Nailing the Diagnosis: Koilonychia

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Summer 2012 - Volume 16 Number 3

A 22-year-old man presented with complaints of chronic diarrhea, general weakness, and easy fatigue. He had been progressively symptomatic for 6 months. On examination, he had pallor and spoon-shaped nails (Figure 1). The rest of the examination findings were normal. Laboratory studies revealed anemia (hemoglobin, 8 g/dL; total leukocyte count, 5400/mm3; platelet count, 432,000/mm3; and peripheral blood smear suggestive of microcytic and hypochromic pattern). The iron profile was suggestive of iron-deficiency anemia. Stool was normal. Immunoglobulin A antitissue transglutaminase was elevated, at 43 U/mL (normal, <8 U/mL). Gastroduodenoscopy was suggestive of grooving in the second part of the duodenum. Duodenal biopsy revealed increased intraepithelial lymphocytes and crypt hyperplasia. The patient was started on a gluten-free diet and iron supplementation. At a 6-month follow-up, the anemia had resolved, and antitissue transglutaminase antibody levels had normalized.

Koilonychia is an abnormality of the nails that is also called spoon-shaped (concave) nails.¹ It is primarily recognized as a manifestation of chronic iron deficiency, which may result from a variety of causes, such as malnutrition; gastrointestinal blood loss; worms; gastrointestinal malignancy; and celiac disease, as in the present case.² Other causes of koilonychia are high altitude, trauma, and exposure to petroleum products, and it can even be hereditary.1,3,4 Therefore, spoon-shaped nails should prompt an evaluation for possible iron deficiency and the underlying cause.

Acknowledgment

Leslie Parker, ELS, provided editorial assistance.

References

    1.    Fawcett RS, Linford S, Stulberg DL. Nail abnormalities: clues to systemic disease. Am Fam Physician 2004 Mar 15;69(6):1417-24.
    2.    Kumar G, Vaidyanathan L, Stead LG. Images in emergency medicine. Koilonychia, or spoon-shaped nails, is generally associated with iron-deficiency anemia. Ann Emerg Med 2007 Feb;49(2):243, 250.
    3.    Prathap P, Asokan N. Familial koilonychia. Indian J Dermatol 2010 Oct;55(4):406-7.
    4.    Sawhney MP. Ladakhi koilonychia. Indian J Dermatol Venereol Leprol 2003 Mar-Apr;69(2):79-80.