Egyptian Journal of Dermatology and Venerology

CASE REPORT
Year
: 2017  |  Volume : 37  |  Issue : 1  |  Page : 18--19

A case of Mees’ line secondary to paraquat


Anupama Bains 
 Department of Dermatology, Venereology and Leprology, AIIMS Jodhpur, Rajasthan, India

Correspondence Address:
Anupama Bains
Department of Dermatology, Venereology and Leprology, AIIMS, Basni Phase-2, Jodhpur 342005, Rajasthan
India

Abstract

Nail abnormalities are window to systemic diseases. Although they are not specific to a disease, they can be of great help in the diagnosis of a disease. Mees’ lines are white transverse bands present in nail that are commonly seen in arsenic poisoning. Here we report a case of Mees’ line secondary to paraquat. Paraquat is a herbicide commonly used in agriculture.



How to cite this article:
Bains A. A case of Mees’ line secondary to paraquat.Egypt J Dermatol Venerol 2017;37:18-19


How to cite this URL:
Bains A. A case of Mees’ line secondary to paraquat. Egypt J Dermatol Venerol [serial online] 2017 [cited 2017 Oct 18 ];37:18-19
Available from: http://www.ejdv.eg.net/text.asp?2017/37/1/18/207493


Full Text

 Introduction



Nail abnormalities are not pathogonomic of a disease but they can be a useful supportive tool in the diagnosis of systemic diseases. Mees’ lines are a type of true leuconychia presenting as transverse white lines and are classically seen in arsenic poisoning, but they can also be present in other systemic diseases. Here we report a case of Mees’ line secondary to paraquat.

 Case report



A 24-year-old woman presented to the dermatology Out Patient Department (OPD) with whitish discoloration and irregularity of surface of fingernails for the past 2 months. There was history of suicidal attempt 3 months back. She had consumed gramoxone, a weed, containing paraquat, for which she was admitted in a local hospital and was managed conservatively. On examination, there were single white transverse bands present over all fingernails of the left hand, but the fingernails of the right hand were spared ([Figure 1] and [Figure 2]). These lines were parallel to the shape of lunula. On palpation, these lines were smooth, nonpalpable, and did not fade on applying pressure to the nail plate. In addition, there was a transverse furrow in the thumbnail of the right hand along with whitish tiny spots over middle finger of the right hand. Toenails were normal. Her mucocutaneous and hair examination was unremarkable. General physical examination and systemic examination were within the normal limit. Complete hemogram, liver, and renal function tests were within normal limits. A diagnosis of Mees’ lines secondary to paraquat was made. The damage is almost certainly due to the local effects of poison while handling the product and is not the result of ingestion, because of the asymmetry of the lesions and the fact that the toenails are unaffected. In addition to Mees’ lines, there was punctate leuconychia over the middle fingernail and Beau’s line over thumbnail of the right hand.{Figure 1}{Figure 2}

 Discussion



Paraquat is a herbicide used in agriculture and horticulture with chemical name 1,1′-dimethyl-4,4′-bipyridinium dichloride. Ingestion is the most common route of poisoning. Other routes are skin or mucosal contact, inhalation, and injection. Lethal dose is about 30 mg/kg. Paraquat poisoning can lead to multiple-organ failure by production of reactive oxygen species that cause cellular damage [1]. The first description of nail changes associated with paraquat was described by Samman and Johnson [2]. Hearn et al. [3] studied nail changes in spray operators who were exposed to paraquat. The most common nail manifestation was the presence of transverse white bands, which was usually seen in index, middle, and ring fingers of the right hand in spray operators. Other nail changes were localized discoloration, irregularity of nail surface, or transverse ridging, furrowing, loosening, and loss of nail [3]. In our patient, Mees’ lines and Beau’s line were also present. Similar changes were also noticed by Baran [4] in workers exposed to these chemicals. Mees’ line is a type of true leuconychia in which pathology lies in the matrix. It presents as a single white transverse line running along the width of the nail plate and is parallel to the lunula. Mees’ lines are characteristically present in arsenic poisoning. Other conditions in which these lines are present are Hodgkin’s disease, congestive heart failure, renal failure, leprosy, tuberculosis, herpes zoster, chemotherapeutic drugs, pneumonia, child birth, carbon monoxide, and thallium poisoning [5],[6]. They are differentiated from Muehrcke’s line as they do not blanch on pressure, grow distally as the nail grows, and are usually single. Muehrcke’s line is a type of apparent leuconychia in which abnormality lies in the vascular bed of the nail and manifests as double white transverse lines [5]. Mees’ lines are formed because of sudden toxic damage to the nail matrix, which leads to abnormal keratinization. Histopathology shows foci of parakeratotic cells [6]. These retained parakeratotic cells cause altered light diffraction [7]. The distribution of Mees’ lines was unilateral and the toenails were spared in the index case. This may be because of collection of the chemical in the nail fold while handling the product. The chemical may have penetrated through the proximal nail fold into the matrix, resulting in nail damage.

 Conclusion



Possibility of nail damage secondary to paraquat should be kept in mind while considering the differential diagnosis of diseases of the nail.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Delirrad M, Majidi M, Boushehri B. Clinical features and prognosis of paraquat poisoning: a review of 41 cases. Int J Clin Exp Med 2015; 8:8122–8128.
2Samman PD, Johnston EN. Nail damage associated with handling of paraquat and diquat. Br Med J 1969; 1:818–819.
3Hearn CE, Keir W. Nail damage in spray operators exposed to paraquat. Br J Ind Med 1971; 28:399–403.
4Baran RL. Letter: nail damage caused by weed killers and insecticides. Arch Dermatol 1974; 110:467.
5Singh G. Nails in systemic disease. Indian J Dermatol Venereol Leprol 2011; 77:646–651.
6Singal A, Arora R. Nail as a window of systemic diseases. Indian Dermatol Online J 2015; 6:67–74.
7Gupta A, Parakh A, Dubey AP. Chemotherapy induced nail changes. Indian J Dermatol 2008; 53:204–205.