An 80-year-old man with dyspnea and bilateral pleural effusions after partial nephrectomy for renal cell carcinoma

An 80-year-oldman presented because of superficial head trauma sustained after falling frombed. On review of systems, he reported worsening dyspnea on exertion, nonproductive cough, and weight loss over the preceding 2 to 3 months. There was no report of chest pain or leg swelling. He had a past medical history of hypertension, coronary artery disease, subclinical hypothyroidism, and renal cell carcinoma treated with partial right nephrectomy approximately 1 year before this presentation. Two months earlier he had been evaluated in the dermatology clinic for painful, dystrophic fingernails. At that time he was diagnosed with acropachy with onycholysis and suspected superinfection, and after failing to improve with vinegar soaks and topical antimicrobials, he underwent surgical nail removal on the second and fourth digits of the right hand. Histological examination of the operative specimens revealed dystrophic nails with negative fungal stains. Hismedications included levothyroxine, hydrochlorothiazide, and clopidogrel. He had never smoked and had done clerical work until retirement. He was originally from Colombia.