Recurrent uveitis in a patient with CREST syndrome: a case report

Introduction

Systemic sclerosis is a connective tissue condition presented with clinical manifestations, including ocular involvement in a small percentage. A few cases of uveitis were described in the literature, especially in CREST syndrome.

Case presentation

The authors reported a case of a 48-year-old male with a blurred vision in his left eye that diagnosed with recurrent uveitis in the setting of CREST syndrome, treated with prednisolone, methotrexate, and golimumab, with improvement.

Discussion

Ocular manifestations of systemic sclerosis include palpebral alterations, keratoconjunctivitis, sicca syndrome, cataracts, pinguecula, and blepharitis. To our knowledge, this is the fifth case of uveitis in a setting of CREST syndrome in the literature, and the first one in sex involvement, as the previous cases were females, and in its treatment by golimumab, an anti-tumor necrosis factor inhibitor.

Conclusion

Although this association is low, we believe that it should be taken into consideration when treating these situations to obtain better treatment results. Collaboration between rheumatologists and ophthalmologists is necessary in deciding on treatment.

PACK syndrome: A case series and review

A rare overlap syndrome between CREST (calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia) syndrome and primary biliary cholangitis (PBC) is described as PACK syndrome, an acronym for primary biliary cholangitis, anticentromere antibodies, CREST syndrome, and keratoconjunctivitis sicca. In this retrospective cohort analysis and review, we present fourteen patients who meet diagnostic criteria for PACK syndrome in one of the largest case series of this group. All patients were female, 86% of whom were White with an average age of 66.7 years (range 39-78 years). The prevalence was 5.08% in our PBC cohort (n=256) similar to previous findings. CREST syndrome was diagnosed prior to PBC in 58% of our patients and limited pulmonary and renal involvement were observed. This syndrome is rare, but given its insidious development, clinicians should be aware of this potential overlap in CREST-only and PBC-only patients.

Noncirrhotic portal hypertension in primary biliary cholangitis with coexisting CREST syndrome

Primary Biliary Cholangitis (PBC) is an autoimmune liver disease that is sometimes associated with CREST (calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia) syndrome. If left untreated, PBC eventually progresses to liver cirrhosis. We describe an adult patient with CREST-PBC who presented with recurrent variceal bleeding and ultimately required transjugular intrahepatic portosystemic shunt (TIPS) insertion. Liver biopsy excluded cirrhosis, resulting in a diagnosis of noncirrhotic portal hypertension. This case report describes the pathophysiology of presinusoidal portal hypertension as a rare complication of PBC and its association with coexisiting CREST.

Acute Spontaneous Colonic Perforation in a Case of Newly Confirmed Scleroderma: Case Report

Scleroderma is a group of autoimmune diseases that principally affects the skin, blood vessels, muscles, and viscera. One of the more well-known subgroups of scleroderma is the limited cutaneous form of the multisystem connective tissue disorder known as CREST (calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasis) syndrome. In this report, we present a case of a spontaneous colonic bowel perforation in a patient with incomplete features of CREST. Our patient underwent a complicated hospital course involving broad-spectrum antibiotic coverage, surgical hemicolectomy, and immunosuppressives. She was eventually discharged home with a return to functional baseline status after esophageal dysmotility confirmation via manometry. Physicians managing patients with scleroderma ensuing to an emergency department encounter must anticipate the multitude of complications that can occur, as was seen in our patient. The threshold for pursuing imaging and additional tests, in addition to admission, should be relatively low, given the extremely high rates of complications and mortality. Early multidisciplinary involvement with infectious disease, rheumatology, surgery, and other respective specialties is crucial for patient outcome optimization.

CREST Syndrome in Systemic Sclerosis Patients - Is Dystrophic Calcinosis a Key Element to a Positive Diagnosis?

Introduction

CREST syndrome is a clinical entity associated with systemic sclerosis, which meets at least three of the five clinical features: calcinosis, Raynaud’s phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia. Three of these clinical features (Raynaud’s phenomenon, sclerodactyly and esophageal dysmotility) are often present in classical subsets of SSc: limited and diffuse, and their presence in association does not define CREST syndrome. Calcinosis seems to be less common in SSc and its association with other clinical features is characteristic of CREST syndrome. Therefore, it can be appreciated that calcinosis is the key element of CREST syndrome.

Methods

This study included a number of 37 candidates with SSc, diagnosed with the help of the American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) 2013 criteria.

Results and Discussions

These three elements (calcinosis, Raynaud’s phenomenon, esophageal dysmotility) were recorded both in the limited subset of SSc, but especially in the subset of diffuse SSc, contrary to the data in the literature.

Conclusion

We appreciate that CREST syndrome is a clinical entity that can overlap with both subsets of SSc. Given the divergent views of the authors on the classification of CREST syndrome, future studies may contribute to a reassessment of SSc classification.

Occlusive retinal vasculitis associated with systemic sclerosis and antiphospholipid antibodies

PURPOSE

To report a series of patients with occlusive retinal vasculitis associated with systemic sclerosis (SSc) and elevated antiphospholipid antibody titers.

METHOD

Case series. Main outcome measures included clinical and fluorescein angiographic findings at presentation and over time.

OBSERVATIONS

Case 1 - A 61-year-old woman initially diagnosed with idiopathic, bilateral panuveitis and retinal vasculitis causing peripheral nonperfusion was subsequently diagnosed with limited cutaneous systemic sclerosis (lcSSc). Her ocular inflammation and retinal vasculitis were controlled with topical and periocular corticosteroids, but she eventually developed peripheral retinal vascular occlusion that progressed to macular ischemia 11 years after presentation. Repeat serologic evaluation detected interval development of antiphospholipid antibodies. Case 2 - A 58-year-old woman was found to have bilateral peripheral nonperfusion and retinal neovascularization in her right eye. Given her elevated hemoglobin A1c of 8.5%, she was diagnosed with presumed proliferative diabetic retinopathy. Three years after initial presentation, she was diagnosed with lcSSc. Subsequent serum workup detected elevated B2-glycoprotein antibody titers. Her peripheral nonperfusion progressed despite adequate glycemic control, resulting in further neovascularization in each eye. Case 3 - A 40-year-old woman with diffuse cutaneous systemic sclerosis (dcSSc) and elevated titers of anti-cardiolipin antibodies developed multiple branch retinal artery occlusions with subsequent neovascularization of the retina, optic disc, and angle in the right eye.

CONCLUSION AND IMPORTANCE

Vision-threatening occlusive retinal vasculitis may develop in select patients with SSc. The presence of elevated anti-phospholipid antibody titers may confer increased risk for this vision-threatening complication.

Oral Health Experiences of the Limited Scleroderma Patient

Purpose: Limited scleroderma is associated with significant risks to the orofacial complex. The purpose of this mixed methods study was to investigate the experiences of participants with limited scleroderma related to oral health quality of life and oral health.Methods: A sequential mixed methods study was used in a population of individuals diagnosed with limited scleroderma. Participants were recruited through rheumatology specialists, referral, and social media; purposive sampling was used to recruit participants to be interviewed. The validated Oral Health Impact profile (OHIP) and Mouth Handicap in Systemic Sclerosis (MHISS) instruments and semi-structured interviews were used for data collection. Quantitative data were analyzed using descriptive statistics and the qualitative data were reported through thematic analysis.Results: Forty-eight (n=48) qualifying participants participated in the quantitative phase, and 12 (n=12) participated in the qualitative phase. Based on a Likert Scale from 0-4, mean OHIP-14 scores ranged from 2.76 to 2.85, with anxiety over oral condition, embarrassed by oral problems, and oral self-consciousness having the greatest negative impact on quality of life. Mean MHISS scores ranged from 2.13 to 3.11. The highest OHRQoL scores were related to dry mouth symptoms. Factors influencing oral health-related quality of life were varied; dry mouth and microstomia were the prevalent complaints. Thematic analysis revealed challenges to oral health included self-care and professional dental care factors, both of which depended upon individual disease expression. Financial and emotional burdens also influenced participants' oral health.Conclusion: The oral health-related quality of life of those with limited scleroderma is impacted by multiple factors and oral health care professionals must seek out improved treatment modalities to address the needs of these vulnerable individuals. Future studies related to interprofessional collaborative care with scleroderma specialists are recommended.

Bilateral uniportal video-assisted thoracoscopic sympathectomy for managing secondary Raynaud's in CREST syndrome: A case report

INTRODUCTION

Secondary Raynaud's is a manifestation that can present in CREST syndrome as a variant of five different diseases: Calcinosis, Raynaud's phenomenon, Esophageal dysmotility, Sclerodactyly, and Telangiectasia. Secondary Raynaud's presents as a result of an imbalance between vasoconstriction and vasodilation potentially leading to tissue ischemia. The mainstay treatment is medical while surgery treatment preserved as a last resort.

PRESENTATION OF CASE

A 28-year-old female presented with secondary Raynaud's and was subsequently diagnosed with CREST syndrome. The patient failed to respond to medical treatment, and gangrene of the right fourth distal phalanx developed. Stellate ganglion block was successfully used as a bridge to surgery. Uniportal video-assisted thoracoscopic surgery (VATS) sympathectomy was performed via a 2-cm incision, the sympathetic ganglia were identified and transected by cauterization at the level of the 3rd, 4th, and 5th intercostal spaces extending for a distance of 5 cm to ensure that the nerve of Kuntz was transected. The postoperative outcome was satisfactory, and the condition of the patient improved in a few months.

DISCUSSION

Different management modalities have been used to relieve the symptoms of secondary Raynaud's. The treatment ranges from lifestyle modification, medical treatment, and lastly surgical intervention. Sympathectomy has been suggested for the management of refractive secondary Raynaud's owing to its considerable clinical response.

CONCLUSION

The use of uniportal VATS sympathectomy results in favorable cosmetic and clinical outcomes including reduced length of hospital stay and postoperative pain.

Multiple Autoimmune Syndrome: An Unusual Combination of Autoimmune Disorders

BACKGROUND

Autoimmune diseases are multifactorial with environmental and heritable factors. Autoimmunity reflects an altered immune status, therefore the presence of more than one disorder is not uncommon. The coexistence of three or more autoimmune diseases in a patient constitutes multiple autoimmune syndrome (MAS). This is an interesting case of a middle-aged female who had celiac disease, primary biliary cholangitis, autoimmune hepatitis and evolving CREST (Calcinosis, Rhaynaud's phenomenon, Esophageal dysmotility, Sclerodactyly and Telangiectasia) syndrome.

CASE REPORT

Fifty years old female patient presented with generalized fatigue, fever, weight loss, vertigo and constipation. She was a diagnosed case of celiac disease, and responded well to glutenfree diet. Family history was unremarkable for any autoimmune disorder. Laboratory workup showed normal complete blood counts, markedly elevated transaminases and alkaline phosphates. Her antinuclear antibodies (ANA) test was strongly positive (>1:320) and showed an anti-centromere pattern. Anti-extractable nuclear antibody(ENA) assay showed anti-mitochondrial and anti- CENP B antibodies. Liver biopsy revealed overlap syndrome (primary biliary cholangitis and autoimmune hepatitis). This patient had celiac disease, primary biliary cholangitis and autoimmune hepatitis. Extensive immunological workup unexpectedly revealed the presence of anti-centromere protein B (anti-CENP B) antibodies which are strongly associated with CREST syndrome. Clinical re-evaluation of the patient gave clues of the evolving CREST syndrome. This case report highlights the importance of adequate immunological investigations in conjunction with clinical information for adequate patient management to achieve favorable consequences in the future.

CONCLUSION

Patients suffering from an autoimmune disease need special attention as multiple immune- mediated disorders may be present simultaneously or sequentially during the course of the disease process. MAS patients are at a higher risk of acquiring infections and tumor development due to prolonged use of immunosuppressants. These patients need close surveillance for the development of another autoimmune disease, so as to control the current disease and to prevent future complications. This case report emphasizes the importance of a multidisciplinary team approach including an immunologist who may facilitate a better understanding of disorders related to the breakdown of immune tolerance.

Novel Mutations and Decreased Expression of the Epigenetic Regulator TET2 in Pulmonary Arterial Hypertension

BACKGROUND

Pulmonary arterial hypertension (PAH) is a lethal vasculopathy. Hereditary cases are associated with germline mutations in BMPR2 and 16 other genes; however, these mutations occur in <25% of patients with idiopathic PAH and are rare in PAH associated with connective tissue diseases. Preclinical studies suggest epigenetic dysregulation, including altered DNA methylation, promotes PAH. Somatic mutations of Tet-methylcytosine-dioxygenase-2 (TET2), a key enzyme in DNA demethylation, occur in cardiovascular disease and are associated with clonal hematopoiesis, inflammation, and adverse vascular remodeling. The role of TET2 in PAH is unknown.

METHODS

To test for a role of TET2, we used a cohort of 2572 cases from the PAH Biobank. Within this cohort, gene-specific rare variant association tests were performed using 1832 unrelated European patients with PAH and 7509 non-Finnish European subjects from the Genome Aggregation Database (gnomAD) as control subjects. In an independent cohort of 140 patients, we quantified TET2 expression in peripheral blood mononuclear cells. To assess causality, we investigated hemodynamic and histological evidence of PAH in hematopoietic Tet2-knockout mice.

RESULTS

We observed an increased burden of rare, predicted deleterious germline variants in TET2 in PAH patients of European ancestry (9/1832) compared with control subjects (6/7509; relative risk=6; P=0.00067). Assessing the whole cohort, 0.39% of patients (10/2572) had 12 TET2 mutations (75% predicted germline and 25% somatic). These patients had no mutations in other PAH-related genes. Patients with TET2 mutations were older (71±7 years versus 48±19 years; P<0.0001), were more unresponsive to vasodilator challenge (0/7 versus 140/1055 [13.2%]), had lower pulmonary vascular resistance (5.2±3.1 versus 10.5±7.0 Wood units; P=0.02), and had increased inflammation (including elevation of interleukin-1β). Circulating TET2 expression did not correlate with age and was decreased in >86% of PAH patients. Tet2-knockout mice spontaneously developed PAH, adverse pulmonary vascular remodeling, and inflammation, with elevated levels of cytokines, including interleukin-1β. Long-term therapy with an antibody targeting interleukin-1β blockade resulted in regression of PAH.

CONCLUSIONS

PAH is the first human disease related to potential TET2 germline mutations. Inherited and acquired abnormalities of TET2 occur in 0.39% of PAH cases. Decreased TET2 expression is ubiquitous and has potential as a PAH biomarker.

Pacinian hyperplasia presenting with Raynaud's phenomenon

Pacinian corpuscle pathology is a rare clinical entity and an uncommonly reported cause of digital pain. While many prior reports implicate hand trauma, we describe a case of Pacinian hyperplasia found in a patient with Raynaud's phenomenon and propose a potential mechanism of disease.

[Systemic sclerosis]

Systemic sclerosis (SSc) is a rare fibrosing rheumatic multi-systemic disease involving many medical specialties. The mortality of SSc is determined by lung fibrosis, pulmonary arterial hypertension and cardiac involvement. With early and intensive treatment, the disease can be stabilized and symptoms relieved. This review summarizes insights into pathophysiology, disease classification, clinical manifestations and successful therapies, as well as recent studies on new immunosuppressant, biological and vasoactive therapies.

Bilateral calcinosis cutis of orbital walls in CREST syndrome

Purpose

To describe a patient with systemic sclerosis who presented with subcutaneous yellow-white nodules on her lateral orbital rims.

Methods

Case report.

Results

A 53-year-old female was referred for management of subcutaneous firm nodules on her lateral orbital rims. She was known to have CREST (calcification, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia) syndrome, a limited variant of systemic sclerosis. Her drug history included diltiazem, captopril, aspirin, and prednisolone. There were bilateral multiple immobile yellow-white subcutaneous nodules with firm consistency, a few of which were in close proximity of periorbital skin. She was scheduled for surgical resection of the lesions and following tissue dissection, the calcified foci were removed. The incisions healed with some delay but the final postoperative follow-up at third month showed satisfactory appearance.

Conclusion

Dystrophic calcinosis cutis occurs in approximately one-fourth of patients with systemic sclerosis (scleroderma), particularly in those with the limited variant or CREST syndrome. The most frequently involved sites are the extremities. Occasionally, calcinosis involves the trunk or head, but involvement of bony orbital walls is extremely rare. Surgical excision can be considered for treatment of discrete foci of calcinosis cutis.

Chronic Anterior Uveitis in a Patient with CREST Syndrome

Systemic sclerosis is a connective tissue pathology with very heterogeneous clinical manifestations, associated in a small percentage with inflammatory eye diseases. In the specific case of uveitis, only isolated cases have been reported in the literature, especially in relation to the CREST syndrome. We present the case of a 53-year-old woman with CREST syndrome and chronic anterior uveitis, which we consider of clinical relevance given its low prevalence.

Intraspinal calcinosis mimicking intervertebral disc extrusion: A clinical and surgical case report

Background:

Subcutaneous calcinosis is a well-recognized manifestation of systemic sclerosis that usually involves multiple pressure points and may also be found in the paraspinal or intraspinal regions. In this case, intraspinal calcinosis uniquely led to a severe neurological deficit.

Case Description:

A patient with severe systemic sclerosis/calcinosis exhibited left greater than right lower extremity radiculopathy attributed to intraspinal left-sided L4-L5 calcinosis. On examination, the patient exhibited bilateral positive Lasegue signs, distal lower extremity weakness (left greater than right), and bilaterally decreased Achilles responses. When the magnetic resonance imaging (MRI) revealed a significant intracanalicular mass on the left side at the L4-L5 level, the patient underwent a left-sided L4-L5 decompressive laminectomy. The MRI scan 5 years later revealed no recurrence of the calcinosis, and the patient had no residual neurological deficit.

Conclusions:

Spinal calcinosis rarely involves the lumbar spinal canal. Here, a patient with a large left-sided L4-L5 focus of intraspinal calcinosis, mimicking a disc herniation, required a laminectomy to resect the lesion. Lumbar calcinosis should be radiologically evaluated utilizing using X-ray, MRI, and computed tomography studies to adequately document the pathology. Patients, when symptomatic, may require surgical decompression and excision of these lesions.

Imaging studies of kleptomania in a middle-aged woman with obsessive-compulsive disorder: a case report

A 57-year-old woman who had been arrested for shoplifting visited our hospital. She was diagnosed with kleptomania. She had previously been diagnosed with CREST (calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia) syndrome and obsessive-compulsive disorder. Cranial magnetic resonance imaging showed mild atrophy of the bilateral dorsolateral prefrontal cortices, left hippocampus, and occipital cortex, as well as diffuse mild T₂ hyperintensity in the deep and subcortical white matter, including the frontal region. During a single-photon emission computed tomography scan, significant hyperperfusion was observed in the right ventral striatum, including the nucleus accumbens, ventral thalamus, and right ventrolateral prefrontal areas. Patchy hypoperfusion was found in the bilateral posterior cingulate, parietal, and occipital regions. The patient's neurocognitive function was normal, except for slight impairment of her executive function. Her symptoms and neuroimaging findings were not suggestive of a specific neurocognitive disorder. Hyperactivity of the right ventral striatum may contribute to both obsessive-compulsive disorder and kleptomania. Although frontotemporal lobar degeneration is a major neurocognitive disorder related to illegal behaviours, CREST syndrome-induced white matter microstructural damage in the orbitofrontal lobe could have caused our patient's kleptomania.

Retinal vasculitis associated with CREST syndrome

Purpose

To report two cases of retinal vasculitis associated with CREST syndrome, a novel ocular finding.

Observations

We report two cases of patients with CREST syndrome with ocular inflammatory disease. Patient 1 presented with a right unilateral panuveitis with extensive retinal vasculitis and evidence of prior uveitis in the contralateral eye. Patient 2 presented with a left branch retinal artery occlusion and bilateral retinal vasculitis. Both patients underwent treatment with prednisone and mycophenolate motefil.

Conclusions and importance

Retinal vasculitis has not been previously reported in CREST syndrome. Prompt therapy with immunomodulatory therapy can potentially minimize ocular morbidity.

Intravenous sodium thiosulfate for treating tumoral calcinosis associated with systemic disorders: Report of four cases

Intravenous sodium thiosulfate (ivSTS) is a promising new therapeutic option for calciphylaxis related to end-stage renal disease. However, its effect on tumoral calcinosis (TC) complicating autoimmune connective-tissue diseases has been scarcely described. We report here 4 cases (3 adults and 1 child) of TC treated with ivSTS. TC was secondary to CREST syndrome, dermatomyositis (1 adult and 1 child) and systemic erythematous lupus and involved multiple sites in all cases. In all 4 patients, TC was responsible for joint pain, reduced mobility, inflammatory flares and skin fistulations. One patient experienced difficulty sitting due to the pain induced by calcified lesions on the buttock; another patient had major disability, moved only with wheelchair and was under opioid treatment for pain. For all patients, treatment with several medications before STS was unsuccessful. The 3 adults received at least 6 cycles of ivSTS (20g/d, 5 days/month) and the child received a daily infusion of 17g STS during 1 month then a 9-g/d infusion during 3 months. Two adults and the child showed clinical improvement with STS treatment and the third adult felt disappointed and stopped STS treatment after 6 months. The child also stopped STS after 6 months due to vomiting. In one patient, an intensive regimen of ivSTS (20g every 2 days) controlled recurrent flares and fistulations. Unfortunately, TC remained unchanged. Further studies are needed to decipher how STS modulates ectopic calcification, the optimal regimen and posology.

Scleroderma and dentistry: Two case reports

Background

Scleroderma is a chronic connective tissue disorder with unknown etiology. It is characterized by excessive deposition of extracellular matrix in the connective tissues causing vascular disturbances which can result in tissue hypoxia. These changes are manifested as atrophy of the skin and/or mucosa, subcutaneous tissue, muscles, and internal organs. Such changes can be classified into two types, namely, morphea (localized) and diffuse (systemic). Morphea can manifest itself as hemifacial atrophy (Parry–Romberg syndrome) although this remains debatable. Hence, we present a case of morphea, associated with Parry–Romberg syndrome, and a second case with the classical signs of progressive systemic sclerosis.

Case presentation

Case one: A 20-year-old man of Dravidian origin presented to our out-patient department with a complaint of facial asymmetry, difficulty in speech, and loss of taste sensation over the last 2 years. There was no history of facial trauma. After physical and radiological investigations, we found gross asymmetry of the left side of his face, a scar on his chin, tongue atrophy, relative microdontia, thinning of the ramus/body of his mandible, and sclerotic lesions on his trunk. Serological investigations were positive for antinuclear antibody for double-stranded deoxyribonucleic acid and mitochondria. A biopsy was suggestive of morphea. Hence, our final diagnosis was mixed morphea with Parry–Romberg syndrome.

Case two: A 53-year-old woman of Dravidian origin presented to our out-patient department with a complaint of gradually decreasing mouth opening over the past 7 years. Her medical history was noncontributory. On clinical examination, we found her perioral, neck, and hand skin to be sclerotic. Also, her fingers exhibited bilateral telangiectasia. An oral examination revealed completely edentulous arches as well as xerostomia and candidiasis. Her serological reports were positive for antinuclear antibodies against centromere B, Scl-70, and Ro-52. A hand and wrist radiograph revealed acro-osteolysis of the middle finger on her right hand. Hence, our final diagnosis was progressive systemic sclerosis.

Conclusion

Through this article, we have tried to emphasize the importance of a general examination when diagnosing rare systemic diseases such as scleroderma and the role of the general dentist when caring for such patients, even though they can be quite rare in general practice.

Reversed shunting in CREST syndrome

The patent foramen ovale (PFO) is one of the most common congenital defects and may as well stand for "potential for opening" in addition to patent foramen ovale. Although patients are usually asymptomatic because the defect is flap-like and does not permit significant left-to-right shunting, the pathological conditions that result in cardiac rotation or higher than normal right atrial pressures can reverse the normal left atrial to right atrial pressure gradient and cause a right-to-left shunt through a PFO. Pulmonary complications of systemic sclerosis (SSc) are common, and are the leading cause of SSc-related death. The most common pulmonary manifestations of SSc are pulmonary hypertension (PAH), interstitial lung disease, and any combination thereof. Compared with the idiopathic form of PAH (IPAH), patients with SSc-associated PAH have a threefold increased risk of death and may receive a diagnosis late in the course of disease because of insidious onset and the high prevalence of cardiac, musculoskeletal, and pulmonary parenchymal comorbidities. © 2015 Wiley Periodicals, Inc. J Clin Ultrasound 44:390-391, 2016.

Axillary Block-Induced Chemical Sympathectomy in the Setting of Digital Ischemia

BACKGROUND

Digital ischemia is associated with several rheumatologic disorders and is often difficult to treat. Symptoms and sequelae can include pain, disability, need for amputation, and poor quality of life.

METHODS

Patients diagnosed with digital ischemia were referred for an ultrasound-guided axillary nerve block using liposomal bupivacaine (Exparel, Pacira Pharmaceuticals). The primary outcome measure was radial and ulnar artery diameter preprocedure and postprocedure. Doppler waveform analyses were performed to measure arterial diameter and blood flow velocity. The QuickDASH questionnaire was administered to evaluate upper extremity function and perceived disability.

RESULTS

Mean radial and ulnar artery diameters increased from 0.19 cm and 0.16 cm to 0.23 cm and 0.20 cm, respectively, 1 hour postprocedure. Concomitant increases in blood flow velocities and hand temperature and lower pain scores were also noted. Although pain generally returned to baseline after 1 week, QuickDASH symptom/disability scores improved at 30 days, and 2 patients' ischemic symptoms resolved spontaneously during the study period in the absence of other interventions.

CONCLUSION

Data regarding chemical sympathectomy using regional anesthesia are limited at this time. Our experience suggests a potential role in the treatment and evaluation of digital ischemia. Patients with digital ischemia from rheumatologic conditions appeared to have a greater benefit from a chemical sympathectomy than patients whose conditions had an atherosclerotic or anatomic etiology. Even when the vasodilatory effects are transient, such an intervention may be useful when a more permanent option such as surgical sympathectomy is being considered. Liposomal bupivacaine is only approved for surgical infiltration at this time.

Scleroderma and pulmonary hypertension complicating two pregnancies: use of neuraxial anesthesia, general anesthesia, epoprostenol and a multidisciplinary approach for cesarean delivery

Literature regarding the anesthetic care of patients with scleroderma during labor and delivery is limited to remote case reports. No recent publications provide information on the anesthetic management of patients with coexisting pulmonary hypertension. This report describes the anesthetic and multidisciplinary management of two pregnant patients with concomitant scleroderma and pulmonary hypertension undergoing cesarean delivery; one with neuraxial anesthesia and one with general anesthesia. Considerations for neuraxial and general anesthesia in patients with concurrent scleroderma and pulmonary hypertension are discussed.

Pathophysiology and recent findings of primary biliary cirrhosis complicated by systemic sclerosis

Primary biliary cirrhosis (PBC) can be complicated by systemic sclerosis (SSc) and, more specifically, limited cutaneous SSc (lcSSc), which was previously called CREST syndrome. Moreover, combined PBC and SSc has been described in many case reports. Although neither the etiology of PBC nor that of SSc has been elucidated, some genetic and immunological factors are known to be shared. Both disorders are autoimmune fibrotic diseases characterized by increased levels of profibrotic cytokines transforming growth factor β (TGFβ) and interleukin-6, which have recently been suggested to influence T-helper 17 cells and regulatory T cells involved in acquired immunity. lcSSc is accompanied by CREST symptoms, although complete CREST cases are rare, with relatively high prevalence of Raynaud's phenomenon, sclerodactyly and telangiectasia, and lower prevalence of calcinosis and esophageal dysmotility. Because patients with anticentromere antibody positive PBC-SSc are at a high risk of developing portal hypertension, particular attention should be paid to the management of gastroesophageal varices. In addition, the management of SSc-related non-hepatic disorders, such as pulmonary fibrosis, pulmonary hypertension, heart disorder, infection and malignancy, is also important for improved outcomes. Because PBC is often complicated by rheumatic disease, hepatologists should keep the possibility of systemic disorder in mind when examining PBC patients.

Successful management of an inadvertent excessive treprostinil overdose

Pulmonary hypertension is defined by 25 mmHg pressure at rest, and 35 mmHg pressure at exercise, in the pulmonary arteries. Hypertension either primary or secondary. The exact prevalence of all types of pulmonary hypertension is not yet known. We present a case of a 58-year-old female patient suffering from CREST syndrome, Raynaud’s syndrome, esophageal motility impairment, and severe pulmonary hypertension who had previously obtained a specially developed implantable pump, named Lenus Pro^®, to facilitate continuous parenteral treatment of pulmonary arterial hypertension with treprostinil. Treprostinil is a prostanoid derivative with very stable physiochemical properties which allows subcutaneous treatment of pulmonary arterial hypertension in the outpatient. Treprostinil is normally dosed individually in a range of 0.6 to 50 ng/kg/minute. In the underlying case, a dose of more than 100 mg given over 1 minute is equivalent to a 1000 fold overdose. The patient’s critical condition required installment of a central venous access, full monitoring, sedation, oxygen nasal tube, fluid balance, and parenteral nutrition. The patient could be hemodynamically stabilized within 24 hours after the overdose. After 6 days of recovery, the patient left the hospital with no remaining health impairment.

Taxane-induced morphea in a patient with CREST syndrome

The taxanes, docetaxel and paclitaxel, are microtubule stabilizing chemotherapeutic agents that have demonstrated antineoplastic effects in a variety of solid tumors. They have been linked to the development of localized cutaneous sclerosis in some patients. We present a case of docetaxel-induced cutaneous sclerosis of the lower extremities in a patient with pre-existing CREST syndrome. We propose that patients with a history of limited or diffuse systemic sclerosis should be given taxane chemotherapy with caution, as these patients may have an immunological predisposition for the development of drug-induced morphea.