A 77-year-old, white man presented with a 5-month history of resting and exertional dyspnea. He complained of increasing abdominal girth, orthopnea, weight loss, shoulder muscle weakness, and bilateral ankle edema. His medical history was significant for COPD, hypertension, and diabetes. Physical examination revealed dystrophic nails (yellowed, thickened, curved with loss of cuticle and horizontal ridging), no clubbing, mild Dupuytren contractures, and bilateral ankle edema. There were bilateral pleural effusions on chest radiography without parenchymal changes. Echocardiography and abdominal ultrasonography findings were normal. A CT scan of the chest was not performed. A dermatology consult corroborated the clinical diagnosis of yellow nail syndrome. The patient had a therapeutic thoracentesis prior to a video-assisted thoracoscopic talc pleurodesis. The results of the pleural fluid analysis showed cholesterol of 111 mg/dL, triglyceride of 54 mg/dL, glucose of 143 mg/dL, and a total protein of 6 g/dL. Intraoperatively, the pleural fluid was not chylous in appearance. Cytology showed reactive mesothelial cells in a background of mature lymphocytes. Parietal pleural biopsy showed reactive mesothelial cells associated with fibrosis, calcification, and a mixed inflammatory cell response.