Quantitative analysis of nailfold capillary abnormalities in patients with connective tissue diseases

Predicting progression from undifferentiated connective tissue disease to definite connective tissue disease: A systematic review and meta-analysis

PURPOSE

Undifferentiated connective tissue disease (UCTD) encapsulates a broad range of conditions including incomplete forms of systemic lupus erythematosus (SLE) and systemic sclerosis (SSc), some of whom progress to a formal clinical diagnosis over time. This systematic review (SR) and meta-analysis aimed to identify clinical and laboratory features and biomarkers that can predict progression of UCTD.

METHODS

A systematic literature search was carried out on MEDLINE, EMBASE and the Cochrane Central Register of Randomized Controlled Trials. Abstracts and full-text manuscripts were screened by two reviewers. Publications were included if they included at least 20 UCTD patients, a minimum of six months of follow up, and provided data on at least one risk factor for developing a defined CTD. The QUIPS tool was used to assess risk of bias (RoB) and GRADE for grading the quality of the evidence. The study is registered with PROSPERO (ID: CRD42021237725).

RESULTS

Fifty-nine studies were included in the SR, and forty-one in the meta-analysis. The predictors for progression to SLE with the highest certainty of evidence included those with younger age (MD -5.96 [-11.05-0.87 years]), serositis (RR 2.69 [1.61-4.51]), or the presence of anti-dsDNA antibodies (RR 4.27 [1.92-9.51]). For SSc, the highest certainty of evidence included puffy fingers (RR [3.09 [1.48-6.43]), abnormal nailfold changes (NFC) (avascular areas [RR 5.71 (3.03-10.8)] or active or late SSc pattern [RR 2.24 (1.25-4.01)] and anti-topoisomerase-I (RR 1.83 [1.45-2.30]). No novel biomarkers were included in the meta-analysis; however HLA molecules, regulatory T cell shift, pro-inflammatory cytokines and complement activation products were identified as potential predictors for evolution of disease.

CONCLUSIONS

Clinical and immunological parameters may predict which patients with UCTD progress to definitive disease; however, the heterogeneous nature and RoB in most studies limits the ability to apply these results in routine clinical practice. Limited data suggest that some novel biomarkers may provide additional predictive value but these will need larger well designed studies to fully delineate their clinical utility.

Reduced levels of S-nitrosothiols in plasma of patients with systemic sclerosis and Raynaud's phenomenon

Objective

S-Nitrosothiols (RSNOs) are bioactive forms of nitric oxide which are involved in cell signalling and redox regulation of vascular function. Circulating S-nitrosothiols are predominantly in the form of S-nitrosoalbumin. In this study plasma concentrations of S-nitrosothiols were measured in patients with systemic sclerosis (SSc) where NO metabolism is known to be abnormal.

Patients and methods

Venous blood was collected from 16 patients with Raynaud's phenomenon (RP), 45 with systemic sclerosis (SSc) (34 patients had limited SSc (IcSSc) and 11 diffuse cutaneous disease (dcSSc)). Twenty six healthy subjects were used as controls. Plasma S-nitrosothiol concentrations were measured by chemiluminescence. The measurements were related to the extent of biological age, capillary/skin scores and disease duration.

Results

Plasma RSNO levels in patients with Raynaud's phenomenon (RP) and in those with SSc was significantly lower compared to the concentrations in control subjects. In SSc, plasma S-nitrosothiols were often below the level of detection (1nM).

Conclusions

Low S-nitrosothiol concentrations were observed in the blood of patients with SSc and patients with RP indicating a profound disturbance of nitric oxide metabolism.

Improved microcirculation imaging of human skin in vivo using optical microangiography with a correlation mapping mask

Optical microangiography based on optical coherence tomography (OCT) is prone to noise that arises from a static tissue region. Here, we propose a method that can significantly reduce this noise. The method is developed based on an approach that uses the magnitude information of OCT signals to produce tissue microangiograms, especially suitable for the case where a swept-source OCT system is deployed. By combined use of two existing OCT microangiography methods-ultrahigh-sensitive optical microangiography (UHS-OMAG) and correlation mapping OCT (cmOCT)-the final tissue microangiogram is generated by masking UHS-OMAG image using the binary representation of cmOCT image. We find that this process masks the residual static artifacts while preserving the vessel structures. The noise rejection capability of the masked approach (termed as mOMAG) is tested on a tissue-like flow phantom as well as an in vivo human skin tissue. Compared to UHS-OMAG and cmOCT, we demonstrate that the proposed method is capable of achieving improved signal-to-noise ratio in providing microcirculation images. Finally, we show its clinical potential by quantitatively assessing the vascular difference between a burn scar and a normal skin of human subject in vivo.

Volumetric cutaneous microangiography of human skin in vivo by VCSEL swept-source optical coherence tomography

Three-dimensional (3D) assessment of cutaneous microcirculation in human skin is essential in the identification of disease states in skin or other organs. Few 3D imaging techniques have revealed the skin micro-vasculatures non-invasively and with sufficient imaging depth. Here, we demonstrate volumetric cutaneous microangiography of the human skin in vivo that utilizes a 1.3 µm high-speed swept-source optical coherence tomography (SS-OCT). The swept source is based on a MEMS tunable vertical cavity surface emission laser (VCSEL) that is advantageous in terms of long coherence length over 50 mm and 100 nm spectral bandwidth that enables the visualization of microstructures within a few mm from the skin surface. We show that skin microvasculature can be delineated in 3D SS-OCT images using ultrahigh-sensitive optical microangiography (UHS-OMAG) with a correlation mapping mask, providing a contrast enhanced blood perfusion map with capillary flow sensitivity. 3D microangiograms of a healthy human finger are shown with distinct cutaneous vessel architectures from different dermal layers and even within hypodermis. These findings suggest that the OCT microangiography could be a beneficial biomedical assay to assess cutaneous vascular functions in clinic.

Preliminary clinical evaluation of semi-automated nailfold capillaroscopy in the assessment of patients with Raynaud's phenomenon

OBJECTIVES

  Nailfold capillaroscopy is well established in screening patients with Raynaud's phenomenon for underlying SSc-spectrum disorders, by identifying abnormal capillaries. Our aim was to compare semi-automatic feature measurement from newly developed software with manual measurements, and determine the degree to which semi-automated data allows disease group classification.

METHODS

  Images from 46 healthy controls, 21 patients with PRP and 49 with SSc were preprocessed, and semi-automated measurements of intercapillary distance and capillary width, tortuosity, and derangement were performed. These were compared with manual measurements. Features were used to classify images into the three subject groups.

RESULTS

  Comparison of automatic and manual measures for distance, width, tortuosity, and derangement had correlations of r=0.583, 0.624, 0.495 (p<0.001), and 0.195 (p=0.040). For automatic measures, correlations were found between width and intercapillary distance, r=0.374, and width and tortuosity, r=0.573 (p<0.001). Significant differences between subject groups were found for all features (p<0.002). Overall, 75% of images correctly matched clinical classification using semi-automated features, compared with 71% for manual measurements.

CONCLUSIONS

  Semi-automatic and manual measurements of distance, width, and tortuosity showed moderate (but statistically significant) correlations. Correlation for derangement was weaker. Semi-automatic measurements are faster than manual measurements. Semi-automatic parameters identify differences between groups, and are as good as manual measurements for between-group classification.

Dermoscopic detection of nail fold capillary abnormality in patients with systemic sclerosis

The diagnosis of systemic sclerosis (SSc) is often difficult. The purpose of the present study was to find the distribution of nail fold capillary abnormality in SSc. Sixty-two patients with SSc (male : female = 7:55, age 21-86 years, mean 60.1) admitted to the outpatient clinics were studied. Eighteen age- and sex-matched normal subjects, 28 patients with systemic lupus erythematosus (SLE) and 10 with dermatomyositis (DM) were also studied. Nail fold capillary loops were observed under immersion oil at a magnification of ×40 with a light microscope. Dilated capillaries, nail fold bleeding and avascular areas were found by dermoscopic observation. The distribution of dilated capillaries, nail fold bleeding and avascular areas in normal controls showed in one (5.6%), one (5.6%) and four cases (22.2%), respectively. The distribution of dilated capillaries, nail fold bleeding and avascular area in SSc patients showed in 27 cases (43.5%), eight cases (12.9%) and 16 cases (25.8%), respectively. The distribution of dilated capillaries and/or nail fold bleeding in SSc patients (29/62, 46.8%) was significantly elevated than that of normal controls (2/18, 11.1%) (P < 0.01). The distribution of overall abnormality in SSc (30/62, 48.4%) showed no significant difference compared with that of normal controls (4/18, 22.2%). Sensitivity and specificity for dilated capillaries and/or nail fold bleeding and overall nail fold abnormality in SSc patients compared with normal controls was calculated as 40.8% and 93.5%, 34.8% and 88.2%, respectively. Dermoscopic observation of dilated capillaries and/or nail fold bleeding is a sensitive and specific method for the detection of SSc.

Involvement of scalp and nails in lupus erythematosus

Lupus erythematosus (LE) is a systemic autoimmune disorder associated with polyclonal B-cell activation resulting in diverse patterns of autoantibody production and a heterogeneous clinical expression constituting a spectrum extending from limited cutaneous disease to life-threatening systemic manifestations. For daily clinical practice, the characteristics of cutaneous lupus erythematosus (CLE) have been well defined in terms of morphology, and clinical and laboratory criteria are available for the classification as systemic lupus erythematosus (SLE). The many different types of skin lesions encountered in patients with LE have been classified into those that are histologically specific for LE and those that are not. While LE non-specific skin lesions on their own do not enable a diagnosis of LE, they can be important reflections of underlying SLE disease activity. This also applies to the involvement of the scalp and nails. Finally, it must be kept in mind that LE patients may also develop drug-related, or other unrelated common disorders of the hair and nails that do not reflect LE disease activity.

Quantitative nailfold video capillaroscopy in patients with idiopathic inflammatory myopathy

OBJECTIVES

To quantify nailfold capillary density and dimensions in patients with idiopathic inflammatory myopathy (IIM) and compare them with those in healthy controls; to look for associations with microvascular disease in IIM; and to determine whether nailfold capillary density and dimensions change over time.

METHODS

Nailfold video microscopy (x300 magnification) was performed on 24 patients with IIM and 35 healthy controls. Capillary density and dimensions (total width and apical width) were quantified. Patients were clinically assessed and disease activity recorded using the Myositis Disease Activity Assessment Tool. Disease severity and physical function were assessed using the myositis damage index and Stanford HAQ, respectively. Findings were analysed using linear and logistic regression, adjusted for age and sex. In a subgroup of 16 patients with IIM and 27 controls, the process was repeated 6-12 months later and the results were analysed using Student's t-test.

RESULTS

Capillary density was lower and dimensions were higher in patients with IIM compared with healthy controls (P < 0.001 for all). Anti-Jo-1 antibody was associated with reduced capillary density. In the longitudinal cohort, the mean change in capillary density was -1.4 in patients vs -0.4 in controls (P = 0.07). Mean change in capillary dimensions did not differ between patients and controls, but some patients demonstrated pronounced changes in capillary morphology over time.

CONCLUSIONS

Reduced capillary density and increased dimensions in patients with IIM can be quantified using nailfold capillaroscopy, suggesting that nailfold capillaroscopy may be useful as an outcome measure of microvascular disease in studies of IIM.

Nailfold capillary microscopy in adults with inflammatory myopathy

OBJECTIVES

To study the presence and characteristics of nailfold capillary changes in a cohort of adult patients with inflammatory myopathies, determine correlations with disease activity and severity, and investigate any relationship between capillary findings and the immunological or clinical characteristics of the groups.

METHODS

Fifty-three consecutive adult patients followed in our outpatient clinic were evaluated using a Wild M3 stereomicroscope with an Intralux 5000 Volpi cold light lamp. A semiquantitative rating scale was used to score capillaroscopy changes. Disease activity and severity were assessed with the Myositis Disease Activity Assessment Tool and Myositis Damage Index, respectively. Associations between capillaroscopy findings and other factors were calculated with the chi(2) and Mann-Whitney U tests. Serum autoantibody profile was determined in all patients.

RESULTS

Twenty-three patients (43%) showed relevant capillaroscopy changes. No significant association was observed between the number of capillaroscopy alterations and the clinical or immunological groups, or disease duration. Disease activity and severity were both significantly associated with a larger number of capillaroscopy findings (P < 0.05). The combination of microhemorrhages and capillary enlargement was significantly more frequent in patients with dermatomyositis (OR, 8.9; 95% CI, 1.8-45.2), and a characteristic capillaroscopy pattern was associated with paraneoplastic myositis (OR, 14.7; 95% CI, 2.0-106.4). Interstitial lung disease significantly correlated with higher capillary score (OR, 3.7; 95% CI, 1.1-13.0).

CONCLUSIONS

Nailfold microcirculation as determined by semiquantitative simple capillaroscopy appears to provide useful information in patients with idiopathic inflammatory myopathy, contributing to an early diagnosis and identifying patients with a poor prognosis.

Nail changes in connective tissue diseases: do nail changes provide clues for the diagnosis?

OBJECTIVE

To evaluate the frequency and the specificity of nail changes associated with connective tissue diseases (CTD).

METHODS

In a case-control study, 190 patients including those with systemic lupus erythematosus (SLE; 56), rheumatoid arthritis (RA, 47), primary Sjögren's syndrome (pSS; 35), systemic sclerosis (SSc; 39), and dermatomyositis/polymyositis (DM/PM; 13) were enrolled in the study. Patients with SLE and other CTDs were compared with two different control groups. Twenty nails were examined. Nail features were noted and classified. Nail samples were collected for mycological cultures.

RESULTS

In patients with SLE, erythema of proximal nailfold (P<0.01), splinter haemorrhages in fingernails (P<0.01), capillary loops in proximal nailfold (P<0.05), periungual erythema (P<0.05), and thin nail plates (P<0.05) were more common than those in controls. Only splinter haemorrhages were associated with the disease activity. In patients with SSc and DM/PM, splinter haemorrhages (P<0.05) and capillary loops in proximal nailfold (P<0.01) in fingernails were common as well. Increase in longitudinal curvature (P<0.001), transverse curvature (P<0.01), and white dull colour in fingernails were other frequent findings in patients with SSc. Increase in transverse curvature was associated with the disease activity in SSc. In patients with RA, splinter haemorrhages (P<0.05), red lunula (P<0.05), and white dull colour (P<0.05) in fingernails were frequent. The sensitivity values of all these changes were very low. However, their specificity values were found to be relatively high.

CONCLUSION

Proximal nailfold is the most important site of affection in CTDs. These nail changes can be used in combination with highly sensitive diagnostic modalities to establish an accurate diagnosis.

Evaluation of Nailfold Videocapillaroscopic Abnormalities in Patients With Systemic Lupus Erythematosus

OBJECTIVE

Nailfold capillaroscopy (NFC) has been shown to have a remarkable value in the differential diagnosis of connective tissue diseases. In fact, NFC patterns reflect the microvascular changes that may play a significant role in pathogenesis. The aims of this study were to determine in patients with systemic lupus erythematosus (SLE) the prevalence of NFC patterns, to evaluate any association with clinical features and laboratory parameters.

MATERIALS AND METHODS

One hundred twenty-three patients with SLE were included in this retrospective study. Video NFC parameters were analyzed in each patient. In all cases, the following parameters were evaluated: capillary arrangement, density, size, and shape.

RESULTS

In patients with SLE, major capillary abnormalities were frequently observed (44 of 123 = 35.8%); however, no specific pattern was noted. There was a significant correlation between the SLEDAI index and the severity of capillary abnormalities (P < 0.0001). Pathologic capillary abnormalities were also significantly increased in SLE with positive anti-U1-RNP antibodies (P < 0.05).

CONCLUSION

NFC may be a useful method to evaluate the microvascular changes in patients with SLE, and the presence of major capillary abnormalities seems to herald a more severe clinical course of the illness.

Nailfold digital capillaroscopy in 447 patients with connective tissue disease and Raynaud's disease

The presence of megacapillaries and a decreased capillary density are the hallmarks of the scleroderma capillary pattern, which can be detected by nailfold capillarmicroscopy. One hundred and eighty-six patients with Raynaud's phenomenon, 65 cases with undifferentiated connective tissue disease (UCTD), 47 patients with systemic lupus erythematosus (SLE), 26 patients with dermato/polymyositis, 14 with rheumatoid arthritis, seven cases with primary Sjögren's syndrome and 102 patients with systemic sclerosis (SSc) were investigated. Of the 16 patients with diffuse cutaneous SSc and the 86 limited cutaneous SSc cases, 14 (87.5%) and 53 (61.6%) showed the scleroderma capillary pattern, respectively. Nine of the 65 (13.8%) cases with UCTD and 24 of the 186 (12.9%) cases with Raynaud's phenomenon also exhibited the same pattern. Four of the 47 (8.5%) with SLE and seven of the 26 (26.9%) with dermato/polymyositis, and no patients with rheumatoid arthritis or Sjögren's syndrome, exhibited the scleroderma capillary pattern. The conclusion is that the scleroderma capillary pattern is often present in SSc and dermato/polymyositis. Furthermore, patients with Raynaud's phenomenon and UCTD may also occasionally exhibit this pattern. Therefore, capillarmicroscopy seems to be a useful tool for the early selection of those patients who are potential candidates for developing scleroderma spectrum disorders.

Hair and nail involvement in lupus erythematosus

Lupus erythematosus (LE) is a systemic autoimmune disorder associated with polyclonal B-cell activation, resulting in diverse patterns of autoantibody production and a heterogeneous clinical expression constituting a spectrum extending from limited cutaneous disease (cutaneous lupus LE) to a life-threatening systemic disease process (systemic LE). While the clinical characteristics of cutaneous LE are well defined in terms of morphology, and for the classification of systemic LE (SLE), clinical and laboratory criteria are available, recent advances in basic and clinical research have contributed to a better understanding of the cellular and molecular events that lead to LE. The importance of genetic susceptibility, environmental factors, and hormonal elements are well appreciated, although we as clinicians are faced with relatively late-term manifestations of the immunologic events that lead to the clinical manifestations of disease. Nevertheless, combining our knowledge of the clinical patterns of LE with the advances in our understanding of the underlying immunology, has led to the concept of "subsets" of disease, where a correlation between immune genetic markers, autoantibody profiles, distinctive cutaneous morphology, and clinical outcome has become possible.