Abstract
ObjectiveSystemic sclerosis (SSc) can lead to ischemic complications such as digital ulcers (DUs). The aim of the study was to find predictors of DUs by clinical and new imaging methods.Patients and methodsAll 79 SSc patients included in the study received a clinical, colour Doppler ultrasound (CDUS), fluorescence optical imaging (FOI) and capillaroscopy examination at baseline, and their capacity to predict new DU development was analysed in 76 patients at 12 months follow-up.ResultsTwenty-two of 76 patients (28.9%) developed new ulcers during follow-up (diffuse SSc 48.1%; limited SSc 18.4%). Receiver operating characteristic (ROC) curve analysis revealed an area under the curve of 0.7576 for DU development, with a specificity of 87% and a sensitivity of 54.6% (p = 0.0003, OR = 8.1 [95%CI 2.5–25.6]) at a cut-off of ≥ 21 points (ACR/EULAR classification criteria for SSc). Capillaroscopy and CDUS had high sensitivity (100% and 95.5%) but low specificity (28.9% and 22.2%) for ulcer occurrence when used alone, but better specificity (46.3%) when combined (OR = 18.1 [95%CI 2.3–144.4]; p = 0.0004). Using FOI, fingers with pathologic staining had a higher risk for new ulcer development in the same finger (p = 0.0153). General future DU (i.e. DU also in other fingers) was associated with a missing FOI signal in the right digit III at baseline (p = 0.048).ConclusionNew imaging modalities can predict digital ulcer development in SSc patients with high sensitivity for capillaroscopy and CDUS and enhanced specificity when combined. A missing signal of FOI in the right digit III at baseline was associated with general future DU.
Highlights
Systemic sclerosis (SSc) is an autoimmune connective tissue disease
Clinical characteristics linked to new digital ulcers Links between some known risk factors and the development of digital ulcers were observed in the follow-up period
Several studies found that active and late capillaroscopic patterns have a high sensitivity for predicting new digital ulcers (DUs), but rather low specificity: independent of the number of patients included in previous studies (n = 77 to n = 423), the sensitivity of advanced capillaroscopic patterns was found to be around 95% [9, 19], but the specificity of those patterns for new DUs was only 12% in a 6-month period [19] and 33% in a 3-year period [9]
Summary
Systemic sclerosis (SSc) is an autoimmune connective tissue disease. The initial symptom in most patients is Raynaud’s phenomenon (RP), a condition characterized by the temporary reduction of blood flow to the fingers and toes (digits) due to a combination of reversible vascular spasms and irreversible alterations of the walls of Friedrich et al Arthritis Research & Therapy (2019) 21:96 been identified [4,5,6,7,8,9,10,11,12,13]. In a multicentre study, it was found that the mean number of capillaries per millimetre in digit III of the dominant hand and clinical signs of severe digital ischemia at baseline have significant associations to new DUs during a 6-month follow-up [19]. Macrovascular changes are present in SSc and linked to ischaemia: pathologic ultrasonography findings of the flow-mediated dilation of the brachial artery in patients with SSc were associated with the development of new DUs during 3 years of follow-up [20]. A higher risk of DU occurrence in a mean follow-up time of 53 months was demonstrated in patients with ulnar artery occlusion [21]. Correlations of CDUS findings with microvascular damage have been reported [3]
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