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Lekieffre M, Gallay L, Landon-Cardinal O, Hot A. Joint and muscle inflammatory disease: A scoping review of the published evidence. Semin Arthritis Rheum 2023; 61:152227. [PMID: 37210805 DOI: 10.1016/j.semarthrit.2023.152227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 04/05/2023] [Accepted: 05/08/2023] [Indexed: 05/23/2023]
Abstract
OBJECTIVES Polyarthritis is commonly reported in idiopathic inflammatory myositis patients, but few studies have focused on the overlap of myositis with rheumatoid arthritis which is a difficult diagnosis in the absence of well-defined diagnostic criteria. The primary objective of this scoping review was to map the field of research to explore the potential diagnoses in patients presenting with both myositis and polyarthritis. METHODS Two electronic databases (MEDLINE/PubMed® and Web of Science®) were systematically searched using the terms (myositis OR 'inflammatory idiopathic myopathies') AND (polyarthritis OR 'rheumatoid arthritis') without any publication date limit. RESULTS Among individual records, 280 reports met inclusion criteria after full-text review. There was heterogeneity in the definition of overlap myositis as well as the characteristics of rheumatoid arthritis. In many studies, key data were lacking; rheumatoid factor status was reported in 56.8% (n=151), anti-citrullinated proteins antibodies status in 18.8% (n=50), and presence or absence of bone erosions in 45.1% (n=120) of the studies. Thirteen different diagnoses were found to associate myositis with polyarthritis: antisynthetase syndrome (29.6%, n=83), overlap myositis with rheumatoid arthritis (16.1%, n=45), drug-induced myositis (20.0%, n=56), rheumatoid myositis (7.5%, n=21), inclusion body myositis (1.8%, n=5), overlap with connective tissue disease (20.0%, n=56), and others (5.0%, n=14). CONCLUSION The spectrum of joint and muscle inflammatory diseases encompasses many diagnoses including primitive and secondary myositis associated with RA or arthritis mimicking RA. This review highlights the need for a consensual definition of OM with RA to better individualise this entity from the numerous differential diagnoses.
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Affiliation(s)
- Maud Lekieffre
- Department of Internal Medicine, Hôpital Edouard Herriot, Hospices Civils de Lyon, 5 place d'Arsonval, Lyon 69003, France.
| | - Laure Gallay
- Department of Internal Medicine, Hôpital Edouard Herriot, Hospices Civils de Lyon, 5 place d'Arsonval, Lyon 69003, France
| | - Océane Landon-Cardinal
- Division of Rheumatology, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Arnaud Hot
- Department of Internal Medicine, Hôpital Edouard Herriot, Hospices Civils de Lyon, 5 place d'Arsonval, Lyon 69003, France
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Aringer M, Costenbader K, Dörner T, Johnson SR. Advances in SLE classification criteria. J Autoimmun 2022; 132:102845. [PMID: 35725680 DOI: 10.1016/j.jaut.2022.102845] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 06/02/2022] [Indexed: 01/07/2023]
Abstract
This year, the American College of Rheumatology (ACR) 1982 classification criteria for systemic lupus erythematosus (SLE) celebrate their 40th anniversary. From this start, the quest for optimal SLE criteria has led to the 1997 ACR update, the 2012 publication of the Systemic Lupus International Collaborating Clinics (SLICC) criteria, and, in 2019, the European League Against Rheumatism (EULAR)/ACR classification criteria. The latter have since been externally validated in more than two dozen studies and have become the gold standard inclusion criterion of SLE clinical trials. This comprehensive review attempts to follow the evolving success story of SLE classification, highlighting relevant decisions and their rationale, and discussing consequences for the way SLE is defined and managed.
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Affiliation(s)
- Martin Aringer
- Division of Rheumatology, Department of Medicine III, and University Center for Autoimmune and Rheumatic Entities (UCARE). University Medical Center and Faculty of Medicine Carl Gustav Carus at the TU Dresden, Dresden, Germany.
| | - Karen Costenbader
- Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Thomas Dörner
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Deutsches Rheumaforschungszentrum (DRFZ), Berlin, Germany
| | - Sindhu R Johnson
- Division of Rheumatology, Department of Medicine, Toronto Western Hospital, Mount Sinai Hospital; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Aringer M, Costenbader K, Johnson SR. Assessing the EULAR/ACR classification criteria for patients with systemic lupus erythematosus. Expert Rev Clin Immunol 2022; 18:135-144. [DOI: 10.1080/1744666x.2022.2033617] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Martin Aringer
- Division of Rheumatology, Department of Medicine III, and University Center for Autoimmune and Rheumatic Entities (UCARE), University Medical Center and Faculty of Medicine Carl Gustav Carus at the TU Dresden
| | - Karen Costenbader
- Division of Rheumatology, Inflammation and Immunity, Brigham and Women’s Hospital, Boston, MA
| | - Sindhu R. Johnson
- Mount Sinai Hospital, Toronto Western Hospital, Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Elmotaleb Gazar Y, Hamoud H, Ismail S. Nailfold capillaroscopy in early stages of mixed connective tissue disease in a sample of Egyptian patients. INDIAN JOURNAL OF RHEUMATOLOGY 2022. [DOI: 10.4103/injr.injr_168_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Alves MR, Isenberg DA. "Mixed connective tissue disease": a condition in search of an identity. Clin Exp Med 2020; 20:159-166. [PMID: 32130548 PMCID: PMC7181542 DOI: 10.1007/s10238-020-00606-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 01/10/2020] [Indexed: 11/26/2022]
Abstract
Mixed connective tissue disease was first described as a new autoimmune rheumatic disease in 1972 based on the claim of a distinct clinical picture associated with anti-RNP antibody positivity. Subsequently, this new entity has divided opinions in the rheumatology community. We have reviewed recent cohort studies with more than 100 patients, comparing the clinical and immunological features, treatment, prognosis and evolution to well-defined autoimmune rheumatic diseases. We also reviewed clinical features of undifferentiated autoimmune rheumatic diseases based on the most recent studies. After gathering and reviewing these data, we discuss whether the designation “mixed connective tissue disease” should be maintained.
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Affiliation(s)
- Marta R Alves
- Internal Medicine, Department of Medicine, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - David A Isenberg
- Division of Medicine, Centre for Rheumatology, University College of London, Room 424, 4th Floor, Rayne Building, 5 University Street, London, WC1E 6JF, UK.
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6
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Ciang NCO, Pereira N, Isenberg DA. Mixed connective tissue disease-enigma variations? Rheumatology (Oxford) 2017; 56:326-333. [PMID: 27436003 DOI: 10.1093/rheumatology/kew265] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Indexed: 01/14/2023] Open
Abstract
In 1972, Sharp et al. described a new autoimmune rheumatic disease that they called MCTD, characterized by overlapping features of SSc, SLE, PM/DM, high levels of anti-U1snRNP and low steroid requirements with good prognosis. MCTD was proposed as a distinct disease. However, soon after the original description, questions about the existence of such a syndrome as well as disputes over the features initially described began to surface. The conundrum of whether MCTD is a distinct disease entity remains controversial. We undertook a literature review, focusing on the articles reporting new data about MCTD published in the last decade, to determine whether any new observations help to answer the conundrum of MCTD. After reviewing recent data, we question whether the term MCTD is appropriately retained, preferring to use the term undifferentiated autoimmune rheumatic disease.
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Affiliation(s)
- Natalia C O Ciang
- Division of Rheumatology, Department of Medicine, Queen Elizabeth Hospital, Hong Kong
| | - Nídia Pereira
- Internal Medicine Department, Hospital Pedro Hispano, Matosinhos, Portugal
| | - David A Isenberg
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
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8
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Kundi M, Assad S, Babar S, Ghani U, Hammad S, Sheikh AG, Kundi AK, Sheikh A. Mixed Connective Tissue Disorder Complicated by Polymyositis, Sjogren's Syndrome, Pleural Effusion and Pericarditis. Cureus 2016; 8:e906. [PMID: 28083450 PMCID: PMC5208556 DOI: 10.7759/cureus.906] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
We report a case of a 24-year-old female with a history of asthma and gastroesophageal reflux disease (GERD). She presented to the emergency room with severe chest pain, chest tightness, and shortness of breath following an upper respiratory tract infection. The patient reported that she had a cough and runny nose one week prior to this presentation, followed by a sudden sharp pain in the center of the chest 8/10 in intensity on the visual analog scale and pleuritic in nature, which aggravated by deep breathing and lying down flat. It was relieved by sitting up straight and did not radiate to her left arm or jaw. Computed tomography (CT) scan of the chest, posteroanterior and lateral views, showed a mild left pleural effusion with adjacent left basilar atelectasis/infiltrate. CT angiography of the chest with axial contrast showed mild left pleural effusion as well as a small pericardial effusion with bilateral lower lobe interstitial infiltrates. There was no evidence of pulmonary embolism. Electrocardiogram (EKG) showed no apparent ST segment elevation or depression that would be consistent with pericarditis, or acute ischemia or infarct. There was non-specific T wave abnormality. The patient was prescribed prednisone on a tapering dose. On follow-up visit, her condition significantly improved.
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Affiliation(s)
- Maryam Kundi
- Department of Internal Medicine, Carthage Area Hospital, New York, USA
| | - Salman Assad
- Department of Medicine, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | | | - Usman Ghani
- Department of Medicine, Shifa International Hospital, Islamabad, Pakistan
| | - Sahla Hammad
- Department of Internal Medicine, Shifa International Hospital, Islamabad, Pakistan
| | - Ahmed G Sheikh
- Family Medicine Residency, UHS Wilson Medical Center Johnson City, NY
| | - Asif K Kundi
- Department of Internal Medicine, Carthage Area Hospital, New York, USA
| | - Amjad Sheikh
- Department of Internal Medicine, Carthage Area Hospital, New York, USA
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Gunnarsson R, Hetlevik SO, Lilleby V, Molberg Ø. Mixed connective tissue disease. Best Pract Res Clin Rheumatol 2016; 30:95-111. [DOI: 10.1016/j.berh.2016.03.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Paradowska-Gorycka A, Stypińska B, Olesińska M, Felis-Giemza A, Mańczak M, Czuszynska Z, Zdrojewski Z, Wojciechowicz J, Jurkowska M. Association of HLA-DRB1 alleles with susceptibility to mixed connective tissue disease in Polish patients. HLA 2015; 87:13-8. [DOI: 10.1111/tan.12698] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 10/08/2015] [Accepted: 10/16/2015] [Indexed: 02/03/2023]
Affiliation(s)
- A. Paradowska-Gorycka
- Department of Biochemistry and Molecular Biology; National Institute of Geriatrics, Rheumatology and Rehabilitation; Warsaw Poland
| | - B. Stypińska
- Department of Biochemistry and Molecular Biology; National Institute of Geriatrics, Rheumatology and Rehabilitation; Warsaw Poland
| | - M. Olesińska
- Department of Connective Tissue Diseases; National Institute of Geriatrics, Rheumatology and Rehabilitation; Warsaw Poland
| | - A. Felis-Giemza
- Department of Connective Tissue Diseases; National Institute of Geriatrics, Rheumatology and Rehabilitation; Warsaw Poland
| | - M. Mańczak
- Department of Epidemiology and Health Promotion; National Institute of Geriatrics, Rheumatology and Rehabilitation; Warsaw Poland
| | - Z. Czuszynska
- Department of Internal Medicine, Connective Tissue Disease and Geriatrics; Medical University of Gdansk; Gdansk Poland
| | - Z. Zdrojewski
- Department of Internal Medicine, Connective Tissue Disease and Geriatrics; Medical University of Gdansk; Gdansk Poland
| | | | - M. Jurkowska
- Department of Biochemistry and Molecular Biology; National Institute of Geriatrics, Rheumatology and Rehabilitation; Warsaw Poland
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U1-RNP and TLR receptors in the pathogenesis of mixed connective tissue diseasePart I. The U1-RNP complex and its biological significance in the pathogenesis of mixed connective tissue disease. Reumatologia 2015; 53:94-100. [PMID: 27407234 PMCID: PMC4847272 DOI: 10.5114/reum.2015.51509] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 04/28/2015] [Indexed: 11/17/2022] Open
Abstract
Mixed connective tissue disease (MCTD) is a rare autoimmune syndrome, signified by complex interactions between disease-related phenomena, including inflammation, proliferative vascular arteriopathy, thrombotic events and humoral autoimmune processes. It is still controversial whether MCTD is a distinct clinical entity among systemic connective tissue diseases, although several authors consider that it is distinct and underline characteristic, distinct clinical, serological and immunogenetic features. The putative target of autoimmunity in MCTD is U1-RNP, which is a complex of U1-RNA and small nuclear RNP. Both the U1-RNA component and the specific proteins, particularly U1-70K, engage immune cells and their receptors in a complex network of interactions that ultimately lead to autoimmunity, inflammation, and tissue injury. U1-RNA is capable of inducing manifestations consistent with TLR activation. Stimulation of innate immunity by native RNA molecules with a double-stranded secondary structure may help explain the high prevalence of autoimmunity to RNA binding proteins.
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Kim MY, Koo HS, Seo YK, Min JH, Lee KJ, Jo SY, Koh HI. A Case of Bad Prognosis for Membranous Nephropathy in a Patient with Mixed Connective Tissue Disease. JOURNAL OF RHEUMATIC DISEASES 2015. [DOI: 10.4078/jrd.2015.22.4.260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Mi Young Kim
- Department of Internal Medicine, Inje University Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Ho Seok Koo
- Division of Nephrology, Inje University Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Young Ki Seo
- Department of Internal Medicine, Inje University Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Jung Hwa Min
- Department of Internal Medicine, Inje University Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Kyung Jin Lee
- Department of Internal Medicine, Inje University Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Soo Yeon Jo
- Department of Internal Medicine, Inje University Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Haeng Il Koh
- Division of Nephrology, Inje University Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
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Paradowska-Gorycka A, Jurkowska M, Czuszynska Z, Felis-Giemza A, Mańczak M, Zdrojewski Z, Olesinska M. IL-10, IL-12B and IL-17 gene polymorphisms in patients with mixed connective tissue disease. Mod Rheumatol 2014; 25:487-9. [DOI: 10.3109/14397595.2014.951143] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Olson AL, Brown KK, Fischer A. Connective Tissue Disease–Associated Lung Disease. Immunol Allergy Clin North Am 2012; 32:513-36. [DOI: 10.1016/j.iac.2012.09.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Szodoray P, Hajas A, Kardos L, Dezso B, Soos G, Zold E, Vegh J, Csipo I, Nakken B, Zeher M, Szegedi G, Bodolay E. Distinct phenotypes in mixed connective tissue disease: subgroups and survival. Lupus 2012; 21:1412-22. [PMID: 22864236 DOI: 10.1177/0961203312456751] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of the present study was to assess the autoantibody profile, dominant clinical symptoms and cluster characteristics of different mixed connective tissue disease (MCTD phenotypes. Two-hundred-and-one patients with MCTD were followed-up longitudinally. Five clinical parameters, Raynaud's phenomenon, pulmonary artery hypertension (PAH), myositis, interstitial lung disease (ILD), erosive arthritis and five auto-antibodies besides anti-U1RNP, antiendothelial cell antibodies (AECA), anti-CCP, anti-cardiolipin (anti-CL), anti-SSA/SSB and IgM rheumatoid factor (RF) were selected for cluster analysis. The mean age of patients was 52.9 ± 12.4 years and the mean follow-up of the disease was 12.5 ± 7.2 years. Patients were classified into three cluster groups. Cluster 1 with 77 patients, cluster 2 with 79 patients and cluster 3 with 45 patients. In cluster 1 the prevalence of PAH (55.8%; p < 0.001), Raynaud's phenomenon (92.2%; p < 0.001) and livedo reticularis (24.6%, p < 0.001) was significantly greater than in cluster 2 and 3. In cluster 2, the incidence of ILD (98.7%; p < 0.001), myositis (77.2%; p < 0.001), and esophageal dysmotility (89.8%; p < 0.001) was significantly greater than that in cluster 1 and 3. In cluster 3, anti-CCP antibodies were present in 31 of 45 patients (68.8%) with erosions. Anti-CCP antibodies were present in 37 of 42 patients (88.0%) with erosions. PAH, angina, venous thrombosis was observed in cluster 1 and pulmonary fibrosis in cluster 2, musculosceletal damage, gastrointestinal symptoms and osteoporotic fractures were most frequent in cluster 3. Cumulative survival assessment indicated cluster 1 patients having the worst prognosis. Cluster analysis is valuable to differentiate among various subsets of MCTD and useful prognostic factor regarding the disease course.
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Affiliation(s)
- P Szodoray
- Institute of Immunology, Oslo University Hospital, Oslo, Norway.
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Cappelli S, Bellando Randone S, Martinović D, Tamas MM, Pasalić K, Allanore Y, Mosca M, Talarico R, Opris D, Kiss CG, Tausche AK, Cardarelli S, Riccieri V, Koneva O, Cuomo G, Becker MO, Sulli A, Guiducci S, Radić M, Bombardieri S, Aringer M, Cozzi F, Valesini G, Ananyeva L, Valentini G, Riemekasten G, Cutolo M, Ionescu R, Czirják L, Damjanov N, Rednic S, Matucci Cerinic M. “To Be or Not To Be,” Ten Years After: Evidence for Mixed Connective Tissue Disease as a Distinct Entity. Semin Arthritis Rheum 2012; 41:589-98. [DOI: 10.1016/j.semarthrit.2011.07.010] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2011] [Revised: 07/27/2011] [Accepted: 07/28/2011] [Indexed: 11/29/2022]
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Isolated central nervous system vasculitis associated with antiribonuclear protein antibody. Case Rep Neurol Med 2011; 2011:495201. [PMID: 22937341 PMCID: PMC3420653 DOI: 10.1155/2011/495201] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Accepted: 06/20/2011] [Indexed: 11/18/2022] Open
Abstract
We describe the case of a young woman who was referred to a tertiary care center with unexplained subacute progressive encephalopathy preceded by long-standing severe headaches. Her extensive workup was remarkable for abnormal intracranial angiography suggestive of small- and medium-vessel vasculitis, persistently elevated protein in the cerebrospinal fluid and persistently high titers of antiribonuclear protein antibody. The patient showed a modest response to intravenous high-dose steroids. We propose that the patient's neurologic disease is secondary to immune-mediated central nervous system vasculitis, possibly as an initial manifestation of mixed connective tissue disease.
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Case history of mixed connective tissue disease. КЛИНИЧЕСКАЯ ПРАКТИКА 2011. [DOI: 10.17816/clinpract83846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The literary review on mixed connective tissue disease is given according to modern international data. The case history of this pathology is described. The case has been observed in the rheumatological department of the Federal Research Clinical Center FMBA of Russia.
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Coexistence of five autoimmune diseases: diagnostic and therapeutic difficulties. Rheumatol Int 2008; 28:919-23. [PMID: 18320193 DOI: 10.1007/s00296-008-0544-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2007] [Accepted: 02/11/2008] [Indexed: 10/22/2022]
Abstract
We report the case of coexistence of five autoimmune diseases in a 36-year-old woman, who initially developed psoriasis. Several years later, the patient was diagnosed with a mixed connective tissue disease and primary biliary cirrhosis (PBC). On admission to the Department of Rheumatology and Connective Tissue Diseases, the patient fulfilled classification criteria of an overlap syndrome systemic lupus erythematosus (SLE) with secondary antiphospholipid syndrome/systemic sclerosis (SSc)/Sjogren's syndrome (SS) with coexisting PBC and psoriasis. The SLE symptoms included discoid lupus erythematosus, arthritis, pancytopenia, antinuclear antibodies and anticardiolipin antibodies. Moreover, the patient met the criteria of antiphospholipid syndrome diagnosed based on preterm delivery before week 34, and high values of anticardiolipin antibodies were found at repeated determinations. The SSc symptoms included sclerodactyly, pulmonary fibrosis with pulmonary hypertension and esophageal dysfunction. The SS syndrome involved xerostomia, xerophthalmia, the positive Schirmer's test and presence of anti-SS antibodies. The literature reports overlap syndromes in various combinations; however, the coexistence of five autoimmune diseases is extremely rare.
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