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Sami F, Sami SA, Tanveer S, Sami H. Hemorrhagic Cardiac Tamponade as a Complication of Limited Cutaneous Systemic Sclerosis. Cureus 2023; 15:e39947. [PMID: 37283596 PMCID: PMC10239686 DOI: 10.7759/cureus.39947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2023] [Indexed: 06/08/2023] Open
Abstract
Cardiac tamponade is an uncommon complication of systemic sclerosis (SSc) with a high mortality rate. Here, we report a case of a 58-year-old patient with limited cutaneous systemic sclerosis (lcSSc), gastroesophageal reflux disease (GERD), diabetes mellitus, pulmonary hypertension (PHTN), and COVID-19 infection, which occurred one month ago, presenting with a large hemorrhagic pericardial effusion and early cardiac tamponade. The patient had an acute onset of progressive dyspnea and anasarca. On examination, she was tachypneic, tachycardic, desaturating on room air, and hypotensive. Pitting edema up to thighs and bilateral basilar crackles were also appreciated. Labs were remarkable for negative troponin, chest X-ray with pulmonary congestion, D-dimer at 6.01, CT angiogram negative, brain natriuretic peptide level at 73 pg/mL, C-reactive protein level at 7.64 mg/dL, normal complement levels, and negative COVID-19 test results. Echocardiography showed early tamponade and a large circumferential effusion with chamber collapse. Right heart catheterization was performed finding PHTN at 54 mmHg. Pericardiocentesis drained 500 mL of the hemorrhagic effusion. Fluid analysis showed RBC at 220,000/uL, WBC at 5000/uL, protein 4.8 g/dL, lactate dehydrogenase level of 1275 U/L, and negative cytology. The patient was treated for serositis from lcSSc flare with mycophenolate mofetil and steroids, and responded very well. Hemorrhagic cardiac tamponade is a very rare phenomenon in limited scleroderma. A recent COVID-19 infection could have served as a trigger factor for our patient's lcSSc in long remission to flare up. Clinicians should maintain a high index of suspicion and a low threshold for intervention when lcSSc patients have an acute onset of cardiac compromise, especially with a history of a recent COVID-19 infection.
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Affiliation(s)
- Faria Sami
- Internal Medicine, Allama Iqbal Medical College, Lahore, PAK
| | | | - Saman Tanveer
- Internal Medicine, Army Medical College, National University of Medical Sciences (NUMS), Rawalpindi, PAK
| | - Hania Sami
- Anatomy, Physiology, and Biochemistry, Shalamar Medical and Dental College, Lahore, PAK
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2
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Lescoat A, Sandler RD, Zimmermann F, Roofeh D, Hughes M, Pauling JD, Murphy SL, Chen YT, Townsend W, Buch MH, Khanna D. Domains and outcome measures for the assessment of limited cutaneous systemic sclerosis: an international collaborative scoping review. Rheumatology (Oxford) 2022; 61:3132-3148. [PMID: 35094049 PMCID: PMC9338174 DOI: 10.1093/rheumatology/keac049] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 12/15/2021] [Accepted: 01/14/2022] [Indexed: 09/01/2023] Open
Abstract
OBJECTIVES The aim of this study was to comprehensively identify instruments within relevant domains employed to assess lcSSc since the endorsement of its consensus definition in 1988. The overall objective is to inform the creation of a Combined Response Index for Scleroderma Trials Assessing lcSSc (CRISTAL). METHODS MEDLINE and Embase were searched using terms selected to comprehensively retrieve titles and abstracts mentioning both lcSSc and dcSSc, along with those only mentioning lcSSc, SSc sine scleroderma, limited SSc and/or CREST/CRST. Because our initial assessment of the literature revealed that very few studies included only lcSSc subjects, we also assessed literature that included both cutaneous subsets. A total of 3964 titles and abstracts were screened by two reviewers, and 270 articles were selected for data extraction. RESULTS We identified 27 domains encompassing 459 instruments. Instruments from 'Skin involvement', 'Pulmonary involvement' and 'Health-related quality of life and general functioning' were the most frequently retrieved. Among the 15 most represented instruments announced as primary end points in efficacy or effectiveness studies, 7 were clinician-reported outcomes (ROs), 7 were patient ROs, and one was a performance outcome (6 min-walk test). The mean proportion of lcSSc patients in studies of lcSSc, including studies that mention both lcSSc and dcSSc, was 56.4%, demonstrating that this subset is underrepresented in the literature, given that the prevalence of lcSSc ranges from 60% to 80% in national registries and international cohorts. CONCLUSION This scoping literature review provides a comprehensive identification of domains and outcomes used to assess lcSSc. Our results also highlight that lcSSc is underrepresented in the literature.
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Affiliation(s)
- Alain Lescoat
- Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail) – UMR_S 1085
- Department of Internal Medicine and Clinical Immunology, Rennes University Hospital, Rennes, France
- Department of Internal Medicine, Division of Rheumatology
- Department of Internal Medicine, Scleroderma Program, University of Michigan, Ann Arbor, MI, USA
| | - Robert D Sandler
- Department of Rheumatology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield
| | - François Zimmermann
- Department of Internal Medicine and Clinical Immunology, Rennes University Hospital, Rennes, France
| | - David Roofeh
- Department of Internal Medicine, Division of Rheumatology
- Department of Internal Medicine, Scleroderma Program, University of Michigan, Ann Arbor, MI, USA
| | - Michael Hughes
- Department of Rheumatology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield
| | - John D Pauling
- Department of Pharmacy and Pharmacology, Royal National Hospital for Rheumatic Diseases, Royal United Hospitals, Bath, UK
| | - Susan L Murphy
- Department of Internal Medicine, Scleroderma Program, University of Michigan, Ann Arbor, MI, USA
- Department of Physical Medicine & Rehabilitation, University of Michigan
- VA Ann Arbor Healthcare System, Geriatric Research Education and Clinical Center, GRECC
| | - Yen T Chen
- Department of Internal Medicine, Scleroderma Program, University of Michigan, Ann Arbor, MI, USA
- Department of Physical Medicine & Rehabilitation, University of Michigan
- VA Ann Arbor Healthcare System, Geriatric Research Education and Clinical Center, GRECC
| | - Whitney Townsend
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, MI, USA
| | - Maya H Buch
- Department of Rheumatology, Centre for Musculoskeletal Research, School of Biological Sciences, Faculty of Biology, Medicine & Health, University of Manchester
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester University Foundation Trust, Manchester, UK
| | - Dinesh Khanna
- Department of Internal Medicine, Division of Rheumatology
- Department of Internal Medicine, Scleroderma Program, University of Michigan, Ann Arbor, MI, USA
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Atzori L, Ferreli C, Matucci-Cerinic C, Pilloni L, Rongioletti F. Primary Localized Cutaneous Nodular Amyloidosis and Limited Cutaneous Systemic Sclerosis: Additional Cases with Dermatoscopic and Histopathological Correlation of Amyloid Deposition. Dermatopathology (Basel) 2021; 8:229-235. [PMID: 34287266 PMCID: PMC8293241 DOI: 10.3390/dermatopathology8030028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/01/2021] [Accepted: 06/22/2021] [Indexed: 11/22/2022] Open
Abstract
Primary localized cutaneous nodular amyloidosis (PLCNA) is a rare condition due to the plasma cell proliferation and skin deposition of immunoglobulin light chains, without systemic amyloidosis or hematological dyscrasias. The association with autoimmune connective tissue diseases has been reported, especially with Sjogren’s syndrome, and in a few cases with systemic sclerosis. Herein, we describe three cases of PLCNA occurring in women with a diagnosis of limited cutaneous systemic sclerosis and review the literature on the topic to highlight a stereotypical presentation. Moreover, we support the usefulness of dermoscopy, characterized by a yellow–orange waxy pattern surrounded by telangiectasias, for a rapid and non-invasive diagnostic assessment. Thus, when asymptomatic nodules occur on lower limbs of women affected with limited systemic sclerosis, and dermoscopy identifies yellow–orange blotches, a diagnosis of PLCNA can be considered and further confirmed by histopathology. Monitoring for systemic amyloidosis development is advisable, although the risk of progression is considered very low.
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Affiliation(s)
- Laura Atzori
- Dermatology Clinic, Department Medical Sciences and Public Health, University of Cagliari, 09124 Cagliari, Italy; (L.A.); (C.F.); (F.R.)
| | - Caterina Ferreli
- Dermatology Clinic, Department Medical Sciences and Public Health, University of Cagliari, 09124 Cagliari, Italy; (L.A.); (C.F.); (F.R.)
| | - Caterina Matucci-Cerinic
- Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, DINOGMI, University of Genova, 16147 Genova, Italy
- Correspondence:
| | - Luca Pilloni
- Pathology Unit, Department Medical Sciences and Public Health, University of Cagliari, 09124 Cagliari, Italy;
| | - Franco Rongioletti
- Dermatology Clinic, Department Medical Sciences and Public Health, University of Cagliari, 09124 Cagliari, Italy; (L.A.); (C.F.); (F.R.)
- Dermatology Unit, Vita-Salute University San Raffaele, 20132 Milan, Italy
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Rees MS, Frampton C, White DHN, Solanki KK. Increased malignancies in our Waikato cohort of patients with systemic sclerosis. Int J Rheum Dis 2021; 24:555-561. [PMID: 33751804 DOI: 10.1111/1756-185x.14091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/14/2021] [Accepted: 02/08/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Systemic sclerosis (SSc) has been associated with an increased risk of malignancy (especially in the skin, lung, breast, and hematological system). AIM To determine the risk of malignancies in our SSc cohort. METHODS The NZ National Cancer Registry supplied details of all malignancies recorded in patients attending the Waikato Hospital Systemic Sclerosis Clinics from 2005 to 2018. Prospectively gathered clinical data were used to look for associations between clinical variables and malignancy. RESULTS Out of the 164 patients in the Waikato SSc cohort, 32 (19.5%) had developed a malignancy. The overall standardized incidence rate was found to be 2.2 (95% CI 1.4-3.4) but was higher for men (4.4, 95% CI 1.4-10.3). The absolute numbers of patients with SSc and malignancies were small and were not adequately powered to investigate the SSc subgroups. The mean age of patients with malignancy was approximately 8 years older than patients without. The most common form of malignancy was skin (14, 43.7%), followed by breast (6, 18.7%), and lymphoma (5, 15.6%). CONCLUSION This study found an increased risk of malignancy for patients within the Waikato SSc cohort. Risk was greater in male patients and the mean age of patients with malignancies was approximately 8 years older than those without malignancy.
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Affiliation(s)
| | - Chris Frampton
- Christchurch School of Medicine, University of Otago, New Zealand
| | - Douglas H N White
- Rheumatology Department, Waikato District Health Board, Hamilton, New Zealand.,Waikato Clinical School, University of Auckland, Auckland, New Zealand
| | - Kamal K Solanki
- Rheumatology Department, Waikato District Health Board, Hamilton, New Zealand.,Waikato Clinical School, University of Auckland, Auckland, New Zealand
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Furst D, Varga J, Roofeh D, Pauling JD, Hughes M, Sandler R, Zimmermann F, Wessel R, Townsend W, Chung L, Denton CP, Merkel PA, Steen V, Allanore Y, Del Galdo F, Godard D, Cella D, Farrington S, Buch MH, Khanna D. Considerations for a combined index for limited cutaneous systemic sclerosis to support drug development and improve outcomes. J Scleroderma Relat Disord 2021; 6:66-76. [PMID: 34316516 PMCID: PMC8313014 DOI: 10.1177/2397198320961967] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Systemic sclerosis (SSc; systemic scleroderma) is characterized by a heterogeneous range of clinical manifestations. SSc is classified into limited cutaneous SSc (lcSSc) and diffuse cutaneous subgroups (dcSSc) based on the extent of skin involvement. Randomized controlled trials in scleroderma have mainly focused on dcSSc partly because the measurement of skin involvement, critical for evaluating a therapeutic intervention is more dynamic in this subset. Nonetheless, lcSSc, the most common cutaneous subset (about 2/3), is also associated with significant morbidity and detrimental impact on health-related quality of life. The lack of interventional studies in lcSSc is partly due to a lack of relevant outcome measures to evaluate this subgroup. Combining several clinically meaningful outcomes selected specifically for lcSSc may improve representativeness in clinical trials and responsiveness of outcomes measured in randomized controlled trials. A composite index dedicated to lcSSc combining such relevant outcomes could advance clinical trial development for lcSSc by providing the opportunity to test and select among candidate drugs that could act as disease-modifying treatments for this neglected subgroup of SSc. This proposed index would include items selected by expert physicians and patients with lcSSc across domains grounded in the lived experience of lcSSc. This article reviews the reasons behind the relative neglect of lcSSc, discusses the current state of outcome measures for lcSSc, identifies challenges, and proposes a roadmap for a combined lcSSc-specific treatment response index.
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Affiliation(s)
| | | | - David Roofeh
- Department of Internal Medicine, Division of Rheumatology, Scleroderma Program, University of Michigan, Ann Arbor, Michigan, USA
| | - John D Pauling
- Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals), Bath, UK
| | - Michael Hughes
- Department of Rheumatology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Robert Sandler
- Department of Rheumatology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - François Zimmermann
- Department of Internal Medicine and Clinical Immunology, Rennes University Hospital, Rennes, France
| | - Rachel Wessel
- Department of Internal Medicine, Division of Rheumatology, Scleroderma Program, University of Michigan, Ann Arbor, Michigan, USA
| | - Whitney Townsend
- Taubman Health Sciences Library, University of Michigan. Ann Arbor, Michigan, USA
| | - Lorinda Chung
- Division of Immunology and Rheumatology, Stanford University School of Medicine, Palo Alto, CA, USA.,Division of Immunology and Rheumatology, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Christopher P Denton
- Centre for Rheumatology and Connective Tissue Diseases, Royal Free Hospital Campus, University College London Medical School, London, UK
| | - Peter A Merkel
- Division of Rheumatology, Department of Medicine, Division of Clinical Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Virginia Steen
- Division of Rheumatology, Georgetown University Medical Center, Washington, DC, USA
| | - Yannick Allanore
- Rheumatology A department, Cochin Hospital, APHP, Paris Descartes University, Paris, France
| | - Francesco Del Galdo
- Institute of Rheumatic and Musculoskeletal Medicine and NIHR Biomedical Research Centre, University of Leeds, Leeds LS7 4SA, UK
| | | | - David Cella
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, 625 Michigan Ave, 21st Floor, Chicago, IL, 60611, USA
| | - Sue Farrington
- Federation of European Scleroderma Associations (FESCA), Tournai, Belgium
| | - Maya H Buch
- Centre for Musculoskeletal Research, School of Biological Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester University Foundation Trust, Manchester, UK
| | - Dinesh Khanna
- Department of Internal Medicine, Division of Rheumatology, Scleroderma Program, University of Michigan, Ann Arbor, Michigan, USA
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Alam F, Abdulaziz HM, Ul Haq I, Mahdy SM, Mohammed Siam AR, Chandra P, Al Emadi S. Characteristics of patients with systemic sclerosis living in Qatar. Qatar Med J 2020; 2019:16. [PMID: 31903322 PMCID: PMC6929649 DOI: 10.5339/qmj.2019.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 07/18/2019] [Indexed: 11/29/2022] Open
Abstract
Objective: The aim of this study was to determine the demographic, clinical, and immunological characteristics of patients with systemic sclerosis living in Qatar. Method: This retrospective study included 42 patients with systemic sclerosis who attended Rheumatology Clinics at Hamad General Hospital in Doha, Qatar, between January 2000 and December 2014. All patients fulfilled the 1980 American College of Rheumatology (ACR) classification criteria for systemic sclerosis. Results: The 42 consecutively recruited patients of mixed ethnicities consisted of 37 (88.1%) females and 5 (11.9%) males. Of the total 42 patients, 22 (52.4%) had diffuse cutaneous systemic sclerosis (dcSSc) and 20 (47.6%) had limited cutaneous systemic sclerosis (lcSSc). Mean age at onset of first symptoms was 34.5 ± 12 years, and mean age at diagnosis was 36.1 ± 11.5 years. During follow-up, Raynaud's phenomenon occurred in 36 (85.7%) patients, sclerodactyly in 39 (92.9%) patients, digital ulcers in 16 (38.1%) patients, calcinosis in 6 (14.3%) patients, telangiectasia in 16 (38.1%) patients, and arthritis in 13 (31%) patients. The gastrointestinal and respiratory systems were the most frequently affected internal organs. Gastrointestinal involvement was present in 36 (85.7%) patients, and respiratory involvement was found in 30 (71.4%) patients. The majority of patients had positive antinuclear antibodies (ANA; 97.6%). Anti-Scl-70 antibody was found in 66.7% and anti-centromere antibody (ACA) was detected in 14.3% of the patients. Conclusion: To our knowledge, this is the first study that describes the clinical and immunological profile of patients with systemic sclerosis living in Qatar. This study cohort showed an earlier age of disease onset and diagnosis than that reported in other international studies. Furthermore, in contrast to several other studies, the diffuse type of scleroderma was more commonly observed than the limited type, which resulted in a high frequency of anti-Scl-70 antibody and interstitial lung disease.
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Affiliation(s)
- Fiaz Alam
- Rheumatology Section, Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | | | - Irfan Ul Haq
- Pulmonary Section, Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Salah Mohamed Mahdy
- Rheumatology Section, Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | | | - Prem Chandra
- Medical Research Centre, Hamad Medical Corporation, Doha, Qatar
| | - Samar Al Emadi
- Rheumatology Section, Department of Medicine, Hamad Medical Corporation, Doha, Qatar
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