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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
apilaroscopie
Raport de capilaroscopie- “Comment”

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

Pattern recognition Scoring semicantitativ


(calitativ)
Scoring cantitativ ( computerizat)
• Scleroderma pattern/ like pattern
• Modificari nonspecifice
(microangiopatie nespecifica)
2 imagini/deget
8 degete

0= fara modificari
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

Capilare dilatate
Capilare gigante
Hemoragii.depozite de hemosiderina
A Corelat cu
Forme severe de
boala cu afectar
vasculara severa
Densitate capilara pulmonara,
Dezorganizare arhitecturala B cardiaca
Capilare ramificate
Scor de evolutie
microangiopatica
Sindrom Raynaud
○dg diferential primar/sec
○monitorizare
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, 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
Raynaud 6 ani
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
tardiv
Follow-up
tratament

Activ
Predictie
complicatii

precoce
Diagnostic
precoce
Diagnostic precoce
VEDOSS
(very early disease onset of systemic sclerosis)
Diagnostic precoce - VEDOSS
G.M, 56 ani, ginecolog
Puffy hands
Raynaud -4 luni
Artralgii art mici maini

ANA+,
antiSCL70>200U/l

Late scleroderma pattern


Diagnostic corect (1)
B.V., 54 ani
2011- Raynaud, ulceratii digitale
2014 - sclerodactilie, indurare tegumentara maini
-ulceratii digitale
ANA +, antiSCL70, antiU1RNP, ACA negativi
Scleroderma pattern
active
Scleroza sistemica cu afectare cutanata
limitata si ulceratii digitale active

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

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


FVC=65%, FEV=62%, DLCO=55%
Ciclofosfamide
CT- pneumopatie interstitiala
Diagnostic diferential

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

Fasciita cu eozinofile
Valoare prognostica –
Capilaroscopie= biomarker al activitatii boli

Smith V1 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

“ 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 (p<0.001/p<0.001). ..
Valoare prognostica –
Capilaroscopie= biomarker al activitatii boli

Ingegnoli F, Ardoino , Boracchi P Cutolo M EUSTAR co-authors 6 months


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

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.”
2014- early

F, 38 ani, SS

2013
– Raynaud
2015-early -Ingrosare tegumentara difuza
-antiSCL70 +
Trat: MTX, vasodilatatoare

2015 – fara afectare viscerala majora


2012-active

Vadeanu
F, 58 ani
●1995- SSc cu afectare
tegumentara difuza,
musculoarticulara, GI si pulmonara
●Tratament 1995-2015:
2015-active
corticosteroizi, vasodilatatoare,
Ciclofosfamide 3 luni→Tbc
●2015 – fara ulceratii/ PAH,
TLCO=73%
2010-late

F, 57 ani
1996 – SS cu afectare
Scoring =4 cutanata limitata, calcificari
sc si afectare GI
2013 – ulceratii digitale

2013-late

Scoring=9
2014
B,74 ani
1995- SSc cu afectare tegumentara difu
Tratament- corticosteroizi, vasodilatoar
2009 - active pattern
2014-2015
- Dispneea clasa III- fibroza pulmonara
(TLCO=38%)
Late pattern -ulceratii digitale
2015
Scleroderma like pattern

Pattern scleroderma
megacapilare rare/deloc !!!!

Poli/dermatomiozita
Boala mixta de tesut conjunctiv
Dermatomiozita

Sclero-like pattern
Scaderea densitatii
Capilare dilatate, tortuozitati
Capilare ramificate
Microhemoragii
BMTC

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

Afectare pulmonara (HTP, alveolita)


Microangiopatie nonspecifica

Modificari nespecifice
Modificari specific izolate

Monitorizare evolutiva…
LUPUS ERITEMATOS SISTEMIC
Normal→modificari nespecifice (54%)
-tortuozitati, anse bizare, dilatate, ramificatii
-Scaderea densitatii capilare
-Plex vv subpapilar ↑ - Fara legatura cu sdr Raynaud
-F rar : sclero-like pattern - Severitatea corelata cu
SLEDAI/ECLAM
- Reversibile in remisiune
Sindrom antifosfolipidic
Hemoragii/depozite de hemosiderina
Anse alungite, tortuoase, dilatate
POLIARTRITA SINDROM
REUMATOIDA SJOGREN
Normal→modificari nespecifice(80%)
-Vizibilitate crescuta plex vv subpapilar
Normal→modificari
-Capilare alungite/dilatate nespecifice→sclero-like pattern
Trombangeita obliteranta

-microhemoragii
-tortuozitati
-edem papilar (aspect “foggy”)
-anse dilatate, megacapilare izolate
-oprire flux capilar
Fumator

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