Yellow nail syndrome is a very rare disorder that has been noticed since 1927. 1 It affects both sexes equally, with an age of more than 40 years being typical. 2 The exact pathogenesis remains unclear but lymphatic system anatomical and functional abnormalities remain the predominant theory, while other hypotheses suggest autoimmune, cancer, and paraneoplastic roles. 3 Also, a very rare familial case has been reported. 1 Although it is only found in 27%-60% of patients The diagnosis depends on the presence of 2 out; of the characteristic nail changes, respiratory tract infection, and lymphedema. The latter occurs in up to 80% of cases and

Rationale: The posterior circulation represents 20% of blood supply to the brain, and its occlusion, commonly by embolism, causes brainstem, cerebellar, and lower cerebral infarctions. The clinical presentation varies from mild symptoms to severe neurological deficits or death. The duration of intervention is vital, commonly with antithrombotic drugs or through intervention. Patient concerns: The first case was a 36-year-old-female admitted due to snakebite. On admission, she developed acute kidney injury, sepsis, and compartment syndrome, for which she underwent fasciotomy, improved, and was discharged. Two days later, she presented with sudden onset of left-sided weakness. The second was an 85-year-old male with hypertension and end-stage renal disease on regular hemodialysis who presented with high-grade continuous fever associated with rigor, confusion, and decreased level of consciousness for 2 days. The third case was a 30-year-old woman admitted to the emergency department because of an abrupt loss of consciousness that occurred when she was going to the bathroom; she was unable to speak, swallow, or move her limbs. There was no fever, sphincteric disturbance, or seizure. She had a history of severe chronic bifrontal headache that started 4 months prior to elective cesarean section. Diagnosis: The patients were diagnosed as top of basilar artery infarction. Interventions: The first patient received enoxaparin, intravenous fluids, proton-pump inhibitors, antibiotics, and rivaroxaban. The second patient received intravenous antibiotics, dual antiplatelet therapy, enoxaparin, blood transfusions, and frequent hemodialysis sessions. The third patient received intravenous fluids, antibiotics, and oral anticoagulants (rivaroxaban 15 mg twice daily for 2 weeks then 20 mg once daily). Outcomes: The 3 patients were discharged following pharmacological treatment. The first and third cases showed improvement in their symptoms. However, the second patient developed bilateral epistaxis and bleeding after medication and did not show improvement in his symptoms; however, he died due to intradialytic hypotension. Lessons: We reported 3 Sudanese patients who had complicated medical sequelae due to top basilar artery occlusion, received anticoagulants and supportive therapy, and showed variable recovery over weeks, with the exception of 1 patient who died after follow-up.

Yellow nail syndrome is a rare lymphatic abnormality without a clear pathogenesis. Hereby, we report A 70-year Sudanese female who presented with recurrent cough, recurrent lower limb swelling and yellowish nail discoloration diagnosed as yellow nail syndrome but unfortunately passed away due to acute respiratory distress syndrome (ARDS).