White fingernails associated with anaemia

White fingernails can be associated with a number of pathological conditions. We report a patient with white fingernails associated with anaemia. A 74-year-old man presented with fatigue and dyspnoea on exertion. He had undergone a subtotal gastrectomy 9 years earlier for ulcer perforation. On physical examination, the patient s skin was found to be pale, and his fingernails were white, findings that were consistent with leuconychia totalis (Fig. 1a). Laboratory investigations gave normal results for white blood cell count (7.7 · 10 ⁄ L; normal range 4–11 · 10 ⁄ L), platelet count (230 · 10 ⁄ L; 150–400 · 10 ⁄ L) and reticulocytes (1.23%; 0.5–1.5%). Haemoglobin was low (6.0 g ⁄ dL; 13.0–18.0 g ⁄ dL) with decreased mean corpuscular volume (61.4 fL; 80–96 fL), as was serum iron (12 lg ⁄ dL; 80–200 lg ⁄ dL) and ferritin (1.5 ng ⁄ mL; 15–332 ng ⁄ mL). Total iron-binding capacity was slightly raised (489 lg ⁄ dL; 252–456 lg ⁄ dL). A peripheral blood smear showed hypochromic, microcytic cells with anisocytosis (Fig. 1b). We diagnosed the patient as having iron-deficiency anaemia caused by impaired iron absorption as a result of his subtotal gastrectomy. He was treated with iron supplementation, and all symptoms had completely resolved after approximately 6 months. Leuconychia refers to whiteness of the nails, which can either occur in patches (leuconychia partialis) or involve the entire nail (leuconychia totalis). Acquired leuconychia may arise after local trauma or in association with a wide range of systemic pathological conditions including anaemia. Although acquired leuconychia totalis may often be no more than a dermatological curiosity, a significant body of literature suggests that nail findings such as leuconychia totalis may serve as important visible markers of systemic diseases, including liver cirrhosis, anaemia, hypocalcemia, hypoalbuminemia, and zinc deficiency, emphasizing the clinical importance of this condition.