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Moinzadeh P, Kuhr K, Siegert E, Mueller-Ladner U, Riemekasten G, Günther C, Kötter I, Henes J, Blank N, Zeidler G, Pfeiffer C, Juche A, Jandova I, Ehrchen J, Schmalzing M, Susok L, Schmeiser T, Sunderkoetter C, Distler JHW, Worm M, Kreuter A, Krieg T, Hunzelmann N. Older age onset of systemic sclerosis - accelerated disease progression in all disease subsets. Rheumatology (Oxford) 2021; 59:3380-3389. [PMID: 32333004 PMCID: PMC7590407 DOI: 10.1093/rheumatology/keaa127] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 01/27/2020] [Indexed: 01/03/2023] Open
Abstract
Objectives Systemic sclerosis is a heterogeneous, multisystem disease. It can occur at any age, but most patients develop the disease between the age of 40 to 50 years. There is controversial evidence on whether/how the age at disease onset affects their clinical phenotype. We here investigate the relationship between age at disease onset and symptoms in a large cohort of SSc patients (lcSSc, dcSSc and SSc-overlap syndromes). Methods Clinical data of the registry of the German Network for Systemic Scleroderma including 3281 patients were evaluated and subdivided into three age groups at disease onset (<40 years, 40–60 years, >60 years). Results Among all SSc patients, 24.5% developed their first non-Raynaud phenomenon symptoms at the age <40 years, and 22.5% were older than 60 years of age. In particular, older patients at onset developed the lcSSc subset significantly more often. Furthermore, they had pulmonary hypertension more often, but digital ulcerations less often. Remarkably, the course of the disease was more rapidly progressing in the older cohort (>60 years), except for gastrointestinal and musculoskeletal involvement. No significant difference was found for the use of corticosteroids. However, significantly, fewer patients older than 60 years received immunosuppressive treatment. Conclusion In this large registry, ∼25% of patients developed SSc at an age above 60 years with an increased frequency of lcSSc. In this age group, an onset of internal organ involvement was significantly accelerated across all three subsets. These findings suggest that, in the elderly cohort, more frequent follow-up examinations are required for an earlier detection of organ complications.
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Affiliation(s)
- Pia Moinzadeh
- Department of Dermatology and Venereology, University Hospital Cologne
| | - Kathrin Kuhr
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine, University of Cologne, Cologne
| | - Elise Siegert
- Department of Rheumatology and Clinical Immunology, Charité - University Medicine Berlin and Berlin Institute of Health (BIH), Berlin
| | - Ulf Mueller-Ladner
- Department of Rheumatology, Justus Liebig University Giessen, Kerckhoff Clinic, Bad Nauheim
| | | | - Claudia Günther
- Department of Dermatology, University Hospital Carl Gustav Carus, Dresden
| | - Ina Kötter
- Department for Internal Medicine, Rheumatology, Immunology and Nephrology, Asklepios Clinic Altona, Hamburg
| | - Jörg Henes
- Centre for Interdisciplinary Clinical Immunology, Rheumatology and Auto-inflammatory Diseases and Department of Internal Medicine II (Oncology, Hematology, Immunology, Rheumatology, Pulmonology), University Hospital Tuebingen, Tuebingen
| | - Norbert Blank
- Department of Rheumatology, University Hospital Heidelberg, Heidelberg
| | - Gabriele Zeidler
- Department of Rheumatology, Johanniter-Hospital Treuenbrietzen, Treuenbrietzen
| | | | - Aaron Juche
- Department of Rheumatology, Immanuel Hospital Berlin-Buch, Berlin
| | - Ilona Jandova
- Department of Rheumatology, University Hospital Freiburg, Freiburg
| | - Jan Ehrchen
- Department of Dermatology and Venereology, University Hospital Muenster, Muenster
| | - Marc Schmalzing
- Department of Internal Medicine, Rheumatology and Clinical Immunology, University Clinic of Wuerzburg, Wuerzburg
| | - Laura Susok
- Department of Dermatology and Venereology, Ruhr-University-Bochum, Bochum
| | - Tim Schmeiser
- Department of Rheumatology and Immunology, St. Josef Hospital Wuppertal, Wuppertal
| | - Cord Sunderkoetter
- Department of Dermatology and Venereology, University Hospital Halle, Halle
| | - Jörg H W Distler
- Department of Rheumatology, University Hospital Erlangen, Erlangen
| | - Margitta Worm
- Department of Dermatology and Allergology, Charité - University Medicine Berlin, Berlin
| | - Alexander Kreuter
- Department of Dermatology, Venereology and Allergology, Helios St. Elisabeth Hospital Oberhausen, University Witten-Herdecke, Oberhausen, Germany
| | - Thomas Krieg
- Department of Dermatology and Venereology, University Hospital Cologne
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Manno RL, Wigley FM, Gelber AC, Hummers LK. Late-age onset systemic sclerosis. J Rheumatol 2011; 38:1317-25. [PMID: 21685299 DOI: 10.3899/jrheum.100956] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Although patients who develop systemic sclerosis (SSc) later in life (≥ 65 yrs) may express the entire clinical spectrum of disease, we hypothesize that patients with late-age onset SSc incur a different risk for specific organ manifestations of disease compared to those with early-age onset SSc. METHODS In total, 2300 patients with SSc were evaluated between 1990 and 2009 and reviewed from a university-based scleroderma center cohort. Demographic profile, SSc subtype, autoantibody status, Medsger severity scores, pulmonary function tests, echocardiography, and right heart catheterization measures were compared between late-age onset vs younger-age onset patients with SSc. RESULTS Overall, 2084 patients (91%) developed SSc prior to age 65, while 216 (9%) were ≥ 65 years. Late-age onset patients had a significantly higher proportion of anticentromere antibodies (42% vs 27%; p = 0.001) compared to early-age onset patients. Risk of pulmonary hypertension (OR 1.76, 95% CI 1.00, 3.12), muscle weakness (OR 1.85, 95% CI 1.30, 1.64), renal impairment (OR 2.83, 95% CI 1.98, 4.04), and cardiac disease (OR 2.69, 95% CI 1.92, 3.78) was greater among those with late-age onset SSc; although risk of digital ischemia (OR 0.64, 95% CI 0.47, 0.86) was reduced. The cumulative incidence of pulmonary hypertension at 5 years was greater among those with late-age onset SSc (9%) compared to those with early-age onset SSc (2.7%; log-rank, p < 0.001). CONCLUSION These findings suggest that older patients with SSc are at greater risk for pulmonary hypertension, renal impairment, cardiac disease, and muscle weakness. Awareness of the distinct risk for specific organ manifestations in SSc, in particular pulmonary hypertension, should guide the care of patients with SSc whose disease begins after age 65.
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Affiliation(s)
- Rebecca L Manno
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA
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Fernández Ibáñez JM, Morales Ballesteros C, Carrasco Fernández JA, Perez Alonso L. [Pulmonary arterial hypertension as symptom of a limited form of systemic sclerosis in a nonagenerian]. Rev Esp Geriatr Gerontol 2010; 45:361-362. [PMID: 20678826 DOI: 10.1016/j.regg.2010.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2009] [Revised: 04/13/2010] [Accepted: 04/14/2010] [Indexed: 05/29/2023]
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Hügle T, Schuetz P, Daikeler T, Tyndall A, Matucci-Cerinic M, Walker UA, van Laar JM. Late-onset systemic sclerosis--a systematic survey of the EULAR scleroderma trials and research group database. Rheumatology (Oxford) 2010; 50:161-5. [PMID: 20884657 DOI: 10.1093/rheumatology/keq321] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE The clinical course of SSc depends on subtype, organ involvement and age. Few data are reported on patients suffering from late-onset SSc. METHODS We analysed data from 8554 patients prospectively followed in the EULAR Scleroderma Trials and Research (EUSTAR) group database. Late-onset SSc was defined as onset of non-RP disease features at or beyond 75 years of age. Disease characteristics, clinical features, disease course and mortality were evaluated. RESULTS A total of 123 patients with SSc onset at or beyond 75 years of age were identified. Compared with patients<75 years they had more frequently limited than diffuse SSc and a higher prevalence of anti-centromere autoantibodies. Fewer old patients had digital ulcers. The modified Rodnan's skin score, the prevalence of lung fibrosis and renal crisis did not differ significantly between groups. Pulmonary hypertension (PH) measured by echocardiography was more prevalent in the late-onset group, as well as arterial hypertension and diastolic dysfunction. Late-onset SSc remained a positive predictor for PH in multivariate analyses. No significant difference of the two groups in skin score or diffusion capacity was observed during follow-up. Mortality due to SSc was higher in the late-onset group, but the survival time from diagnosis was longer compared with the younger patients. CONCLUSION Late-onset SSc shows a distinct clinical presentation and outcome. Patients with late-onset SSc suffer more frequently from the limited subtype and PH, but fewer patients have digital ulcers. PH may in part be determined by underlying cardiovascular disease.
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Affiliation(s)
- Thomas Hügle
- Musculoskeletal Research Group, Institute of Cellular Medicine, The Medical School, Framlington Place, Newcastle University, Newcastle upon Tyne NE2 4HH, UK.
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Derk CT, Artlett CM, Jimenez SA. Morbidity and mortality of patients diagnosed with systemic sclerosis after the age of 75: a nested case-control study. Clin Rheumatol 2006; 25:831-4. [PMID: 16435160 DOI: 10.1007/s10067-005-0177-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2005] [Revised: 11/30/2005] [Accepted: 12/03/2005] [Indexed: 05/06/2023]
Abstract
This study aims to characterize the clinical features of a cohort of patients diagnosed with systemic sclerosis (SSc) after the age of 75 and compare them to a group diagnosed at a younger age. We record the review of 769 patients diagnosed with SSc over the past 16 years. Utilizing a nested case-control model, we compare demographics, disease severity, morbidity, and mortality data of all patients diagnosed after the age of 75 to sex- and disease-type-matched, randomly selected group of patients diagnosed with SSc before the age of 60. Twelve patients were diagnosed with SSc after the age of 75, seven with the diffuse, and five with the limited form. It took longer to diagnose SSc in the older patients, and comparison of disease severity revealed a worse pulmonary picture and a more frequent development of malignancy in the older patients as compared with the younger ones. During a mean follow-up of 36.2 months, our cohort of patients did not have worsening in their disease severity, though 6 months after the last follow-up, six patients died. We conclude that a diagnosis of SSc at an older age appears to be a poor prognostic indicator related to both disease severity and comorbidities. A higher clinical suspicion will lead to an earlier diagnosis and a potential decrease in morbidity and mortality.
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Affiliation(s)
- Chris T Derk
- Department of Medicine, Division of Rheumatology, Thomas Jefferson University, Philadelphia, PA, 19017, USA.
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Schachna L, Wigley FM, Chang B, White B, Wise RA, Gelber AC. Age and Risk of Pulmonary Arterial Hypertension in Scleroderma*. Chest 2003; 124:2098-104. [PMID: 14665486 DOI: 10.1378/chest.124.6.2098] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
STUDY OBJECTIVES To investigate whether age at disease onset is a risk factor for pulmonary arterial hypertension (PAH) in scleroderma. SETTING Scleroderma center. PATIENTS Seven hundred nine consecutive scleroderma patients who underwent echocardiography. MEASUREMENTS The risk of PAH associated with age at disease onset was modeled as both a continuous and categorical variable. Risk estimates were adjusted for sex, race, scleroderma subtype, disease duration, smoking status, FVC, anticentromere and antitopoisomerase I antibody status. RESULTS Overall, 274 patients (38.6%), 272 patients by Doppler echocardiography and 2 patients by M-mode echocardiography, had PAH at baseline or during follow-up. There were 114 patients with mild PAH (right ventricular systolic pressure [RVSP], 36 to 45 mm Hg), 66 patients with moderate PAH (RVSP, 46 to 55 mm Hg), and 92 patients with severe PAH (RVSP > or =56 mm Hg). A 52% increase in risk of PAH was demonstrated for every 10 years of age at disease onset (odds ratio [OR], 1.52; 95% confidence interval [CI], 1.31 to 1.76). In addition, there was a twofold greater risk of PAH (OR, 2.30; 95% CI, 1.32 to 3.99) for late-onset (age > or =60 years) vs earlier-onset (< 60 years) disease. These associations remained evident and were somewhat strengthened when the analyses were restricted to patients with moderate and severe PAH. CONCLUSIONS We identified increasing age at scleroderma onset as a risk factor for PAH. Vigilance among these high-risk patients may provide an opportunity to intervene prior to development of irreversible pulmonary vascular disease.
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Affiliation(s)
- Lionel Schachna
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Abstract
Autoimmune disease in the elderly is hypothesized to be caused by an imbalance in T-cell expansion and deletion after an encounter with self-antigens. A decrease in thymic output leads to a decreased pool of naive T cells in the periphery and to increased oligoclonal expansion of T cells. This expansion may be caused by stimulation with autoantigens that drive high-affinity interactions with self-antigens. Accumulation of presenescent, apoptosis-resistant, and proinflammatory T cells results in the growth of these autoreactive T cells. A decreased T-cell activation response that occurs with age leads to several defects that diminish the immune response.
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Affiliation(s)
- Hui-Chen Hsu
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham, 701 South 19th Street, Lyons Harrison Research Building 473, Birmingham, AL 35294, USA
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Abstract
Systemic sclerosis is a generalized disorder characterized by fibrosis and microvascular injury in affected organs. Despite being recognized nearly 250 years ago, knowledge regarding pathogenesis remains limited, and treatment remains directed at symptomatic improvement. Early recognition of systemic sclerosis, however, is important in order to monitor for specific disease complications (i.e., fibrosing alveolitis, scleroderma renal crisis) as well as initiate manifestation specific therapies that improve quality of life.
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Affiliation(s)
- H Mitchell
- Department of Medicine, Medical University of South Carolina, Charleston, USA
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Affiliation(s)
- A J Silman
- ARC Eidemiology Research Unit, University of Manchester
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Affiliation(s)
- A J Silman
- Arthritis and Rheumatism Council Epidemiology Research Unit, Manchester University Medical School, UK
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Systemic sclerosis in old age. BRITISH MEDICAL JOURNAL 1979; 2:1313-4. [PMID: 519428 PMCID: PMC1597378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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