Bladder involvement in systemic sclerosis: urodynamic and histological evaluation in 23 patients

Autonomic dysfunction in systemic sclerosis: A scoping review

INTRODUCTION

Over the years several lines of evidence have implied a pathological involvement of autonomic nervous system (ANS) in systemic sclerosis (SSc). However, the relationship between autonomic dysfunction and SSc is not yet fully understood. The aims of this scoping review were to map the research done in this field and inform future research to investigate pathogenic hypotheses of ANS involvement.

METHODS

We performed a scoping review of publications collected through a literature search of MEDLINE and Web of Science databases, looking for dysautonomia in SSc. We included original data from papers that addressed ANS involvement in SSc regarding pathogenesis, clinical presentation and diagnostic tools.

RESULTS

467 papers were identified, 109 studies were selected to be included in the present review, reporting data from a total of 2742 SSc patients. Cardiovascular system was the most extensively investigated, assessing heart rate variability with 24 h HolterECG or Ewing's autonomic tests. Important signs of dysautonomia were also found in digital vasculopathy, gastrointestinal system and SSc skin, assessed both with non-invasive techniques and histologically. Research hypotheses mainly regarding the relationship between sympathetic system - ischemia and the role of neurotrophins were then developed and discussed.

CONCLUSION

We described the currently available evidence on pathogenesis, clinical presentation and diagnostic assessment of dysautonomia in SSc patients. A strong influence of ANS deregulation on SSc clearly emerges from the literature. Future research is warranted to clarify the mechanisms and timing of autonomic dysfunction in SSc.

Pathogenetic rationale for prescribing menopausal hormone therapy for systemic sclerosis

Systemic scleroderma (SS) is characterized by dysregulation of the innate and adaptive immune systems, vasculopathy, and generalized fibrosis. As with most autoimmune diseases, women predominate among patients, who get sick 3–14 times more often than men. It is assumed that gender differences and modulation of sex hormones are essential in the pathogenesis of SS. Estrogens are able to influence the immune response, have a vasodilating effect and stimulate the synthesis of collagen in the skin. The development of SS leads to a significant decrease in the quality of life, psychological disorders associated with changes in appearance, as well as the need for lifelong medication with the frequent development of side effects. Age-related estrogen deficiency associated with the onset of menopause is accompanied by a decrease in the quality of life and, in some cases, a change in the clinical manifestations of somatic diseases. This review considers the impact of menopause and menopausal hormone therapy (MHT) on the course and clinical manifestations of systemic scleroderma. It is noted that SS in some cases is accompanied by an early onset of menopause. The use of MHT is not associated with the progression of cutaneous fibrosis, and may also improve the vascular manifestations of SS.

Urinary incontinence in systemic sclerosis: a prospective multicentre cohort study

Investigate the natural history of urinary incontinence (UI) in systemic sclerosis (SSc) and assess its impact on quality of life (QoL). A longitudinal, international observational study followed 189 patients with SSc for a median duration of 5 years (IQR: 4.8–5.3). Presence, subtype and severity of UI, hospital admission and QoL were assessed using serial self-administered questionnaires. Mortality data came from national death registries. Multilevel mixed-effect logistic regressions explored factors associated with UI. Cox models adjusted the effects of UI on hospitalization and death for age, sex and subtype of SSc. Mean annual rates of new-onset UI and remission were 16.3% (95%CI 8.3%–24.2%) and 20.8% (95%CI 12.6–29.1), respectively. Among UI patients, 57.9% (95%CI 51.8–64.0) changed from one UI subtype to another. Between annual questionnaires, the severity of UI was the same in 51.1% (95%CI 40.8–61.4), milder or resolved in 35.2% (95%CI 25.3–44.9), and worse in 13.8% (95%CI 6.7–20.9). Anti-centromere antibodies, digestive symptoms, sex, age, neurological or urological comorbidities, diuretics and puffy fingers were all associated with UI. The two strongest predictors of UI and UI subtypes were a recent UI episode and the subtype of previous leakage episodes. UI at inclusion was not associated with hospital admission (adjusted HR: 1.86; 95%CI 0.88–3.93), time to death (aHR: 0.84; 95%CI 0.41–1.73) or change in QoL over time. Self-reported UI among SSc patients is highly dynamic: it waxes and wanes, changing from one subtype to another over time.

Lower urinary tract symptoms in systemic sclerosis: a detailed investigation

OBJECTIVES

Urinary tract involvement is a seldom-reported manifestation of SSc that could compromise patients' quality of life. This study compares lower urinary tract symptoms (LUTS) in SSc patients and in healthy subjects and their association with clinical and diagnostic parameters.

METHODS

LUTS were assessed through self-reported questionnaires in 42 SSc patients and 50 matched healthy subjects. Statistical analyses were performed to explore LUTS in the two populations and their association with SSc variables, including nailfold videocapillaroscopy patterns, SSc-related antibodies and DXA parameters.

RESULTS

SSc patients showed significantly higher prevalence and severity of urinary incontinence (UI) and overactive bladder (OAB) than healthy controls (P < 0.005, P < 0.01). SSc was a strong predictor of LUTS, independent of demographic data, comorbidities and treatments (odds ratio 5.57, 95% CI 1.64-18.88). In SSc patients OAB positively correlated with sarcopenia (P < 0.001), and both OAB and UI significantly correlated with reduced BMD (P < 0.05, P = 0.001). UI positively correlated with Scl70 antibodies (P < 0.05) and ciclosporin treatment (P = 0.001) and negatively with RNA polymerase III antibodies (P < 0.05); OAB positively correlated with calcinosis (P < 0.005) and negatively with methotrexate treatment (P < 0.05). Nailfold videocapillaroscopy 'active' and 'late' patterns were predominant among SSc patients presenting urinary symptoms, although no statistical correlation was found.

CONCLUSION

For the first time urinary tract involvement was found to be significantly higher in SSc patients than in healthy matched controls. In addition, sarcopenia, bone damage and calcinosis appeared significantly correlated with LUTS, suggesting a possible interplay.

Ganglionic Acetylcholine Receptor Antibodies and Autonomic Dysfunction in Autoimmune Rheumatic Diseases

Autonomic neuropathy has been reported in autoimmune rheumatic diseases (ARD) including Sjögren’s syndrome, systemic sclerosis, rheumatoid arthritis, and systemic lupus erythematosus. However, the pathophysiological mechanism underlying autonomic dysfunction remains unknown to researchers. On the other hand, autoimmune autonomic ganglionopathy (AAG) is an acquired immune-mediated disorder, which causes dysautonomia that is mediated by autoantibodies against ganglionic acetylcholine receptors (gAChRs). The purpose of this review was to describe the characteristics of autonomic disturbance through previous case reports and the functional tests used in these studies and address the importance of anti-gAChR antibodies. We have established luciferase immunoprecipitation systems to detect antibodies against gAChR in the past and determined the prevalence of gAChR antibodies in various autoimmune diseases including AAG and rheumatic diseases. Autonomic dysfunction, which affects lower parasympathetic and higher sympathetic activity, is usually observed in ARD. The anti-gAChR antibodies may play a crucial role in autonomic dysfunction observed in ARD. Further studies are necessary to determine whether anti-gAChR antibody levels are correlated with the severity of autonomic dysfunction in ARD.

Systemic sclerosis and urinary symptoms: a complex pathophysiology

Lower urinary tract symptoms (LUTS) have long been overlooked in systemic sclerosis (SSc). However, they are out of proportion of what would be expected based on age, sex, and presence of usual risk factors. Thus, there must be specific scleroderma-related mechanisms to result in LUTS. Fibrosis, nervous involvement (notably, dysautonomia), early signs of menopauses, and functional restriction play certainly a role, but available evidence shows inconsistent results. Thus, these factors are not sufficient to explain all aspect of LUTS in SSc. In vitro experiments point out a promising alternative mechanism, already observed in other rheumatologic diseases: an antibody-mediated etiology. However, more research is needed to better understand the pathophysiology of LUTS in SSc and develop specific treatment.

Anal incontinence and vesico-sphincter events in systemic sclerosis: An epidemiologic bicentric cohort study

OBJECTIVE

To estimate the frequency and severity of anal incontinence and vesico-sphincter events, associated factors, and impact on the quality of life of patients with systemic sclerosis.

METHODS

Questionnaires assessing anal incontinence (Miller score), vesico-sphincter events (Urogenital Distress Inventory) and quality of life [Short Form Health Survey 36v2 (SF-36), and Hospital Anxiety and Depression Scale] were mailed to 139 patients with systemic sclerosis at the university hospitals of Besançon and Poitiers, France. Clinical data were collected from the medical records to identify risk factors.

RESULTS

Among the 121 (87%) responders, severe vesico-sphincter events or severe anal incontinence occurred in 3.4% and 12.4% of cases, respectively. Frequent urination (66.3%) and anal incontinence to gas (50.4%) were the most frequent symptoms. Anal incontinence was associated positively with vesico-sphincter events, unrelated to obstetrical factors. No correlations were seen with age, sex, or systemic sclerosis characteristics. In multivariate analysis, moderate or severe vesico-sphincter events was associated with higher anxiety and depression scores and lower SF-36 scores; the same results were observed for anal incontinence, but did not reach significance.

CONCLUSION

Vesico-sphincter events and anal incontinence are common in systemic sclerosis, and sometimes severe, with a potential negative impact in quality of life. These results will be confirmed by a case-control study with dynamic and manometric assessment, and could legitimate a systematic screening to ensure early therapy and multidisciplinary individual management.

Neurologic involvement in scleroderma: a systematic review

OBJECTIVES

To perform a systematic review of neurologic involvement in Systemic sclerosis (SSc) and Localized Scleroderma (LS), describing clinical features, neuroimaging, and treatment.

METHODS

We performed a literature search in PubMed using the following MeSH terms, scleroderma, systemic sclerosis, localized scleroderma, localized scleroderma "en coup de sabre", Parry-Romberg syndrome, cognitive impairment, memory, seizures, epilepsy, headache, depression, anxiety, mood disorders, Center for Epidemiologic Studies Depression (CES-D), SF-36, Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Patient Health Questionnaire-9 (PHQ-9), neuropsychiatric, psychosis, neurologic involvement, neuropathy, peripheral nerves, cranial nerves, carpal tunnel syndrome, ulnar entrapment, tarsal tunnel syndrome, mononeuropathy, polyneuropathy, radiculopathy, myelopathy, autonomic nervous system, nervous system, electroencephalography (EEG), electromyography (EMG), magnetic resonance imaging (MRI), and magnetic resonance angiography (MRA). Patients with other connective tissue disease knowingly responsible for nervous system involvement were excluded from the analyses.

RESULTS

A total of 182 case reports/studies addressing SSc and 50 referring to LS were identified. SSc patients totalized 9506, while data on 224 LS patients were available. In LS, seizures (41.58%) and headache (18.81%) predominated. Nonetheless, descriptions of varied cranial nerve involvement and hemiparesis were made. Central nervous system involvement in SSc was characterized by headache (23.73%), seizures (13.56%) and cognitive impairment (8.47%). Depression and anxiety were frequently observed (73.15% and 23.95%, respectively). Myopathy (51.8%), trigeminal neuropathy (16.52%), peripheral sensorimotor polyneuropathy (14.25%), and carpal tunnel syndrome (6.56%) were the most frequent peripheral nervous system involvement in SSc. Autonomic neuropathy involving cardiovascular and gastrointestinal systems was regularly described. Treatment of nervous system involvement, on the other hand, varied in a case-to-case basis. However, corticosteroids and cyclophosphamide were usually prescribed in severe cases.

CONCLUSIONS

Previously considered a rare event, nervous system involvement in scleroderma has been increasingly recognized. Seizures and headache are the most reported features in LS en coup de sabre, while peripheral and autonomic nervous systems involvement predominate in SSc. Moreover, recently, reports have frequently documented white matter lesions in asymptomatic SSc patients, suggesting smaller branches and perforating arteries involvement.

Ciprofloxacin utility as antifibrotic in the skin of patients with scleroderma

Scleroderma is an autoimmune connective tissue disorder that is characterized by microvascular injury, excessive fibrosis of the skin, and distinctive visceral changes that can involve the lungs, heart, kidneys and gastrointestinal tract. To date, although several drugs have been used to reduce fibrosis in scleroderma, there exists no effective pharmacological treatment. To determine if oral ciprofloxacin reduces the severity of scleroderma, a controlled, double-blind randomized clinical trial, with placebo, was conducted on 32 patients with diffuse and limited scleroderma, who received oral ciprofloxacin (250 mg) or placebo every 12 h. Skin induration and thickness of the patients were clinically evaluated using the modified Rodnan skin score at the beginning and once per month during 6 months of treatment with ciprofloxacin. To monitor progression of the disease, a monthly hematological exam and clinical evaluation was done to explore renal and hepatic function for each patient. Thirty patients completed the study; one from the treatment group was excluded when presenting a skin reaction and another from the placebo group abandoned the study due to an exacerbation of disease. At the sixth month of the study, the ciprofloxacin group of patients showed a diminution in the modified Rodnan skin score (58% vs 18%, P = 0.003), showing no significant alterations in the laboratory assays in either groups of patients. Our results suggest that oral administration of ciprofloxacin for 6 months reduces the severity of symptoms affecting the skin of patients with systemic scleroderma, and does so without important secondary effects.

Autonomic dysfunction in rheumatic diseases

Patients who have rheumatic diseases often present with dysfunctions that are related to the autonomic nervous system (ANS) and are due to peripheral autonomic neuropathy or central changes. This article describes the prevalence of autonomic dysfunctions in patients who have rheumatic diseases. In the second part of this article, another form of ANS dysfunction-complex regional pain syndromes-is demonstrated. Clinically, these syndromes are characterized by pain (spontaneous, hyperalgesia, allodynia); active movement disorders, including an increased physiologic tremor, abnormal regulation of blood flow and sweating, edema of skin and subcutaneous tissues; and trophic changes of skin, appendages of skin, and subcutaneous tissues. In conclusion, this discussion shows that alterations of the ANS occur in rheumatic and related diseases, that these alterations may be involved in the pathogenesis of these diseases, and that we need more refined methods to study the changes that are related to the ANS.

Atteinte vésicale dans la sclérodermie : à propos de 3 cas

Lower urinary tract involvement is the common manifestation of systemic sclerosis. It may represent a troublesome disturbance affecting the quality of life in systemic sclerosis patients. We report three patients with progressive systemic sclerosis who manifested pathologic abnormalities in the urinary bladder. The first patient manifested a recurrent macroscopic hematuria requiring transfusions. Both other patients developed functional and urodynamic abnormalities. With a review of the literature on this involvement of the bladder in systemic sclerosis we try to more understand urinary symptoms and urodynamics features of vesical involvement in systemic sclerosis patients.

A case report of bilateral hydroureteronephrosis associated with systemic sclerosis

Abstract This report describes a case of atrophic bladder and bilateral hydroureteronephrosis that occurred in a patient with systemic sclerosis (SSc). A 49-year-old woman who had a 12-year history of SSc was admitted to our hospital because of bilateral hydroureteronephrosis indicated by uroflowmetric and radiological studies. Histological examination of the patient's bladder after biopsy revealed fibrotic replacement of submucosa and infiltration of mononuclear cells, but no deposition of immunoglobulins and complement components were observed. Nephrostomy to relieve the urinary retention was required. There have been few reports regarding SSc complications in hydronephrosis. The association between hydronephrosis and the pathological disorder of SSc is discussed.