Yellow nail syndrome (YNS) is characterized by yellowish nails, lymphedema, sinusitis, and pulmonary involvement and can be triggered by various underlying conditions, such as sinusitis or titanium exposure from an artificial joint or dental implant. Since YNS is potentially treatable, its timely diagnosis is important. The authors recently experienced a case of YNS in a patient who developed sinusitis, yellowish nails, bilateral edema of the extremities, and subclinical rheumatoid arthritis after the implantation of a cardiac pacemaker made from titanium. This case may be the first report of YNS induced by a titanium cardiac pacemaker. A 65-year-old Japanese man developed edema of the face, bilateral hands and forearms, stiffness of the fingers of both hands, an abnormal sensation that affected the whole body, and generalized rash, in the month after the implantation of a cardiac pacemaker for complete atrioventricular block. The implanted pacing system was composed of a Medtronic Ad-visa MRI™ and CapSureFix MRI™ (Medtronic, Minneapo-lis, USA) leads; the body of the pacemaker was made from titanium, while the tip of the lead was coated in titanium. The patient's medical history included hypertension and right carotid artery stenosis with asymptomatic right cerebral stroke. After undergoing carotid endarterectomy, the patient developed atrioventricular block and a permanent cardiac pacemaker was implanted. After right carotid endarterec-tomy, the stent was not placed. When the patient was diagnosed with stroke, he started to take the following medications: low-dose aspirin, clopido-grel, candesartan, pitavastatin, amlodipine, lansoprazole, and eicosapentaenoic acid. On examination, the patient was alert, hemodynamically stable and afebrile. The abnormal physical findings included yellow-colored fingernails (Fig. 1) and (all) toenails, fine crackles at the lung bases, and swelling of the forearms and hands; the extent of the swelling on the left side was greater than that on the right side (Fig. 2). Blood tests showed normal a leukocyte count and C-reactive protein level and were negative for antinuclear anti-bodies, rheumatoid factor, and anti-cyclic citrullinated pep-tide (CCP) antibodies. The erythrocyte sedimentation rate was 32 mm/h. Spirometry showed no evidence of obstructive or restrictive disease. Whole-body contrast-enhanced CT showed no pulmonary lesions, pleural effusion or any findings suggestive of malig-nancy. Upper gastrointestinal endoscopy and colonoscopy showed no evidence of neoplasms. A hand radiograph indicated mild bone erosion of the hands, which was predominant at the metacarpophalangeal joints. Echography of the joints revealed the thickening of the synovial membranes around the carpal bones with increased blood flow, suggesting the presence of synovitis. Head MRI showed bilateral maxillary sinusitis. Based on the yellow nails and diffuse edema as well as the symptoms and signs in relation to the patient's paranasal sinuses and joints, yellow nail syndrome (YNS) along with sinusitis and ...
