Yellow nail syndrome following multiple orthopedic surgeries: a case report

J Med Case Rep. 2019 Jul 1;13(1):200. doi: 10.1186/s13256-019-2136-2.


Background: Yellow nail syndrome is a rare condition associated with a triad of symptoms: yellow nails, lung lesions, and lymphedema. We report a case of yellow nail syndrome caused by titanium exposure from multiple artificial joint replacements.

Case presentation: 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, however, following the surgery. On the basis of these findings, the patient was diagnosed with yellow nail syndrome due to titanium exposure.

Conclusions: Clinicians should examine the nails of patients with unexplained pleural effusion. Moreover, they should inquire about titanium exposure when obtaining the patient's medical history.

Keywords: Pleural effusion; Spinal fusion; Titanium; Yellow nail syndrome.

Publication types

  • Case Reports

MeSH terms

  • Aged
  • Arthroplasty, Replacement, Knee
  • Female
  • Humans
  • Internal Fixators / adverse effects*
  • Knee Prosthesis / adverse effects*
  • Pleural Effusion / chemically induced
  • Spinal Fusion
  • Titanium / adverse effects*
  • Yellow Nail Syndrome / chemically induced*


  • Titanium