Objective
Acrocyanosis (AC) is a common manifestation of starving syndrome in anorexia nervosa. We characterized microvascular changes associated with AC and determined discriminating factors between acrally symptomatic and nonsymptomatic patients.
Methods
We examined 34 patients with anorexia nervosa (15 restrictive–anorectic type, 19 binge-eating/purging type, duration 1–25 years). Nineteen were symptomatic (SP) and 15 were nonsymptomatic (NSP). All underwent photo-pletysmography, sonography of the brachial artery, capillary microscopy and laboratory analysis.
Results
Disease characteristics and body mass index did not differ between SP and NSP. In SP more dilatated efferent capillary loops and venoles were present (P<.001) and capillary flow velocities were reduced (0.21±0.12 ml/min vs. 0.34±0.15 ml/min; P=.015). Flow-mediated and nitroglycerin-induced dilatation showed no differences. Symptomatic patients had lower leukocyte counts (P=.008), lower eosinophils (P=.003) and lower LDL (P=.045) concentrations. A logistic regression model identified only leukocytes (P=.017) and eosinophils (P=.023) to be associated with AC.
Conclusions
In acrally symptomatic patients the typical microvascular features of AC are present. AC is associated with lower leukocyte counts and lower eosinophils.
Anorexia nervosa is a serious life-threatening eating disorder characterized by a disturbance of the body scheme and self-determined restrictive dietary regimes leading to progressive weight loss with severe secondary endocrinological and metabolic consequences summarized as “starvation syndrome” [1] and [2]. According to Mayerhausen et al. [3] and Schulze at al. [4] who analyzed dermatologic manifestations of anorexia nervosa, at least one third of the patients additionally develop a reddish-blue discoloration of their fingers, clinically referred to as acrocyanosis. This acral syndrome sometimes gains clinical importance not only by increased cold sensitivity, but also by increasing social isolation due to stigmatization.
The aim of our study was to characterize the microvascular changes in anorexia nervosa by microcirculatory assessment and to determine discriminating factors for its appearance.
Patients and methods
Patients
We examined 34 patients (32 females, 2 males) suffering from anorexia nervosa. All patients were treated in an inpatient or outpatient setting in the Clinical Department of Psychosomatic and Psychosocial Psychiatry at the University of Innsbruck. The study protocol was approved by the Ethical Committee of the Medical Faculty of the University of Innsbruck.
Diagnosis was made using the ICD-10 and DSM-IV criteria. A restrictive–anorectic type was distinguished from a binge-eating/purging type using self-induced emesis, diuretics or laxatives for weight loss [5].
Calorie intake was insured by administration of five high-caloric formula meals per day (Fresenius 750 MCT, Fresenius Kabi, Austria) during the initial indoor treatment phase (4–6 weeks). Thereafter nutrition consisted of two high-caloric formula intakes and three regular meals per day. Calcium and vitamin D was additionally supplemented (Cal-D-VitR, Roche, Austria) and gastral motility was stimulated by prescription of domperidone (MotiliumR, Janssen–Cilag, France).
All patients received pyschotherapy, adjuvant physiotherapy and ergotherapy.
All patients underwent a complete angiological examination including photo-pletysmography, capillary microscopy with laser-doppler anemometry and high-resolution brachial artery ultrasound.
Acrocyanosis was clinically defined by the presence of cold reddish-blue discolored fingers and hands, the induceability of a so-called “iris aperture sign” and facultatively an enhanced sweating of the affected palms and fingers [6] and [7].
Apparative examination
Finger artery occlusions were excluded by photo-pletysmography carried out from the fingertips D1–D5 using a commercially available photo-plethysmometer (Guttman, Germany).
Capillary light microscopy was performed with a Capiscope (KK-Research Technology LTD, UK) connected to a standard computer unit. Images were generated by a lens providing a magnification of ×200 and a CCD camera giving high-resolution images of 752×582 pixels. The Capiscope contains a laser-doppler anemometer for measurement of flow velocities of single capillaries.
Capillary morphology was assessed according to the recommendations of the Microcirculatory Section of the German Society of Angiology (DGA) [8]. Capillary flow velocities were determined in the efferent capillary loops near the apex of five capillaries per finger and are expressed as means of these measurements.
Brachialis sonography was carried out following Celermajer et al. [9] with an HDI 5000 and a 5–12 MHz linear ultrasound transducer (ATL Ultrasound, USA). For determination of the arterial width the endothel-endothel diameter was used. Flow-mediated dilatation (FMD) and nitroglycerin-induced dilatation (NTG) were calculated by putting the basal vessel diameter as 100%.
Laboratory parameters
A total of 40 parameters were registered: Blood count, differential white blood count, glucose, creatinine, AST, ALT, trigycerides, total, HDL and LDL cholesterol, TSH, fT3, fT4, serum-electrophoresis, C3c, C4, CRP, rheumafactor, cardiolipin-antibodies, ANA and leptin.
All blood samples were drawn from antecubital or cubital veins between 7 and 8 o'clock in the morning after a 12-h overnight fast.
