Collagen disease: the enemy within

Surprisingly, the autoimmune diseases predominate in women of childbearing years. Recent evidence suggests that these diseases are the result of some interaction of the hypothalamic-gonadal axis with the immune system. The median age for rheumatoid arthritis is 45 years, the median age for lupus erythematosus is 25. Other illnesses, which are autoimmune in character, such as Sjögren syndrome, scleroderma and the vasculitides, are also more commonly found in women. There is no link that ties these illnesses together, except for gender and various disparate immune manifestations such as autoantibodies. The etiopathogenesis of these diseases is reviewed. These diseases are notoriously difficult to diagnose; they mimic other illnesses in their early presentations. Accompanying illnesses such as migraine headaches, Hashimoto's thyroiditis, and fibromyalgia are discussed as related entities. Immunosuppression of diseases like rheumatoid arthritis and lupus erythematosus, is discussed. Various methods of management are considered, such as the use of steroids, cytotoxic agents, and new experimental agents, such as DHEA and IVIG.

Acquired reactive perforating collagenosis with IgA nephropathy

A 25-year-old Japanese man developed numerous discrete umbilicated papules on his face, trunk, and both forearms at the onset of IgA nephropathy. The newest lesion was a nonumbilicated skin-colored papule. On histopathologic examination, alteration of capillaries was observed in both newer and umbilicated papules. In our case, a primary cause of the reactive perforating collagenosis could be an alteration of the capillaries.

Enteropathic arthritis in association with collagenous colitis

A 46-year-old man simultaneously developed chronic seronegative non destructive oligoarthritis and chronic watery diarrhoea. Biopsies from the colorectal mucosa showed a thickened subepithelial collagen layer consistent with collagenous colitis. Collagenous colitis should be added to the list of causes of enteropathic arthritis.

Bipolar affective disorder, stress fractures, fungal dermopathy and 'tree frog fingers'

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Loss of decorin from the surface zone of articular cartilage in a chick model of osteoarthritis

The objective of this study was to immunolocalize decorin and to assess changes as a result of pyridoxine (PN) deficiency in chick articular cartilage from femoral condyles. After maintenance on a normal diet for the first two weeks after hatching, 15 broiler chickens were deprived of this vitamin for 6 weeks. It was previously shown that the ankle joints of PN-deficient animals are swollen with effusions. They also present an abnormal gait, enlarged bony margins, and fissuring of the articular cartilages. Milder changes (no fissures) were also shown in the knee joints. Data from a previous study were suggestive that sulfated glycosaminoglycans are lost from the knee cartilage surface into synovial fluid. The current study was focused on the small proteoglycan, decorin, which coats the surface of collagen fibrils and may regulate their morphology. To examine decorin in normal and PN-deficient articular cartilage, a monoclonal antibody to an epitope on the protein core of decorin was used for immunohistochemical staining of tissue sections and for Western Blot analysis of cartilage extracts. Reduction of staining with the antibody was demonstrated in the tangential surface zone of PN-deficient cartilage, and Western Blot analysis showed reduced intensity of decorin bands compared to normal controls. These data suggest that a lack of decorin may play a role in the enlargement of collagen bundles in the tangential zone of PN-deficient articular cartilage as observed in a previous electron microscopic study.

[Immunological analysis of HTLV-I env-pX transgenic rat with various collagen vascular diseases]

Human T lymphocyte virus type-I (HTLV-I) is an etiologic agent of not only adult T cell leukemia but also HTLV-I associated myelopathy/tropical spastic paraparesis, HTLV-I associated arthropathy and other immunological disorders, such as Sjögren syndrome, dermatitis, polymyositis, and uveitis. We recently reported that a wide spectrum of collagen vascular diseases, including inflammatory arthropathy resembling rheumatoid arthritis, myocarditis, dermatitis, necrotizing arteritis, myositis and sialoadenitis similar to Sjögren's syndrome, developed in the transgenic rat carrying HTLV-I env-pX region under the control of its own long terminal repeat (env-pX rat). To investigate the pathogenetic role of these diseases, cell surface molecules and functions of lymphocytes from env-pX rats were examined in this study. In env-pX rats with diseases, not only infiltrating lymphocytes in the inflammatory sites but also peripheral lymphocytes expressed a large number of co-stimulating molecules such as CD80/86 and ICAM-1, compared with those of normal rats or rats with adjuvant-induced arthritis or myosin-induced myocarditis. Moreover, the expression of CD80/86 and ICAM-1 was already up-regulated on the surface of peripheral lymphocytes in env-pX rat before developing any diseases. Lymphocytes, taken from env-pX rats immunized with myosin in vivo, showed significantly higher cellular response against myosin in vitro than those of normal rats. Lymphocytes from env-pX rats also showed the hyper-reactivity to the stimulation by super-antigens, but no significant difference of the usage of T cell receptor V beta was found compared with those of normal rats. These results suggest that the env-pX transgene may induce the high expression of CD80/86 and ICAM-1 on the lymphocytes and the resulting hyper-immune responsiveness in env-pX rats.

Silicon tissue assay: a measurement of capsular levels from chemotherapeutic port-a-catheter devices

A plethora of data has been used to condemn and defend the role of silicone and its association with "adjuvant disease." In the ongoing attempt to enhance our knowledge, we have chosen to identify tissue silicon levels (n = 15) in capsules that form around chemotherapeutic port-a-catheter devices, which consist of a metal dome encapsuled by silicone. We have compared these levels with previously established silicon levels in augmented breast capsules, distant tissue sites in these same augmented women, and nonaugmented cadaveric tissues from various geographic locations in the United States. All specimens were harvested by a "no touch" technique, not formalin fixed, frozen, and shipped to an independent toxicology laboratory for analysis. Inductively coupled plasma atomic emission spectroscopy was employed to obtain the tissue silicon measurements. Results demonstrated silicon values ranging from nondetectable in 9 patients to as high as 41 micrograms/gm. These values fell in between our cadaveric (0.5 to 6.8 micrograms/gm) and augmented tissue silicon levels (18 to 8700 micrograms/gm). Although the sample size is small and the power of statistical analysis is low, there was no correlation between the patient's silicon level and age, type of cancer, type of chemotherapeutic agent, radiation therapy, or length of time the port-a-catheters were in place. Although detectable levels of silicon identified around port-a-catheter devices were higher than expected, it is impossible to make any conclusions about these levels and the role of a potential collagen-vascular disease. What we have shown, however, is that silicone breast implants may not be the only medical device that can elevate tissue silicon levels. Our data seem to suggest that there may be a progression of measurable tissue silicon levels based on the amount of environmental or device-related silicon exposure a person has had at a particular time in his or her life. It is our belief that as we identify these tissue silicon levels, they will serve as a baseline and reference for further scientific studies.

[Development of collagen vascular diseases and production of autoantibodies in HTLV-I env-pX transgenic rats]

Human T lymphocyte virus type I (HTLV- I) is now known to be associated with a number of diverse clinical disorders, not only adult T cell leukemia but also HTLV- I associated myelopathy/tropical spastic paraparesis, HTLV- I -associated arthropathy, HTLV- I uveitis, and probably Sjögren's syndrome, T cell alveolitis, polymyositis, and infective dermatitis. To investigate virus-host interactions and pathogenetic mechanisms in these diverse disorders, inbred rat, which is susceptible to HTLV- I infection and develops HAM/TSP-like disease by HTLV- I infection, was used as a host of HTLV- I gene transfer model. HTLV- I LTR-env-pX-LTR construct was injected to rat ova, and two lines of the transgenic rat (env-pX rat) were established. Both lines of env-pX rats expressed HTLV- I env and pX genes in various tissues, and developed a wide spectrum of collagen vascular diseases, including chronic destructive arthritis similar to rheumatoid arthritis, necrotizing arteritis mimicking polyarteritis nodosa, myositis, myocarditis, and chronic sialoadenitis and dacryoadenitis resembling Sjögren's syndrome in humans. Thrombosis and thymic atrophy were also observed. These rats showed hyper-gamma globulinemia and a number of autoantibodies, including high titered rheumatoid factors, anti-dsDNA antibodies and anti-cardiolipin antibodies were presented in the serum. Results suggest that the HTLV- I env-pX gene may play a pathogenic role in development of collagen vascular diseases associated with autoimmune phenomenon. The env-pX rat appears to be a suitable animal model for elucidating pathogenetic mechanisms implicated in HTLV- I -induced diseases and also in various collagen vascular diseases of unknown etiology in humans.

The connective tissue diseases and the overall influence of gender

The autoimmune diseases are more common in women than men. The actual prevalence ranges from the high of 10 to 15 females for each male for systemic lupus erythematosus to four females for every male with rheumatoid arthritis. Though these diseases are found in the very young and the aged, the high prevalence is observed after puberty in most patients. These diseases vary with regard to severity, and most investigators suspect that the signs and symptoms of these diseases vary with menstrual cycle and change severity during pregnancy. The collagen diseases are devastating to the health of young women. Rheumatoid arthritis occurring at a mean age of 40 years results in debilitating erosive changes in bone with morning stiffness and eventual crippling. Systemic lupus erythematosus, Sjögren's syndrome and others, common to women of the childbearing years, act in several ways to destroy organ systems of the body. Virtually any organ system of the female anatomy can be affected by these illnesses. In the case of lupus, the disease has protean manifestations, such as procoagulation, renal destruction, skin disease, unrelenting arthropathy and arthritis, and encephalopathy (to name only a few). The underlying mechanisms are not known; however, the immune system acts to destroy tissue via immune complex deposition and through the action of cytotoxic lymphocyte activity. There is an association of both clinical signs and autoantibody subpopulations with markers of the HLA-D or MHC II locus on chromosome 6. No constitutive gene for any of the collagen vascular diseases has been identified in the human. Evidence exists to support an altered metabolism of estrogens and androgens in patients with these diseases. Recent data also indicate that increased estrogen levels might initiate autoimmune diseases in many women and men. Estrogen hydroxylation is increased in both men and women with autoimmune diseases like lupus. The mechanisms are unknown, although estrogenic metabolites have been shown to increase B cell differentiation and activate T cells. Moreover, isolated cases of hyperprolactinemia have been observed in association with these hyperestrogenic states, and treatment of hyperprolactinemia has been shown to ameliorate diseases like lupus. Androgen oxidation is also increased in patients with autoimmune disease, but this abnormality has been observed only in patients with lupus, and only women at that. The result is that women with autoimmune diseases like lupus and rheumatoid arthritis have lower plasma androgens than control cases. These data have supported the use of weak androgens, e.g., DHEA, for the treatment of lupus.

[Interstitial lung disease in patients with connective tissue diseases]

Interstitial lung disease is a significant prognostic factor in connective tissue diseases. To further clarify clinical and immunological features of interstitial lung disease, we studied 894 consecutive patients with connective tissue diseases first evaluated between 1970 and 1993. Interstitial lung disease was found in 101 of 181 (56%) patients with systemic sclerosis, 92 of 183 (50%) with overlap syndrome, 35 of 76 (46%) with polymyositis/dermatomyositis, and 13 of 444 (3%) with systemic lupus erythematosus (p < 0.05, systemic lupus erythematosus vs. other connective tissue diseases). The presence of interstitial lung disease correlated with decreased survival in systemic sclerosis and in polymyositis/dermatomyositis, but not in overlap syndrome or in systemic lupus erythematosus. Interstitial lung disease in patients with connective tissue diseases was classified into two types: acute (n = 8) and chronic (n = 233). Among the 8 patients with acute disease, 4 (all with dermatomyositis) died of respiratory failure and 3 (all with systemic lupus erythematosus) responded to corticosteroids. Among the 233 patients with chronic interstitial lung disease, 20 had polymyositis/dermatomyositis with anti-aminoacyl tRNA synthetase antibodies and 40 had overlap syndrome with anti-U1 RNP antibodies. Respiratory failure in these patients was not frequent and occurred late in the course of the disease. As a cause of death, respiratory failure was associated with autoantibodies to topoisomerase I and aminoacyl tRNA synthetase but not anti-U1 RNP. Autoantibodies to aminoacyl tRNA synthetases were detected before the development of interstitial lung disease in 9 patients with polymyositis/dermatomyositis. We conclude that the clinical features of interstitial lung disease associated with connective tissue diseases vary with the type of connective tissue disease, and that analysis of autoantibodies can be useful in establishing a diagnosis and in forecasting the course and outcome.

[Expression of bc1-2 protein in collagen vascular diseases with pulmonary interstitial involvement]

Expression of bc1-2 protein was studied immunohistochemically in 25 patients with collagen vascular diseases and in 10 patients with idiopathic interstitial pneumonia. The collagen vascular diseases included rheumatoid arthritis (n = 9), progressive systemic sclerosis (n = 9), polymyositis/dermatomyositis (n = 4), Sjögren's syndrome (n = 2), and systemic lupus erythematosus (n = 1). All 35 patients underwent open lung biopsy; cellular infiltration, fibrosis, and lymphoid aggregation were scored according to Cherniack's classification. T lymphocytes (CD43: DFT-1) and B lymphocytes (CD20:L-26) were also evaluated. Expression of bc1-2 protein was dominant in T lymphocytes infiltrating the alveolar interstitium and in B lymphocytes in the mantle zone of lymphoid follicles. In collagen vascular diseases, the degree of expression of bc1-2 protein in those T lymphocytes was closely related to the alveolar lymphocyte infiltration score. However, these findings were not marked in the patients with idiopathic interstitial pneumonia, and were not related to the underlying disease in the patients with collagen vascular diseases. The expression of bc1-2 protein in T lymphocytes was not related to fibrosis or to lymphoid aggregation. Expression of bc1-2 protein in B lymphocytes did not correlate with pathological scores or with underlying disease. Bc1-2 protein has been recognized as an oncogene that suppresses apoptosis. Marked expression of bc1-2 protein in T lymphocytes from patients with collagen vascular diseases indicates that oversuppression of apoptosis may be related to the pathogenesis of pulmonary interstitial involvement in these conditions. Further clinicopathological studies focusing on apoptosis in collagen vascular diseases and in idiopathic interstitial pneumonia are needed.

Fibrogenesis imperfecta ossium

The clinical features, investigation, treatment and outcome of two adults with fibrogenesis imperfecta ossium are described. In this rare acquired disorder of bone, normal lamellar collagen is replaced by structurally unsound collagen-deficient tissue, which leads to extreme bone fragility and ununited fractures. Transmission microscopy and SEM showed striking ultrastructural changes in bone structure and mineralisation. Both patients had monoclonal IgG paraproteins in the plasma and one excreted monoclonal lambda light chains in the urine. No abnormal plasma cells were found in the bone marrow and there was no evidence of amyloid deposition in the tissues. In both patients initial treatment with 1 alpha-hydroxycholecalciferol appeared to be ineffective, but in one, repeated courses of melphalan and corticosteroids over three years together with 1 alpha-hydroxycholecalciferol produced striking clinical and histological improvement. The findings in these and other patients strongly suggest that paraproteinaemia is an integral feature of fibrogenesis imperfecta ossium, and this needs further investigation.

[Spontaneous tendon ruptures. Etiology, pathogenesis and therapy]

Spontaneous tendon ruptures are ascribed to recurrent microtrauma resulting from continuous mechanical loading in a critical zone, to muscular imbalance combined with poor coordination as a result of inappropriate training, and also to deteriorating circulation with increasing age. Ruptures of the rotator cuff occur more frequently with increasing age, and the size of the rupture also correlates with age. The frequency of the complaint in men, the predominant involvement of the dominant shoulder, and also the above-average occurrence in occupations involving strenuous physical work indicate that degenerative change plays a role. In about 50% of patients presenting with a ruptured rotator cuff, the genesis is clearly traumatic. A trauma will almost always be the cause of an isolated rupture of the subscapularis tendon. The choice of reconstruction technique for a ruptured rotator cuff depends on the patient's age and level of activity in daily life. In the case of young patients, further surgical measures to repair the defect are indicated following failure of primary suture of the tendon, but in older patients subacromial debridement alone is considered the appropriate procedure. Rupture of the long head of the biceps tendon is usually a sequela of a rotator cuff rupture and the resulting loss of protective cover. Isolated ruptures of the long head of the biceps tendon are much rarer. They tend to occur in middle-aged patients and are usually the result of a relatively minor trauma. Ruptures of the distal biceps tendon are also relatively rare (3%) and are always of traumatic origin. There is no absolute indication for surgical intervention for a ruptured long head of the biceps tendon. Surgical repair is essential in the case of rupture of the distal biceps tendon. Transosseous reinsertion at the tuberosity of the radius is the recommended method of repair. Today's frequent cases of rupture of the Achilles tendon in the framework of sports activities are ascribed to inappropriate training procedures in combination with poor muscular coordination. An exogenous cause is the administration of local injections for pain relief in the form of a so-called tendon anesthetic. Today an increasingly important role is assigned to functional therapy with ultrasound support, although suturing the tendon is still the intervention of choice to meet the high functional demands imposed in the framework of top-level sports.(ABSTRACT TRUNCATED AT 400 WORDS)

[Present status of idiopathic interstitial pneumonia--from epidemiology to etiology]

The present status of idiopathic interstitial pneumonia (IIP) was evaluated from data collected as part of the Financial Support Program for patients with IIP, conducted in Hokkaido since 1979. The prevalence of IIP in 1992 was 4.08/100,000, and the yearly incidence was 1.23/100,000. The ratio of men to women was 1.85/1.0. Under age 55, women were more numerous than men, and over age 55, men were more numerous than women. Clinical and epidemiological analyses of the patients with IIP, with collagen vascular disease-interstitial pneumonia suggested possible contribution of dust inhalation to the etiology IIP. A prospective study revealed that about 20% of the subjects had systemic signs and symptoms of collagen diseases from 2 months to 10 years after the diagnosis of IIP. In addition, about 15% of the subjects with IIP developed lung cancer during the follow-up period. This incidence was significantly higher than that in the patients with chronic obstructive pulmonary diseases and the same smoking history, which suggests that IIP itself is a risk factor for lung cancer.

Endothelin and collagen vascular disease: a review with special reference to Raynaud's phenomenon and systemic sclerosis

Endothelin-1 (ET-1), endothelin-2, and endothelin-3, a family of 21-aminoacid peptides, are potent, long-acting vasoconstrictors of mammalian blood vessels. Elevated levels of ET-1 have been found in the circulation of patients with various diseases, all of which have some degree of vascular involvement that is associated with endothelial cell activation. These diseases include systemic sclerosis, primary and secondary Raynaud's phenomenon, pulmonary hypertension, Buerger's disease, and Takayasu's arteritis. The role of circulating ET-1 in the pathogenesis of the vascular and fibrotic lesions in these conditions remains to be elucidated. This review focuses on the recent findings of the clinical significance and pathogenetic role of endothelin in collagen vascular diseases, especially in Raynaud's phenomenon and systemic sclerosis. Although the etiology of systemic sclerosis is unknown, a vascular pathogenesis is supported by a variety of clinical and laboratory observations. The fact that plasma levels of ET-1 are elevated in patients with systemic sclerosis and this elevation is more remarkable in patients with diffuse scleroderma compared with limited scleroderma patients might further support the vascular pathogenesis of systemic sclerosis.

Collagenous colitis and lymphocytic colitis

Collagenous and lymphocytic colitis are newly recognized causes of chronic watery diarrhea that typically affect middle-aged patients. Although endoscopic studies are normal, inflammatory changes and (in the case of collagenous colitis) collagen deposition occur histologically in the colonic mucosa. The pathogenesis of these disorders remains a mystery, but the possible causes are intriguing. Patients may experience spontaneous remissions and relapses, but treatment with sulfasalazine or prednisone is usually effective for patients with distressing symptoms.