Images in Emergency Medicine

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[Ann Emerg Med. 2007;49:243.]

A 49 year-old woman presented to our emergency department (ED) with 2 months of progressive shortness of breath, lightheadedness, headache, and palpitations. She was initially evaluated at another ED and found to have hemoglobin level of 2 g/dL and received a transfusion. She had no melena, and her last menstrual period was 6 months earlier. She had a history of peptic ulcer disease. On examination, she was pale, with a systolic ejection murmur (grade 3/6) and eyeball bruit with koilonychia (Figure 1). Rectal examination results were normal. Blood film showed hypochromic microcytes (Figure 2). Esophagogastroduodenoscopy and colonoscopy results were normal. Anti-Gliadin antibodies were elevated: immunoglobulin A 7.3 (0 to 4.9) and immunoglobulin G 37.3 (0 to 9.9). Ferritin level was 3 (14 to 307) μg/L. Pregnancy test was negative. She declined small-bowel biopsy. She was diagnosed with iron deficiency anemia because of celiac disease. After commencing a gluten-free diet, she remains well on follow-up.

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• Figure 1. 

  Photograph of patient’s left hand showing spoon-shaped nails (koilonychia) in her index and middle fingers.

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• Figure 2. 

  Photomicrograph of peripheral blood smear from patient showing mixed picture of hypochromia and microcytosis (patient’s own erythrocytes), and normochromia and normocytosis (transfused blood). Used with permission of Gautam Kumar, MBBS, MRCP, Department of Internal Medicine, Mayo Clinic, Rochester, MN.

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Diagnosis 

Koilonychia, or spoon-shaped nails, is generally associated with iron-deficiency anemia. Nail matrix angulation as a result of connective tissue changes has been suggested as a possible cause.¹ Celiac disease is an underdiagnosed enteropathy characterized by gluten sensitivity, resulting in inflammation, small intestinal mucosal atrophy, and iron-deficiency anemia (hence, the koilonychia in our patient). Because of the protean manifestations of this disorder, a high index of suspicion is vital for diagnosis. Koilonychia has also been reported in several normal and abnormal states: idiopathic, hereditary, traumatic, occupational, endocrine-related, and even in polycythemia vera.² Koilonychia points to the chronicity of anemia in our ED patient and helps narrow the differential diagnoses.

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References 

1. Stone OJ. Spoon nails and clubbing. Cutis. 1975;16:235–241
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2. Stone OJ, Maberry JD. Spoon nails and clubbing. Tex Med. 1965;61:620–627
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