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A 30 year old woman was admitted to hospital with a rapidly progressive decline in level of consciousness and seizures. Neuroimaging studies disclosed thrombus in the superior sagittal sinus, bilateral cerebral venous infarctions, and oedema. She was treated with intravenous heparin and propofol for control of agitation and increased intracranial pressure. She made an excellent recovery. Three weeks after admission she alerted us to a painless brownish discolouration of many of her fingernails. Bilateral subungual haematomas in different stages of resolution were noted (figure). These lesions had been created by frequent nail bed compression with a pencil to monitor motor response, a common practice of applying noxious pain stimuli in comatose patients admitted to neurological intensive care units.
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