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A 72-year-old woman with diabetes mellitus, hypertension, and peripheral vascular disease was hospitalized with chest tightness and acute shortness of breath. She reported a four-month history of worsening dyspnea on exertion, orthopnea, and a progressive whitening of her fingernails. Physical examination revealed an elevated jugular venous pressure, an S4 gallop rhythm, bilateral pulmonary rales, peripheral pitting edema, and complete whitening of the nail units of her hands and feet. Laboratory investigations showed a normal complete blood count, as well as normal renal and liver function. Electrocardiography revealed deep T-wave inversions in leads V1 through V3. Echocardiography showed an ejection fraction of 40 percent with apical-wall hypokinesis, and coronary angiography demonstrated a 90 percent stenosis of the midportion of the left anterior descending artery, confirming the diagnosis of ischemic cardiomyopathy. Whitening of the nail unit can occur as a result of a change in the nail plate (true leukonychia) or injury to the nail bed (pseudoleukonychia). Acquired leukonychia totalis has been associated with several systemic diseases, including hepatic cirrhosis, chronic renal failure, congestive heart failure, diabetes mellitus, chronic hypoalbuminemia, and Hodgkin's lymphoma. The patient underwent coronary angioplasty with stent insertion in the affected artery. At follow-up six months later, the appearance of her nails had returned to normal.
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