LAUSR

An 81-yeareold woman, a lifetime nonsmoker, was referred for fingernail changes concerning for onychomycosis on her left hand. She had diabetes and was on hemodialysis for nonsteroidal antiinflammatory drugeinduced nephropathy. She reported a painful left hand and fingertips for 2 months but denied weakness, cold intolerance, color changes, and numbness. The tips of her left index and ring fingers had hyperkeratotic subungual material adjacent to small crusted ulcers (Fig 1). Her right hand was uninvolved (Fig 2). Her left radial and ulnar arterial pulses were diminished; her right-sided pulses were normal. An arteriovenous hemodialysis fistula had been placed on her left antecubital fossa 4 years earlier and was functioning normally.