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Hassan F, Khoury A, Awad J, Jeries H, Naffaa ME. A very rare cause of blue finger: A case-based review. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2023; 8:NP1-NP5. [PMID: 37744045 PMCID: PMC10515991 DOI: 10.1177/23971983231162679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 02/21/2023] [Indexed: 09/26/2023]
Abstract
Introduction Cryofibrinogen is an abnormal, cold-insoluble protein composed of a combination of fibrinogen, fibrin, and fibronectin. Cryofibrinogenemia can be essential (e.g. primary) or secondary to various conditions. While low levels of cryofibrinogen can be seen in asymptomatic healthy individuals without evidence of clinical features typical of cryofibrinogenemia, cryofibrinogenemia associated with clinical features is considered very rare. The clinical features of cryofibrinogenemia ranges from skin manifestations, including Raynaud's phenomenon and livedo reticularis, to more severe organ-threatening manifestations such as tissue ischemia and gangrene. Case description We report a case of a 48-year-old male who presented with blue finger and palpable purpura on his distal extremities. Laboratory workup was positive for anti-nuclear antibodies, anti-double-stranded DNA, anti-ribonucleoprotein, and rheumatoid factor, while antineutrophil cytoplasmic antibodies and cryoglobulins were negative. Testing for hypercoagulable states and infectious etiologies was unrevealing. Later, angiographic computed tomography showed multiple pulmonary embolisms and disruption of blood flow to the left fifth digit. As the aforementioned workup could not explain the presence of the thrombus by a thromboembolic cause, a search for an in situ cause other than antiphospholipid syndrome was initiated and concentrated mainly on cryofibrinogenemia. Blood samples collected using prewarmed anticoagulant containing tubes were sent to central lab familiar with performing the test. Two weeks later, a positive result for the presence of cryofibrinogen confirmed the diagnosis of cryofibrinogenemia. Due to the presence of multiple signs compatible with mixed connective tissue disease, he was diagnosed with cryofibrinogenemia secondary to mixed connective tissue disease, and treatment with prednisone, low-molecular-weight heparin, prostacyclin and hydroxychloroquine was initiaed with favorable outcome. Conclusion Cryofibrinogenemia is a rare and underdiagnosed condition. Clinicians should be aware of this cryopathy especially in the cases of Raynaud's phenomenon and ischemic ulcers not explained by other causes. Precautions must be taken during the diagnostic process, and therapy should be given as soon as possible.
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Affiliation(s)
- Fadi Hassan
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
- Rheumatology Unit, Galilee Medical Center, Nahariya, Israel
| | - Amir Khoury
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
- Department of Internal Medicine “F”, Galilee Medical Center, Nahariya, Israel
| | - Jamal Awad
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
- Department of Internal Medicine “F”, Galilee Medical Center, Nahariya, Israel
| | - Helana Jeries
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
- Rheumatology Unit, Galilee Medical Center, Nahariya, Israel
| | - Mohammad E Naffaa
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
- Rheumatology Unit, Galilee Medical Center, Nahariya, Israel
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5
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Santiago MB, Melo BS. Cryofibrinogenemia: What Rheumatologists Should Know. Curr Rheumatol Rev 2022; 18:186-194. [PMID: 35339184 DOI: 10.2174/1573397118666220325110737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 12/13/2021] [Accepted: 01/31/2022] [Indexed: 11/22/2022]
Abstract
Cryofibrinogenemia refers to the presence of cryofibrinogen in plasma. This protein has the property of precipitating at lower temperatures. Cryofibrinogenemia is a rare disorder, clinically characterized by skin lesions, such as ulcers, necrosis, livedo reticularis, arthralgia, thrombosis, and limb ischemia. These features are most often observed in rheumatological practice and consist in the differential diagnoses of antiphospholipid syndrome, primary vasculitis, thrombotic thrombocytopenic purpura, and cryoglobulinemia. Classical histopathological findings include the presence of thrombi within the lumen of blood vessels of the skin without vasculitis. To date, there are no validated classification criteria. Management includes corticosteroids, immunosuppressive therapy, anticoagulants, and fibrinolytic agents. This narrative review aims to make physicians, particularly rheumatologists, aware of existence of this underdiagnosed condition. There are no epidemiological studies evaluating the prevalence of cryofibrinogenemia in different rheumatological disorders. Studies are also required to investigate if certain features of rheumatological diseases are related to the presence of cryofibrinogenemia.
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Affiliation(s)
- Mittermayer B Santiago
- Hospital Santa Izabel, Praça Almeida Couto 500, CEP: 40.000-000, Salvador, Bahia, Brazil.
- Serviços Especializados em Reumatologia da Bahia, Rua Conde Filho, 117, CEP: 40150-150, Salvador, Bahia, Brazil.
- Serviço de Reumatologia do Hospital Universitário Professor Edgard Santos, Rua Augusto Viana, CEP: 40110-060, Salvador, Bahia, Brazil.
- Escola Bahiana de Medicina e Saúde Pública, Av. Dom João VI, 275, CEP: 40290-000, Salvador, Bahia, Brazil
| | - Bartira Souza Melo
- Hospital Santa Izabel, Praça Almeida Couto 500, CEP: 40.000-000, Salvador, Bahia, Brazil
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6
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Molaee H, Emadi SN, M'Imunya JMN, Davoudi-Monfared E, Mohammed A, Razavi Z. Chilblain or Perniosis-like Skin Lesions in children during the COVID-19 pandemic: A Systematic Review of Articles. Dermatol Ther 2022; 35:e15298. [PMID: 34981615 DOI: 10.1111/dth.15298] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 12/24/2021] [Accepted: 12/31/2021] [Indexed: 11/27/2022]
Abstract
COVID toes or chilblain-like skin lesions represent a widespread and specific skin presentation in the feet attributed to COVID-19 infection. They may last for several months. We conducted this study to investigate chilblain-like lesions in children during the COVID-19 pandemic, any predisposition, location, clinical course, and prognosis. We searched Google Scholar, Scopus, and Medline (PubMed) databases using the following keywords: "Coronavirus" OR "COVID-19" AND "Chilblains" OR "Pernio" OR "Perniosis" OR "Children" OR "Cutaneous" OR "skin." The inclusion criteria were: studies that described the specific vascular skin lesion. studies that included patients that were aged > one month till 18 years. . Case reports, case series, retrospective or prospective cohort studies, case-control studies. Twenty-eight articles were included. The total number of children with CLL was 433. The mean age of children presenting CLL during the COVID-19 pandemic was estimated as 12.58 ± 2.15. Of note, 53.6% of them were male. The nasopharyngeal SARS-CoV-2 RT-PCR test and anti-SARS-CoV-2 antibodies were mostly negative for the virus. In conclusion, it is crucial to be familiar with various presentations of COVID-19 infection and their clinical significance to approach the earliest diagnosis, immediate treatment, estimate the prognosis and finally isolate the patients to prevent spreading. Chilblain-like lesions as a possible cutaneous presentation of COVID-19 in children may last several months with the indolent course.
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Affiliation(s)
- Hamideh Molaee
- Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Seyed Naser Emadi
- Skin Research Center of Razi and Imam khomeini hospital, Research Center for War-affected People, Tehran University of Medical Sciences and the Iranian Red Crescent Society, Tehran, Iran
| | | | - Esmat Davoudi-Monfared
- Health Management Research Center, Department of community medicine, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Asha Mohammed
- Public Health department, The Kenya Red Cross Society, Tehran, Iran
| | - Zahra Razavi
- Department of dermatology, Razi hospital, Tehran University of Medical Sciences, Tehran, Iran
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7
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Frumholtz L, Bouaziz JD, Battistella M, Hadjadj J, Chocron R, Bengoufa D, Le Buanec H, Barnabei L, Meynier S, Schwartz O, Grzelak L, Smith N, Charbit B, Duffy D, Yatim N, Calugareanu A, Philippe A, Guerin CL, Joly B, Siguret V, Jaume L, Bachelez H, Bagot M, Rieux-Laucat F, Maylin S, Legoff J, Delaugerre C, Gendron N, Smadja DM, Cassius C. Type I interferon response and vascular alteration in chilblain-like lesions during the COVID-19 outbreak. Br J Dermatol 2021; 185:1176-1185. [PMID: 34611893 PMCID: PMC8652826 DOI: 10.1111/bjd.20707] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2021] [Indexed: 12/14/2022]
Abstract
Background The outbreak of chilblain‐like lesions (CLL) during the COVID‐19 pandemic has been reported extensively, potentially related to SARS‐CoV‐2 infection, yet its underlying pathophysiology is unclear. Objectives To study skin and blood endothelial and immune system activation in CLL in comparison with healthy controls and seasonal chilblains (SC), defined as cold‐induced sporadic chilblains occurring during 2015 and 2019 with exclusion of chilblain lupus. Methods This observational study was conducted during 9–16 April 2020 at Saint‐Louis Hospital, Paris, France. All patients referred with CLL seen during this period of the COVID‐19 pandemic were included in this study. We excluded patients with a history of chilblains or chilblain lupus. Fifty patients were included. Results Histological patterns were similar and transcriptomic signatures overlapped in both the CLL and SC groups, with type I interferon polarization and a cytotoxic–natural killer gene signature. CLL were characterized by higher IgA tissue deposition and more significant transcriptomic activation of complement and angiogenesis factors compared with SC. We observed in CLL a systemic immune response associated with IgA antineutrophil cytoplasmic antibodies in 73% of patients, and elevated type I interferon blood signature in comparison with healthy controls. Finally, using blood biomarkers related to endothelial dysfunction and activation, and to angiogenesis or endothelial progenitor cell mobilization, we confirmed endothelial dysfunction in CLL. Conclusions Our findings support an activation loop in the skin in CLL associated with endothelial alteration and immune infiltration of cytotoxic and type I IFN‐polarized cells leading to clinical manifestations.
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Affiliation(s)
- L Frumholtz
- Dermatology Department, AP-HP, Hôpital Saint-Louis, F-75010, Paris, France
| | - J-D Bouaziz
- Dermatology Department, AP-HP, Hôpital Saint-Louis, F-75010, Paris, France.,Université de Paris, Human Immunology Pathophysiology Immunotherapy, INSERM U976, Institut de Recherche Saint-Louis, F-75010, Paris, France
| | - M Battistella
- Université de Paris, Human Immunology Pathophysiology Immunotherapy, INSERM U976, Institut de Recherche Saint-Louis, F-75010, Paris, France.,Pathology Department, AP-HP, Hôpital Saint-Louis, F-75010, Paris, France
| | - J Hadjadj
- Université de Paris, Imagine Institute, Laboratory of Immunogenetics of Pediatric Autoimmune Diseases, INSERM U1163, F-75015, Paris, France.,Department of Internal Medicine, National Reference Centre for Rare Systemic Autoimmune Diseases, AP-HP, Hôpital Cochin, F-75014, Paris, France
| | - R Chocron
- Université de Paris, PARCC, INSERM, F-75006, Paris, France.,Emergency Department, AP-HP, Georges Pompidou European Hospital, F-75015, Paris, France
| | - D Bengoufa
- Immunobiology Department, AP-HP, Hôpital Saint-Louis, F-75010, Paris, France
| | - H Le Buanec
- Université de Paris, Human Immunology Pathophysiology Immunotherapy, INSERM U976, Institut de Recherche Saint-Louis, F-75010, Paris, France
| | - L Barnabei
- Université de Paris, Imagine Institute, Laboratory of Immunogenetics of Pediatric Autoimmune Diseases, INSERM U1163, F-75015, Paris, France
| | - S Meynier
- Université de Paris, Imagine Institute, Laboratory of Immunogenetics of Pediatric Autoimmune Diseases, INSERM U1163, F-75015, Paris, France
| | - O Schwartz
- Institut Pasteur, Virus and Immunity Unit, F-75015, Paris, France
| | - L Grzelak
- Institut Pasteur, Virus and Immunity Unit, F-75015, Paris, France
| | - N Smith
- Institut Pasteur, Translational Immunology Lab, F-75015, Paris, France
| | - B Charbit
- Institut Pasteur, Cytometry and Biomarkers UTechS, CRT, F-75015, Paris, France
| | - D Duffy
- Institut Pasteur, Translational Immunology Lab, F-75015, Paris, France.,Institut Pasteur, Cytometry and Biomarkers UTechS, CRT, F-75015, Paris, France
| | - N Yatim
- Dermatology Department, AP-HP, Hôpital Saint-Louis, F-75010, Paris, France.,Institut Pasteur, Translational Immunology Lab, F-75015, Paris, France
| | - A Calugareanu
- Dermatology Department, AP-HP, Hôpital Saint-Louis, F-75010, Paris, France.,Université de Paris, Human Immunology Pathophysiology Immunotherapy, INSERM U976, Institut de Recherche Saint-Louis, F-75010, Paris, France
| | - A Philippe
- Institut Pasteur, Cytometry and Biomarkers UTechS, CRT, F-75015, Paris, France
| | - C L Guerin
- Université de Paris, Innovative Therapies in Haemostasis, INSERM, F-75006, Paris, France.,Institut Curie, Cytometry Platform, F-75006, Paris, France
| | - B Joly
- Biological Haematology Department, AP-HP, Hôpital Lariboisière, F-75010, Paris, France.,Université de Paris, EA3518, Institut de Recherche Saint-Louis, F-75010, Paris, France
| | - V Siguret
- Biological Haematology Department, AP-HP, Hôpital Lariboisière, F-75010, Paris, France.,Université de Paris, INSERM UMR S1140, F-75010, Paris, France
| | - L Jaume
- Dermatology Department, AP-HP, Hôpital Saint-Louis, F-75010, Paris, France
| | - H Bachelez
- Dermatology Department, AP-HP, Hôpital Saint-Louis, F-75010, Paris, France.,Université de Paris, Imagine Institute, Laboratory of Genetics of Skin Diseases, INSERM U1163, F-75015, Paris, France
| | - M Bagot
- Dermatology Department, AP-HP, Hôpital Saint-Louis, F-75010, Paris, France.,Université de Paris, Human Immunology Pathophysiology Immunotherapy, INSERM U976, Institut de Recherche Saint-Louis, F-75010, Paris, France
| | - F Rieux-Laucat
- Université de Paris, Imagine Institute, Laboratory of Immunogenetics of Pediatric Autoimmune Diseases, INSERM U1163, F-75015, Paris, France
| | - S Maylin
- Virology Department, AP-HP, Hôpital Saint-Louis, F-75010, Paris, France
| | - J Legoff
- Virology Department, AP-HP, Hôpital Saint-Louis, F-75010, Paris, France.,Université de Paris, Team Insight, INSERM U976, Institut de Recherche Saint-Louis, F-75010, Paris, France
| | - C Delaugerre
- Virology Department, AP-HP, Hôpital Saint-Louis, F-75010, Paris, France
| | - N Gendron
- Université de Paris, Innovative Therapies in Haemostasis, INSERM, F-75006, Paris, France.,Hematology Department and Biosurgical Research Lab (Carpentier Foundation), Assistance Publique Hôpitaux de Paris-Centre Université de Paris (APHP-CUP), F-75015, Paris, France
| | - D M Smadja
- Université de Paris, Innovative Therapies in Haemostasis, INSERM, F-75006, Paris, France.,Hematology Department and Biosurgical Research Lab (Carpentier Foundation), Assistance Publique Hôpitaux de Paris-Centre Université de Paris (APHP-CUP), F-75015, Paris, France
| | - C Cassius
- Dermatology Department, AP-HP, Hôpital Saint-Louis, F-75010, Paris, France.,Université de Paris, Human Immunology Pathophysiology Immunotherapy, INSERM U976, Institut de Recherche Saint-Louis, F-75010, Paris, France
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9
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Sánchez-García V, Hernández-Quiles R, de-Miguel-Balsa E, Docampo-Simón A, Belinchón-Romero I, Ramos-Rincón JM. Are the chilblain-like lesions observed during the COVID-19 pandemic due to severe acute respiratory syndrome coronavirus 2? Systematic review and meta-analysis. J Eur Acad Dermatol Venereol 2021; 36:24-38. [PMID: 34545625 PMCID: PMC8657348 DOI: 10.1111/jdv.17672] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 07/05/2021] [Accepted: 08/10/2021] [Indexed: 01/07/2023]
Abstract
The expansion of the COVID‐19 pandemic has been accompanied by numerous reports of chilblain‐like lesions (CLL) in different countries; however, the pathogenesis of these lesions is still unclear. This systematic review and meta‐analysis aimed to assess the prevalence of COVID‐19 (diagnosed using PCR and/or serology) in patients with CLL. We undertook a literature search in PubMed, Embase, and Scopus (to 15 March 2021), including studies that reported on the number of patients with CLL with positive PCR and/or serology for severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) or with a clinical suspicion of COVID‐19. Regardless of data heterogeneity, a random‐effects model was used to pool prevalence estimates. The meta‐analysis included 63 original studies, involving 2919 cases of CLL. A subgroup of these patients underwent diagnostic tests for COVID‐19 (PCR: n = 1154, 39.5%; serology: n = 943, 32.3%). The pooled prevalence of COVID‐19 in the overall sample and in the subgroup who were tested for COVID‐19 was, respectively: (i) positive PCR: 2.6% [95% confidence interval (CI) 1.9% to 3.4%] and 5.5% (95% CI, 3.7–7.7%); (ii) positive serology for SARS‐CoV‐2: 7.2% (95% CI, 4.7–10.2%) and 11.8% (95% CI, 7.9–16.3%); and (iii) positive PCR and/or serology, 15.2% (95% CI, 10.4–20.7%) and 7.5% (95% CI, 5.1–10.3%). Altogether, a small proportion of diagnostic tests for SARS‐CoV‐2, both PCR and serologies, show positive results in patients with CLL.
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Affiliation(s)
- V Sánchez-García
- Dermatology Department, Alicante University General Hospital-ISABIAL, Alicante, Spain
| | - R Hernández-Quiles
- Dermatology Department, Alicante University General Hospital-ISABIAL, Alicante, Spain
| | - E de-Miguel-Balsa
- Intensive Care Department, Elche University General Hospital, Alicante, Spain.,Clinical Medicine Department, University Miguel Hernández of Elche, Alicante, Spain
| | - A Docampo-Simón
- Dermatology Department, Alicante University General Hospital-ISABIAL, Alicante, Spain
| | - I Belinchón-Romero
- Dermatology Department, Alicante University General Hospital-ISABIAL, Alicante, Spain.,Clinical Medicine Department, University Miguel Hernández of Elche, Alicante, Spain
| | - J M Ramos-Rincón
- Clinical Medicine Department, University Miguel Hernández of Elche, Alicante, Spain.,Internal Medicine Department, Alicante University General Hospital-ISABIAL, Alicante, Spain
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