Nail fold videocapillaroscopy in mixed cryoglobulinaemia

Nailfold videocapillaroscopy in antineutrophil cytoplasmic antibody-associated vasculitis

OBJECTIVE

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a group of illnesses that cause inflammation and alterations to small vessels in the body. Some of the most common and detrimental manifestations, including alveolar hemorrhage and glomerulonephritis, are caused by this capillary inflammation. We sought to clarify whether patients with AAV would have abnormal nailfold capillaries when evaluated with nailfold videocapillaroscopy.

METHODS

Patients with a current diagnosis of AAV and a control group were identified for enrollment. Nailfold videocapillaroscopy images were used for a semiquantitative analysis on capillary density, morphology, dilation, and microhemorrhage after review by 2 rheumatologists. Disease characteristics, occurrence of recent disease flare, and presence of ANCA were recorded.

RESULTS

Thirty-three patients with a diagnosis of AAV and 21 controls were recruited. The AAV group had a median age of 59 and 17 (52%) were women. Granulomatosis with polyangiitis was the most common diagnosis (19 [58%]), followed by eosinophilic granulomatosis with polyangiitis (7 [21%]) and microscopic polyangiitis (7 [21%]). Twenty-seven patients (82%) had positive ANCA tests. After assessment of capillary density, dilation, morphology, microhemorrhages, and disorganization, there were no statistically significant differences between the 2 groups.

CONCLUSION

There was no evidence of differences in nailfold capillaroscopy abnormalities between those diagnosed with AAV and the control group. While this cohort was relatively small, we did not find a high enough prevalence or specific phenotype of capillary abnormalities that could aid in diagnosis or prognostication of these diseases in the clinical setting.

[Periungueal capillaroscopy: an easy and reliable method to evaluate all microcirculation diseases]

Periungueal capillaroscopy is a simple and reliable non-invasive technique allowing evaluation of cutaneous microcirculation. It was promoted for decades in patients with Raynaud's phenomenon in order to differentiate between the benign primary Raynaud's phenomenon and the secondary form in connective tissue diseases, especially systemic sclerosis. Nevertheless, the value of this procedure has also been shown in numerous pathologies such as diabetes or cardiovascular diseases. This literature review points to the versatility of this useful exam and its results in a large spectrum of diseases with microvascular involvement.

The role of nail-videocapillaroscopy in early diagnosis of scleroderma

Raynaud's phenomenon (RP) is a clinical sign of precocious abnormal microcirculation and can be considered a major risk factor for the development of connective tissue disease, especially systemic sclerosis (SSc). Nailfold videocapillaroscopy is the most valuable tool for the early diagnosis of SSc and related disorders. It allows classification of capillary abnormalities. Scoring capillaroscopic alterations, which change significantly during patient follow-up, should be systematically used in order to monitor microangiopathy. The effectiveness of the nailfold videocapillaroscopy in allowing an early diagnosis of SSc and monitoring the progression of the disease, and its predictive value of clinical complications make it a powerful tool for clinical evaluation and research.

Techniques to assess tissue oxygenation in the clinical setting

The microcirculation plays an essential role in health and disease. Microvascular perfusion can be assessed directly using laser Doppler flowmetry and various imaging techniques or indirectly using regional capnometry and measurement of indicators of mismatch between oxygen delivery and oxygen consumption or indices of disturbed cellular oxygen utilization. Assessment of microvascular oxygen availability implies measurement of oxygen pressure or measurement of hemoglobin oxygen saturation. Microvascular function is assessed using other methods, including venous plethysmography. In this paper, I review current knowledge concerning assessment of the microcirculation with special emphasis on methods that could be used at the bedside.

Videocapillaroscopy in postburn scars: in vivo analysis of the microcirculation

OBJECTIVE

The aim of the study was the evaluation in vivo of the differences between the microcirculatory characteristics of the postburn scar and the healthy skin.

METHODS

Twelve patients with postburn scars were included in the study, evaluating fifteen scar areas and twelve healthy skin areas by means of contact optical probe videocapillaroscopy. The examined areas for each patient were the right and the left upper limb. Capillary density, length and diameter, together with capillary distribution pattern (punctiform, reticular, directional) and the presence of microhaemorrhages and neoangiogenesis were studied.

RESULTS

The results were obtained by two different researchers using the capillaroscope's software. Capillary loop diameter and length, capillary distribution pattern and presence of neoangiogenesis were found to be significantly increased in postburn scars compared with controls. There were also significant differences between hypertrophic tissue in the active phase and the one in the remission phase for capillary diameter and presence of neoangiogenesis.

CONCLUSION

Videocapillaroscopy showed "in vivo" a change in local microcirculation architecture using a microscope. Patients with hypertrophic burn scars showed a variety of microcirculatory changes, often clustered in a characteristic pattern of abnormally oriented, dilated capillaries and neoangiogenetic phenomena. This methodology is highly likely to be of value in the assessment and prognostication of burn outcome.

Case Presentation: Xenograft Resistance to Protease Degradation in a Vasculitic Ulcer

Vasculitic ulcers are related to numerous underlying etiologies including autoimmune disease, rheumatoid arthritis and other inflammatory conditions.The resulting ulcerations are associated with high levels of pain, inflammation and tissue necrosis. Current therapies, including surgical intervention, are limited by the underlying inflammatory process and complications secondary to the wound etiology. conservative care has been relatively unsuccessful in promoting wound closure.This case presentations reviews the successful results of using a xenograft in the treatment of an inflammatory ulcer associated with cryoglobulinemia and vasculitis. Product integrity was maintained postoperatively, compared to an allograft, thereby allowing the wound treatment site to progress to closure.The type of cross linkage of acellular grafts may have a direct effect on product stability and treatment outcomes.

Indications and results of videocapillaroscopy in clinical practice

Nailfold videocapillaroscopy (NVC) is one of the best diagnostic non-invasive imaging techniques to evaluate microcirculation in vivo and is increasingly employed in the field of rheumatology. Indeed, at present, the most important utility of NVC is in the identification of microvascular involvement in many rheumatic diseases, particularly in systemic sclerosis. More recently, this technique has been shown to be applicable to the study of many other extra-rheumatic diseases, such as arterial hypertension, diabetes mellitus, acromegaly, hyperthyroidism, cardiac syndrome X, primary biliary cirrhosis, Crohn's disease, psoriasis, familial Mediterranean fever. This article sets down the methodology of examination and normal pattern of capillary vessels and reviews the applications of NVC in clinical practice and its results in rheumatic and non-rheumatic diseases.

Multicenter study on hepatitis C virus-related cryoglobulinemic glomerulonephritis

BACKGROUND

Mixed cryoglobulinemia is a multisystem disorder associated strongly with hepatitis C virus (HCV) infection. The kidney frequently is involved, and glomerulonephritis represents the key factor affecting prognosis.

METHODS

Clinical, serological, immunogenetic, and morphological data were collected retrospectively from medical records of 146 patients with cryoglobulinemic glomerulonephritis who underwent biopsies in 25 Italian centers and 34 cryoglobulinemic controls without renal involvement.

RESULTS

Eighty-seven percent of patients were infected with HCV; genotype 1b was more frequent than genotype 2 (55% versus 43%). Diffuse membranoproliferative glomerulonephritis was the most prevalent histological pattern (83%). Type II cryoglobulin (immunoglobulin Mkappa [IgMkappa]/IgG) was detected in 74.4% of cases. The remainder had type III (polyclonal IgM/IgG) cryoglobulins. A multivariate Cox proportional hazard model showed that age, serum creatinine level, and proteinuria at the onset of renal disease were associated independently with risk for developing severe renal failure at follow-up. Overall survival at 10 years was about 80%. Kaplan-Meier survival curves were worsened by a basal creatinine value greater than 1.5 mg/dL (>133 mumol/L), but were unaffected by sex and HCV infection. Cardiovascular disease was the cause of death in more than 60% of patients.

CONCLUSION

Data confirm the close association between mixed cryoglobulinemia and HCV infection and between glomerulonephritis and type II cryoglobulin. Survival profiles are better than previously reported in the literature, probably because of improvement in therapeutic regimens. Causes of death reflect this improvement in survival, with an increased prevalence of cardiovascular events compared with infectious complications and hepatic failure, which were predominant in the past.

Capillaroscopy

Raynaud's phenomenon (RP) is the most common and significant clinical condition with an indication for a microvascular analysis to be carried out as soon as possible. Microvascular involvement is a key feature of RP and several rheumatic diseases are characterised by the presence of RP. Nailfold capillary microscopy shows an impressive cost/effectiveness ratio: it is simple, non-invasive and inexpensive. Well recognised nailfold videocapillaroscopic patterns (NVC) have been described mainly in systemic sclerosis (SSc) patients with secondary RP. The peripheral microvascular damage in SSc is characterised by increasing structural alterations of the capillaries (giant capillaries and microhaemorrhagies) with a progressive decrease in their density. The detection of the scleroderma NVC pattern allows an early distinction between the primary RP (functional, not disease associated) and the secondary RP (disease associated). Other major NVC patterns have been described in the field of rheumatic diseases. Interestingly, correlations are evident between the NVC and the clinical symptoms, severity of the disease and the laboratory findings.