Fingernail, Toenail Changes and Flank Pain in a 20-Year-Old

Sumaira Nabi, MBBS; Shahzad Ahmed, MBBS; Mazhar Badshah, MBBS


November 29, 2022

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.


A 20-year-old woman presents with a 2-week history of bilateral flank pain and episodic vomiting. In addition, she has malar angiofibromas on her face, a leathery patch of skin on her lower back, and periungual fibromas on her fingers and toes (Figures 1-4).

Figure 1.

Figure 2.

Figure 3.

Figure 4.

She has no history of fever, dysuria, polyuria, hematuria, or urinary urgency. She was diagnosed with epilepsy in early childhood and has taken multiple antiepileptic drugs, with variable control. She is currently taking oral levetiracetam (500 mg three times per day) and oral carbamazepine (400 mg three times per day). She is single and unemployed. She is a nonsmoker and denies substance abuse. Her family history is noncontributory.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.