Intracerebral calcification in systemic sclerosis

[Systemic sclerosis and macrovascular involvement: Status of the issue in 2019]

Systemic sclerosis (SSc) is a rare immune disease leading to fibrosis of the skin and internal organs. Microvasculopathy is a hallmark of SSc. However, some patients have severe macrovascular complications as affecting cerebral, cardiac or peripheral vessels. To date, macrovascular involvement in SSc remains a matter of debate. Many studies have shown an increased prevalence of macrovascular involvement in SSc in comparison with controlled subjects with similar cardiovascular risk factors. Various methods were used: ankle brachial pressure index, intima media thickness, imagery, coronary calcium score, pulse wave velocity, or flow mediated dilation. The pathophysiology of macrovascular involvement remains unknown and is probably multifactorial: accelerated atherosclerosis, endothelial dysfunction, or reflected wave of microvessel obliteration. The aim of this study was to perform a comprehensible review of the literature, through the study of different types of involved vessels. Results of the main studies are summarized in tables according to the method of investigation used.

Cardiovascular Manifestations of Systemic Sclerosis: A Danish Nationwide Cohort Study

Background

Cardiovascular involvement in systemic sclerosis (SSc) comprises a wide range of manifestations with prevalence and incidence that remain uncertain.

Methods and Results

In the Danish administrative registries between 1995 and 2015, all patients aged ≥18 years with a first diagnosis of SSc were matched by age and sex with controls (1:5) from the general population. Prevalence of cardiovascular diseases at the time of the SSc diagnosis and incidence during follow‐up were assessed by in‐ and outpatient discharge diagnoses. Conditional logistic and Cox proportional hazards regression models were used respectively to calculate odds ratios for prevalent cardiovascular diseases and hazard ratios (HRs) for incident diseases associated with SSc. Patients with SSc (n=2778; 76% women; mean±SD age: 55±15 years) had more established cardiovascular risk factors than their respective controls at baseline, including greater prevalence of hypertension (31.2% versus 21.0%, P<0.0001) and treated dyslipidemia (9.8% versus 8.5%, P=0.02). SSc was associated with an increased relative risk of developing most cardiovascular diseases, including myocardial infarction (HR: 2.08; 95% CI, 1.65–2.64), peripheral vascular disease (HR: 5.73; 95% CI, 4.63–7.09), pulmonary hypertension (HR: 21.18; 95% CI, 14.73–30.45), mitral regurgitation (HR: 4.60; 95% CI, 3.12–6.79), aortic regurgitation (HR: 3.78; 95% CI, 2.55–5.58), aortic stenosis (HR: 2.99; 95% CI, 2.25–3.97), pericarditis (HR: 8.78; 95% CI, 4.84–15.93), heart failure (HR: 2.86; 95% CI, 2.43–3.37), atrial fibrillation (HR: 1.75; 95% CI, 1.51–2.04), and venous thromboembolism (HR: 2.10; 95% CI, 1.65–2.67). Additional adjustment for medications and comorbidities yielded results similar to the main analyses.

Conclusions

In this nationwide study, SSc was associated with greater risks of distinct cardiovascular diseases for patients than for matched controls, suggesting a significant disease‐related adverse impact across the vascular bed and specific cardiac structures.

Cockayne syndrome: Clinical features, model systems and pathways

Cockayne syndrome (CS) is a disorder characterized by a variety of clinical features including cachectic dwarfism, severe neurological manifestations including microcephaly and cognitive deficits, pigmentary retinopathy, cataracts, sensorineural deafness, and ambulatory and feeding difficulties, leading to death by 12 years of age on average. It is an autosomal recessive disorder, with a prevalence of approximately 2.5 per million. There are several phenotypes (1-3) and two complementation groups (CSA and CSB), and CS overlaps with xeroderma pigmentosum (XP). It has been considered a progeria, and many of the clinical features resemble accelerated aging. As such, the study of CS affords an opportunity to better understand the underlying mechanisms of aging. The molecular basis of CS has traditionally been ascribed to defects in transcription and transcription-coupled nucleotide excision repair (TC-NER). However, recent work suggests that defects in base excision DNA repair and mitochondrial functions may also play key roles. This opens up the possibility for molecular interventions in CS, and by extrapolation, possibly in aging.

Clinical, biochemical, and radiological characterization of the calcinosis in a cohort of Mexican patients with systemic sclerosis

Calcinosis is a frequent complication of systemic sclerosis (SSc) that is usually located in extremities but may occur across the board. The aim of our study was to identify and quantify the distribution of calcinosis in a cohort of Mexican patients with SSc and its association with clinical features and autoantibodies. A cohort of patients with SSc (2013 ACR/EULAR criteria), classified in diffuse cutaneous (dcSSc) and limited cutaneous (lcSSc) (Le Roy criteria), was studied. For their analysis, patients were allocated into those with and without calcinosis (clinical and/or radiological). The evaluation included the modified Rodnan scale for skin and Medsger disease severity scale (DSS). Calcium, phosphorus, vitamin D, and parathyroid hormone (PTH) and antinuclear antibodies and extractable nuclear antigens were determined in serum. A total of 109 patients were included, 41 (37 %) with and 68 (63 %) without calcinosis. Calcinosis was more frequent in patients with dcSSc (55 vs 27 %). In total, we identified 354 sites with calcinosis and mean per patient of 12.0 ± 9.1; the most common sites affected were the hands (83 %), proximal upper extremity (27 %), and proximal lower extremity (22 %). Patients with calcinosis had a higher score of Rodnan scale, Mesdger DSS, and frequency of anti-nucleolar and anti-Scl-70 antibodies compared to those without calcinosis. Abnormal PTH elevation was found in 35 % of patients with calcinosis and 23 % without it. The prevalence of calcinosis is high in Mexican patients with SSc, especially in diffuse variety, and is associated with increased severity of disease.

Early Cardiovascular Disease After the Diagnosis of Systemic Sclerosis

PURPOSE

The purpose of this study is to assess risk and time trends of newly recorded myocardial infarction and stroke in cases with systemic sclerosis.

METHODS

We conducted a matched incident cohort study (1996-2010) among patients satisfying at least one of the following: 1) diagnosis of systemic sclerosis on at least 2 visits within a 2-year period by a nonrheumatologist physician; or 2) diagnosis of systemic sclerosis on at least one visit by a rheumatologist or from hospitalization; as well as receiving no prior systemic sclerosis diagnosis between 1990 and 1995. Ten controls were matched by birth year, sex, and calendar year of exposure from the general population for each case. Incident myocardial infarction, stroke, and myocardial infarction or stroke was recorded from hospital or death certificates. We estimated incidence rate ratios and hazard ratios (HRs) after adjusting for confounders.

RESULTS

Among 1239 individuals with systemic sclerosis and no history of myocardial infarction (83% female, 56 years old), the incidence rate for myocardial infarction was 13.0/1000 person-years vs 4.1/1000 person-years in the comparison cohort. The incidence rate for stroke was 8.0/1000 person-years vs 3.7/1000 among controls. The adjusted HRs were 3.49 (95% confidence interval [CI], 2.52-4.83) and 2.35 (95% CI, 1.59-3.48) for myocardial infarction and stroke, respectively. For myocardial infarction and stroke, the risk was highest within the first year following diagnosis (HR 8.95; 95% CI, 5.43-14.74 and HR 5.25; 95% CI, 2.90-9.53, respectively).

CONCLUSION

This large general population-based study indicates an increased risk of myocardial infarction and stroke in patients with systemic sclerosis, especially within the first year of diagnosis.

Risk of ischemic stroke in patients with systemic sclerosis: A systematic review and meta-analysis

BACKGROUND

Several chronic inflammatory disorders, such as rheumatoid arthritis and idiopathic inflammatory myositis, have been shown to increase risk of ischemic stroke but the data on systemic sclerosis (SSc) remains unclear.

METHODS

We conducted a systematic review and meta-analysis of observational studies that reported odds ratio, relative risk, hazard ratio, or standardized incidence ratio comparing risk of ischemic stroke in patients with SSc versus non-SSc participants. Pooled risk ratio and 95% confidence intervals (CIs) were calculated using a random-effect, generic inverse variance method of DerSimonian and Laird.

RESULTS

Four retrospective cohort studies were identified and included in our data analysis. We found a statistically significant elevated ischemic stroke risk in patients with SSc with a pooled risk ratio of 1.68 (95% CI, 1.26-2.24). The statistical heterogeneity was moderate with an I(2) of 69%.

CONCLUSIONS

Our study demonstrated a statistically significant increased ischemic stroke risk among patients with SSc.

Cardiovascular disease in systemic sclerosis

Cardiovascular (CV) system involvement is a frequent complication of autoimmune diseases such as systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA). It still remains unclear if a premature atherosclerosis (ATS) occurs even in systemic sclerosis (SSc). Although microvascular disease is a hallmark of SSc, in the last few years a number of studies highlighted a higher prevalence of macrovascular disease in SSc patients in comparison to healthy individuals and these data have been correlated with a poorer prognosis. The mechanisms promoting ATS in SSc are not fully understood, but it is believed to be secondary to multi-system organ inflammation, endothelial wall damage and vasculopathy. Both traditional risk factors and endothelial dysfunction have been proposed to participate to the onset and progression of ATS in such patients. In particular, endothelial cell injury induced by anti-endothelial antibodies, ischemia/reperfusion damage, immune-mediated cytotoxicity represent the main causes of vascular injury together with an impaired vascular repair mechanism that determine a defective vasculogenesis. Aim of this review is to analyse both causes and clinical manifestations of macrovascular involvement and ATS in SSc.

Blinded by the UV light: how the focus on transcription-coupled NER has distracted from understanding the mechanisms of Cockayne syndrome neurologic disease

Cockayne syndrome (CS) is a devastating neurodevelopmental disorder, with growth abnormalities, progeriod features, and sun sensitivity. CS is typically considered to be a DNA repair disorder, since cells from CS patients have a defect in transcription-coupled nucleotide excision repair (TC-NER). However, cells from UV-sensitive syndrome patients also lack TC-NER, but these patients do not suffer from the neurologic and other abnormalities that CS patients do. Also, the neurologic abnormalities that affect CS patients (CS neurologic disease) are qualitatively different from those seen in NER-deficient XP patients. Therefore, the TC-NER defect explains the sun sensitive phenotype common to both CS and UVsS, but cannot explain CS neurologic disease. However, as CS neurologic disease is of much greater clinical significance than the sun sensitivity, there is a pressing need to understand its molecular basis. While there is evidence for defective repair of oxidative DNA damage and mitochondrial abnormalities in CS cells, here I propose that the defects in transcription by both RNA polymerases I and II that have been documented in CS cells provide a better explanation for many of the severe growth and neurodevelopmental defects in CS patients than defective DNA repair. The implications of these ideas for interpreting results from mouse models of CS, and for the development of treatments and therapies for CS patients are discussed.

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.

Determinants of disability, quality of life and depression in dermatological patients with systemic scleroderma

BACKGROUND

Systemic scleroderma (SSc) is a rare disease and knowledge about the relationship between clinical signs, disability, quality of life and depressive symptoms is still limited. Although patients with SSc are frequently treated by dermatologists, the vast majority of published evidence is based on rheumatological samples.

OBJECTIVES

To identify determinants of disability, decreased quality of life, and depression in a sample of dermatological patients with SSc.

METHODS

This was a cross-sectional study on consecutive patients with SSc attending one specialist dermatological centre between April 2008 and November 2009. Validated questionnaires, the Health Assessment Questionnaire (HAQ), EuroQol (EQ-5D) and the Center for Epidemiologic Studies Depression scale (CES-D) were utilized to measure disability, quality of life and depressive symptoms. Additionally, disease characteristics (SSc subtype, skin thickness, organ involvement), subjective symptoms of SSc, treatment and socioeconomic characteristics were collected by trained investigators. Based on an a priori hypothesized causal model, multivariate logistic regression models were used to analyse determinants of disability, quality of life and depression in patients with SSc.

RESULTS

A total of 72 patients [59 female (82%), mean age 59years] were enrolled. According to the CES-D, 69% (48 out of 70) were screened positive for depression. Quality of life impairment and female sex and were independent risk factors for depressive symptoms. Disease-specific disability was the main determinant of quality of life impairment in SSc. Pain involvement of the musculoskeletal system and male sex were the main determinants of disability in our sample of patients with SSc.

CONCLUSIONS

The high psychosomatic morbidity in our sample of consecutive patients with SSc calls for the investigation of interdisciplinary models of care.

Atherosclerosis in systemic sclerosis: a systematic review and meta-analysis

OBJECTIVE

Systemic sclerosis (SSc) is characterized by calcification, vasculopathy, and endothelial wall damage, all of which can increase the risk of developing atherosclerosis and cardiovascular disease. The aim of this study was to perform a systematic review and meta-analysis to determine whether the risk of atherosclerosis is increased in SSc patients compared to healthy individuals.

METHODS

A systematic search was performed to identify studies published in PubMed and the Cochrane database up to May 2010, and recently published abstracts were also reviewed. Two reviewers independently screened articles to identify studies comparing the rate of atherosclerosis in SSc patients to that in healthy controls. The studies utilized one of the following methods: angiography, Doppler ultrasound to assess plaque and carotid intima-media thickness (IMT), computed tomography, magnetic resonance imaging, flow-mediated vasodilation (assessed as the FMD%), the ankle-brachial index, or autopsy. For carotid IMT and FMD% values, we computed a pooled estimate of the summary mean difference and explored predictors of carotid IMT using random-effects meta-regression.

RESULTS

Of the 3,156 articles initially identified, 31 were selected for systematic review. The meta-analysis included 14 studies assessing carotid IMT and 7 assessing brachial artery FMD%. Compared to healthy controls, SSc patients had a higher prevalence of coronary atherosclerosis, peripheral vascular disease, and cerebrovascular calcification. Meta-analysis showed that SSc patients had increased carotid IMT (summary mean difference 0.11 mm, 95% confidence interval [95% CI] 0.05 mm, 0.17 mm; P = 0.0006) and lower FMD% (summary mean difference -3.07%, 95% CI -5.44%, -0.69%; P = 0.01) compared to controls. There was marked heterogeneity between the studies, which was mainly attributable to variations in disease duration and differences in the mean/median age between SSc patients and controls.

CONCLUSION

Patients with SSc have an increased risk of atherosclerosis compared to healthy subjects. Further studies should elucidate the mechanism of this increased risk.

Mood and anxiety disorders in systemic sclerosis patients

OBJECTIVE

To assess the prevalence of mood and anxiety disorders in systemic sclerosis (SSc) patients and the association of these disorders with clinical features.

METHODS

Between May 2002 and May 2004, 100 SSc patients fulfilling the American Rheumatism Association and/or Leroy & Medsger criteria were recruited: 51 were from a SSc patient association meeting, and 49 were hospitalized in an internal medicine department and recruited consecutively. Mood and anxiety disorders were assessed by use of a structured clinical interview [the Mini International Neuropsychiatric Interview (MINI)] performed by a psychiatrist and a self-reporting questionnaire [the Hospital Anxiety and Depression Scale (HADS)]. On the same day, psychiatric treatment and clinical features were recorded by a physician.

RESULTS

As assessed by the MINI, 19% [95% confidence interval 12-28%] of all SSc patients were currently experiencing a major depressive episode (MDE), 56% [46-65%] had a lifetime history of MDE and 14% [8-22%] had current dysthymia. Current MDE was more prevalent among hospitalized patients than among other patients (28% versus 10%, p=0.02). Specific anxiety disorders were diagnosed in 37 [28-47] patients. Less than 50% of the patients with mood disorders received psychiatric treatment. Patients with or without current depression did not differ in clinical symptoms of SSc, except for digestive symptoms.

CONCLUSION

The current and lifetime prevalence of major depression and anxiety disorders is high in SSc patients, especially during hospitalization. However, only half of such patients receive adequate psychiatric treatment. Therefore, a better assessment of psychiatric disorders in SSc patients is needed.

Linear scleroderma "en coup de sabre": initial presentation as intractable partial seizures in a child

Linear scleroderma is a form of localized scleroderma characterized by sclerotic lesions distributed in a linear, band-like pattern. The "en coup de sabre" subtype of linear scleroderma is more often associated with systemic morbidity, including ocular, oral, and neurological abnormalities. Here, we report one patient with typical linear scleroderma "en coup de sabre" (LSCS). Initially, he presented with refractory partial seizures before the characteristic skins lesion on his head developed. This was a rare case with obvious brain parenchyma involvement. We did not prescribe medication but performed serial brain magnetic resonance imaging follow-up for the intraparenchymal lesion. The atrophic changes of the skin, face and brain remained the same, and his seizures had not worsened at the most recent follow-up. Parry-Romberg syndrome, a very similar condition, should be differentiated from LSCS.

Cerebral Vasculopathy Is Associated with Severe Vascular Manifestations in Systemic Sclerosis

Objective.

To investigate brain involvement in patients with systemic sclerosis (SSc).

Methods.

Sixty-three patients with SSc fulfilling the American College of Rheumatology and/or Leroy and Medsger criteria were retrospectively studied, including 30 (47.6%) with limited cutaneous and 27 (42.9%) with diffuse cutaneous SSc. Forty-one patients underwent computed tomography (CT) scan and magnetic resonance imaging (MRI) of the brain, 11 patients only CT scan, and the remaining 11 patients only MRI. Cerebral vasculopathy on MRI and CT scan was defined as absent or mild (score < 1), moderate (1 ≤ score < 2), or severe (score ≥ 2) on a 4-point scale (0 to 3).

Results.

Cerebral vasculopathy was identified on CT scan in 22 patients (moderate in 12 and severe in 10) and on MRI in 38 patients (moderate in 28 and severe in 10). Patients with severe cerebral vasculopathy seen on MRI were more likely to have pulmonary arterial hypertension (PAH; p = 0.003) and showed a tendency to have scleroderma renal crisis (SRC; p = 0.25, test for trend p = 0.097). A similar association was found between severe cerebral vasculopathy seen on CT scan and PAH (p = 0.026) or SRC (p = 0.04). After adjusting for age and hypertension, severe cerebral vasculopathy was still associated with increased risk of severe vascular manifestations [odds ratio (OR) 32, 95% confidence interval (CI) 3.45–297, p = 0.002 for CT scan; OR 26, 95% CI 1.71–394, p = 0.019 for MRI].

Conclusion.

Severe cerebral vasculopathy is associated with severe vascular manifestations in SSc patients. SSc patients with severe vascular complications should undergo neuroradiological imaging assessment of brain involvement.

Cognitive and cerebral hemodynamic impairment in scleroderma patients

BACKGROUND AND PURPOSES

Neurological involvement in systemic sclerosis is unusual despite the possible cerebral localization of vascular lesions. The aim of this study was to evaluate cognitive performances and cerebral vasoreactivity in young scleroderma patients without any signs or symptoms of nervous system involvement.

METHODS

Sixteen scleroderma patients and 16 sex- and age-matched healthy subjects without vascular risk factors were included. A neuropsychological assessment for the evaluation of different areas of cognition was performed. For an assessment of cerebrovascular reactivity (CVR), each subject was submitted to hypercapnia with transcranial Doppler ultrasonography using the Breath-Holding Index (BHI).

RESULTS

Patients had significantly lower adjusted mean levels of performance with respect to controls in the Modified Card Sorting Test (P < 0.001) and in the Trail Making Test Parts A and B (P < 0.001 and P < 0.05 respectively). Regarding CVR, BHI values were significantly lower in patients with respect to controls: 0.82 +/- 0.44 vs. 1.34 +/- 0.18, P < 0.0001.

CONCLUSIONS

These findings show the presence of reduced performances of executive functions in scleroderma patients. The associated alteration of CVR in the absence of other apparent causes of cerebrovascular impairment suggests that cognitive problems may be related to an alteration in cerebral perfusion regulation specifically linked to the disease. Further studies are needed to evaluate whether cognitive changes may be positively influenced by treatments aimed to improve vessels functionality in scleroderma patients.

Linear scleroderma en coup de sabre with associated neurologic abnormalities

Linear scleroderma represents a unique form of localized scleroderma that primarily affects the pediatric population, with 67% of patients diagnosed before 18 years of age. When linear scleroderma occurs on the head, it is referred to as linear scleroderma en coup de sabre, given the resemblance of the skin lesions to the stroke of a sabre. Here we describe 3 pediatric patients with linear scleroderma en coup de sabre who presented with neurologic abnormalities before or concurrent with the diagnosis of their skin disease. Our patients' cases highlight the underrecognized relationship between neurologic complications and linear scleroderma en coup de sabre and illustrate the importance of a thorough skin examination in patients with unexplained neurologic disease.

Basal ganglia calcification in BB/E rats with diabetes

Human diabetes is associated with cognitive impairment and structural abnormalities in the brain such as cerebral atrophy. The aetiology of these abnormalities is not known. The BB/E rat is a well-established model of type 1 (insulin dependent) diabetes. A cohort of 34 BB/E rats with diabetes was divided into three sub-groups according to age (and duration of diabetes). Basal ganglia calcification (BGC) was present in the brains of more than 50% of diabetic animals, but not in any of 37 non-diabetic BB/E rats. BGC occurred more commonly in those animals which had the longest duration of diabetes (p=0.001), such that BGC was present in only 8% of animals with diabetes for 20 weeks, but in 100% of animals with diabetes for 60 weeks. There were no other significant light microscopic neuropathologic changes in diabetic animals. It will be important to investigate the mechanism of brain calcification, whether a similar process occurs in humans with diabetes, and its possible relationship to cognitive decline.

Mineralization of the basal ganglia: implications for neuropsychiatry, pathology and neuroimaging

This article examines the evidence for and against the existence of basal ganglia mineralization as a defined clinico-pathological entity. In reviewing the literature on basal ganglia mineralization, this article emphasizes evidence derived from different neuroimaging modalities, genetics, metabolic studies, postmortem series and their possible neuropsychiatric correlates. Relevant articles were collected through Medline and Index Medicus searches. Researchers have encountered multiple difficulties in accepting basal ganglia mineralization as a distinct entity. This syndrome lacks set clinical criteria or a unique etiology; not surprisingly, numerous articles have applied varied definitions. Because many of the reported cases have not been examined postmortem, both the extent and nature of their mineralization remains uncertain. Furthermore, researchers have considered small foci of basal ganglia mineralization a normal phenomenon of aging. However, when brain deposits are extensive, they are associated with a set of age-dependent, progressive clinical symptoms. They include cognitive impairment, extrapyramidal symptoms and psychosis. Most cases are related to abnormalities of calcium metabolism, but rare familial cases of idiopathic origin have been reported. Overabundant mineralization of the brain is judged pathological based on its amount, distribution and accompanying clinical symptoms. Although its relation with calcium dysregulation is well known, modern studies have emphasized abnormalities of iron and dopamine metabolism. The authors suggest that these metabolic abnormalities may link basal ganglia mineralization to psychotic symptomatology.

The use of pupillometry in joint and connective tissue diseases

The central and peripheral nervous systems are variably affected in the rheumatic diseases. Automated standardized infrared pupillometry allows the safe, noninvasive assessment of the pupillary innervation. Pupillometry has already been used in studying the autonomic nervous system (ANS) in various rheumatic diseases. In systemic lupus erythematosus, the irideal parasympathetic branch of ANS was more affected then the sympathetic branch. In Sjögren's syndrome, signs of pupillary parasympathetic denervation have been reported. In rheumatoid arthritis, pupil parasympathetic dysfunction has been shown to correlate with ocular dryness. In systemic sclerosis (SSc), both sympathetic and parasympathetic irideal impairment have been demonstrated. Beside providing autonomic innervation, sensory nerves fibers are able to control iris diameter. Exogenous ocular instillation of substance P (SP), a sensory neuropeptide, can determine an omathropine-resistant, non-cholinergic myosis, acting on specific receptors present on the iris sphincter muscle. We first studied pupillary SP-ergic responsiveness in SSc, evaluating substance P (SP)-stimulated pupillary diameters by pupillometry. A higher basal and SP-stimulated myosis was found in lSSc versus both dSSc and controls, whereas no differences existed between dSSc and controls. From the literature, the pupillary parasympathetic nervous system seems to be more affected than the sympathetic branch of ANS in the rheumatic diseases characterized by an inflammatory status. However, we found in SSc both sympathetic and parasympathetic pupil control to be equally impaired. From our experience, we conclude that pupillary nervous control is differently affected in the two subsets of SSc, and that the SP-ergic system seems to be impaired only in lSSc.