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Nail Changes in Cirrhosis and Reversal After Adult & Pediatric Liver Transplantation

      Various nail changes have been described in patients of liver cirrhosis including Terry's nails, leukonychia, dystrophic nails, onychorrhexis, as well as onycholysis and clubbing. Reversal of these changes after liver transplantation have been described in a pediatric patient,
      • Gandhi V.
      • Nagral A.
      • Philiip S.
      • Malkani R.H.
      • Pimputkar R.
      Reversal of nail changes after liver transplantation in a child.
      in an adult with primary biliary cirrhosis
      • Marinho R.T.
      • Perdigoto R.
      Images in Hepatology. Reversible nail changes in Primary biliary cirrhosis after liver transplantation.
      and in 11 adult patients with cirrhosis
      • Boldys H.
      • Pageaux G.P.
      • Larrey D.
      • Michel H.
      Evolution of cutaneous changes observed in cirrhosis patients before and after liver transplantation.
      . There is paucity of knowledge about the pathophysiology of these changes, but changes in nail bed vascularity and overgrowth of connective tissue has been postulated as a mechanism for occurrence of terry's nails
      • Witkowska A.B.
      • Jasterzbski T.J.
      • Schwartz R.A.
      Terry’s nails: A sign of systemic disease.
      . We are submitting images showing reversal of nail changes of cirrhosis after liver transplantation in an adult and a pediatric patient. Our adult patient is a 56-years-old gentleman who was suffering from decompensated liver cirrhosis due to autoimmune hepatitis. His decompensation was in the form of jaundice, ascites, and an episode of variceal bleed. His nails were white, dystrophic, and had longitudinal ridges. This image was taken two months after liver transplantation. It shows the new normal growing nails (adjacent to the nail bed) (yellow arrowhead) and the old nails distally with aforementioned changes (red arrowhead) with a sharp line of transition (yellow arrow) (Figure 1). Our pediatric patient is a 9-month-old child suffering from decompensated secondary biliary cirrhosis after failed kasai surgery for extrahepatic biliary atresia. His nails were white and dystrophic (Figure 2). This image was taken at 6 weeks from his liver transplantation and shows similar features. Our observation is that the nail changes start very early after transplantation as seen in aforementioned cases.
      Figure 1
      Figure 1Reversal of Nail Changes after Pediatric liver transplant. a. Yellow arrowhead – New normal growing nail. b. Red arrowhead – Old Nail. c. Yellow arrow – Sharp line of transition.
      Figure 2
      Figure 2Reversal of Nail Changes after Adult liver transplantation.

      References

        • Gandhi V.
        • Nagral A.
        • Philiip S.
        • Malkani R.H.
        • Pimputkar R.
        Reversal of nail changes after liver transplantation in a child.
        Indian J Gastroenterol. 2009 Jul-Aug; 28: 154-156
        • Marinho R.T.
        • Perdigoto R.
        Images in Hepatology. Reversible nail changes in Primary biliary cirrhosis after liver transplantation.
        J Hepatol. 1999 Feb; 30: 330
        • Boldys H.
        • Pageaux G.P.
        • Larrey D.
        • Michel H.
        Evolution of cutaneous changes observed in cirrhosis patients before and after liver transplantation.
        Pol Arch Med Wewn. 1993 Feb; 89: 151-158
        • Witkowska A.B.
        • Jasterzbski T.J.
        • Schwartz R.A.
        Terry’s nails: A sign of systemic disease.
        Indian J Dermatol. 2017 May-Jun; 62: 309-311