Mees lines

Description

Nail sign: white bands (leukonychia striata) traversing the full width of the nail, running parallel to the lunula, with no palpable ridges. As the nail grows they bands move distally and finally disappear when trimmed. The finding was initially related to acute arsenic poisoning.

The finding of leukonychia striata has subsequently been recorded in cases of heavy metal poisoning (arsenic, thallium and selenium); renal dysfunction; chemotherapy; systemic illness and high altitude mountaineering.


History

1900Ernest Septimus Reynolds (1861 – 1926) wrote extensively regarding the effects of arsenic upon the beer drinking population of North England and the Midlands. In 1901 he published his findings and reviews in the Lancet and Medico-Chirurgical Transactions concentrating on the signs and symptoms of polyneuropathy due to acute arsenic poisoning.

Nails: In many cases the nails are affected. After the patients have stopped taking the beer for some weeks the best appearances are seen, for then there is a transverse white ridge across the nail; proximal to this the nail is normal, but distal to it the nail is whiter, cracked, thin, and towards the tip almost papery and much flattened. In some cases there have been a series of parallel transverse ridges of the nails, also suggesting a series of week-end drinking bouts. These deformed nails of course break easily.

Reynolds 1901

1901Florence R. Sabin (1871 – 1953) described the signs and symptoms of a patient suffering from arsenical neuritis whom she saw in consultation with Dr William Osler:

The patient is a young woman who was brought to the hospital two months ago, November 23, 1900, after having taken about a dram of ‘Rough on Rats’…Her stomach was washed out repeatedly and large doses of the antidote given, together with epsom salts and castor oil. She was dismissed in five days feeling well, but noted that on walking up the steps of her home her feet were numb and the steps felt soft.

The numbness of the feet gradually increased and she became unable to walk. When she came to the hospital again she had double footdrop and wrist-drop, the muscles involved, however, were not entirely paralyzed. Her hands were so weak that she could not feed herself…On both hands there is a white line running transversely across each nail.

Sabin 1901

1904Charles John Aldrich (1861 – 1908) provided an early published description (1904) of three cases he treated in 1899, fifteen years before RA Mees 1919 description. Aldrich termed the phenomenon ‘Leuconychia striata arsenicalis transversus’

Five years ago at the Cleveland City Hospital, while examining a woman suffering from a very severe arsenical neuritis, I was struck by the observance of a peculiar white transverse line occupying the middle of the outer third of the finger-nails of each hand...she had taken a teaspoonful of “Rough on Rats,” which is well known to contain a large quantity of arsenic.

Aldrich 1904: 701

The white streaks were about one-sixteenth of an inch in width, quite regular, with fairly sharp margins, and occupying an identical position on each nail. They were slightly larger on some nails than upon others and a little wider in the centre than near the margins; extended from side to side, forming a crescentic band, with the convexity directed to the free margins of the nail, and presenting a curve identical with that of the lunula. The markings were less plainly seen upon the toe-nails.

Aldrich 1904: 703

1919Rudolf Adriaan Mees (1873-1964) reviewed the cases of three patients with ‘polyneuritis arsenicosa’ (polyneuropathy due to acute arsenic intoxication) as a result of ingesting a large single dose of arsenic salts. He discusses two cases of attempted suicide and one of attempted murder.

Original
English

Op de foto’s is het vershijnsel duidelijk waar te nemen. Over de nagels ziet men witte dwarsbanden loopen, die duidelijk niets met de lunula te maken hebben, aangezien onder den band, even goed als er boven, de nagel normaal rood van kleur is. Zooals begrijpelijk is, groeit dexe dwarsband met den nagel op en bij vergelijking van fig 1 met fig 2 ziet men een duidelijke verschuiving naar de peripherie van den nagelband op de laaste figuur…De breedte van den nagelband is ongeveer 1.5mm…Alle nagels van handen en vooten vertoonen denzelfeden dwarsband; hij is echter op de teenen veel minder duidelijk dan op de vingers

Mees 1919: 391

The phenomenon is clearly visible in the photos. White transverse bands are seen running over the nails, which clearly have nothing to do with the lunula, since under the band, as well as above, the nail is normally red in color. This transverse band grows with the nail and when comparing Fig. 1 with Fig. 2, a clear shift is seen towards the periphery of the nail band on the last figure…The width of the nail band is about 1.5mm…All nails of hands and feet show the same cross-band; however, it is much less clear on the toes than on the fingers

Mees 1919: 391

Mees suggested the use of the nail sign in diagnosing polyneuropathy due to acute arsenic intoxication

Original
English

Waneer mocht blijken, dat bij polyneuritis arsenicose deze nagelband steeds aanwezig is van de tweede maand na de toediening van het vergift af en ongeveer twee maanden zeer duidelijk aanwezig blijft, dan kandit verschijnsel forensische beteekenis hebben. De band toch is nog aanwezig, als het arsenicum uit de urine is verdwenen. Een moeilijk te diagnosticeeren geval van polyneuritis zou dan door het aanwezig zijn van den nagelband asl polyneuritis aresenicos kunnen worden herkend.

Mees 1919: 395

If it turns out that in polyneuropathy due to acute arsenic intoxication this nail band is always present from the second month after the administration of the poison and remains very clearly present for about two months, this phenomenon can have forensic significance. The band is still present when the arsenic has disappeared from the urine. A case of polyneuropathy that is difficult to diagnose could then be recognized by the presence of the nail band as polyneuropathy due to acute arsenic intoxication

Mees 1919: 395

Mees had described the nail sign; identified the predisposing cause; hypothesised as to the pathological basis; and proposed the signs use in forensic analysis. identified. Now he set about reviewing the international literature for evidence of previous published documentation of the nail sign:

Original
English

Wanneer ik nu naga, wat er in de literatuur van dit nagelverschijnsel te vinden is, dan kom ik tot de slotsom, dat op deze dwarsbanden dee aandacht nog niet werd gevestigd. De verhandelingen van REYNOLDS, waarin een uitgebreide epidemie van arsenicum-vergiftiging tengevolge van biergebruik wordt beschreven, bevatten niets daaroment. Het overzicht van deze verhandelingen (1901) in de Review of Neurology (1905) door denzelfden schrijver vermeldt alleen atrophische nagels zonder verdere aanduiding.

Mees 1919: 395

Now, when I examine what can be found in the literature of this nail phenomenon, I come to the conclusion that attention has not yet been drawn to these transverse bands. REYNOLDS treatises, which describe a comprehensive epidemic of arsenic poisoning from beer consumption, contain nothing. The review of these treatises (1901) in the Review of Neurology (1905) by the same author mentions only atrophic nails without further indication.

Mees 1919: 395

However, Reynolds did clearly define the nail changes of arsenical poisoning as a transverse white line in his 1901 papers presented in both the Lancet and Medico-Chirurgical Transactions.

Mees also refers to Reynolds publication in the Review of Neurology and Psychiatry (1905). In this paper Reynolds provided a comparative overview of arsenical neuritis and alcoholic neuritis to complement Buchanan’s paper ‘Some aspects of alcoholism‘ published within the same journal. True, there is no specific mention of nail changes, however this particular article was focused on the differences between alcohol and arsenic poisoning with respect to neuritis, neuropathy and skin pigmentation. No reference is made to the work of Sabin (1901) and Aldrich (1904)


Associated Persons


Alternative names

  • leukonychia striata; leuconychia striata arsenicalis transversus
  • Reynolds lines
  • Aldrich – Mees lines;
  • Reynolds-Sabin-Aldrich-Mees lines

Leukonychia striata in chronic disease

1877Jacob Mendez Da Costa (1833 – 1900) described transverse white bands the full width of the finger nail appearing after a relapse of typhoid fever. Coloured illustration of a hand the nails of which are traversed with several white bands, each corresponding to a relapse of the typhoid from which the patient had suffered. Systemic illness variant of Mees lines

1877 – Morris Longstreth published in the same journal edition as Da Costa his personal account of transverse white bands extending over the surface of the nails. These bands appeared after each exacerbation his own relapsing fever in 1869 with each band relating to a relapse of teh fever.


References


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Emergency physician MA (Oxon) MBChB (Edin) FACEM FFSEM with a passion for rugby; medical history; medical education; and informatics. Asynchronous learning #FOAMed evangelist. Co-founder and CTO of Life in the Fast lane | Eponyms | Books | vocortex |

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