The impact of non-persistence on the direct and indirect costs in patients immune-mediated rheumatic diseases treated with sub- system for patients suffering from acute coronary syn- cutaneous TNF-alpha inhibitors. Rheumatol Int drome and treated with percutaneous coronary interven- 2017;37:204958. tion. Eur J Health Econ 2010;11:44955. 16 Svedbom A, Dale ´ n J,M, Black CM, Kachroo S. Persistence 18 Solomon DH, Reed GW, Kremer JM et al. Disease activity and costs with subcutaneous TNF-alpha inhibitors in in rheumatoid arthritis and the risk of cardiovascular immune-mediated rheumatic disease stratified by treatment events. Arthritis Rheumatol 2015;67:144955. line. Patient Pref Adherence 2017;11: 95106. 19 Au K, Reed G, Curtis JR et al. High disease activity is 17 Friedel H, Delges A, Clouth J, Trautvetter DT. associated with an increased risk of infection in patients Expenditures of the German statutory health insurance with rheumatoid arthritis. Ann Rheum Dis 2011;70:78591. Rheumatology 2018;57:1281 doi:10.1093/rheumatology/key061 Clinical Vignette Advance Access publication 9 March 2018 Blue toe syndrome in cutaneous polyarteritis FIG.1 Livedo and blue toe in the 2 patients nodosa Blue toe syndrome is a blue discoloration of the toes already reported once in cutaneous polyarteritis nodosa (cPAN) . Macular lymphocytic arteritis (MLA) is a cutaneous medium-vessel vasculitis characterized by pigmented macules and lymphocytic infiltration of the ves- sels, mostly considered as a benign form of cPAN . We report two patients having blue toe syndrome, one with cPAN and one with MLA. The first patient had a livedo racemosa (Fig. 1A) and later a blue toe appearance of the second right toe (Fig. 1B) that became necrotic. cPAN diagnosis was confirmed by histology of the livedo that showed inflammatory medium sized arteriolitis of the dermo-hypodermic junction. The second patient had a livedo racemosa (Fig. 1C) and a sudden purplish appear- ance of the toes (Fig. 1D). Treatment using high dose ster- oids and prostacyclin allowed regression of the blue toe syndrome in both cases. Infiltrated livedo (A) then blue toe (B) in patient 1. Atypical cPAN skin symptoms include white atrophy, Non-infiltrated livedo (C) then blue toe and peripheral acrocyanosis, RP, peripheral gangrene and ulcers and ‘in- ischaemia (D) in patient 2. flammatory plaques with peripheral nodules. The mechan- isms involved in our cases may combine initial vessel wall 3 4 Conakry, Guinea, Pathology Department and Internal inflammation and late thrombotic events. The occurrence Medecine Department Saint Louis Hospital, Paris, France of blue toes in the course of cPAN or MLA is a rare but probably severe complication requiring urgent recognition *Florence Cordoliani and Jean-David Bouaziz equally con- and management. tributed to this study. Correspondence to: Jean-David Bouaziz, Department of Funding: No specific funding was received from any Dermatology, Saint Louis Hospital, 1 Avenue Claude bodies in the public, commercial or not-for-profit sectors Vellefaux, 75475 Paris, France. to carry out the work described in this manuscript. E-mail: email@example.com Disclosure statement: The authors have declared no References conflicts of interest. 1 Tschetter AJ, Liu V, Wanat KA. Cutaneous polyarteritis 1,2 1 Thierno Mamadou Tounkara , Marie Jachiet , nodosa presenting as a solitary blue toe. J Am Acad 1 3 Laure Frumholtz , Maxime Battistella , Dermatol 2014;71:e957. 2 4 1 Mohamed Cisse , Alfred Mahr , Martine Bagot , 2 Buffiere-Morgado A, Battistella M, Vignon-Pennamen MD 1, 1, Florence Cordoliani * and Jean-David Bouaziz * et al. Relationship between cutaneous polyarteritis nodosa Dermatology Department, Saint Louis Hospital and Paris VII (cPAN) and macular lymphocytic arteritis (MLA): blinded Sorbonne Paris Cite´ University, Paris, France, Dermatology histologic assessment of 35 cPAN cases. J Am Acad Department, Gamal Abdel Nasser University of Conakry, Dermatol 2015;73:101320. The Author(s) 2018. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: firstname.lastname@example.org https://academic.oup.com/rheumatology 1281 Downloaded from https://academic.oup.com/rheumatology/article-abstract/57/7/1281/4925530 by Ed 'DeepDyve' Gillespie user on 26 June 2018
Rheumatology – Oxford University Press
Published: Mar 9, 2018
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