A Subtle Clue to a Serious Diagnosis

A 48-year-old man presents with flank pain and weight loss. A subtle nail finding on physical exam points towards a devastating systemic diagnosis.

Splinter hemorrhages


A previously healthy 48-year-old man presented to the emergency department with acute onset of pain in both flanks. During the preceding 6 months he had had an unintentional weight loss of approximately 5 kg. On physical examination, the following nail changes were noted. What is the finding?

What is the most likely diagnosis?

Nicotine staining
Splinter hemorrhages
Ungal melanoma
Janeway lesion
Onycholysis

Nonbacterial thrombotic endocarditis, Pancreatic cancer, Paraneoplastic syndrome, Physical Examination, Splinter hemorrhages

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