Nailfold capillaroscopy in Buerger’s disease: A useful tool?

Abstract

Thromboangiitis obliterans (TAO, or Buerger's disease) is a rare inflammatory vasculitis that commonly involves small and medium-sized arteries of the extremities of tobacco smokers between the ages of 25 and 50 years. Although the diagnosis is based on the clinical picture and angiographic findings, we studied the microvascular involvement by nailfold capillaroscopy. We evaluated by nailfold capillaroscopy 2 patients with Buerger's disease, at baseline and after 6 months of tobacco discontinuation and therapy with prostanoids. Both patients presented similar capillaroscopic abnormalities, resembling a scleroderma-like pattern. The microvascular rearrangement was significantly reduced after 6 months of evaluation. The capillaroscopic abnormalities shown in the two patients could be related to thromboangiitis obliterans, and nailfold capillaroscopy could be a useful tool to evaluate disease progression and the response to treatment.Key words: Thromboangiitis obliterans, nailfold capillaroscopy, acral skin ulcers IntroductionThromboangiitis obliterans (TAO, or Buerger's disease) is a relatively rare segmental non-atherosclerotic inflammatory disorder of peripheral blood vessels, affecting small and medium-sized arteries and veins of the extremities. Exposure to tobacco is central to the initiation, maintenance, and progression of the disease (1).Although commonly accepted diagnostic criteria are still unavailable, nowadays, the most used are Shionoya's criteria (1-3). Discontinuation of tobacco is the cornerstone of therapy. Other forms of treatment, including vasodilators (prostaglandin analogs and calcium channel blockers), have all been tried, with limited effect in decreasing pain and avoiding amputation (1-3).Patients may present with early findings of pain or coldness in the fingers and Raynaud phenomenon (RP), followed by rest pain and acral skin ulcers (3).Nailfold capillaroscopy (NFC) is a simple and non-invasive technique that allows the in vivo assessment of the microvascular environment, and it has been demonstrated to be helpful in the differential diagnosis of some diseases, primarily capable of differentiating between primary and secondary RP, systemic sclerosis (SSc), and dermatomyositis (4-6).Since TAO is a vasculitic syndrome characterized by small and medium vessel involvement, often associated with acral ulcers, the aim of our preliminary study was to investigate whether NFC could represent a tool in the diagnosis and follow-up of the disease during the acute phase and over a 6-month follow-up. Case PresentationWe evaluated two male patients who were referred to our outpatient clinic for RP and painful acral ulcers. The first patient, a 48-year-old man, presented with a 5-week history of pain in his hands and feet, ulcerations, and digital gangrene, which was associated with blue discoloration and claudication of both feet.He was a lifelong heavy smoker (about 20 cigarettes/day since 20 years) but had no other cardiovascular risk factors. He had a history of RP affecting both hands for ...