Stigmata of liver cirrhosis

Q: What are Muehrcke's nails?

Answer: Muehrcke's nails, also called Muehrcke's lines or Muehrcke's striae, are white bands across the second, third, and fourth fingernails. In other words, they are the manifestations of leukonychia due to an abnormality in the vasculature of the nail bed. This is one of the stigmata of liver cirrhosis but can occur in other diseases such as nephrotic syndrome, glomerulonephritis, malnutrition, and in mountain climbers.

The objective of this question is to highlight the importance of (vanishing art of) physical exams in clinical medicine. 

The authors of this website use liver cirrhosis as an example here. Liver cirrhosis is a classic disease where history and physical exam can establish the diagnosis without any labs or imaging, though it should be done to re-confirm the diagnosis. Some of the classic stigmata of cirrhosis are: 

• jaundice
• spider angiomas (or nevi or telangiectasias)
• palmar erythema
• pruritus
• xerosis
• xanthelasma
• paper money skin
• muehrcke's nails
• hepatomegaly 
• ascites
• caput medusa
• splenomegaly
• dupuytren's contracture
• gynecomastia
• scant chest hair and axillary hair 
• asterixis
• fetor hepaticus

#physical-exam

#hepatology

#nephrology

References:

1. MUEHRCKE RC. The finger-nails in chronic hypoalbuminaemia; a new physical sign. Br Med J. 1956 Jun 9;1(4979):1327-8. doi: 10.1136/bmj.1.4979.1327. PMID: 13316143; PMCID: PMC1980060.

2. Schwartz RA, Vickerman CE. Muehrcke's lines of the fingernails. Arch Intern Med. 1979 Feb;139(2):242. PMID: 434982.

3. Smith A, Baumgartner K, Bositis C. Cirrhosis: Diagnosis and Management. Am Fam Physician. 2019 Dec 15;100(12):759-770. PMID: 31845776.