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Capilaroscopia unghiala- importanta practica Laura Groseanu Centrul de Cercetare in Patogenia si Tratamentul Bolilor
Capilaroscopia unghiala- importanta practica Laura Groseanu Centrul de Cercetare in Patogenia si Tratamentul Bolilor

Capilaroscopia unghiala- importanta practica

Laura Groseanu

Centrul de Cercetare in Patogenia si Tratamentul Bolilor Reumatismale, Spitalul Clinic “Sf. Maria”, Clinica de Medicina Interna si Reumatologie Bucuresti

port pilaroscopie
port pilaroscopie

port

pilaroscopie

port pilaroscopie
port pilaroscopie

Raport de capilaroscopie- “Comment”

Raport de capilaroscopie- “Comment” ● Transparenta cutanata ●Plex venos subpapilar ● Densitate capilara
Raport de capilaroscopie- “Comment” ● Transparenta cutanata ●Plex venos subpapilar ● Densitate capilara

Transparenta cutanata ●Plex venos subpapilar Densitate capilara ●Arhitecturala vasculara ●Anomalii morfologice Microhemoragii ●Neovascularizatie

● Densitate capilara ●Arhitecturala vasculara ●Anomalii morfologice ● Microhemoragii ●Neovascularizatie
• • Evaluare capilaroscopica Pattern recognition (calitativ) Scoring semicantitativ Scoring cantitativ (
• •

Evaluare capilaroscopica

• • Evaluare capilaroscopica Pattern recognition (calitativ) Scoring semicantitativ Scoring cantitativ (
• • Evaluare capilaroscopica Pattern recognition (calitativ) Scoring semicantitativ Scoring cantitativ (

Pattern recognition (calitativ)

Scoring semicantitativ

Scoring cantitativ ( computerizat)

Scleroderma pattern/ like pattern

Modificari nonspecifice

(microangiopatie nespecifica)

0= 1= < 33% modificari din nr capilare per mm 2= 33–66% modificari din nr

0=

1= < 33% modificari din nr capilare per mm 2= 33–66% modificari din nr capilare per mm

3= > 66% modificari din nr capilare per mm

fara modificari

2 imagini/deget 8 degete
2 imagini/deget
8 degete
capilare per mm fara modificari 2 imagini/deget 8 degete Capilare dilatate Capilare gigante A Hemoragii.depozite
capilare per mm fara modificari 2 imagini/deget 8 degete Capilare dilatate Capilare gigante A Hemoragii.depozite
capilare per mm fara modificari 2 imagini/deget 8 degete Capilare dilatate Capilare gigante A Hemoragii.depozite
Capilare dilatate Capilare gigante A Hemoragii.depozite de hemosiderina
Capilare dilatate
Capilare gigante
A
Hemoragii.depozite de hemosiderina

Corelat cu Forme severe d boala cu afecta vasculara severa pulmonara, cardiaca

B
B

Densitate capilara

Dezorganizare arhitecturala

Capilare ramificate

Scor de evolutie microangiopatica

Sindrom Raynaud ○dg diferential primar/sec ○monitorizare Scleroza sistemica ○dg precoce ○dg diferential sdr
Sindrom Raynaud ○dg diferential primar/sec ○monitorizare Scleroza sistemica ○dg precoce ○dg diferential sdr

Sindrom Raynaud ○dg diferential primar/sec ○monitorizare Scleroza sistemica ○dg precoce ○dg diferential sdr sclero-like ○dg corect ○ prognostic ○follow-up

Scleroza sistemica ○dg precoce ○dg diferential sdr sclero-like ○ dg corect ○ prognostic ○follow-up
Scleroza sistemica ○dg precoce ○dg diferential sdr sclero-like ○ dg corect ○ prognostic ○follow-up

Sdr Raynaud primar

(1) Raynaud clinic (2) Capilaroscopie normala (3) FARA elemente sugestive pt cauze sec: ulceratii, gangrena,
(1) Raynaud clinic
(2) Capilaroscopie normala
(3) FARA elemente sugestive pt cauze sec: ulceratii,
gangrena, necroze, sclerodactilie, calcinoza , modificari
cutanate
(4)fara istoric de boala autoimuna
(5) ANA negativ/titru mic
Rol diagnostic-
reduce costul investigatiilor suplimentare costitoare
Rol prognostic –
monitorizarea tranzitiei catre Raynaud secundar (12,5%) 1
1 Hirschl M et al Transition from primary Raynaud's phenomenon to secondary Raynaud's phenomenon identified by diagnosis
of an associated disease: results of ten years of prospective surveillance Arthritis Rheum. 2006 Jun;54(6):1974-81
Sindrom Raynaud primar Fara modificari specifice -Anse alungite -tortuozitati 23 ani, studenta UMF Mama- LES

Sindrom Raynaud primar

Fara modificari specifice -Anse alungite -tortuozitati 23 ani, studenta UMF Mama- LES Raynaud 6 ani
Fara modificari specifice
-Anse alungite
-tortuozitati
23 ani, studenta UMF
Mama- LES
Raynaud 6 ani
Sindrom Raynaud secundar - - - - - 2013 I.I., femeie, 23 ani Raynaud –

Sindrom Raynaud secundar

- - - - -
-
-
-
-
-

2013

I.I., femeie, 23 ani Raynaud – 1 an

aug2016 – ulceratii digitale+++→gangrena

sclerodactilie

dispnee clasa III

ANA+++, antiU1RNP>200Ui/ml

BRD , sPAP=85mmHg

deces – nov2017

→gangrena sclerodactilie dispnee clasa III ANA+++, antiU1RNP>200Ui/ml BRD , sPAP=85mmHg deces – nov2017
tardiv Follow-up tratament Activ Predictie complicatii precoce Diagnostic precoce
tardiv
Follow-up
tratament
Activ
Predictie
complicatii
precoce
Diagnostic
precoce
Diagnostic precoce VEDOSS (very early disease onset of systemic sclerosis)

Diagnostic precoce VEDOSS

Diagnostic precoce VEDOSS (very early disease onset of systemic sclerosis)
(very early disease onset of systemic sclerosis)
(very early disease onset of systemic sclerosis)

Diagnostic precoce - VEDOSS

Diagnostic precoce - VEDOSS G.M, 56 ani, ginecolog Puffy hands Raynaud -4 luni Artralgii art mici

G.M, 56 ani, ginecolog Puffy hands Raynaud -4 luni Artralgii art mici maini

Puffy hands Raynaud -4 luni Artralgii art mici maini ANA+, antiSCL70>200U/l Late scleroderma pattern
Puffy hands Raynaud -4 luni Artralgii art mici maini ANA+, antiSCL70>200U/l Late scleroderma pattern
Puffy hands Raynaud -4 luni Artralgii art mici maini ANA+, antiSCL70>200U/l Late scleroderma pattern
Puffy hands Raynaud -4 luni Artralgii art mici maini ANA+, antiSCL70>200U/l Late scleroderma pattern

ANA+,

antiSCL70>200U/l

Late scleroderma pattern

Puffy hands Raynaud -4 luni Artralgii art mici maini ANA+, antiSCL70>200U/l Late scleroderma pattern

Diagnostic corect (1)

Diagnostic corect (1) B.V., 54 ani 2011- Raynaud, ulceratii digitale 2014 - sclerodactilie, indurare tegumentara

B.V., 54 ani 2011- Raynaud, ulceratii digitale 2014 - sclerodactilie, indurare tegumentara maini -ulceratii digitale ANA +, antiSCL70, antiU1RNP, ACA negativi

2014 - sclerodactilie, indurare tegumentara maini -ulceratii digitale ANA +, antiSCL70, antiU1RNP, ACA negativi
2014 - sclerodactilie, indurare tegumentara maini -ulceratii digitale ANA +, antiSCL70, antiU1RNP, ACA negativi
2014 - sclerodactilie, indurare tegumentara maini -ulceratii digitale ANA +, antiSCL70, antiU1RNP, ACA negativi
2014 - sclerodactilie, indurare tegumentara maini -ulceratii digitale ANA +, antiSCL70, antiU1RNP, ACA negativi
2014 - sclerodactilie, indurare tegumentara maini -ulceratii digitale ANA +, antiSCL70, antiU1RNP, ACA negativi
2014 - sclerodactilie, indurare tegumentara maini -ulceratii digitale ANA +, antiSCL70, antiU1RNP, ACA negativi
Scleroderma pattern active
Scleroderma pattern active

Scleroderma pattern active

Scleroderma pattern active
Scleroderma pattern active
Scleroza sistemica cu afectare cutanata limitata si ulceratii digitale active Bosentan 9 luni

Scleroza sistemica cu afectare cutanata limitata si ulceratii digitale active

Bosentan 9 luni
Bosentan 9 luni
Diagnostic corect (2) A.M., 43 ani, mediu rural Feb 2012- arttralgii art mici maini, Raynaud

Diagnostic corect (2)

Diagnostic corect (2) A.M., 43 ani, mediu rural Feb 2012- arttralgii art mici maini, Raynaud +/-

A.M., 43 ani, mediu rural Feb 2012- arttralgii art mici maini, Raynaud +/- Sdr inflamator, RF+++

Poliartrita reumatoida→Prednison 20mg/zi, MTX 10mg/sapt
Poliartrita reumatoida→Prednison 20mg/zi, MTX 10mg/sapt

May 2015 – persistenta artralgiilor - Raynaud ++ - discrete indurare tegumentara maini, fata,torace anterior

Diagnostic corect (2) SSc pattern active-late SCL 70 Ab >200 IU/ml

Diagnostic corect (2)

Diagnostic corect (2) SSc pattern active-late SCL 70 Ab >200 IU/ml
SSc pattern active-late
SSc pattern active-late

SCL 70 Ab >200 IU/ml

FVC=65%, FEV=62%, DLCO=55% CT- pneumopatie interstitiala Ciclofosfamide
FVC=65%, FEV=62%, DLCO=55%
CT- pneumopatie interstitiala
Ciclofosfamide
Diagnostic diferential 65 ani, femeie Afectare cutanata (indurare) rapid progresiva Artralgii Nu relateaza

Diagnostic diferential

Diagnostic diferential 65 ani, femeie Afectare cutanata (indurare) rapid progresiva Artralgii Nu relateaza

65 ani, femeie Afectare cutanata (indurare) rapid progresiva Artralgii Nu relateaza Raynaud, ANA -

femeie Afectare cutanata (indurare) rapid progresiva Artralgii Nu relateaza Raynaud, ANA - Fasciita cu eozinofile
Fasciita cu eozinofile
Fasciita cu eozinofile
Valoare prognostica – Capilaroscopie= biomarker al activitatii bol Smith V 1 et al.,Cutolo M Do

Valoare prognostica – Capilaroscopie= biomarker al activitatii bol

prognostica – Capilaroscopie= biomarker al activitatii bol Smith V 1 et al.,Cutolo M Do worsening scleroderma

Smith V 1 et al.,Cutolo M Do worsening scleroderma capillaroscopic patterns predict future severe organ involvement? a pilot study. Ann Rheum Dis. 2012

Oct;71(10):1636-9

a pilot study. Ann Rheum Dis. 2012 Oct;71(10):1636-9 “ NVC patterns were significantly associated with severe

NVC patterns were significantly associated with severe peripheral vascular (p<0.001), skin (p=0.002), joint (p=0.003), muscle (p<0.001), GI (p=0.038), lung (p<0.001) and heart (p=0.009) involvement…the odds ratio for severe peripheral involvement was 3.36/2.18 (95% CI 1.77- 6.96/1.06-4.88) for the “active” and 11.27/4.77 for the “late” NVC scleroderma pattern versus the “normal” and “early” pattern….the estimated odds ratio to present with ILD is stronger according to worsening NVC patterns

Valoare prognostica – Capilaroscopie= biomarker al activitatii bol Ingegnoli F, Ardoino , Boracchi P Cutolo

Valoare prognostica – Capilaroscopie= biomarker al activitatii bol

prognostica – Capilaroscopie= biomarker al activitatii bol Ingegnoli F, Ardoino , Boracchi P Cutolo M EUSTAR

Ingegnoli F, Ardoino , Boracchi P Cutolo M EUSTAR co-authors

Ingegnoli F, Ardoino , Boracchi P Cutolo M EUSTAR co-authors Nailfold capillaroscopy in systemic sclerosis: data

Nailfold capillaroscopy in systemic sclerosis: data from the EULAR scleroderma trials and research (EUSTAR) database. Microvasc Res. 2013 Sep;89:122-8

(EUSTAR) database. Microvasc Res. 2013 Sep;89:122-8 110centre EUSTAR, 2754 pacienti “…The "early"
(EUSTAR) database. Microvasc Res. 2013 Sep;89:122-8 110centre EUSTAR, 2754 pacienti “…The "early"

110centre EUSTAR, 2754 pacienti “…The "early" and "active" scleroderma patterns were generally observed in patients with mild/moderate skin involvement and a low number of disease manifestations, while the "late" scleroderma pattern was found more frequently in the more severe forms of the disease.”

6 months
6 months
the "late" scleroderma pattern was found more frequently in the more severe forms of the disease
the "late" scleroderma pattern was found more frequently in the more severe forms of the disease
2014- early 2015-early
2014- early
2015-early

F, 38 ani, SS

2013

– Raynaud -Ingrosare tegumentara difuza -antiSCL70 + Trat: MTX, vasodilatatoare

2015 – fara afectare viscerala majora

2012-active Vadeanu 2015-active
2012-active
Vadeanu
2015-active

F, 58 ani ●1995- SSc cu afectare tegumentara difuza, musculoarticulara, GI si pulmonara ●Tratament 1995-2015:

corticosteroizi, vasodilatatoare, Ciclofosfamide 3 luni→Tbc ●2015 – fara ulceratii/ PAH,

TLCO=73%

2010-late
2010-late
2010-late coring =4 2013-late Scoring=9 F, 57 ani 1996 – SS cu afectare cutanata limitata, calcificari
coring =4
coring =4

2013-late

Scoring=9

F, 57 ani 1996 – SS cu afectare cutanata limitata, calcificari sc si afectare GI 2013 – ulceratii digitale

F, 57 ani 1996 – SS cu afectare cutanata limitata, calcificari sc si afectare GI 2013
2014 Late pattern 2015
2014
Late pattern
2015

B,74 ani 1995- SSc cu afectare tegumentara difu Tratament- corticosteroizi, vasodilatoar 2009 - active pattern 2014-2015

vasodilatoar 2009 - active pattern 2014-2015 - Dispneea clasa III- fibroza pulmonara (TLCO=38%)

- Dispneea clasa III- fibroza pulmonara

(TLCO=38%)

-ulceratii digitale

vasodilatoar 2009 - active pattern 2014-2015 - Dispneea clasa III- fibroza pulmonara (TLCO=38%) -ulceratii digitale
Scleroderma like pattern Pattern scleroderma megacapilare rare/deloc !!!! Poli/dermatomiozita Boala mixta de tesut

Scleroderma like pattern

Pattern scleroderma megacapilare rare/deloc !!!!
Pattern scleroderma
megacapilare rare/deloc !!!!
like pattern Pattern scleroderma megacapilare rare/deloc !!!! Poli/dermatomiozita Boala mixta de tesut conjunctiv

Poli/dermatomiozita

Boala mixta de tesut conjunctiv

Dermatomiozita

Dermatomiozita Sclero-like pattern Scaderea densitatii Capilare dilatate, tortuozitati Capilare ramificate
Sclero-like pattern Scaderea densitatii Capilare dilatate, tortuozitati Capilare ramificate Microhemoragii
Sclero-like pattern
Scaderea densitatii
Capilare dilatate, tortuozitati
Capilare ramificate
Microhemoragii
Sclero-like pattern Scaderea densitatii Capilare dilatate, tortuozitati Capilare ramificate Microhemoragii
BMTC Normal → sclero-like pattern Dilatatii capilare Neovascularizatie Scaderea densitatii—zone avasculare Afectare
BMTC Normal → sclero-like pattern Dilatatii capilare Neovascularizatie Scaderea densitatii—zone avasculare Afectare
BMTC Normal → sclero-like pattern Dilatatii capilare Neovascularizatie Scaderea densitatii—zone avasculare Afectare

BMTC

BMTC Normal → sclero-like pattern Dilatatii capilare Neovascularizatie Scaderea densitatii—zone avasculare Afectare

Normalsclero-like pattern Dilatatii capilare Neovascularizatie Scaderea densitatii—zone avasculare

pattern Dilatatii capilare Neovascularizatie Scaderea densitatii—zone avasculare Afectare pulmonara (HTP, alveolita)
pattern Dilatatii capilare Neovascularizatie Scaderea densitatii—zone avasculare Afectare pulmonara (HTP, alveolita)

Afectare pulmonara (HTP, alveolita)

pattern Dilatatii capilare Neovascularizatie Scaderea densitatii—zone avasculare Afectare pulmonara (HTP, alveolita)
Microangiopatie nonspecifica Modificari nespecifice Modificari specific izolate Monitorizare evolutiva…

Microangiopatie nonspecifica

Microangiopatie nonspecifica Modificari nespecifice Modificari specific izolate Monitorizare evolutiva…

Modificari nespecifice Modificari specific izolate

Microangiopatie nonspecifica Modificari nespecifice Modificari specific izolate Monitorizare evolutiva…

Monitorizare evolutiva…

LUPUS ERITEMATOS SISTEMIC Normal→modificari nespecifice (54%) -tortuozitati, anse bizare, dilatate, ramificatii

LUPUS ERITEMATOS SISTEMIC

Normal→modificari nespecifice (54%) -tortuozitati, anse bizare, dilatate, ramificatii -Scaderea densitatii capilare
Normal→modificari nespecifice (54%)
-tortuozitati, anse bizare, dilatate, ramificatii
-Scaderea densitatii capilare
-Plex vv subpapilar ↑
-F rar : sclero-like pattern
- Fara legatura cu sdr Raynaud
- Severitatea corelata cu
SLEDAI/ECLAM
- Reversibile in remisiune
Sindrom antifosfolipidic Hemoragii/depozite de hemosiderina Anse alungite, tortuoase, dilatate

Sindrom antifosfolipidic

Sindrom antifosfolipidic Hemoragii/depozite de hemosiderina Anse alungite, tortuoase, dilatate

Hemoragii/depozite de hemosiderina Anse alungite, tortuoase, dilatate

Sindrom antifosfolipidic Hemoragii/depozite de hemosiderina Anse alungite, tortuoase, dilatate

POLIARTRITA

REUMATOIDA

Normal→modificari nespecifice(80%)

REUMATOIDA Normal →modificari nespecifice(80%) - Vizibilitate crescuta plex vv subpapilar - Capilare
REUMATOIDA Normal →modificari nespecifice(80%) - Vizibilitate crescuta plex vv subpapilar - Capilare

-Vizibilitate crescuta plex vv subpapilar

-Capilare alungite/dilatate

crescuta plex vv subpapilar - Capilare alungite/dilatate SINDROM SJOGREN Normal →modificari

SINDROM

SJOGREN

Normal→modificari nespecifice→sclero-like pattern

plex vv subpapilar - Capilare alungite/dilatate SINDROM SJOGREN Normal →modificari nespecifice→sclero-like pattern

Trombangeita obliteranta

-microhemoragii -tortuozitati -edem papilar (aspect “foggy”) -anse dilatate, megacapilare izolate -oprire flux
-microhemoragii
-tortuozitati
-edem papilar (aspect “foggy”)
-anse dilatate, megacapilare izolate
-oprire flux capilar
-tortuozitati -edem papilar (aspect “foggy”) -anse dilatate, megacapilare izolate -oprire flux capilar
Fumator Modificari nespecifice -Reducere diametru -Reducerea densitatii capilare -Tortuozitati -Capilare ramificate

Fumator

Fumator Modificari nespecifice -Reducere diametru -Reducerea densitatii capilare -Tortuozitati -Capilare ramificate
Fumator Modificari nespecifice -Reducere diametru -Reducerea densitatii capilare -Tortuozitati -Capilare ramificate

Modificari nespecifice -Reducere diametru -Reducerea densitatii capilare -Tortuozitati -Capilare ramificate -Fragmentare flux sanguin

nespecifice -Reducere diametru -Reducerea densitatii capilare -Tortuozitati -Capilare ramificate -Fragmentare flux sanguin