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Systemic sclerosis capillaries — SCE Rheumatology MCQ

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HardMusculoskeletal investigationsSystemic sclerosis capillariesSCE Rheumatology

A 36-year-old woman has Raynaud phenomenon, puffy fingers and skin thickening confined distal to the metacarpophalangeal joints, consistent with sclerodactyly. ANA is positive, but systemic-sclerosis-specific autoantibody results are pending. She has no fingertip lesions or telangiectasia, and initial cardiopulmonary assessment is normal. Which investigation is most appropriate next to identify systemic-sclerosis-specific microangiopathy and provide additional evidence for early systemic sclerosis?

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Correct answer: A — Nailfold videocapillaroscopy

Nailfold videocapillaroscopy is the best next investigation. Raynaud phenomenon, puffy fingers, ANA positivity and sclerodactyly strongly suggest early systemic sclerosis. Capillaroscopy can demonstrate a scleroderma pattern, including giant capillaries, microhaemorrhages, capillary loss and architectural disorganisation. Abnormal nailfold capillaries are an independently weighted ACR/EULAR classification item and are also part of the VEDOSS assessment framework. Digital angiography is reserved for selected severe or anatomically complex digital ischaemia and does not assess the characteristic nailfold microangiopathy. Thermography assesses vascular function but is not an ACR/EULAR classification item. Hand MRI may demonstrate inflammatory or structural abnormalities but is not the key investigation for suspected systemic-sclerosis microvasculopathy. Skin biopsy is neither routinely required nor sufficiently specific for classification.

Reference: Vanhaecke A et al. Standardisation of nailfold capillaroscopy for the assessment of patients with Raynaud's phenomenon and systemic sclerosis. Autoimmunity Reviews. 2020. https://pubmed.ncbi.nlm.nih.gov/38287630/