You are asked to make a diagnosis in two different patients, given only scanty clues. The first patient is a 35 year-old-man who presents with enlarged lymph nodes in his neck. He states they become painful when he drinks an alcoholic beverage. The second patient is a 56-year-old man who has run a fever for 6 months. An extensive in-hospital workup, including an exploratory laparotomy, failed to yield a diagnosis. The clue to his diagnosis can be found by careful inspection of his thumb nail (see picture). These two patients suffer from the same disease.
DIAGNOSIS: Hodgkin's disease (HD): A small percentage of patient's with HD will experience pain in diseased lymph nodes when they drink alcoholic beverages (patient # 1); others may develop a Pel-Epstein fever (see temperature curve) which highly supports a diagnosis of HD, although the pattern can be confused with the relapsing fever seen in some patients with chronic brucellosis (undulant fever). You can see that the Pel Epstein fever is characterized periods of rising temperature interspersed with periods of normal temperature; true rigor can accompany the temperature spikes. The periodic horizontal thinning of the thumbnails (these are called Beau's lines) in patient #2 occurred every time his temperature reached 38.2 degrees Celsius, and provided the clue that he had a relapsing fever. We have named these regularly spaced Beau's lines "the Ladder Nail sign".