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Rheumatology 2006 45(5):599; doi:10.1093/rheumatology/kei204
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© The Author 2005. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

CLINICAL VIGNETTE

Nailfold capillaroscopic picture by chance

P. M. Houtman and T. L. T. A. Jansen

Medical Centre Leeuwarden, Rheumatology, Leeuwarden, The Netherlands

Correspondence to: P. M. Houtman. E-mail: n.houtman{at}znb.nl

A 71-yr-old man was referred for evaluation of complaints of Raynaud's phenomenon. He had a 3-yr history of cold-induced bluish discoloration, and some broadening and progressive (although not yet disabling) stiffness of his fingers. He underwent bypass grafting because of intermittent claudication due to atherosclerosis of the aorta and iliac arteries and was treated for his hyperhomocysteinaemia. He did not remember a tick bite or erythema chronicum migrans. Physical examination did not reveal sclerotic skin lesions or arthritis.

Capillaroscopy of all nailfolds was performed. A normal capillary density of short capillary loops was observed in all nailfolds. Remarkably, the left fifth finger showed marked architectural disarrangement of the capillaries apart from a normal appearance of the distal rows; there were slightly enlarged capillary loops surrounding an avascular area. Serological testing revealed the presence of antibodies to Borrelia burgdorferi and confirmed the diagnosis acrodermatitis chronica atrophicans (ACA), a feature of Lyme borreliosis. Antinuclear antibody tests were negative. After treatment with doxycycline (100 mg twice daily for 30 days), capillary microscopy showed a completely normalized pattern.
Figure 1
FIG. 1. Capillaroscopic image of acrodermatitis chronica atrophicans showing an avascular area with some enlarged capillary loops at the edge (magnification 18x).

Capillaroscopy is a simple, uninvasive imaging technique to study the microcirculation and is one of the diagnostic tools for early detection of systemic sclerosis and related disorders. This capillaroscopic image can be added to the morphological features of the diseases in the rheumatological field. ACA is more frequently observed in Europe than in the USA. Chronic joint and bone involvement underlying the skin lesions have been noted in long-standing ACA. Radiographs showed periostal thickening of bones, suggesting periostitis, and subluxations of finger or toe joints in some cases. It might be expected that adequate prevention of tick bites and rapid antibiotic treatment of early recognized cases decreases the incidence of the late features.


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