Case Report

Blue-Finger-Syndrome and Tofacitinib

Popp F1*, Benecke U2, Fischer S3, Kempis J1, Koeger P2 and Mueller RB1
1Department of Rheumatology, Kantonsspital St. Gallen, Switzerland
2Department of Angiology, Kantonsspital St. Gallen, Switzerland
3Department of Anaesthesiology, Luzerner Kantonsspital, Switzerland

*Corresponding author: Florian Popp, Department of Rheumatology, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007 St. Gallen, Switzerland

Published: 18 Jul, 2017
Cite this article as: Popp F, Benecke U, Fischer S, Kempis J, Koeger P, Mueller RB. Blue-Finger- Syndrome and Tofacitinib. Ann Clin Case Rep. 2017; 2: 1404.

Clinical Image

A 61-year-old male patient with seropositive, ACPA-positive, erosive rheumatoid arthritis (RA) presented with a painful, blue-livid discoloration of his right index finger. Three weeks prior, due to worsening RA-symptoms, RA-therapy was changed from tocilizumab to tofacitinib. Arteriography showed a significant hypovascularization, oscillography a pathologic pattern. Angiological, hematological, cardiac and rheumatological workup demonstrated no significant findings but atherosclerotic changes including the right radial artery. In conclusion the blue-finger-syndrome can be interpreted as result of atherosclerotic changes, as a potential unexpected adverse event to tofacitinib or as a combination of both. Tofacitinib was permanently discontinued; iloprost and enoxaparin were initiated followed by phenprocoumon, which in the further course was replaced by acetylsalicylic acid. This resulted in rapid improvement of the symptoms. During a one year followup no additional vascular event was observed.
The blue-finger-syndrome results from blockage, usually thromboembolic or traumatic, of smaller blood vessels. Consequently, search for thromboembolic sources is required. Further causes include antiphospholipid-antibody-syndrome, connective-tissue-disease or vasculitis. To our knowledge, the blue-finger-syndrome has not yet been described under tofacitinib-therapy. In this patient an increase of LDL-cholesterol has been observed subsequent to initiation of tofacitinib. Therefore Atorvastatin was started during follow-up. An increase of cholesterol in association with tofacitinib-therapy [1,2] is reported not to augment the risk of cardiovascular events [1,3,4]. In general, the cardiovascular safety profile of tofacitinib is similar to other biological disease-modifying anti-rheumatic drugs [5]. Nonetheless, a drug-associated cause should be discussed (Figure 1).

Figure 1

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Figure 1
Ateriography before and after 3 ml 0.01% nitroglycerin i.a. Osicillography right index finger at the year after the event, Osicillography right index finger ½ year after the event and Osicillography right index finger 1 year after the event.


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