Indian Journal of Dermatology
  Publication of IADVL, WB
  Official organ of AADV
Indexed with Science Citation Index (E) , Web of Science and PubMed
 
Users online: 3250  
Home About  Editorial Board  Current Issue Archives Online Early Coming Soon Guidelines Subscriptions  e-Alerts    Login  
    Small font sizeDefault font sizeIncrease font size Print this page Email this page


 
Table of Contents 
CASE REPORT
Year : 2014  |  Volume : 59  |  Issue : 2  |  Page : 195-196
Digital gangrene associated with anticentromere antibodies


Department of Medicine, Government Medical College, Thrissur, Kerala, India

Date of Web Publication21-Feb-2014

Correspondence Address:
Mary Grace
Assistant Professor in Medicine, Government Medical College, Thrissur, Kerala
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.127686

Rights and Permissions

   Abstract 

Anticentromere antibodies have been associated with peripheral vascular occlusive disease, but then it is mostly accompanied by sclerodactyly in the context of a connective tissue disorder. We report a case of digital gangrene in a 75 year old lady with no other associations except positive anticentromere antibodies.


Keywords: Digital gangrene, anticentromere antibody, vasculitis


How to cite this article:
Grace M, Varada, Dhanesh E S. Digital gangrene associated with anticentromere antibodies. Indian J Dermatol 2014;59:195-6

How to cite this URL:
Grace M, Varada, Dhanesh E S. Digital gangrene associated with anticentromere antibodies. Indian J Dermatol [serial online] 2014 [cited 2019 Nov 17];59:195-6. Available from: http://www.e-ijd.org/text.asp?2014/59/2/195/127686

What was known?
Anticentromere antibodies are known to be associated with peripheral vascular occlusive disease, mostly in the context of a connective tissue disorder.



   Introduction Top


The presence of anticentromere antibodies (ACA) is most commonly associated with limited scleroderma. To a lesser extent, ACA have been reported in other disorders including: Raynaud's syndrome, Raynaud's phenomenon associated with sclerodactyly, primary biliary cirrhosis (PBC), and Sjogren's syndrome. [1] Patients with circulating ACA associated with limited scleroderma or sclerodactyly have been reported to be at increased risk of significant peripheral vascular occlusive disease. [2] There is only scanty evidence in literature, of digital ischemia associated with ACA without associated Raynaud's phenomenon, sclerodactyly or other connective tissue disease. The only previous case report was in 53 year old lady who had digital gangrene and positive ACA. We report the case of a 75-year-old woman presenting with digital gangrene and a positive ACA without other features of connective tissue disease.


   Case Report Top


A 75 year old lady presented with sudden onset of severe pain and blackish discoloration of the index finger of her left hand. She did not give any history suggestive of Raynaud's phenomenon, or arthritis. In fact she did not have any significant illness in the past, including diabetes, hypertension, or coronary artery disease. She did not have any addictions and she was not on any regular medications. On examination, there was digital necrosis of the distal finger [Figure 1] with an adjacent area of pale swollen tissue with ulceration. No sclerodactyly was evident. There was no evidence of peripheral vascular disease. All her peripheral pulses were felt equally on both sides. There was no audible bruit. Her BP was 130/80 mm of Hg. All system examinations were within normal limits. Investigations revealed normal hemoglobin, total leukocyte count, platelet count and ESR. Her blood sugar, renal and liver function tests were within normal limits. ECG, X-ray chest and USG abdomen were also normal. Her ANA titre was elevated and ANA profile showed a strongly positive anticentromere antibody. Anti-double stranded DNA, anti-Sjogren's Syndrome A, anti-Sjogren's Syndrome B and anti-ribonucleoprotein antibodies (anti-SSA, anti-SSB, anti-RNP), anti-Sm, anti-Scl-70 were negative.
Figure 1: Digital gangrene

Click here to view



   Discussion Top


The common causes of digital gangrene are atherosclerosis, diabetes, connective tissue diseases, vasculitis, infectious causes like infective endocarditis and HIV. Connective tissue diseases are the commonest cause of digital ischemia in young and middle aged especially females. Presence of a positive ANA need not signify an underlying disease. A high titre of ACA is reported in association with thrombotic vascular disease. [3] Hence the presence of a positive ACA should alert one to the presence of an underlying connective tissue disorder. However, ACA has been detected incidentally in patients without other features of connective tissue disease. [4] ACA antibodies are commonly associated with CREST syndrome, diffuse systemic sclerosis, PBC and other connective tissue diseases. There is also a strong correlation between ACA and Raynaud's phenomenon. Other associations of ACA include rheumatoid arthritis, systemic lupus erythematosus systemic lupus erythematosus (SLE), erythema nodosum, polyarthritis and relatives of patients with scleroderma. There have been case reports of patients with digital ischemia associated with ACA, but they also had other risk factors like smoking, Raynaud's phenomenon. [3]

Can there be a situation where a patient develops digital ischemia without other commonly associated risk factors but has ACA positivity? There has been one case report (and to our knowledge the only one in world literature), where a 53 year old lady presented with digital ischemia in association with a positive antinuclear antibody ANA and ACA without features of sclerodactyly, Raynaud's phenomenon or any other connective tissue disease or other risk factors like smoking, diabetes. [5] It has been postulated that ACA, rather than being a marker antibody may have a direct pathogenic role in vascular endothelial injury. [6]

It has been observed that human dermal endothelial cells (HDEC) exposed to sera containing ACA demonstrate increased apoptosis and altered gene expression. These include increased expression of genes linked to apoptosis and development of fibrosis, as well as diminished expression of angiogenesis promoting genes. [7]


   Conclusions Top


Our patient's case illustrates the need to consider an autoimmune contribution to pathogenesis of digital ischemia even in the absence of a recognizable connective tissue disease and as this particular case demonstrates even in the elderly. Furthermore, digital ischemia may be the presenting feature or initial manifestation of an underlying evolving connective tissue disease.

 
   References Top

1.Vlachoyiannopoulos PG, Drosos AA, Wiik A, Moutsopoulos HM. Patients with anticentromere antibodies, clinical features, diagnoses and evolution. Br J Rheumatol 1993;32:297-301.  Back to cited text no. 1
    
2.Wigley FM, Wise RA, Miller R, Needleman BW, Spence RJ. Anticentromere antibody as a predictor of digital ischemic loss in patients with systemic sclerosis. Arthritis Rheum 1992;35:688-93.  Back to cited text no. 2
    
3.Buchanan RR, Riglar AG. The titre of anti-centromere antibodies: Its relationship to Raynaud's phenomenon and vascular occlusion. Br J Rheumatol 1989;28:221-6.  Back to cited text no. 3
    
4.Lee SL, Tsay GJ, Tsai RT. Anticentromere antibodies in subjects with no apparent connective tissue disease. Ann Rheum Dis 1993;52:586-9.  Back to cited text no. 4
    
5.Bolster L, Taylor-Gjevre RM, Nair B, Gjevre JA. Digital gangrene associated with anticentromere antibodies: A case report. J Med Case Rep 2010;4:189.  Back to cited text no. 5
    
6.Takahashi M, Okada J, Kondo H. Six cases positive for anti-centromere antibodies with ulcer and gangrene in the extremities. Br J Rheumatol 1997;36:889-93.  Back to cited text no. 6
    
7.Ahmed SS, Tan FK, Arnett FC, Jin L, Geng YJ. Induction of apoptosis and fibrillin 1 expression in human dermal endothelial cells by scleroderma sera containing anti-endothelial cell antibodies. Arthritis Rheum 2006;54:2250-62.  Back to cited text no. 7
    

What is new?
The possibility of an autoimmune basis to the pathogenesis of digital ischemia should be considered even in the elderly.


    Figures

  [Figure 1]



 

Top
Print this article  Email this article
 
 
  Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Article in PDF (832 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
   Introduction
   Case Report
   Discussion
   Conclusions
    References
    Article Figures

 Article Access Statistics
    Viewed1539    
    Printed56    
    Emailed0    
    PDF Downloaded60    
    Comments [Add]    

Recommend this journal