Beau’s lines with onychomadesis in convalescence of invasive pneumococcal disease

Abstract

A male in his mid-fifties, with a past medical history of coronary artery disease, was admitted to the hospital with pneumococcal bacteremia and severe necrotizing pneumonia requiring intubation and vasopressor support. The patient’s intensive care unit (ICU) stay was complicated by candidemia, likely related to a central line. Convalescence was slow. The patient spent 3 weeks in ICU followed by 1 month in a medical ward and a short-term stay at a rehabilitation facility. He was discharged 2 months post-admission. One month post-discharge, the patient presented for follow-up at the Infectious Diseases clinic after completing the appropriate course of antibacterial and antifungal therapy. The patient felt well and was almost back to his pre-morbid state of health. His physical examination was unremarkable except for obvious fingernail changes. Figure 1 shows the patient’s thumbs (Fig. 1A) and second to fifth digits on the right hand (Fig. 1B), demonstrating Beau’s lines with onychomadesis. Figure 1 Photographic image of patient’s thumbs (A) and second to fifth digits on the right hand (B), demonstrating Beau’s lines with onychomadesis. Beau’s lines were first described by Joseph Honoré Simone Beau who observed transverse grooves in the nail plate of patients having recovered from Typhoid and other systemic disorders [1, 2]. Direct fingernail trauma can cause Beau’s lines in individual digits; however, when multiple digits are involved it is often a sign of a severe systemic assault. The most extreme presentation of this is characterized by onychomadesis, or shedding of the nail plate as nail plate growth shuts down temporarily until the challenge resolves. Wester et al. [3] reported Beau’s lines with onychomadesis involving fingernails and toenails in a patient suffering meningitis followed by a large pulmonary abscess. Gugelmann and Gaieski [4] showed a milder case of Beau’s lines without onychomadesis following a severe cardiac arrest. Beau’s lines appear approximately 4–8 weeks post-systemic assault; the nail plate takes about 9 months to regrow assuming resolution of the underlying condition [1, 3].