The Egyptian Rheumatologist (2011) 33, 61–67
Egyptian Society for Joint Diseases and Arthritis
The Egyptian Rheumatologist www.rheumatology.eg.net www.sciencedirect.com
ORIGINAL ARTICLE
Nailfold capilloroscopy in systemic lupus erythematosus O. Ragab a, A. Ashmawy b, M. Abdo a, A. Mokbel a b
a,*
Department of Rheumatology and Rehabilitation, Faculty of Medicine, Cairo University, Egypt Department of Internal Medicine, Faculty of Medicine, Cairo University, Egypt
Received 8 April 2010; accepted 12 May 2010 Available online 19 January 2010
KEYWORDS Systemic lupus erythematosus; Nailfold capilloroscopy; Microvascular involvement; Meandering capillary pattern
Abstract Introduction: Nailfold capillaroscopy is a non-invasive technique to recognize peripheral microangiopathy, which is an important feature in SLE. Aim of the work: To study the prevalence of nailfold capillaroscopy (NFC) changes in patients with systemic lupus erythematosus (SLE), find out the patterns of these changes and to correlate these findings with different clinical and laboratory parameters. Patients and methods: Forty patients with SLE, all fulfilling the 1997 revised criteria for the classification of SLE were included. All patients included in this study were subjected to full history taking, clinical examination, laboratory investigations as well as nailfold capillaroscopy (NFC) examination. Results: The prevalence of nailfold capilloroscopic (NFC) changes in SLE patients was 75%. Nailfold capillaroscopic abnormalities were significantly more frequent in SLE patients than in controls (P < 0.05). Different abnormal NFC changes were seen with the meandering pattern more frequently seen. The afferent and efferent capillary loops diameters were significantly increased in the SLE patients than in the control group (P < 0.05). Some of the NFC abnormalities showed statistical significant correlations with different clinical and laboratoryparameters. Capillary loop afferent and
Abbreviations: NFC, nailfold capillaroscopy; RP, Raynaud’s phenomenon; SLE, systemic lupus erythematosus; SLEDAI, Systemic Lupus Erythematosus Disease Activity Index; ESR, erythrocyte sedimentation rate; CBC, complete blood picture; ANA, antinuclear antibodies; DNA, deoxyribonucleic acid; lm, micrometer. * Corresponding author. Address: Saray El Manial Street, El Manial, Cairo 12411, Egypt. Tel.: +20 10 511 0752; fax: +20 23 303 1181. E-mail address:
[email protected] (A. Mokbel). 1110-1164 Ó 2011 Egyptian Society for Joint Diseases and Arthritis. Production and hosting by Elsevier B.V. All rights reserved. Peer review under responsibility of Egyptian Society for Joint Diseases and Arthritis. doi:10.1016/j.ejr.2010.12.003
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O. Ragab et al. efferent diameters were significantly correlated with disease duration (P < 0.05) as well as the occurrence of digital gangrene (P < 0.05). Also the capillary loop afferent diameter was found to be correlated with the intake of cyclophosphamide (P < 0.05). Conclusion: Significant microcirculatory changes occur in systemic lupus erythematosus (SLE) patients as proved by the high prevalence of capillary abnormalities in lupus patients compared to controls by means of nailfold capillaroscopy. Some nailfold capillaroscopy changes e.g. meandering capillaries may complete picture of SLE diagnosis. Duration of SLE disease may have an impact on microcirculation of these patients. The presence of some nailfold capillaroscopy changes in SLE patients may be an alarming sign to fatal ischemia of the digits. Ó 2011 Egyptian Society for Joint Diseases and Arthritis. Production and hosting by Elsevier B.V. All rights reserved.
1. Introduction Nailfold capillaroscopy (NFC) is a non-invasive and safe technique used to recognize peripheral microangiopathy and it is also reported to have both diagnostic and prognostic value [1]. Microvascular involvement is an important feature in SLE [2]. NFC may be a useful method to evaluate the microvascular changes in patients with SLE [3], and it was proved to be an easy-to-perform, able to achieve useful data that evaluates better such a pleomorphic disease especially concerning its outcome and prognosis [2]. In SLE patients NFC studies have described many different capillary forms and patterns and a variable prevalence of capillary abnormalities has been reported [4]. However, sensitivity of the capillaroscopic method is lower in SLE patients in respect to the so-called scleroderma-related diseases, but it can provide a valid support for the diagnosis [5]. The typical capillaroscopic pattern in SLE (SLE pattern) consists basically of increased capillary tortuosity, which may affect the three branches of the capillary loop, with changes like meandering, corkscrew or circumvolutions and lengthening of loops, which at times resemble glomeruloid structures [6]. NFC can be useful in the diagnostic procedure of the disease and lead to more effective strategies in the treatment of systemic organ dysfunction in SLE and abnormalities in nailfold capillaroscopy may reflect the extent of microvascular involvement in SLE. They also reported that all SLE patients with internal organ manifestations showed severe or moderate pathological changes under NFC [7]. This study aimed to investigate the pattern of NFC changes in patients with SLE and correlate it with various clinical and laboratory data. 2. Patients and methods Forty patients with SLE attending the Rheumatology and Rehabilitation department, Cairo University Hospital were selected. All patients fulfilled the 1997 American College of Rheumatology criteria for SLE [8]. Twenty age and sex matched apparently healthy subjects were served as a control. SLE patients who had associated diabetes mellitus or secondary antiphospholipid syndrome were excluded, as both of these conditions can cause microangiopathic changes that could be detected in NFC and affect the study results. All patients were subjected to the following: 1. Full history taking including onset, course, duration of the disease and manifestations of various systems affections.
2. Thorough clinical examination with special emphasis on skin manifestations suggesting vasculitis. 3. Laboratory investigations included complete blood count (CBC), erythrocyte sedimentation rate (ESR), complete urine analysis, total 24 h urinary proteins, kidney and liver function tests, antinuclear antibodies (ANA), anti-DNA and quantitative determination of serum complement levels (C3, C4). 4. Assessment of disease activity was done using the SLE Disease Activity Index (SLEDAI) [9]. 5. Assessment of the capillary circulation was done using the nailfold capilloroscopy.
2.1. Nailfold capilloroscopy examination Nailfold capillaroscopy was done using a dynamic capillaroscope (K.K. England) consisting of a light source, green filter, dimming control, charge coupled device camera connected to a frame grabber and a PC with a software dedicated to calibrate and measure linear dimensions and areas. Nailfold capillaroscopy examination was done to all patients and controls, where all subjects were examined in the sitting position with the hand at the level of the heart. Each patient was acclimatized for 15 min at a room temperature of 20–24 °C prior to NFC. The fourth and fifth fingers of each hand were examined, due to the greater skin transparency in these fingers and their examination usually offers the best capillary visibility [10]. No interfering substances on the surface of the skin. Fingers affected by recent local trauma were not analyzed. The patient’s forearm was placed on a firm support on the investigation table to allow easy fixation of the patient’s fingers under the microscope. The finger chosen for investigation was placed under the microscope objective. A drop of paraffin oil was applied to the nailfold before recording to make the skin transparent and improve resolution. Only capillaries in the distal row of the nailfold were analyzed and scored [2]. The following NFC parameters were considered: (1) Capillary loop diameters (afferent and efferent loops diameters): The average diameter of the arteriolar limb is 15.0 ± 2.5 lm whilst the venular limb is slightly bigger at 16.7 ± 3.0 lm [11]. Enlarged capillaries were defined as those having four or more times the width of normal neighbor loops in the three limbs, ascendant, transition, and descendant [12].
Nailfold capilloroscopy in systemic lupus erythematosus (2) Presence of morphological abnormalities: Nailfold capillaries in the healthy subject usually show a regular architecture, uniform shape, distribution and diameter, and most of them show a hairpin or U shaped aspect [13]. The capillary morphology was classified as normal (regular distribution of hairpin-like capillaries) or abnormal when there was >10% capillary dystrophies in the form of tortuous capillaries, meandering capillaries, corkscrew and bushy capillaries [4]. (3) Capillary hemorrhages which were evaluated near the distal row inferred that the occurrence of micropetechiae of focal distribution was related to everyday microtrauma that may occur in healthy individuals but the occurrence of micropetechiae of diffuse distribution is pathological [14]. Capillary hemorrhages were considered as abnormal when they were >10%, according to Caspary et al. [4].
2.2. Statistical analysis An IBM compatible PC was used to store and analyze the data and to produce graphic presentation of important results. Calculations were done by means of statistically software package namely ‘‘SPSS 13’’ for Windows (SPSS, Chicago, IL, USA). Results are expressed as mean ± SD. Comparisons were made by the unpaired ‘‘t’’ test. Correlation between variables was tested with Pearsons’ correlation analysis. Chi-square test was used for qualitative data. Significance of results was considered non-significant if P value >0.05, significant if P value
