view. She was rehydrated with intravenous fluid because of the gastroenteritis. Oral carbimazole and propanolol were commenced. The clinical condition improved as evidenced by the resting pulse rate which dropped to an average of 84/minute and she was less nervous. The patient was discharged from the hospital after 4 weeks and followed up in the Consultant outpatient clinic. Her menses was restored and it was regular. She has since resumed her study in the University. Her weight rose to 51 Kg (BMI=19.4 Kg/m2) 5 month af-ter discharge. However, she was lost to follow up.DISCUSSIONIn this patient, the diagnosis of Hyperthyroidism due to Graves’ disease was based on increased heart rate at rest, presence of diffuse goiter, low normal serum TSH (Thyroid stimulating hormone) and elevated se-rum T3 (Triiodothyronine) and T4 (Tetraiodothyro-nine) values. This is in keeping with the criteria used for diagnosis of Graves’ disease in a previous study9. The finger tremor, mild ophthalmopathy and low Body Mass Index (BMI) of 16.8 Kg/m2 were all con-sistent with the diagnosis of Graves’ disease. Other causes of hyperthyroidism in childhood and adoles-cence include subacute thyroiditis, thyroid neoplasms, McCune-Albright syndrome, TSH hypersecretion, io-dine or thyroid hormone ingestion. Epidemiologically, Graves’ disease is by far the commonest cause of hy-perthyroidism in the paediatric age group5,6. The goi-ter in this patient was not tender as would be expected in thyroiditis. Thyroid cancer is rare in childhood5,6. Table 1. Laboratory findings in a 16-year-old girl with hyperthyroidism.Laboratory parameter Normal serum values Observed serum values in UBTH  Initial After 2 monthsTSH 0.4-6.2 U/ml 0.6 U/ml 3.4 U/mlT3 0.7-2.0 ng/ml 6.2 ng/ml 7.6 ng/mlT4 4.8-10.8 µg/dl 35.2 µg/dl 19.8 µg/dlRandom blood glucose 4.7-6.7 mmol/L 6.2 mmol/L –Pelvic scan Right ovarian cyst measuring 55.1 x 52.9 mmNeck scan Thyroid lobes measure 36 x 17 mm (Right) and 36 x 15 mm (Left) with no  focal or cystic mass lesion.Abdominal scan NormalTSH = Thyroid Stimulating Hormone; T3 = Triiodothyronine; T4  =Tetraiodothyronine. Plummer’s Nails in Grave’s Disease 15The child with thyroid cancer usually presents a thy-roid nodule or an asymptomatic asymmetrical neck mass5,6. The goiter in the index patient was symmetri-cal, diffuse, smooth and non-tender, thereby making these other differentials less likely. In our patient, there was no history of acute exposure to iodine or ingestion of thyroid hormone. Hypermetabolic states such as severe anaemia, chronic infections, pheochro-mocytoma, and muscle-wasting disease may mimick hyperthyroidism clinically but the results of the thy-roid function tests are normal5. In the index patient, the thyroid function tests were deranged. The toe nails of the index patient was concave shaped, “scoop shovel” configuration, in keeping with the typical description of Plummer’s nails in Graves disease2. Most reports of Plummer’s nails are in adults3,4. Reports of its occurrence in children and adolescents with Graves’ disease are scarce. In this context, the present report, hopefully, will contribute to raising the awareness of clinicians of the associa-tion of Plummer’s nails with Graves’ disease in the paediatric age group. This is even more relevant in de-veloping countries where laboratory facilities for ad-equate investigation of endocrine disorders are often lacking. As proposed by Nakat Sui and Lin any patient (children and adolescents inclusive) with unexplained onycholysis should be screened for asymptomatic thyroid disease3.Following treatment and subsequent discharge, our patient gained weight with improvement in her BMI. This is not surprising as previous studies have reported a similar finding among patients treated for Graves’ disease9-11. The index patient gained 7 Kg five months after therapy and discharge from hospital. The mean weight gain six months after therapy was 5 Kg in the study by Brunova et al11. In one of the studies it was concluded that excessive weight gain within six months of treatment is seen in children with Graves disease and the gain in weight could persist9. The risk of persistence of the weight gain makes it a challenge for the clinician, given the known adverse effects of overweight and obesity12. The weight gain is believed to be due to disappearance of hypermetabolism, linked to the hyperthyroid state10.In conclusion, it is my hope that the present report will contribute in raising the awareness of the general paeditrician concerning the association between nail changes (Plummer’s nail) and Graves’ disease. The is-sue of excessive weight gain following treatment for Graves’ disease in adolescent patients is emphasized.Figure 1. Smooth, diffuse thyroid swelling. Figure 2. Onycholysis (Plummer’s nails).16 Aristotle University Medical Journal, Vol. 39, Issue 3, October 2012  1. Fawcett RS, Hart TM, Linford S, Stullberg DL. Nail abnormalities: clues to systemic disease. Am Fam Physician 2004; 69(6): 1417-1424.  2. Rosen T, Kleman GA. Thyroid and skin. In: Callen JP, Jorrizo JL, Greer KE, Pennys NS, Piette WW, Zone JJ eds. Dermatological signs of internal disease. 2nd ed. Philadelphia, WB Saunders Company, 1995:183-195.  3. Nakat Sui T, Lin AN. Onycholysis and thyroid disease: a report of three cases. J Cutan Med Surg 1998; 3(1): 40-42.  4. Atia A, Johnson BS, Aldelmalak HD,Sinnot B. Ony-cholysis (Plummer’s nail) in a patient with hyperthy-roidism. Endocr Pract 2008; 14(1): 132.  5. Morelli JG. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics, 18th ed. Philadelphia, Saunders Elsever, 2007: 2731-2734.  6. Fisher DA. The thyroid. In: Kaplan SA, ed. Clinical Pediatric Endocrinology, 2nd ed. Philadelphia, WB Saunders Company,1990: 87-126.  7. Noronha PA, Zubkov B. Nails and nail disorders in children and adults. Am Fam Physician 1997; 55(6): 2129-2140.   8. Scher RK. Toe nail disorders. Clin Dermatol 1983; 1(1): 114-124.  9. Van Veenendaal NR, Rivkees SA. Treatment of pae-diatric Graves’ disease is associated with excessive weight gain. J Clin Endocrionol Metab 2011; 96(10): 3257-3263.10. Portmann L, Glusti V. Weight changes in hyperthyroid patients: a challenge for clinicians? Rev Med Suisse 2007; 3(105): 854-858.11. Brunova J, Bruna J, Joubert G, Koninq M. Weight gain in patients after therapy for hyperthyroidism. S Afr Med J 2003; 93(7): 529-531.12. Han TS, Tijhuis MA, Lean ME, Seidell JC. Quality of life in relation to overweight and body fat distribution. Am J Public Health 1998; 88: 1814-1820.13. Visscher TL, Seidell JC. The public health impact of obesity. Annu Rev Public Health 2001; 22: 355-375. REFERENCES

Plummer’s nails (onycholysis) in an adolescent nigerian girl with hyperthyroidism due to Graves’ disease

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Plummer’s nails (onycholysis) in an adolescent nigerian girl with hyperthyroidism due to Graves’ disease

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Aristotle University of Thessaloniki: Open Journals / ΑΡΙΣΤΟΤΕΛΕΙΟ ΠΑΝΕΠΙΣΤΗΜΙΟ ΘΕΣΣΑΛΟΝΙΚΗΣ