A 42-year-old man presented with a 3 month history of Raynaud's phenomenon (RP), skin thickening and pain in multiple joints. He had a unremarkable past medical history and did not use any medication. He was a cigarettes smoker at the time and had a 30 pack-year smoking history.
On presentation he had diffuse skin thickening with a modified Rodnan skin score (mRSS) of 13, multiple fingertip pitting scars and oligoarthritis of both wrists and elbows. Laboratory tests revealed a slightly elevated erythrocyte sedimentation rate (ESR) of 28 (reference <15 mm/h), positive antinuclear antibodies (ANA) and anti-topoisomerase I antibodies. Nailfold capillary microscopy (NCM) showed a late scleroderma pattern with decreased capillary density and abnormal capillaries. A high-resolution CT (HRCT) of the chest and echocardiogram showed no cardiopulmonary involvement. The diagnosis of diffuse cutaneous systemic sclerosis (dcSSc) was established and he was counselled to quit smoking.
Treatment was initiated with intravenous cyclophosphamide (750mg/m2) every 4 weeks. RP was treated with nifedipine retard 20mg once-daily and for heartburn complaints omeprazole 20mg once-daily was initiated. His arthritis was treated with prednisolone 10mg once-daily. However, after 3 cycles of cyclophosphamide his disease had progressed with worsening of the mRSS to 32 and development of limited SSc-ILD, diagnosed by pulmonary function tests and HRCT-scan. The pulmonary function test results and mRSS values are shown in  Figure 1 .
Given his poor prognosis, after counseling the patient and his partner, it was jointly decided to intensify treatment and perform a HCT. Before stem cell mobilization, he was referred to a fertility clinic to perform semen cryopreservation because of the increased risk of infertility following high-dose alkylating agent conditioning. The procedure of the HCT was performed as described before, including the same medication dosing regimen. In brief, peripheral blood hematopoietic stem cells were mobilized with intravenous cyclophosphamide 2000mg/m2 and G-CSF (filgrastim). After conditioning with cyclophosphamide 200mg/kg, intravenous rabbit antithymocyte globulin (rATG, Genzyme) 7.5 mg/kg and intravenous methylprednisolone 1 mg/kg, CD34+, stem cells were reinfused. The procedure was complicated by neutropenic fever based on a central line-associated bloodstream infection, for which he received broad-spectrum antibiotic treatment.
After the HCT patient recovered very quickly. His skin involvement as measured by mRSS decreased and his pulmonary function test results improved over time ( Figure 1 ). Patient remained in a drug-free remission for 4 years. Unfortunately he failed to quit smoking.
Four years after his HCT patient complained of fatigue and worsening of his RP with stable mRSS. But 4 years and 3 months post-HCT the patient returned to our outpatient clinic and showed clinical signs of a relapse of his SSc with severe RP, tendon friction rubs and deterioration of pulmonary function test results and mRSS. A new HRCT of the chest showed increase of ground glass opacities, consistent with progression of SSc-ILD. Treatment with mycophenolate mofetil 1500mg twice-daily was initiated, but was evaluated as ineffective after 3 months as the mRSS increased and pulmonary function tests showed decreased values. Treatment with i.v. Rituximab was considered, as well as a second HCT.
Since there is almost no evidence for a second HCT in SSc in terms of safety and efficacy, this treatment is experimental, which we discussed with the patient. We also counselled him about the possible risks of a second HCT including the increased risk of treatment-related mortality. This time, patient managed to quit smoking, which was a strict requirement.
Nearly 5 years after the first HCT, a second HCT was performed. The same protocol for stem cell mobilization and conditioning was used, except for the use of a different type of rATG (Fresenius) because of the risk of sensibilization. There were no adverse events during the procedure. Treatment with cyclosporine was initiated directly post-HCT. Pneumocystis jirovecii pneumonia (PJP) prophylaxis with co-trimoxazole was given up to 1 year post-HCT. Because serology showed cytomegalovirus (CMV) IgG positivity, post-HCT treatment with valganciclovir 900mg once-daily was given for prevention of CMV reactivation.
Within 3 months after the second HCT, again significant improvement of mRSS and pulmonary function was seen ( Figure 1 ). 6 months post-HCT, cyclosporine was discontinued and treatment with mycophenolate mofetil was initiated. The HRCT scan 1 year after the second HCT showed an decrease in the amount of ground glass opacities and fibrotic changes. At this moment the second HCT was performed 2 years ago and the disease is still in remission with mycophenolate mofetil in a dose of 2 times 1000 mg daily.
Vasculopathy is one of the key features of SSc and occurs early in the disease course. NCM allows visualization of microvascular damage and is a useful tool for follow up of SSc microangiopathy. Typical findings on NCM in patients with SSc include loss of capillaries, hemorrhages, giant capillaries, neovascularization and avascular areas. Based on these findings, NCM scleroderma patterns can be classified as "early", "active" or "late". An early pattern is defined by relatively well-preserved capillary distribution, presence of giant capillaries, few capillary hemorrhages and no evident loss of capillaries. The active pattern is specified by frequent giant capillaries and capillary hemorrhages, moderate capillary loss and mild capillary architecture disorganization. A late pattern is characterized by irregular enlargement of capillaries, few or absent giant capillaries, severe capillary loss with avascular areas, ramified/bushy capillaries and disorganization of the normal capillary array.
In our patient, NCM images were obtained at baseline, 6 and 9 months after the first HCT, before the second HCT and 6, 9, 12 and 18 months after the second HCT. NCM images were acquired using an optical probe video capillaroscope equipped with a 200x contact lens and connected to image analysis software (at time of the first HCT VideoCap 3.0, at the time of the second HCT Optilia OP-120 011, Mediscope Digital, videomicroscope (USB interface), OptiPix Capillaroscopy software, clinic 1.7.x with a 200x high resolution objective lens with unpolarized light). Two images per finger were evaluated and consisted of both quantitative and qualitative parameters, as described by the by the EULAR Study Group on Microcirculation in Rheumatic Diseases/Scleroderma Clinical Trials Consortium on Capillaroscopy. Evaluation of images was performed by 2 experienced physicians (MV and BK). Consensus was reached on every visit. Mean capillary density was calculated by taking the mean capillary density of 2 images of every finger and adding all means, divided through the number of evaluable fingers. The pattern of the nailfold capillaroscopy was determined as described earlier.
NCM findings throughout the disease course are shown in  Table 1  and NCM images before and after the first and second HCT are shown in  Figure 2 . Normal capillary density is defined as >9 capillaries/mm2. At baseline, the NCM images showed a late pattern, with neoangiogenesis and severe capillary loss. Mean capillary density at baseline was 3.2 capillaries/mm2. 6 and 9 months after the first HCT, the NCM images showed an active pattern with the presence of giant capillaries and a mean capillary density of 6 capillaries/mm2 and 7.5 capillaries/mm2 respectively. Shortly before the second HCT, the NCM images showed a late scleroderma pattern, with severe capillary loss and a capillary density of 3.8 capillaries/mm2. 6 months after the second HCT, NCM images again showed an active pattern with a capillary density of 5 capillaries/mm2. 9, 12 and 18 months after the second HCT, NCM images showed a late scleroderma pattern with gradual deterioration of capillary density.