Imatinib Induced Blue Nails

Excerpt

A 22-years-old female presented with fatigue for the past 6-months. Examination was remarkable for mild pallor, and hepatosplenomegaly. Blood investigations were: hemoglobin-107 g/l, white cell count: 119 × 10⁹/l, and platelets: 837 × 10⁹/l. Peripheral smear suggested a possibility of myeloproliferative neoplasm. BCR-ABL1 mRNA transcript was detected in the peripheral blood by RT-PCR, confirming the diagnosis of chronic myeloid leukemia. Imatinib (400 mg once a day) was initiated, following which she developed bluish discoloration of the nails of hands and feet after 4-weeks of therapy (Fig. 1). There was no mucocutaneous hyperpigmentation elsewhere. Keeping a possibility of drug-induced hyperpigmentation, imatinib was continued, and patient was reassured. While imatinib-induced hypopigmentation is common (40%), hyperpigmentation is unusual. While nail discoloration due to imatinib has been reported in about 3% cases, isolated nail hyperpigmentation is extremely rare [1]. Postulated mechanisms include paradoxical melanocyte stimulation through c-kit activation, deposition of drug-metabolite chelated to iron or melanin, and drug-induced immune dysregulation leading to melanin pigment incontinence [2]. We highlight the need for a periodic meticulous mucocutaneous examination of patients taking imatinib. Patients with mucocutaneous side effects due to imatinib should be reassured, while continuing the therapy.

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