Abnormal Nails in a Patient With Severe Anemia

REPORT OF A CASE  A 35-year-old man was referred for evaluation of abnormal fingernails and toenails. His physical examination revealed a cachectic man who appeared older than his stated age. He had hypoplasia and/or aplasia of all fingernails and toenails (Figure 1). Reticulated hyperpigmentation and hypopigmentation were noted over his neck and upper chest area (Figure 2). His hair was sparse. Examination of his oropharynx showed him to be edentulous with a thickened, hyperconvoluted, fixed tongue.Laboratory studies revealed the following abnormal results: hemoglobin, 39 g/L; hematocrit, 0.11; leukocytes, 3.4×10⁹/L; mean corpuscular volume, 115 fL; platelets, 15 ×10⁹/L; and serum albumin, 31 g/L. Serum chemistry studies, urinalysis, and chest radiography revealed no abnormalities, and the serum levels of iron, ferritin, and folate were normal, as were the total iron-binding capacity, prothrombin time, and partial thromboplastin time. The vitamin B₁₂ level was 140 pmol/L (185 pg/mL)