Objectives: Early microvascular damage and dysfunction are clinically mirrored in Raynaud’s phenomenon (RP). Currently, nailfold capillaroscopy (NC) is applied to differentiate between primary RP (PRP) and secondary RP (PRP), associated with connective tissue disease. However, abnormal morphology can also be caused due to age-related changes and cardiovascular disease. Thermography (TG) is a non-invasive technique which enables quantification of cutaneous vascular function. An approach using both NC and TG could improve the differentiation between PRP and SRP. Methods: Thirty RP patients (PRP, n = 21; SRP, n = 9) underwent nailfold capillaroscopy and thermography. Morphologic features were scored and patients were categorized according to the guidelines of EULAR Study group on Microcirculation in Rheumatic Diseases. TG of the hand was performed before, directly and ten minutes after a cold challenge test. Baseline images and rewarming curves were analyzed. Results: Capillary abnormalities with NC were found in all SRP patients (9/9) and in 48% (10/21) of PRP patients. Out of 10 PRP patients with altered capillary morphology, 9 (90%) had a cardiovascular disease. For all patients mean temperature was significantly higher 10 minutes after cold induction than before (p < 0,01). The gradient of the rewarming curve was significantly lower in patients with SRP compared to PRP patients (p = 0.015). Conclusions: Nailfold capillaroscopy and thermography can reliably be used to measure microvascular damage and dysfunction. Additional thermography can assist in differentiating between PRP and SRP, especially in elderly patients or in presence of a cardiovascular disease. Keywords: Raynaud’s phenomenon; Nailfold capillaroscopy; Thermography
Raynaud's phenomenon (RP) is defined as episodic attacks of artery and arteriole vasoconstriction. To differentiate between the benign RP (pRP) and the form associated with connective tissue diseases (sRP) the capillary morphology can be studied using nailfold capillaroscopy (nCS). However, abnormal morphology can also be caused due to age-related changes and has been described in patients with diabetes and cardiovascular disease. In addition, this technique cannot provide functional information. Thermal imaging (thermography; TG) is a non-invasive technique which enables quantification of cutaneous blood vessel function. In veterinary medicine, thermal imaging is applied for various clinical settings. A combined approach using both nCS and TG could improve the differentiation between pRP and sRP.
Objectives
The aim of this pilot study was to determine which technique (TG versus nCS) allows the best discrimination amongst older patients with pRP and sRP.
Methods
Thirty patients with RP (pRP, n=21; sRP, n=9) underwent nCS (Olympus SZ51) and TG (Flirr B 620). Nailfold morphologic features were measured and scored on capillary density, giant capillaries, ramification and hemorrages. The patients were divided into three categories: normal, slightly abnormal (slightly enlarged capillaries) and severely abnormal (destruction of capillary structure and hemorrages). TG of the hand was performed before, directly after and 10 min after a cold challenge test with cold manchets of 3°C. Rewarming and reperfusion were monitored and baseline images and rewarming curves were analysed.
Results
Capillary abnormalities with nCS were found in all patients with sRP (9/9) and in 52% (11/21) of patients with pRP. Out of 11 pRP patients with altered capillary morphology, 7 (63%) had a cardiovascular disease. TG demonstrated a lower average temperature at baseline in the pRP group compared to the sRP group (d 1,68°C, p<0,01). In patients with pRP temperature decreased after cold induction (−2.34°C, p=0,01), whereas in sRP patient temperature stayed consistent (+0.07°C, p=0,46) (table 1). In both groups temperature increased ten minutes after cold induction (pRP +2.62°C, p<0,01; sRP +1.57°C, p<0,01). The gradient of the rewarming curve was significantly lower in patients with sRP compared to the pRP group (median 0.16 vs. 0.26 °C/min; p=0.015).
Conclusions
Nailfold capillaroscopy and thermography can reliably be used to measure microvascular damage and dysfunction. TG is better suitable to differentiate between older patients with pRP and sRP. Furthermore, in presence of cardiovascular disease, TG appears to be a more reliable technique than nCS for differentiating between patients with pRP and sRP.
Summaryβ2-microglobulin excretion in 24 hour urine collections were studied in patients with upper and lower urinary tract infections and the results compared with normal subjects. In upper U.T.I. the 24 hour excretion of β2m was significantly increased as the values in patients with only a cystitis were completely normal. There was no overlap between the 2 groups. Preliminary studies have been performed to compare the values of β2-m excretion with immunofluorescence of antibody coated bacteria for the diagnosis of pyelonephritis.
The results of scintiphotography with gallium-67 (67Ga), renography with technetium-99m diethylene triamine penta-acetic acid, immunofluorescence of antibody coated bacteria, and determination of renal beta 2 microglobulin excretion were compared in 19 patients with upper and 15 patients with lower urinary tract infection. All patients with acute pyelonephritis showed an appreciable unilateral or bilateral uptake of 67Ga and an increased excretion of beta 2 microglobulin, whereas immunofluorescence of antibody coated bacteria yielded positive results in only 10. In patients with lower urinary tract infections excretion of beta 2 microglobulin and uptake of 67Ga were always normal, whereas immunofluorescence of antibody coated bacteria was positive in three cases. Scintiphotography with 67Ga and determination of renal beta 2 microglobulin excretion are currently the most reliable non-invasive methods of detecting acute pyelonephritis.
Upper extremity angiography can make an important contribution to the diagnosis in vasculopathy. The present study was designed to assess the diagnostic role of upper extremity angiography in patients with disturbed circulation of the hand, according to a standardised protocol.The study was carried out in an outpatient setting in 103 patients suffering from bilateral Raynaud's phenomenon without any obvious underlying disease and who were unresponsive to nifedipine and aspirin. All patients had angiographies taken according to a standardized technique using vasodilating medication, and reviewed according to a standardised protocol that covered all the known characteristics of angiopathy such as diminished flow, stops, tortuosity, irregularity of the wall, tapering, collaterals and blushing.Standardised angiograms showed vasculopathy compatible with primary vasospasm in 42 patients [all women; mean age 35.1 years], atherosclerotic vascular disease in 44 patients [M/F 9/35; mean age 46.7 years], peripheral embolism in 8 patients [M/F 4/4; mean age 38.4 years], vasculitis in 3 patients [3 women; mean age 38 years] and Buerger's disease in 3 patients [3 men; mean age 47 years]. Inter-observer differences were present in 4 cases, but consensus could be reached through open discussion. An unexpected 47% of patients with atherosclerotic vascular disease had dyslipidemia, frequently of familial origin.The standardised angiography protocol proved to be helpful in the assessment of upper extremity angiography. Surprisingly, a high prevalence of angiographic abnormalities compatible with atherosclerotic vascular disease could already be diagnosed in relatively young patients with Raynaud's phenomenon, of whom 47% showed hypercholesterolemia.
