[A case of neuromyelitis optica spectrum disorder associated with a limited cutaneous systemic sclerosis and Sjögren syndrome]

A 51-year-old woman was referred to our department for a precise examination of her neuromyelitis optica spectrum disorder (NMOSD) symptoms. She had recurrent attacks of consciousness disturbance, cerebellar ataxia and diplopia (10 years ago), paraparesis and dysesthesia in four limbs (7 years ago), and consciousness disturbance and paraparesis (4 years ago). Neurological examination disclosed bilateral temporal pallor of the optic disc, atrophy and fasciculation of the right side of the tongue, dysesthesia in four limbs, mild motor weakness of both lower limbs, hyperreflexia in the right leg, pathological reflexes in bilateral lower limbs, and spastic bladder. T2-weighted cranial MRI showed lesions in the bilateral hypothalami and the dorsal portion of the medulla oblongata on the right side. T2-weighted spinal MRI revealed longitudinally extensive spinal cord lesions at T2-T8. A visual-evoked potential study disclosed prolonged latency of P100 bilaterally. During the examination, slight skin changes on the lower extremities indicative of scleroderma were observed, with no evidence of organ involvement. Skin biopsy showed increased numbers and swelling of collagen fibers. Thus, the patient was diagnosed with limited cutaneous systemic sclerosis (lcSSc). She also clinically manifested Sjögren syndrome. Her serum was positive for anti-nuclear, anti-centromere, and anti-aquaporin-4 antibodies. Following the administration of corticosteroids (25 mg/alternative day) the patient became stable. A variety of collagen diseases or autoimmune disorders have been reported to be major complications of NMOSD; however, the coexistence of lcSSc and NMOSD is extremely rare. To the best of our knowledge, this is the first description of a case with the coexistence of both conditions. Physicians should be aware of scleroderma in patients with NMOSD, even if patients do not complain of skin symptoms.

Elevated MMP-7 levels in patients with systemic sclerosis: correlation with pulmonary involvement

BACKGROUND

Fibrosis is characterized by an excessive accumulation of connective tissue because of an imbalance between synthesis and degradation of extracellular matrix proteins. Systemic sclerosis (SSc) is a prototypic chronic inflammatory disease leading to a severe fibrosis of the skin and many internal organs. QUESTIONS ADDRESSED: We investigated whether serum MMP-7 levels reflect the activity of the fibrotic reaction in systemic sclerosis.

EXPERIMENTAL DESIGN

Serum samples were obtained from 123 patients with systemic sclerosis. MMP-serum levels of all patients with SSc were compared with age-matched healthy controls.

RESULTS

Significantly increased median serum MMP-7 levels were found in patients with SSc when compared with controls. The median MMP-7 serum level of patients with lung fibrosis (LF) was significantly higher compared with those without LF. Accordingly, patients with dyspnea and DLCO (diffusion capacity of the lung for carbon monoxide) levels below 60% showed significantly higher median MMP-7 levels.

CONCLUSIONS

Elevated MMP-7 levels are associated with an advanced stage of SSc and LF. These data suggest that in SSc MMP-7 is involved in the process of fibrotic tissue remodelling.

Early detection of median nerve syndrome at the carpal tunnel with high-resolution 18 MHz ultrasonography in systemic sclerosis patients

OBJECTIVES

To investigate carpal tunnel syndrome (CTS) with ultrasound (US) in asymptomatic SSc patients and to seek out the relationship between CTS and SSc clinical variables

METHODS

In 64 SSc patients (55 women and 9 men, mean age 57±14 years) and in 30 healthy controls, area (MNA), transverse (MNT) and anteroposterior (MNAP) diameters of MN at carpal tunnel were studied with US (My Lab 25 XVG US Esaote 18 MHz). MN flattening ratio (MNFR) was calculated. Duration of disease, subset (limited, diffuse), phase of skin involvement (oedematous, atrophic, fibrotic), modified Rodnan skin score (mRSS) and friction tendon rub were also recorded.

RESULTS

MNA (p<0.001), MNT (p<0.005) and MNFR (p<0.005) were significantly higher in the SSc patients than in controls, while no difference in MNAP was found. There was no correlation between median nerve (MN) and SSc clinical features (only lower MNAP correlated inversely with longer disease duration; Spearman coefficient -0.2).

CONCLUSIONS

MN involvement is frequently present in all phases of asymptomatic SSc patients, independently to clinical variables.

Gastrointestinal involvement in patients with systemic sclerosis

INTRODUCTION

Gastrointestinal (GI) involvement is a serious complication of systemic sclerosis (SSc).

OBJECTIVES

The aim of the study was to determine the incidence of GI manifestations in SSc.

PATIENTS AND METHODS

We studied 73 patients with SSc (60 women and 13 men). Diffuse cutaneous SSc (dcSSc) was diagnosed in 30 patients and limited cutaneous SSc (lcSSc) in 43 patients. Upper GI involvement was assessed based on clinical symptoms such as dysphagia and gastroesophageal reflux-related complications. The majority of patients underwent radiographic examination including a barium swallow. Lower GI involvement was evaluated on the basis of such clinical symptoms as constipation and diarrhea.

RESULTS

GI symptoms were observed in 54 (74%) SSc patients. Upper GI symptoms were observed in 54 (74%) patients and lower GI symptoms in 22 (30%) patients. The presence of anticentromere antibodies is associated with a lower risk of GI involvement. There are no significant differences in the incidence of pulmonary involvement between SSc patients with and without GI symptoms.

CONCLUSIONS

GI involvement is observed in the majority of SSc patients. Clinical symptoms of GI involvement are significantly more common in patients with dcSSc. The incidence of upper GI symptoms is significantly higher than that of lower GI symptoms.

Pulmonary arterial hypertension occurrence after liver transplant in systemic sclerosis: a report of 2 cases sustainably treated by sildenafil

We present the unusual cases of 2 systemic sclerosis patients with a history of liver transplant, who developed pulmonary hypertension in the course of their diseases. Sildenafil was the preferred pulmonary arterial hypertension drug because of its safety within this context. Clinical and functional responses were good, with a follow-up of more than 2 years.

Reliability and validity of the delta finger-to-palm (FTP), a new measure of finger range of motion in systemic sclerosis

OBJECTIVES

To determine the reliability and validity of a new measure of finger motion in patients with systemic sclerosis (SSc), the 'delta finger-topalm' (delta FTP) and compare its psychometric properties to the traditional measure of finger motion, the finger-topalm (FTP).

METHODS

Phase 1: The reliability of the delta FTP and FTP were examined in 39 patients with SSc. Phase 2: Criterion and convergent construct validity of both measures were examined in 17 patients with SSc by comparing them to other clinical measures: Total Active Range of Motion (TAROM), Hand Mobility in Scleroderma (HAMIS), the Duruoz Hand Index (DHI), Health Assessment Questionnaire (HAQ), and modified Rodnan skin score (mRSS). Phase 3: Sensitivity to change of the delta FTP was investigated in 24 patients with early diffuse cutaneous SSc.

RESULTS

Both measures had excellent intra-rater and inter-rater reliability (ICC 0.92 to 0.99). Fair to strong correlations (rs=0.49-0.94) were observed between the delta FTP and TAROM, HAMIS, and DHI. Fair to moderate correlations were observed between delta FTP and HAQ components related to hand function and upper extremity mRSS. Correlations of the traditional FTP with these measures were fair to strong, but most often the delta FTP outperformed the FTP. The effect size and standardised response mean for the mean delta FTP were 0.50 and 1.10 respectively, over a 2-8 month period.

CONCLUSIONS

The delta FTP is a valid and reliable measure of finger motion in patients with SSc which outperforms the FTP.

Mandibular function is severely impaired in systemic sclerosis patients

AIMS

To evaluate the presence of temporomandibular disorders (TMD) in systemic sclerosis (SSc) patients and its possible association with the severity of skin involvement.

METHODS

The presence of TMD was evaluated in 35 SSc women and 30 age- and sex-matched healthy controls by means of the anamnestic (A(i)) and clinical (D(i)) Helkimo indices; the jaw mobility was further analyzed (M(I)). Skin involvement was scored by the Modified Rodnan Skin Score (MRSS).

RESULTS

Signs and symptoms of TMD were more frequent in SSc patients than in controls, the frequency distribution of the different clinical dysfunction indices differing significantly (P < .001) between patients (D(i)0 8.6%, D(i)I 48.6%, D(i)II 22.8%, and D(i)III 20%) and controls (D(i)0 50%, D(i)I 33.3%, and D(i)II 16.7%). Cyclophosphamide for severe and rapidly progressive cutaneous fibrosis was prescribed in six out of seven patients with severe signs (D(i)III), in contrast this treatment was indicated for only two out of 25 patients with mild to moderate signs (D(i)I and D(i)II, P < .001). Impaired jaw mobility was more frequent in SSc patients than controls (P < .001). It was severe in 77.1% (M(I)II) and mild in 22.9% (M(I)I) of the cases, in contrast to controls (M(I)0 33.4%, M(I)I 53.3%, and M(I)II 13.3%; P < .001). Approximately half of SSc patients with severe (M(I)II) but none of those with mild impairment were on cyclophosphamide treatment for severe cutaneous fibrosis (P = .02).

CONCLUSION

Severe signs of TMD according to the anamnestic and clinical Helkimo indices were very frequent in SSc patients.

Acute right heart failure and achalasia-like syndrome in a patient with limited cutaneous systemic sclerosis and primary biliary cirrhosis

We report a case of a 63-year-old woman who developed acute right heart failure and an achalasia-like syndrome with limited cutaneous systemic sclerosis (lcSSc) and primary biliary cirrhosis. Intravenous administration of diuretics improved her acute heart failure. Anti-centromere antibodies and anti-mitochondria antibodies were present. A coronary angiogram and a Swan-Ganz catheter revealed no abnormalities. Thallium-201 scan at rest demonstrated mild perfusion defects in both the apex and the anteroseptal and the inferior myocardium. A cine-esophagram revealed an achalasia-like syndrome. Though rare, physicians should be aware that some patients with lcSSc may develop acute right heart failure or achalasia-like syndrome.

Hormone replacement therapy may prevent the development of isolated pulmonary hypertension in patients with systemic sclerosis and limited cutaneous involvement

BACKGROUND

Isolated pulmonary hypertension (iPHT) is a near-fatal consequence of systemic sclerosis (SSc); in female patients, the risk of its development is increased during the post-menopausal period, when the protective effects of oestrogens on the endothelium decrease. In many animal and human models, hormone replacement therapy (HRT) and oestrogen administration proved efficacious in counteracting many mechanisms that might be implicated in the pathogenesis of iPHT. Accordingly, it has been hypothesized that HRT might help to prevent the development of iPHT.

METHODS

A retrospective cohort study was conducted on 61 SSc patients with the limited cutaneous form of the disease and no sign of pulmonary hypertension on echocardiogram (pulmonary artery pressure, PAP > 35 mmHg) at the time of menopause. All the patients had to be stably treated with calcium-channel blockers and not to have risk factors for secondary PHT throughout the duration of the observational period.

RESULTS

Twenty patients (32.8%) received HRT for a mean of 6.7 +/- 3.7 years. None of these patients developed iPHT after a mean of 7.2 +/- 3.5 years from menopause, whereas eight out of 41 patients not receiving HRT (19.5%) developed iPHT after a similar time period (7.5 +/- 3.9 years, p = 0.032). These rates were not explained by differences between the two groups with respect to autoantibodies, age, age at onset of SSc, diffusing capacity of the lung for carbon monoxide (DLCO) at menopause, or duration of therapy with calcium-channel blockers.

CONCLUSION

HRT administration may be effective in SSc post-menopausal women, preventing the development of iPHT.

No effects of bosentan on microvasculature in patients with limited cutaneous systemic sclerosis

The endothelium-derived vasoconstrictor molecule endothelin-1 (ET-1) has been suggested to play a role in the pathogenesis of Raynaud’s phenomenon (RP) and systemic sclerosis (SSc). We studied the effect of bosentan on microvascular structure and function in patients with RP secondary to limited cutaneous SSc in a mechanistic pilot study. In this single center, open study, 15 patients with limited cutaneous SSc were treated with bosentan for 16 weeks with a follow-up period of 4 weeks. Changes in microvascular structure and function were studied with assessment of vasodilatory microvascular responses using laser Doppler fluxmetry combined with iontophoresis, capillary permeability using fluorescence videomicroscopy, nailfold capillary microscopy, and serological markers of endothelial activation. No significant changes were seen in vasodilator responses to acetylcholine and sodium nitroprusside following bosentan treatment. No effect was noted on capillary permeability during treatment. The number of nailfold capillaries remained unchanged. The endothelial activation marker vascular cell adhesion molecule did not change during treatment, but levels of thrombomodulin significantly decreased after 12 weeks of treatment. Bosentan did not induce significant changes in vasodilator responses, capillary permeability, and capillary density during treatment, so no evidence was obtained for structural improvement of microvascular structure and function in this short-time mechanistic pilot study in patients with lcSSc.

Association of psoriasin (S100A7) with clinical manifestations of systemic sclerosis: is its presence in whole saliva a potential predictor of pulmonary involvement?

OBJECTIVE

To evaluate psoriasin (S100A7) expression in whole saliva (WS) of patients with diffuse systemic sclerosis (dSSc) and limited SSc (lSSc), and to correlate its presence with the different clinical manifestations of the disease.

METHODS

Forty-four patients with limited or diffuse SSc were enrolled for study. WS proteins were separated by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and psoriasin was identified by Western blot analysis using a specific polyclonal antibody. Patients with other rheumatic diseases with and without lung involvement were enrolled as pathological controls. Statistical analysis was performed to correlate each clinical manifestation with the presence of psoriasin.

RESULTS

Three bands of 12, 24, and 50 kDa corresponding to monomeric and dimeric/multimeric forms of psoriasin were evidenced by immunoblot analysis in WS of 31 out of 44 patients with SSc (70.4%). In the other 13 WS samples, the 12 kDa band was totally absent, while the dimeric and multimeric bands were expressed at optical intensity (OD) levels comparable to the other samples. From a clinical point of view, the presence of 12 kDa monomeric psoriasin was significantly associated with SSc pulmonary involvement and with anti-Scl-70 antibody positivity. No control showed the psoriasin 12 kDa band.

CONCLUSION

Our results identified salivary 12 kDa psoriasin as a potential predictor of pulmonary involvement in SSc. Thus, a psoriasin assay might be considered as a rapid, noninvasive, useful salivary biomarker for the detection of pulmonary involvement in SSc.

TCRBV20S1 and TCRBV3S1 gene segment polymorphisms in systemic sclerosis

OBJECTIVE

To compare the frequencies of variants of TCRBV20S1 and TCRBV3S1 gene segments in patients with systemic sclerosis (SSc) and in controls. The null allele (allele 2) of TCRBV20S1 is associated with reduced levels of Vbeta20+ T-cells in the peripheral blood, while allele 1 of TCRBV3S1 is related to a low frequency of Vbeta3.1+ T-cells.

METHODS

One hundred thirty patients with SSc and 118 healthy volunteer controls were genotyped for TCRBV20S1, and 117 patients and 85 controls were genotyped for TCRBV3S1 variants by PCR-RFLP. Patients underwent clinical evaluation, serology, pulmonary function tests, high resolution computed tomography, and Doppler echocardiography.

RESULTS

The genotypic frequencies of TCRBV20S1 were 0.46 (allele 1/allele 1), 0.43 (allele 1/allele 2), and 0.11 (allele 2/allele 2) in SSc patients; in controls the frequencies were 0.70, 0.26, and 0.04, respectively (p < 0.001). The Mantel-Haenszel odds ratio (stratified by race and sex) of the allele 2 carrier state was 3.88 (95% CI 1.94 to 7.75). The allelic and genotypic frequencies of the TCRBV3S1 gene segment did not differ significantly in patients and controls. However, among patients, allele 1 (TCRBV3S1) carriers had a higher prevalence of interstitial lung disease (adjusted p = 0.032).

CONCLUSION

The null allele of the TCRBV20S1 and the allele 1 of TCRBV3S1 gene segments may be considered risk factors for the development of SSc and interstitial lung disease, respectively, suggesting a protective role of Vbeta20+ and Vbeta3.1+ cells in the pathogenic immune responses in SSc.

Cardiac magnetic resonance imaging detects subclinical right ventricular impairment in systemic sclerosis

OBJECTIVE

To assess myocardial involvement in patients with systemic sclerosis (SSc) with no signs or symptoms of cardiac impairment (New York Heart Association functional class I).

METHODS

Fifty patients (45 women, 5 men, age 53.3 +/- 12.9 yrs) who did not complain of serious diseases other than SSc were recruited out of 119 consecutive patients with SSc. Thirty-three were found to have limited cutaneous SSc (lSSc) and 17 diffuse SSc (dSSc). All underwent cardiovascular magnetic resonance imaging (MRI) to determine right and left systolic and diastolic volumes and ventricular ejection fractions (RVEF and LVEF). Thirty-one healthy subjects matched for sex, age, and body surface area (BSA) were studied as controls. Diffusion lung capacity test (DLCO) and high resolution computed tomography were performed to evaluate lung involvement.

RESULTS

Disease duration between patients with lSSc (14.1 +/- 11.4 yrs) and those with dSSc (6.9 +/-4.4yrs) was found to be significantly different (p < 0.003). lSSc patients were older than those with dSSc (54.8 +/- 13.7 yrs vs 50.4 +/- 9.9 yrs, respectively; p < 0.04). Anticentromere antibodies and Scl-70 were positive in 23 (46%) and 17 patients (34%). Except for the left and right systolic volumes, all unadjusted cardiac MRI measures were significantly reduced in SSc compared to the controls (p < 0.001 and p < 0.009). These differences persisted after adjustment for subjects' height and BSA. Raw RVEF data and RVEF data matched for height and BSA were significantly reduced in dSSc patients in comparison to lSSc (p < 0.03).

CONCLUSION

Compromised RVF was found in patients with asymptomatic SSc. Unlike standard diagnostic techniques, cardiac MRI appears to be a rapid and noninvasive means of determining subclinical right myocardial involvement that is otherwise undetected in patients with SSc.

Clinical subsets, skin thickness progression rate, and serum antibody levels in systemic sclerosis patients with anti-topoisomerase I antibody

OBJECTIVE

To describe the clinical and laboratory features and natural history of the disease in systemic sclerosis (SSc; scleroderma) patients with anti-topoisomerase I (anti-topo I) antibody who have different skin thickness progression rates (STPRs).

METHODS

SSc patients (n = 212) who were anti-topo I antibody positive were divided into 5 subgroups based on STPRs. Skin thickness was measured using the modified Rodnan skin thickness score (MRSS). Anti-topo I IgG antibody levels were determined.

RESULTS

Sixty patients who were anti-topo I antibody positive had diffuse cutaneous SSc (dcSSc) with rapid progression, 82 had dcSSC with intermediate progression, and 29 had dcSSc with slow progression, 14 had limited cutaneous SSc (lcSSc) that became dcSSc, and 27 had lcSSc that did not change throughout. Patients beginning with lcSSc were younger at disease onset and had longer disease duration when diagnosed as having SSc. Interstitial lung disease was common and was equally distributed across the subgroups. Renal crisis occurred most often in patients with rapid progression (22%) and was absent in lcSSc patients. Cardiac involvement was most frequent in the dcSSc subgroups. Both kidney and heart disease occurred most often within 3 years after the onset of skin thickening. The 10-year cumulative survival rate was <40% for patients with rapid and intermediate progression. Renal and cardiac causes of death were disproportionately frequent in these 2 subgroups. Anti-topo I antibody levels correlated with the STPR and the MRSS.

CONCLUSION

Anti-topo I antibody-positive patients with SSc with a rapid STPR have reduced survival rates, primarily due to early and often fatal renal and cardiac involvement. Anti-topo I antibody levels parallel the MRSS at the first visit and the STPR. This information is important for managing physicians and researchers planning clinical trials involving patients with early dcSSc.

Scleroderma patients nailfold videocapillaroscopic patterns are associated with disease subset and disease severity

OBJECTIVE

To evaluate in a large group of scleroderma patients, the association of nailfold videocapillaroscopic patterns with both demographic and clinical features.

METHODS

One hundred and three Italian patients (91 women and 12 men, mean age 54.3 years, median disease duration 7 yrs, 68 with limited and 35 with diffuse subset of disease), consecutively enrolled for the study, underwent nailfold videocapillaroscopy; the microvascular alterations were classified into three different patterns, early, active and late. The nailfold videocapillaroscopic patterns were correlated with such numerous clinical features as sex, age, disease duration, disease subset, disease activity, haematochemical data, involvement of skin, heart, lung and peripheral vessels.

RESULTS

Nailfold videocapillaroscopic patterns were significantly associated with disease subsets (P = 0.018). Severity of skin, lung, heart and peripheral vascular involvement progressively increased across nailfold videocapillaroscopic patterns, from early to late pattern (P < 0.001 for cutaneous and peripheral vascular involvement; P = 0.003 and 0.002 for lung and heart involvement, respectively) as well as homocysteine plasma levels (P = 0.02). Patients with late pattern showed an increased risk to have an active disease [OR (odds ratio) 3.50; 95% CI (confidence interval) 1.31-9.39], to present digital ulcers (OR 5.74; 95% CI 2.08-15.89) and moderate to severe skin (OR 5.28; 95% CI 1.93-14.19), heart (OR 5.75; 95% CI 2.04-16.21) and lung involvement (OR 4.41; 95% CI 1.63-11.92).

CONCLUSIONS

Our study showed that scleroderma microangiopathy correlates with disease subset and severity of peripheral vascular, skin, heart and lung involvement; patients with late pattern showed an increased risk to have an active disease and to show a moderate/severe skin or visceral involvement compared to patients with early and active patterns. Therefore nailfold videocapillaroscopy, a simple, non-invasive and non-expensive investigation, is useful in staging scleroderma patients and also provides prognostic information.

Parry Romberg syndrome and linear scleroderma in coup de sabre mimicking Rasmussen encephalitis

We present one patient with Parry Romberg syndrome and another with linear scleroderma in coup de sabre, with focal neurologic deficits and intractable seizures arising from the hemisphere ipsilateral to the cutaneous lesion. Brain MRI showed progressive hemispheric atrophy. Pathology after functional hemispherectomy showed chronic inflammatory features suggestive of Rasmussen encephalitis.