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Exploring thermography: a promising tool in differentiation between infection and ischemia of the acra in systemic sclerosis

2016; Wiley; Volume: 20; Issue: 12 Linguagem: Inglês

10.1111/1756-185x.12859

1756-185X

Maria A.C. van der Weijden, Laura M. van Vugt, Daphne Valk, Willem Wisselink, Richard M. van Vugt, Alexandre E. Voskuyl, Willem F. Lems,

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International Journal of Rheumatic DiseasesVolume 20, Issue 12 p. 2190-2193 CorrespondenceFree Access Exploring thermography: a promising tool in differentiation between infection and ischemia of the acra in systemic sclerosis Maria A. C. van der Weijden, Corresponding Author Maria A. C. van der Weijden [email protected] Department of Rheumatology, VU University Medical Center, Amsterdam, The Netherlands Correspondence: Dr M.A.C. van der Weijden email: [email protected]Search for more papers by this authorLaura M. van Vugt, Laura M. van Vugt Department of Rheumatology, VU University Medical Center, Amsterdam, The NetherlandsSearch for more papers by this authorDaphne Valk, Daphne Valk Veterinary Department, Artis Natura Magistra Royal Zoo, Amsterdam, The NetherlandsSearch for more papers by this authorWillem Wisselink, Willem Wisselink Department of Vascular Surgery, VU University Medical Center, Amsterdam, The NetherlandsSearch for more papers by this authorRichard M. van Vugt, Richard M. van Vugt Department of Rheumatology, VU University Medical Center, Amsterdam, The NetherlandsSearch for more papers by this authorAlexandre E. Voskuyl, Alexandre E. Voskuyl Department of Rheumatology, VU University Medical Center, Amsterdam, The NetherlandsSearch for more papers by this authorWillem F. Lems, Willem F. Lems Department of Rheumatology, VU University Medical Center, Amsterdam, The NetherlandsSearch for more papers by this author Maria A. C. van der Weijden, Corresponding Author Maria A. C. van der Weijden [email protected] Department of Rheumatology, VU University Medical Center, Amsterdam, The Netherlands Correspondence: Dr M.A.C. van der Weijden email: [email protected]Search for more papers by this authorLaura M. van Vugt, Laura M. van Vugt Department of Rheumatology, VU University Medical Center, Amsterdam, The NetherlandsSearch for more papers by this authorDaphne Valk, Daphne Valk Veterinary Department, Artis Natura Magistra Royal Zoo, Amsterdam, The NetherlandsSearch for more papers by this authorWillem Wisselink, Willem Wisselink Department of Vascular Surgery, VU University Medical Center, Amsterdam, The NetherlandsSearch for more papers by this authorRichard M. van Vugt, Richard M. van Vugt Department of Rheumatology, VU University Medical Center, Amsterdam, The NetherlandsSearch for more papers by this authorAlexandre E. Voskuyl, Alexandre E. Voskuyl Department of Rheumatology, VU University Medical Center, Amsterdam, The NetherlandsSearch for more papers by this authorWillem F. Lems, Willem F. Lems Department of Rheumatology, VU University Medical Center, Amsterdam, The NetherlandsSearch for more papers by this author First published: 02 April 2016 https://doi.org/10.1111/1756-185X.12859Citations: 4AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Dear Editor, Systemic sclerosis is a connective tissue disease characterized by the presence of skin fibrosis and vascular abnormalities, among which Raynaud's phenomenon is the most prevalent feature. Severely disturbed peripheral microvascular blood circulation may occur, leading to pain and ischemic skin defects, that is, digital ulcers and sometimes even to severe necrosis of acra. Furthermore, secondary infections and poor healing of wounds may occur due to ischemia.1 In patients with painful acra because of ulcers it may be difficult to differentiate between an infection and ischemia due to a compromised microcirculation, especially in clinical practice when it concerns patients with deep infections or a dark skin. Thermography has become an increasingly important tool for diagnosing medical issues in veterinary medicine in recent years. However, only a few publications about its clinical use in human medicine are known.2, 3 In this concise report we have addressed the potential added value of thermography in the clinical practice of rheumatology. The case we present considers a 46-year-old black woman, who has had diffuse cutaneous systemic sclerosis since 2000. Digital ulcers of her acra were the predominant features of her disease, resulting in multiple different ascending amputations of her left leg in November and December 2014 (toes, forefoot, ankle, lower leg) because of compromised perfusion. Again, she became hospitalized in March 2015, this time with severe pain and a new ulcer at the tip of digit 1 of the right foot and small ulcers on the other toes. At that time, she was taking bosentan and nifedipine and in addition, 4 months before, she received treatment with ilomedine, a prostacyclin analogue, in an attempt to save her left foot. Laboratory examination revealed an increased C-reactive protein (CRP: 144 mg/L) with a normal leukocyte count of 7.6 × 109/L. The wound culture of the ulcer of digit 1 of the right foot showed Staphylococcus aureus, whereas signs of osteomyelitis were shown on X-ray and magnetic resonance imaging (MRI). Furthermore, thermographic recordings, which were made under standardized conditions (proper care was taken of control of examination room conditions, patient preparation, number of studies and views, equipment, thermogram analysis), showed dark blue distal regions of digits 2–5 compatible with lower temperature due to poor perfusion, whereas digit 1 showed a red local region indicating higher temperature, possibly due to inflammation probably caused by infection (Fig. 1). The diagnosis of primarily a bacterial osteomyelitis was made in combination with severe ischemia in a patient with decreased microcirculation due to scleroderma. Treatment was initiated with intravenous antibiotics for 6 weeks and again ilomedine was given for 5 days. In addition, a sympaticusblock at popliteal level was given to increase the perfusion, in view of the poor effect of previous administration of ilomedine in the past. After optimizing her vasodilator medication and treatment with antibiotics, she was discharged from the hospital. Nevertheless, after 1 month she was hospitalized again because of progressive pain in digit 1 of the right foot. The thermographic recordings showed unaltered dark blue distal regions of digits 2–5, but now also with very dark spots in digit 1, likely indicating a very poor perfusion and even avascular parts and necrosis (Fig. 2). Laboratory examination showed a slightly raised CRP (58 mg/L) with no further abnormalities. The wound culture showed this time Staphylococcus aureus and Pseudomonas alcaligenes and the X-ray of the right foot had not significantly changed over time. Because the patient already received maximal vasodilatation and was in severe pain, very few options remained. This time there were no clear signs of an active deep infection and the thermographic pictures showed serious compromised peripheral perfusion with also avascular parts of digit 1 without signs of macrovascular compromise on angiography (Fig. 3). Because of the clinical picture (no fever, only a slightly raised CRP, cold peripheral acra and a visible ulcer of digit I), the angiography without signs of macrovascular problems (Fig. 3) and the thermographic recordings with unaltered dark blue distal regions and extremely dark blue parts of digit 1 indicating low temperatures of the acra probably because of very poor perfusion (Fig. 2), we decided to perform a transmetatarsal forefoot amputation. This procedure was uncomplicated followed by primary healing of the wound. Figure 1Open in figure viewerPowerPoint Thermographic recording of the right foot (first episode). This thermal image shows areas of low temperature (blue toes 2–4) which indicate poor peripheral perfusion, but increased thermal activity at the proximal phalange of the big toe (red local region of digit 1), suggestive of inflammation possibly because of infection. Figure 2Open in figure viewerPowerPoint Thermographic recording of the right foot (second episode, a). This thermal image shows unaltered low temperatures at all toes (blue toes) as an indication of compromised peripheral perfusion. The tip of the big toe with a visible ulcer (b) presents with two spots of very low temperature (a) which might be indicative for ischemic necrosis. Figure 3Open in figure viewerPowerPoint Computed tomography–angiography showed no signs of macrovascular problems. However, such an imaging method cannot exclude microvascular pathology. The correlation of body temperature and diseases has been known for centuries but in recent years, due to the advantage of new technologies, skin temperature has been used as a convenient and effective diagnostic tool to detect various diseases.4 Thermography essentially records infrared radiation from the skin surface and is a physiologic imaging modality which detects changes in skin temperature associated with variations in blood flow. Anatomic imaging modalities, like conventional radiographs, but also more invasive and costly techniques such as computed tomography, MRI and angiography, focus on affected structures but only provide a static image of disease processes. In veterinary medicine, thermography has proven to be a safe, valuable and non-invasive technique for diagnosing medical issues in non-domestic animals in daily practice in which it is difficult to observe injured areas on the limbs.5 Over the last 40 years, thermal imaging has been utilized and considerable progress has been made in the performance of imaging equipment and standardization of the technique. Also in human medicine it is being used for imaging of several conditions (although in daily clinical practice it is still not incorporated), for example, Raynaud's phenomenon,6 infections,7, 8 foot ulcers,9 arthritis3, 10 fever screening,11 peripheral vascular disorders12 and postoperative monitoring of flap surgery.13 Our case illustrates the potential value of thermography in cases of severe impairment of the microcirculation in systemic sclerosis, by objectively showing significant temperature changes which was helpful in clinical decision-making. At first admission the aggravating pain was primarily due to an active deep infection of digit 1 and the typical signs of inflammation on thermography resolved after treatment with antibiotics. At second admission there were no clear signs of a deep infection but fields of ischemia were more pronounced on thermography, leading to the clinical decision of amputation at the metatarsal level. Thermography was of added value in both hospitalization episodes. Especially in the last episode, it prevented the patient from being (needlessly) hospitalized once more for longstanding antibiotic treatment and it was supportive for choosing the right localization to amputate, instead of exposing the patient to multiple ascending amputations. In conclusion, additional thermography has shown to be a promising tool in the differentiation between inflammation due to infection or ischemia in a patient with severe scleroderma that was of clinical significance and relevance for decision-making. In our opinion, further studies are needed to determine the place of thermography in the imaging landscape of vasculopathy and rheumatology. References 1Matucci-Cerinic M, Kahaleh B, Wigley FM (2013) Review: evidence that systemic sclerosis is a vascular disease. Arthritis Rheum 65 (8), 1953– 62. 2Collins AJ, Ring EF, Cosh JA, Bacon PA (1974) Quantitation of thermography in arthritis using multi-isothermal analysis. I. The thermographic index. Ann Rheum Dis 33 (2), 113– 5. 3Spalding SJ, Kwoh CK, Boudreau R et al. (2008) Three-dimensional and thermal surface imaging produces reliable measures of joint shape and temperature: a potential tool for quantifying arthritis. Arthritis Res Ther 10 (1), R10. 4Ring EF, Ammer K (2012) Infrared thermal imaging in medicine. Physiol Meas 33 (3), R33– 46. 5Rekant SI, Lyons MA, Pacheco JM, Arzt J, Rodriguez LL (2016) Veterinary applications of infrared thermography. Am J Vet Res 77 (1), 98– 107. 6Lim MJ, Kwon SR, Jung KH, Joo K, Park SG, Park W (2014) Digital thermography of the fingers and toes in Raynaud's phenomenon. J Korean Med Sci 29 (4), 502– 6. 7Fujita K, Noguchi M, Yuzuriha S, Yanagisawa D, Matsuo K (2013) Usefulness of infrared thermal imaging camera for screening of postoperative surgical site infection after the nuss procedure. Case Rep Surg 2013, 946156. 8Romano CL, Logoluso N, Dell'Oro F, Elia A, Drago L (2012) Telethermographic findings after uncomplicated and septic total knee replacement. Knee 19(3), 193– 7. 9Liu C, van Netten JJ, van Baal JG, Bus SA, van der Heijden F (2015) Automatic detection of diabetic foot complications with infrared thermography by asymmetric analysis. J Biomed Opt 20(2), 26003. 10Lasanen R, Piippo-Savolainen E, Remes-Pakarinen T et al. (2015) Thermal imaging in screening of joint inflammation and rheumatoid arthritis in children. Physiol Meas 36 (2), 273– 82. 11Chiu WT, Lin PW, Chiou HY et al. (2005) Infrared thermography to mass-screen suspected SARS patients with fever. Asia Pac J Public Health 17 (1), 26– 8. 12Bagavathiappan S, Saravanan T, Philip J et al. (2009) Infrared thermal imaging for detection of peripheral vascular disorders. J Med Phys 34 (1), 43– 7. 13de Weerd L, Miland AO, Mercer JB (2009) Perfusion dynamics of free DIEP and SIEA flaps during the first postoperative week monitored with dynamic infrared thermography. Ann Plast Surg 62 (1), 42– 7. Citing Literature Volume20, Issue12December 2017Pages 2190-2193 FiguresReferencesRelatedInformation