Koilonychia in a patient with rheumatoid arthritis and ascariasis

Koilonychia or spoon-shaped nails is a manifestation of chronic iron deficiency. Rheumatoid arthritis (RA) is a chronic inflammatory disease marked by symmetric peripheral arthritis. A mild normocytic or microcytic anemia due to chronic inflammation is frequent in patients with RA and other connective tissue diseases. A 53-year-old previously healthy farmer was referred to rheumatology outpatient clinic because of 8-week history of morning joint stiffness lasting >1 hour, tenderness and swelling of symmetrical joints of his upper and lower extremities. Rheumatoid factor (RF) was 512 IU/mL (normal range: 0-8), erythrocyte sedimentation rate (ESR) was 71 mm/h (normal range: 3-8), hemoglobin 9.9 g/dL (normal range for men 14- 18g/dL), global patient score ( VAS) was 100 mm (0-100 mm), number of tender joints (TJ) was 28 (out of 28 assessed), number of swollen joints (SJ) was 20, disease activity score DAS28 (by ESR) was 8.83 (DAS28>5.1 is considered high disease activity in rheumatoid arthritis-RA). On examination koilonychia was detected. According to ACR/EULAR 2010 rheumatoid arthritis classification RA was diagnosed. Treatment with methylprednisolone was started (16 mg/day), methotrexate (MTX) 15 mg/week, folic acid (5 mg/week), meloxicam 15 mg/day and esomeprazole 20 mg/day. One month later hemoglobin was 10.7g/dL and weight loss of 2 kg was recorded. Chest X-ray, abdominal ultrasonography and ECG were normal. An ova and parasite (O&P) exam was ordered and eggs of ascaris lumbricoides were detected. The patient received single dose of albendazolum. Koilonychia may result from anemia of chronic diseases in the course of RA, bleeding from the gastrointestinal tract, intestinal worms, gastrointestinal malignancy, celiac disease, high altitude, trauma, exposure to petroleum products or it can be hereditary. Ascariasis occurs when worm eggs are swallowed. This can happen from food, drink and soil. Hand hygiene is crucial. Anemia of chronic diseases is not the only reason of low hemoglobin in patients with arthritis. Differential diagnosis should include possible infection and tumors. An ova and parasite test cannot be neglected.