Morphoea presenting shortly after the onset of Schmidt's syndrome

Localized scleroderma: clinical spectrum and therapeutic update

Scleroderma is a rare connective tissue disease that is manifested by cutaneous sclerosis and variable systemic involvement. Two categories of scleroderma are known: systemic sclerosis, characterized by cutaneous sclerosis and visceral involvement, and localized scleroderma or morphea which classically presents benign and self-limited evolution and is confined to the skin and/or underlying tissues. Localized scleroderma is a rare disease of unknown etiology. Recent studies show that the localized form may affect internal organs and have variable morbidity. Treatment should be started very early, before complications occur due to the high morbidity of localized scleroderma. In this review, we report the most important aspects and particularities in the treatment of patients diagnosed with localized scleroderma.

Localized scleroderma in childhood is not just a skin disease

OBJECTIVE

Juvenile localized scleroderma is usually considered a disease that is confined to the skin and subcutaneous tissue. We studied the prevalence and clinical features of extracutaneous manifestations in a large cohort of children with juvenile localized scleroderma.

METHODS

Data from a multinational study on juvenile scleroderma was used for this in-depth study. Clinical features of patients with extracutaneous manifestations were compared with those of patients who had exclusively skin involvement.

RESULTS

Seven hundred fifty patients entered the study. One hundred sixty-eight patients (22.4%) presented with a total of 193 extracutaneous manifestations, as follows: articular (47.2%), neurologic (17.1%), vascular (9.3%), ocular (8.3%), gastrointestinal (6.2%), respiratory (2.6%), cardiac (1%), and renal (1%). Other autoimmune conditions were present in 7.3% of patients. Neurologic involvement consisted of epilepsy, central nervous system vasculitis, peripheral neuropathy, vascular malformations, headache, and neuroimaging abnormalities. Ocular manifestations were episcleritis, uveitis, xerophthalmia, glaucoma, and papilledema. In more than one-fourth of these children, articular, neurologic, and ocular involvements were unrelated to the site of skin lesions. Raynaud's phenomenon was reported in 16 patients. Respiratory involvement consisted essentially of restrictive lung disease. Gastrointestinal involvement was reported in 12 patients and consisted exclusively of gastroesophageal reflux. Thirty patients (4%) had multiple extracutaneous features, but systemic sclerosis (SSc) developed in only 1 patient. In patients with extracutaneous involvement, the prevalence of antinuclear antibodies and rheumatoid factor was significantly higher than that among patients with only skin involvement. However, Scl-70 and anticentromere, markers of SSc, were not significantly increased.

CONCLUSION

Extracutaneous manifestations of juvenile localized scleroderma developed in almost one-fourth of the children in this study. These extracutaneous manifestations often were unrelated to the site of the skin lesions and sometimes were associated with multiple organ involvement. The risk of developing SSc was very low. This subgroup of patients with juvenile localized scleroderma should be evaluated extensively, treated more aggressively, and monitored carefully.

Systemic manifestations in localized scleroderma

In this paper, the various systemic manifestations reported in localized scleroderma, their incidence, their relationship with systemic sclerosis, and their relationship with other autoimmune or connective tissue diseases will be analyzed.

Schmidt’S Syndrome and Severe Hyponatremia: Report of an Unusual Case and Review of the Related Literature

OBJECTIVE

To describe a rare case of profound hyponatremia in a male patient with autoimmune polyglandular syndrome type 2 (Schmidt's syndrome).

METHODS

We present the clinical and laboratory data in our patient and review the related published reports from the English language literature on the association of hyponatremia with Schmidt's syndrome.

RESULTS

A 31-year-old man presented to the emergency department because of nausea, anorexia, and weakness for 6 days. He was found to have severe hyponatremia (serum sodium concentration, 101 mEq/L) and mild hyperkalemia. Endocrine testing revealed the presence of Addison's disease and severe primary hypothyroidism, consistent with Schmidt's syndrome. The patient responded to treatment with volume and hormone replacement. An extensive literature search disclosed only one previously reported case (of a female patient) in which Schmidt's syndrome led to the development of a degree of hyponatremia as severe as that in our patient.

CONCLUSION

Concomitant occurrence of primary adrenal insufficiency and primary hypothyroidism can result in a greater degree of hyponatremia than would be expected from either disease alone. Likely explanations include the additive effects of primary hypothyroidism and adrenal failure in the development of hyponatremia and, possibly, in some patients exquisite renal sensitivity to hemodynamic changes and altered hormonal status.