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Marathe M, Borkar S. Limited Cutaneous Scleroderma: A Case Report. Cureus 2023; 15:e45336. [PMID: 37849593 PMCID: PMC10577515 DOI: 10.7759/cureus.45336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/16/2023] [Indexed: 10/19/2023] Open
Abstract
Scleroderma is an uncommon disease that affects the connective tissue, causing skin hardening and sometimes organ damage. There are two main forms of scleroderma: localised scleroderma, or morphea, which usually has a mild and limited course and only affects the skin and/or the tissues below it, and systemic sclerosis, which involves skin hardening and internal organ problems. The cause of localised scleroderma is unknown. Recent studies suggest that this form can have different levels of severity and can affect some organs. To avoid complications due to the high morbidity of localised scleroderma, early treatment is recommended. In this article, we present the main aspects and details of the management of patients with localised scleroderma.
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Affiliation(s)
- Manvi Marathe
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Shweta Borkar
- Internal Medicine, Datta Meghe Medical College, Nagpur, IND
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Alghamdi M, Derbes SJ. <p>Systemic Sclerosis Sine Scleroderma Manifested with Gastrointestinal Bleeding, Antiphospholipid Syndrome and Positive Anti-RNA Polymerase III Antibody: Case Report and Literature Review</p>. Int Med Case Rep J 2020; 13:323-326. [PMID: 32801944 PMCID: PMC7414972 DOI: 10.2147/imcrj.s254859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 07/18/2020] [Indexed: 11/23/2022] Open
Abstract
Systemic sclerosis sine scleroderma (ssSSc) is a rare disease in which patients present with internal organ manifestations of systemic sclerosis in the absence of cutaneous findings. They tend to have serological markers characteristic of systemic sclerosis (SSc), including positive antinuclear antibodies (ANA) and anticentromere antibodies (ACA). The disease has been rarely reported in the literature, and the diagnosis can be easily missed due to a lack of relevant skin findings. Here we report a patient who presented with chronic gastrointestinal bleeding with angioectasia, antiphospholipid syndrome (APS), positive ANA, positive ACA, and positive anti-RNA polymerase III antibody. The constellation of all these findings has, to our knowledge, never been described in the literature. The purpose of presenting this case is to raise the clinician’s awareness of the occurrence of this disease when similar internal organs manifestations of scleroderma are encountered, and to monitor for the development of other internal manifestations and intervene promptly and accordingly.
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Affiliation(s)
- Mansour Alghamdi
- Department of Medicine, Rheumatology Section, Louisiana State University School of Medicine, New Orleans, LA, USA
- Correspondence: Mansour Alghamdi Department of Medicine, Rheumatology Section, Louisiana State University School of Medicine, New Orleans, LA, USA Email
| | - Stephen J Derbes
- Department of Medicine, Rheumatology Section, Louisiana State University School of Medicine, New Orleans, LA, USA
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Pregnancy in myositis and scleroderma. Best Pract Res Clin Obstet Gynaecol 2019; 64:59-67. [PMID: 31928915 DOI: 10.1016/j.bpobgyn.2019.10.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 10/04/2019] [Accepted: 10/06/2019] [Indexed: 11/22/2022]
Abstract
Myositis and scleroderma are both rare autoimmune diseases with female predominance and often occur before and during reproductive years. The rarity of diseases explains the low frequency of concurrent disease and pregnancy. Like other autoimmune diseases, myositis and scleroderma may be more active during pregnancy as well. To date, many patients with myositis and scleroderma can have favorable pregnancy outcomes with careful management. This chapter provides a current overview of pregnancy outcomes in myositis and scleroderma. A major theme that appears to have emerged across these inflammatory diseases is that active maternal disease during pregnancy is associated with adverse pregnancy outcomes, and thus, personalized management is necessary depending on the disease state and comorbidities.
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Trapiella-Martínez L, Díaz-López JB, Caminal-Montero L, Tolosa-Vilella C, Guillén-Del Castillo A, Colunga-Argüelles D, Rubio-Rivas M, Iniesta-Arandia N, Castillo-Palma MJ, Sáez-Comet L, Egurbide-Arberas MV, Ortego-Centeno N, Freire M, Vargas-Hitos JA, Ríos-Blanco JJ, Todolí-Parra JA, Rodríguez-Carballeira M, Marín-Ballvé A, Chamorro-Fernández AJ, Pla-Salas X, Madroñero-Vuelta AB, Ruiz-Muñóz M, Fonollosa-Pla V, Simeón-Aznar CP. Very early and early systemic sclerosis in the Spanish scleroderma Registry (RESCLE) cohort. Autoimmun Rev 2017; 16:796-802. [DOI: 10.1016/j.autrev.2017.05.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Accepted: 05/12/2017] [Indexed: 12/29/2022]
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Abstract
Lipotransfer for soft tissue filling is a well-established plastic and aesthetic surgical technique. Elective fat grafting is considered a safe and well-tolerated procedure. Coleman and others have reported that fat grafting may have tissue regenerative properties and not only serve as a soft tissue filler. There have been reports from our group and others that it may improve fibrosis secondary to many different pathological aetiologies including scleroderma, burn injury, lichen sclerosis, graft vs host disease, and radiation. The mechanism of action remains unclear but has been postulated that is adipose derived stem cells (ADSCs) related. Lipoaspirate has been characterised and shown to contain several cell populations including fibroblasts, endothelial cells, and ADSCs. The ADSCs have shown to secrete angiogenic, immunodulatory, and antiapoptotic factors as well as proliferate and differentiate into different cell types similarly to other stem cell sources. We have shown that ADSCs are functionally different in scleroderma patients but despite this lipotransfer produces a significant reversal in the effects of fibrosis in these patients. The advantage of lipoaspirate containing a valuable source of regenerative properties, ease of access, isolation, and processing may serve a significant future role in the treatment of fibrotic conditions.
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Affiliation(s)
- Michelle F Griffin
- University College London (UCL) Centre for Nanotechnology and Regenerative Medicine, Division of Surgery & Interventional Science, Royal Free Hospital, UCL, London, UK
| | | | - Peter E Butler
- Charles Wolfson Center for Reconstructive Surgery, Royal Free Hospital, London, UK
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Faraj K, Perez-Cruet K, Perez-Cruet M. CREST Calcinosis Affecting the Lumbar and Cervical Spine and the Use of Minimally-Invasive Surgery. Cureus 2017; 9:e1145. [PMID: 28491486 PMCID: PMC5422109 DOI: 10.7759/cureus.1145] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Calcinosis in CREST (calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia) syndrome can affect the spinal and paraspinal areas. We present the first case to our knowledge where a CREST syndrome patient required surgery for spinal calcinosis in both the cervical and lumbar areas. A 66-year-old female with a history of CREST syndrome presented with right-sided lower extremity radicular pain. A computed tomography (CT) scan showed bilateral lumbar masses (5.8 cm on the right, 3.8 cm on the left) that projected into the foramina and into the spinal canal. The patient underwent minimally invasive bilateral surgical resection of the paraspinal masses, posterior decompressive laminectomy, posterior interbody, and posterolateral fusion. The specimen was consistent with the calcinosis of CREST syndrome. The patient’s lumbar symptoms were relieved, however, two years later she presented with right radicular arm pain. A CT scan revealed a large lobulated benign tumor-like lesion on the left at C6-C7 encroaching upon the neural foramen and a large right lobulated lesion encroaching into the neural foramen with severe compression of the neural foramen at the C7-T1 level and extension into the canal, with anterior and posterior subluxation present throughout the cervical spine. Surgery was performed, which involved cervical mass resections, posterior spinal cord decompression, reconstruction, and fusion. The patient did well and has been symptom-free since her surgery. Calcinosis of the spine is a known entity that can cause morbidity in patients with CREST syndrome. Minimal invasive surgical approaches are effective and can be considered for some of these patients.
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Affiliation(s)
- Kassem Faraj
- Surgery, Oakland University William Beaumont School of Medicine
| | | | - Mick Perez-Cruet
- Michigan Head and Spine Institute, Oakland University William Beaumont School of Medicine
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Teodoro R, Gomes L, Barbosa L, Freitas M, Almeida L, Furtado P. CRISE RENAL ESCLRERODÉRMICA RECIDIVANTE NECESSITANDO DE ALTAS DOSES DE IECA. REVISTA BRASILEIRA DE REUMATOLOGIA 2017. [DOI: 10.1016/j.rbr.2017.07.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Khaira K, Allen R, Amsterdam EA. A Diagnosis at Hand: Pulmonary Arterial Hypertension. Am J Med 2016; 129:812-5. [PMID: 27154783 DOI: 10.1016/j.amjmed.2016.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 04/07/2016] [Accepted: 04/07/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Kavita Khaira
- Department of Internal Medicine, UC Davis Medical Center, Sacramento, Calif
| | - Roblee Allen
- Division of Pulmonary and Critical Care Medicine, UC Davis Medical Center, Sacramento, Calif
| | - Ezra A Amsterdam
- Division of Cardiovascular Medicine, UC Davis Medical Center, Sacramento, Calif.
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An Unusual Case of Obstruction Due to Colonic Intussusception in a Scleroderma Patient. ACG Case Rep J 2015; 2:30-2. [PMID: 26157898 PMCID: PMC4435351 DOI: 10.14309/crj.2014.75] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 08/29/2014] [Indexed: 01/01/2023] Open
Abstract
Scleroderma is an autoimmune disease that can affect multiple organ systems, including the gastrointestinal tract. Intussusception, the telescoping of the bowel that can lead to intestinal obstruction, is an uncommon phenomenon in adults. We report the first case of sigmoid intussusception in a patient with scleroderma.
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Jokerst C, Purdy H, Bhalla S. An Overview of Collagen Vascular Disease–Associated Interstitial Lung Disease. Semin Roentgenol 2015; 50:31-9. [DOI: 10.1053/j.ro.2014.04.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Abstract
Lung transplantation for scleroderma-related lung disease is controversial due to extra-pulmonary organ involvement that may threaten allograft and patient survival after transplant surgery. Despite concerns, several lung transplant programs do offer lung transplantation to patients with scleroderma-related lung disease. In this review, we evaluate the scleroderma-related extra-pulmonary organ involvement that may result in poorer outcomes after lung transplantation as well as the existing evidence on survival, freedom from bronchiolitis obliterans syndrome (BOS), and other important clinical outcomes after lung transplantation. Among the nine studies reviewed, comprising 226 subjects, survival and freedom from BOS appears to be similar for subjects undergoing lung transplantation for scleroderma compared to non-scleroderma lung diseases. Although scleroderma is a systemic disease with several unique potential threats to allograft and patient survival, lung transplantation appears to be a reasonable intervention for this patient population.
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Noh JW, Kim J, Kim JW. Localized scleroderma: a clinical study at a single center in Korea. Int J Rheum Dis 2013; 16:437-41. [PMID: 23992265 DOI: 10.1111/1756-185x.12080] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Localized scleroderma (morphea) is a rare autoimmune disease limited to the skin, characterized by cutaneous fibrosing and obstructive vasculopathy. Localized scleroderma may invade into the subcutaneous fat layer and cause permanent functional disability. Because of its rarity, there have been few clinical surveys of patients with localized scleroderma in Korea. The aim of this study was to elucidate the clinical presentation, serological data, and clinical outcomes of localized scleroderma. METHODS This was a retrospective survey conducted by reviewing available medical records during a 7 year-period from 2004 to 2010 in a single medical center in Jeju Island, South Korea. In total 43 patients with localized scleroderma were included. RESULTS Localized scleroderma occurred primarily in females (female to male ratio 2.6 : 1.0). Most patients were between 10 and 29 years of age and the mean age at diagnosis was 26.2 years. Plaque (51.2%) and linear morphea (37.2%) were most common. No case was associated with systemic scleroderma (systemic sclerosis). The most common site of plaque morphea was the trunk (47.8%). In the linear type, the most common site was head-neck (52.9%). Fluorescent antinuclear antibody was positive in 23.3% of all cases. Treatment included systemic corticosteroids, colchicine, anti-malarial agents, D-penicillamine or intralesional triamcinolone injection. Clinical improvement, including significant and partial response, was seen in only 62.8% of treated patients. CONCLUSION Localized scleroderma is a chronic inflammatory condition confined to the skin. In order to exclude other conditions, thorough history taking, physical examination, serologic studies and histopathologic examinations should be conducted.
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Affiliation(s)
- Jung Won Noh
- Depatment of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea
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William BM, Harbert T, Ganti AK, Bierman PJ. Small lymphocytic lymphoma in a patient with CREST syndrome. Hematol Oncol Stem Cell Ther 2012; 4:132-5. [PMID: 21982887 DOI: 10.5144/1658-3876.2011.132] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
We report a case of a 61-year-old man with a history of CREST syndrome (calcinosis cutis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia) who presented for evaluation of thrombocytopenia. He had evident cervical adenopathy and lymph node biopsy showed small lymphocytic lymphoma (SLL) with evident systemic adenopathy and bone marrow involvement. The patient achieved a complete remission with FCR (fludarabine/cyclophosphamide/rituximab) chemotherapy. About 30 cases of lymphomas are reported in the literature in association with systemic sclerosis. To our knowledge, there are no reports of a small lymphocytic lymphoma (SLL) in association with limited cutaneous systemic sclerosis with classic features of the CREST syndrome.
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Affiliation(s)
- Basem M William
- University of Nebraska Medical Center and Omaha Veterans Affairs Medical Center, Omaha, Nebraska 68198-7680, USA.
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Moniuszko A, Gińdzieńska-Sieśkiewicz E, Pancewicz SA, Czupryna P, Zajkowska J, Sierakowski S. Evaluation of skin thickness lesions in patients with Lyme disease measured by modified Rodnan total skin score. Rheumatol Int 2011; 32:3189-91. [PMID: 21960047 DOI: 10.1007/s00296-011-2157-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2011] [Accepted: 09/10/2011] [Indexed: 11/25/2022]
Abstract
Recently, a possible etiological connection between infection with Borrelia burgdorferi and various skin lesions, including morphea and systemic sclerosis (SSc), has been discussed. The aim of our study was the evaluation of frequency of skin thickening typical of SSc or morphea in the group of patients with Lyme disease (LD) with frequent exposition to tick bites. The group consisted of 110 patients with LD frequently exposed to tick bites form the northeastern Poland, which is an endemic area for this disease. To measure the skin lesions, the modified Rodnan total skin score (RTSS) was used. In the analyzed group, no skin changes typical of morphea or skin thickening were found. According to RTSS, all patients scored 0 points. Raynaud's phenomenon in all patients was not found. The relationship between scleroderma or morphea and LD is still a matter of controversy. Described by some authors, cases with LD and scleroderma may be associated with co-existence of B. burgdorferi infection with autoimmune process.
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Affiliation(s)
- A Moniuszko
- Department of Infectious Diseases and Neuroinfections, Medical University in Białystok, Żurawia Street 14, 15-540 Bialystok, Poland.
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Cunningham J, Harisinghani MG, Taheri D. Case records of the Massachusetts General Hospital. Case 30-2011. A 62-year-old woman with renal failure. N Engl J Med 2011; 365:1233-43. [PMID: 21991897 DOI: 10.1056/nejmcpc1100921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- John Cunningham
- Centre for Nephrology, Royal Free and University College London Medical School, London
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Naschitz J, Yeshurun D, Shajrawi I, Misselevich I, Boss J. The fasciitis-panniculitis syndrome in circulatory disorders of the limbs. Int J Angiol 2011. [DOI: 10.1007/bf02043212] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Rojana-Udomsart A, Fabian V, Hollingsworth PN, Walters SE, Zilko PJ, Mastaglia FL. Paraspinal and scapular myopathy associated with scleroderma. J Clin Neuromuscul Dis 2010; 11:213-222. [PMID: 20516811 DOI: 10.1097/cnd.0b013e3181c139f6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
OBJECTIVE To describe a form of inflammatory myopathy with prominent involvement of the paraspinal and scapular muscles in patients with scleroderma. METHODS Review of clinical records, laboratory investigations, and muscle biopsies. RESULTS Patients presented with a "dropped head" resulting from weakness of the posterior cervical muscles (three cases) or camptocormia ("bent spine") resulting from weakness of the paraspinal muscles (two cases) and variable weakness and atrophy of shoulder girdle muscles with mild or absent pelvic girdle involvement. Biopsies from the deltoid or paraspinal muscles showed myositis of variable severity and scleroderma vasculopathy in all cases. The response to prednisolone and cytotoxic agents was poor, but there was a good response to intravenous immunoglobulin therapy in one case. CONCLUSIONS Patients with scleroderma may develop a restricted form of immune-mediated inflammatory myopathy with a predilection for the paraspinal and scapular muscles, which is poorly responsive to treatment with glucocorticoids and immunosuppressive agents and may require consideration of other treatment modalities.
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Affiliation(s)
- Arada Rojana-Udomsart
- Centre for Neuromuscular and Neurological Disorders, University of Western Australia, Nedlands, Western Australia
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Perez-Bocanegra C, Solans-Laque R, Simeon-Aznar CP, Campillo M, Fonollosa-Pla V, Vilardell-Tarres M. Age-related survival and clinical features in systemic sclerosis patients older or younger than 65 at diagnosis. Rheumatology (Oxford) 2010; 49:1112-7. [DOI: 10.1093/rheumatology/keq046] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Chen Y, Leask A, Abraham DJ, Pala D, Shiwen X, Khan K, Liu S, Carter DE, Wilcox-Adelman S, Goetinck P, Denton CP, Black CM, Pitsillides AA, Sarraf CE, Eastwood M. Heparan sulfate-dependent ERK activation contributes to the overexpression of fibrotic proteins and enhanced contraction by scleroderma fibroblasts. ACTA ACUST UNITED AC 2008; 58:577-85. [PMID: 18240216 DOI: 10.1002/art.23146] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To investigate the contribution of heparan sulfate proteoglycan and Ras/MEK/ERK to the overexpression of profibrotic proteins and the enhanced contractile ability of dermal fibroblasts from patients with systemic sclerosis (SSc; scleroderma). METHODS The effects of the MEK/ERK inhibitor U0126, the heparan sulfate side chain formation inhibitor beta-xyloside, and soluble heparin on the overexpression of profibrotic genes were compared in fibroblasts from lesional skin of patients with diffuse SSc and fibroblasts from healthy control subjects. Identified protein expressions were compared with the contractile abilities of fibroblasts while they resided within a collagen lattice. Forces generated were measured using a culture force monitor. RESULTS Inhibiting MEK/ERK with U0126 significantly reduced expression of a cohort of proadhesive and procontractile proteins that normally are overexpressed by scleroderma fibroblasts, including integrin alpha4 and integrin beta1. Antagonizing heparan sulfate side chain formation with beta-xyloside or the addition of soluble heparin prevented ERK activation, in addition to reducing the expression of these proadhesive/contractile proteins. Treatment with either U0126, beta-xyloside, or heparin resulted in a reduction in the overall peak contractile force generated by dermal fibroblasts. Blocking platelet-derived growth factor receptor with Gleevec (imatinib mesylate) reduced overall contractile ability and the elevated syndecan 4 expression and ERK activation in SSc fibroblasts. CONCLUSION The results of this study suggest that heparan sulfate-dependent ERK activation contributes to the enhanced contractile ability demonstrated by dermal fibroblasts from lesional skin of patients with scleroderma. These results are consistent with the notion that the MEK/ERK procontractile pathway is dysregulated in scleroderma dermal fibroblasts. Additionally, the results suggest that antagonizing the MEK/ERK pathway is likely to modulate heparan sulfate proteoglycan activity, which in turn may have a profound effect on the fibrotic response in SSc.
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Pelidou SH, Tsifetaki N, Giannopoulos S, Deretzi G, Voulgari P, Kyritsis A. Multiple sclerosis associated with systemic sclerosis. Rheumatol Int 2006; 27:771-3. [PMID: 17171345 DOI: 10.1007/s00296-006-0282-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2006] [Accepted: 11/17/2006] [Indexed: 10/23/2022]
Abstract
Multiple sclerosis (MS) has been increasingly reported in association with other autoimmune diseases not primary affected the nervous system. The coexistence of MS and systemic sclerosis (SSc) has been rarely described. We report here the case of a 46-year-old female patient with longstanding MS since the age of 26, who developed SSc 12 years later. Her MS was of the relapsing-remitting type, but the definite diagnosis was not made until the age of 33. MS diagnosis was based on medical history, magnetic resonance imaging (MRI) studies and positive cerebrospinal fluid analysis. One year after the diagnosis of MS, she developed Raynaud's phenomenon, skin tightness and hypopigmented patches, suggestive of scleroderma. Further investigation with laboratory studies, including serology, hand and chest X-rays, and chest computerized tomography scan confirmed the SSc diagnosis. Our report highlights the interesting association between MS and SSc that may be due to an overlapping pathogenetic mechanism for both processes.
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Affiliation(s)
- Syngliti-Henrietta Pelidou
- Department of Neurology, University of Ioannina Medical School, University Hospital of Ioannina, 1 Panepistimioupoli, Ioannina, 451 10, Greece
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Jandali S, Mehrara B. Free Anterolateral Thigh Perforator Flap in a Patient with Systemic Sclerosis and Raynaud???s Phenomenon. Plast Reconstr Surg 2006; 118:90e-92e. [PMID: 16980839 DOI: 10.1097/01.prs.0000232388.59236.3a] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Shareef Jandali
- New York, N.Y. From the Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center
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Routsias JG, Vlachoyiannopoulos PG, Tzioufas AG. Autoantibodies to intracellular autoantigens and their B-cell epitopes: molecular probes to study the autoimmune response. Crit Rev Clin Lab Sci 2006; 43:203-48. [PMID: 16574554 DOI: 10.1080/10408360500523837] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
A common laboratory finding in systemic autoimmune diseases is the presence of autoantibodies against intracellular autoantigens. Although their pathogenesis is not fully understood, autoantibodies are important tools for establishing diagnosis, classification, and prognosis of autoimmune diseases. Autoantibodies mainly target multicomponent complexes containing both protein antigens and (ribo)-nucleic acid(s), such as the spliceosome or Ro/La RNPs. In this review, we address the main characteristics and the clinical value of the main autoantibody types with respect to their disease association, and we describe the corresponding autoantigens, their biologic function, and their B-cell antigenic determinants (epitopes). The structural characteristics and clinical associations of these epitopes, and their utility as tools to investigate the autoimmune response, are discussed in detail. New insights into the pathogenetic role of epitopes in systemic autoimmunity are also examined. In this regard, using the defined structures of the B-cell antigenic epitopes, complementary epitopes can be designed according to the "molecular recognition" theory. These complementary epitopes can be used as probes to study pathogenetic and immunoregulatory aspects of the anti-idiotypic response. The origin of humoral autoimmunity and the spreading of the epitopes in systemic lupus erythematosus are also discussed. Finally, the ability of post-translational modifications to induce autoreactive immune attack via the generation of neo-epitopes is summarized.
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Affiliation(s)
- John G Routsias
- Department of Pathophysiology, School of Medicine, University of Athens, Athens, Greece
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Alkotob ML, Soltani P, Sheatt MA, Katsetos MC, Rothfield N, Hager WD, Foley RJ, Silverman DI. Reduced Exercise Capacity and Stress-Induced Pulmonary Hypertension in Patients With Scleroderma. Chest 2006; 130:176-81. [PMID: 16840399 DOI: 10.1378/chest.130.1.176] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVES We sought to determine the incidence of stress-induced pulmonary artery (PA) systolic hypertension in a referral population of patients with scleroderma, and to examine the relation between stress-induced pulmonary systolic hypertension and exercise capacity in this population. BACKGROUND Early detection of patients with scleroderma at risk for pulmonary hypertension (PHTN) could lead to more timely intervention and thus reduce morbidity and improve mortality. The change in PA systolic pressure (PASP) with exercise provides a possible tool for such detection. METHODS Sixty-five patients with scleroderma (9 men and 56 women; mean age 51 +/- 12 years [SD]), normal resting PASP, and normal resting left ventricular function underwent exercise Doppler echocardiography using a standard Bruce protocol. Tricuspid regurgitation velocity was measured before and after exercise. Exercise variables including workload achieved in metabolic equivalents (METS), total exercise time, percentage of target heart rate achieved, and PASP at rest and within 60 s after exercise were recorded. RESULTS Thirty patients (46%) demonstrated an increase in PASP to > 35 mm Hg plus an estimated right atrial pressure of 5 mm Hg. Postexercise PASP inversely correlated to both the maximum workload achieved (r = - 0.34, p = 0.006) and exercise time (r = - 0.31, p = 0.01). In women, the correlation was more significant (r = - 0.38, p = 0.003). Patients in the lowest quartile of exercise time, with the least cardiac workload achieved, produced the highest postexercise PASP. CONCLUSION Stress-induced PHTN is common in patients with scleroderma, even when resting PASP is normal. Stress Doppler echocardiography identifies scleroderma patients with an abnormal rise in PASP during exertion. Peak PASP is linearly related to exercise time and maximum workload achieved. Measurement of PASP during exercise may prove to be a useful tool for the identification of future resting PHTN.
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Affiliation(s)
- M Luay Alkotob
- Pat and Jim Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington, USA
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Abstract
We review data from controlled trials and randomised controlled trials to examine the hypothesis for the pathogenesis of systemic sclerosis. Strategies used to treat the vascular complications in systemic sclerosis have so far shown the biggest successes, especially in the management of renal crisis and pulmonary arterial hypertension. Because these drugs have improved function and quality of life and have increased survival rates, they can truly be classified as disease-modifying compounds. Immunosuppressive therapy with cyclophosphamide in particular has also shown evidence of efficacy, and randomised controlled trials of autologous stem-cell transplantation are underway. So far, strategies to reduce or control fibrosis directly (bosentan, interferon gamma, and relaxin) have been disappointing but new strategies against fibrosis based on advanced understanding of the molecular biology of systemic sclerosis hold promise. Treatments against several cardinal features of the disorder simultaneously have not yet been examined but are being considered for future trials.
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Affiliation(s)
- Christina Charles
- Department of Medicine, Division of Rheumatology, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-1670, USA
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Chen Y, Shi-Wen X, van Beek J, Kennedy L, McLeod M, Renzoni EA, Bou-Gharios G, Wilcox-Adelman S, Goetinck PF, Eastwood M, Black CM, Abraham DJ, Leask A. Matrix contraction by dermal fibroblasts requires transforming growth factor-beta/activin-linked kinase 5, heparan sulfate-containing proteoglycans, and MEK/ERK: insights into pathological scarring in chronic fibrotic disease. THE AMERICAN JOURNAL OF PATHOLOGY 2006; 167:1699-711. [PMID: 16314481 PMCID: PMC1613194 DOI: 10.1016/s0002-9440(10)61252-7] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Scarring is characterized by excessive synthesis and contraction of extracellular matrix. Here, we show that fibroblasts from scarred (lesional) areas of patients with the chronic fibrotic disorder diffuse scleroderma [diffuse systemic sclerosis (dSSc)] show an enhanced ability to adhere to and contract extracellular matrix, relative to fibroblasts from unscarred (nonlesional) areas of dSSc patients and dermal fibroblasts from normal, healthy individuals. The contractile abilities of normal and dSSc dermal fibroblasts were suppressed by blocking heparin sulfate-containing proteoglycan biosynthesis or antagonizing transforming growth factor-beta receptor type I [activin-linked kinase (ALK5)] or ras/mitogen-activated protein kinase (MEK)/extracellular signal-regulated kinase (ERK). Compared with both normal and nonlesional fibroblasts, lesional dSSc fibroblasts overexpressed the heparin sulfate-containing proteoglycan syndecan 4. We also found that the procontractile signals from transforming growth factor (TGF)-beta were integrated through syndecan 4 and MEK/ERK because the ability of TGFbeta to induce contraction of dermal fibroblasts was prevented by MEK antagonism. TGFbeta could not induce a contractile phenotype or phosphorylate ERK in syndecan 4(-/-) dermal fibroblasts. These results suggest that integrating TGFbeta and ERK signals via syndecan 4 is essential for the contractile ability of dermal fibroblasts. We conclude that antagonizing MEK/ERK, TGFbeta1/ALK5, or syndecan 4 may alleviate scarring in chronic fibrotic disease.
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Affiliation(s)
- Yunliang Chen
- Centre for Rheumatology, University College London, Royal Free Campus, UK
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26
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Chen Y, Shi-wen X, Eastwood M, Black CM, Denton CP, Leask A, Abraham DJ. Contribution of activin receptor–like kinase 5 (transforming growth factor β receptor type I) signaling to the fibrotic phenotype of scleroderma fibroblasts. ACTA ACUST UNITED AC 2006; 54:1309-16. [PMID: 16575856 DOI: 10.1002/art.21725] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To use a specific transforming growth factor beta receptor type I (TGFbetaRI; activin receptor-like kinase 5 [ALK-5]) kinase inhibitor (SD208) to determine the role of activation of the TGFbetaRI kinase (ALK-5) in maintaining the profibrotic phenotype of dermal fibroblasts in systemic sclerosis (SSc). METHODS The effect of SD208 on the expression of key biochemical markers of the fibrotic phenotype was compared in fibroblasts cultured from clinically involved (lesional) and clinically uninvolved skin of patients with diffuse cutaneous SSc (dcSSc) and in fibroblasts from healthy controls matched for age, sex, and anatomic site. Protein expression was compared together with the ability of fibroblasts to adhere to the extracellular matrix and to remodel and contract a free-floating fibroblast-populated type I collagen lattice. RESULTS Inhibiting TGFbetaRI kinase reduced the expression of a cohort of fibrotic markers by dermal fibroblasts from patients with dcSSc, including type I collagen and beta1 integrin. Moreover, inhibition also attenuated the elevated adhesive and contractile abilities of dcSSc fibroblasts. CONCLUSION Our data suggest that some of the key profibrotic features of lesional SSc fibroblasts are dependent upon ALK-5 activity. Thus, TGFbetaRI kinase-mediated signaling may contribute to dermal fibrosis in dcSSc.
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Affiliation(s)
- Yunliang Chen
- Royal Free and University College Medical School, London, UK
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27
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Interstitial Disease in Systemic Sclerosis. ACTA ACUST UNITED AC 2004. [DOI: 10.1016/s1571-5078(04)02010-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Perazella MA, Ishibe S, Perazella MA, Reilly RF. Nephrogenic fibrosing dermopathy: an unusual skin condition associated with kidney disease. Semin Dial 2003; 16:276-80. [PMID: 12753692 DOI: 10.1046/j.1525-139x.2003.16053.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We report the case of a patient who, while on long-term hemodialysis (HD), developed nephrogenic fibrosing dermopathy, a newly described sclerosing skin disorder. This disorder is characterized by thickened, hardened skin with brawny hyperpigmentation and raised plaques. The most common patient complaints are pruritus and dysesthesia. The extremities are predominantly involved with sparing of the torso and face. Dysfunction of internal organs has not been described, distinguishing it from other fibrosing conditions such as scleroderma. The skin biopsy is characterized by haphazardly arranged dermal collagen spindle cells in the reticular dermis. Extensive mucin deposits are interposed between collagen bundles and there are an increased number of fibroblast-type cells. In contrast to scleroderma, inflammatory cells are generally absent. Corticosteroid therapy can be tried, but in our patient was of no benefit.
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Affiliation(s)
- Mark A Perazella
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut 06520, USA
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29
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Cozzi F, Marson P, Rosada M, De Silvestro G, Bullo A, Punzi L, Todesco S. Long-term therapy with plasma exchange in systemic sclerosis: effects on laboratory markers reflecting disease activity. Transfus Apher Sci 2001; 25:25-31. [PMID: 11791759 DOI: 10.1016/s1473-0502(01)00078-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Plasma exchange (PEX) is a technique that has been applied to the treatment of many immunological disorders, including connective tissue diseases. The crucial role of some humoral factors in the pathogenesis of systemic sclerosis (SSc) could explain the good clinical results obtained in terms of slowing down the disease progression, but the efficacy of PEX in the treatment of SSc is not yet well defined, owing to the lack of controlled studies and validated parameters of disease activity. To demonstrate the long-term efficacy of PEX in the treatment of SSc we treated a group of 28 SSc patients affected with recent onset and/or rapidly progressive disease. Most of these had a diffuse form of SSc, with anti-Sc170 antibody as a disease marker. Before and after long-term PEX treatment we evaluated disease activity parameters including the serum levels of interleukin 2 soluble receptor (sIL-2R) and aminoterminal type III procollagen peptide (PIIINP), plus the percentage of DR+ T cells in the peripheral blood. We also assessed clinical parameters of total skin score and total visceral score. The same parameters were evaluated in 25 SSc patients who did not satisfy the admission criteria for PEX, treated long-term with drugs only. At baseline, serum PIIINP and sIL-2R levels and the percentage of DR+ T cells were significantly increased in PEX patients as compared to others. Following long-term PEX treatment, all the laboratory parameters significantly decreased and the clinical scores showed a slight but not significant improvement. Conversely, in the other group of SSc patients treated for the same period with drugs only, no significant change of laboratory parameters was detected and the clinical scores slightly worsened. Our data suggest that long-term PEX therapy seems to be effective in slowing down the clinical course of patients with severe and rapidly progressive SSc.
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Affiliation(s)
- F Cozzi
- Division of Rheumatology, Università di Padova, Italy.
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30
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Xu S, Denton CP, Holmes A, Dashwood MR, Abraham DJ, Black CM. Endothelins: effect on matrix biosynthesis and proliferation in normal and scleroderma fibroblasts. J Cardiovasc Pharmacol 1998; 31 Suppl 1:S360-3. [PMID: 9595482 DOI: 10.1097/00005344-199800001-00101] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We investigated the effect of endothelin-1 (ET-1) in normal and systemic sclerosis (SSc) dermal fibroblasts. Collagen type I, collagen type III, and MMP-1 levels in culture supernatants were measured by competition ELISA and cellular mRNA expression was examined by Northern blotting. Mitogenic responses to ET-1 were assessed by [3H]TdR incorporation. ET receptor mRNA expression was examined by RT-PCR analysis of fibroblast RNA and with surface binding studies using radiolabeled ET receptor ligands and specific receptor antagonists. ET-1 enhanced release of collagen types I and III by control and SSc fibroblast strains, but the effects were significantly greater for control cells (p < 0.05). This effect appeared to involve both ETA and ETB receptor subtypes. SSc fibroblasts demonstrated lower constitutive MMP-1 production than control fibroblasts (p < 0.01), but ET-1 treatment decreased MMP-1 in normal fibroblasts to levels observed in SSc. Mitogenic response (percent control [3H]TdR incorporation) to ET-1 for SSc fibroblasts was 130 +/- 34, significantly less (p < 0.01) than that for normal fibroblasts strains (290 +/- 25). This response appeared to be predominantly mediated via the ETA receptor subtype. Surface binding studies suggested a significantly lower level of ETA binding sites in SSc compared with normal fibroblasts (p < 0.05). These data suggest that ET-1 induces a fibrogenic phenotype in normal dermal fibroblasts that resembles that seen in fibroblasts grown from lesional SSc skin. Moreover, SSc cells appear to be refractory to these effects, and this reduced responsiveness is associated with an altered ratio of ETA:ETB receptor expression, supporting a role for ET-1 in the fibrotic pathology of SSc.
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Affiliation(s)
- S Xu
- Academic Unit of Rheumatology, Royal Free Hospital School of Medicine, London, England
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31
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Durward G, Blackford S, Roberts D, Jones MK. Cutaneous scleroderma in association with carcinoid syndrome. Postgrad Med J 1995; 71:299-300. [PMID: 7596938 PMCID: PMC2398099 DOI: 10.1136/pgmj.71.835.299] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
A case of scleroderma in a woman with carcinoid syndrome is described and the similarities between our case and those in the literature are reviewed. The carcinoid tumours were all of midgut origin and liver metastases were present. All subsequently developed fibrotic heart disease and none had clinical features or autoantibodies suggestive of systemic sclerosis. The association between carcinoid syndrome and particular features of scleroderma is likely to be more than fortuitous.
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Affiliation(s)
- G Durward
- Department of Medicine, Singleton Hospital, Swansea, S Wales, UK
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