[Mixed connective tissue disease and its management]

Mixed connective tissue disease (MCTD) is a rare autoimmune condition. Since its first description 50 years ago, its mere existence has been debated, given that it shares features of other autoimmune diseases, such as systemic lupus erythematosus (SLE), systemic sclerosis, inflammatory myopathy, rheumatoid arthritis and Sjogren's syndrome. Also, while antibodies to U1-RNP are essential for the diagnosis of MCTD, these antibodies may be expressed in other circumstances, such as in case of SLE. Nevertheless, the patient fulfilling criteria for MCTD needs specific management. In this review, we describe the clinical features and the potential complications of this complex disease, often wrongly disregarded as benign. We will also emphasize the recommended follow-up exams and address treatment, which is currently lacking formal recommendations.

[Standardized diagnosis and treatment of undifferentiated connective tissue disease and mixed connective tissue disease]

Undifferentiated connective tissue disease (CTD) usually refers to patients who are presented with certain symptoms and signs related to CTD, and positive serological evidence of autoimmune diseases but don't fulfill any of the classification criteria for a certain CTD. Mixed CTD refers to patients who are presented with one or more clinical manifestations such as hand swelling, synovitis, myositis, Raynaud's phenomenon, and acrosclerosis. Patients with mixed CTD always have high-titer anti-nuclear antibodies (ANA) of speckled pattern and high-titer anti-U₁ ribonuclear protein (RNP) antibody in serum, while with negative anti-Sm antibody. The update of diagnosis and treatment of undifferentiated CTD and mixed CTD lags behind other established CTD. There is a lack of evidence from randomized controlled trials or guidelines/recommendations on the treatment of undifferentiated CTD or mixed CTD. At present, the conventional therapy is mainly adopted according to the specific clinical manifestations of the disease. The standardized diagnosis and treatment of undifferentiated CTD and mixed CTD were drafted by the Chinese Rheumatology Association based on the previous guidelines and the progress of available evidence, so as to improve the management of these patients in China.

Pulmonary hypertension in connective tissue diseases, new evidence and challenges

Pulmonary arterial hypertension is a lethal complication of different connective tissue diseases such as systemic sclerosis, mixed connective tissue disease and systemic lupus erythematosus. Although the treatment possibilities for patients with pulmonary arterial hypertension have increased in the last two decades and survival of patients with idiopathic pulmonary arterial hypertension has improved, the latter is not the case for patients with pulmonary arterial hypertension associated with connective tissue disease. In this narrative review, we review recent literature and describe the improvement of early diagnostic possibilities, screening modalities and treatment options. We also point out the pitfalls in diagnosis in this patient category and describe the unmet needs and what the focus of future research should be.

Management of multiple neurological complications in mixed connective tissue disease: A case report

RATIONALE

Mixed connective tissue disease (MCTD) refers to an overlapping condition of different autoimmune disorders such as systemic lupus erythematosus, cutaneous systemic sclerosis, rheumatoid arthritis, polymyositis, and dermatomyositis. However, MCTD manifesting as transverse myelitis is extremely rare. Herein, we report a case of MCTD with both central and peripheral nervous system involvement.

PATIENT CONCERNS

We describe and discuss the clinical findings and management of a 36-year-old man presented with a 2-week history of sudden bilateral lower-limb paralysis and dysuresia. Further investigation of his medical history showed a 6-month history of autoimmune symptoms.

DIAGNOSES

The patient was diagnosed with MCTD, transverse myelitis, mononeuritis multiplex, and multiple lacunar infarctions.

INTERVENTIONS

A combination of low-dose methylprednisolone (40 mg/d) and hydroxychloroquine sulfate (400 mg/d) was administered.

OUTCOMES

After treatment, the symptoms were significantly improved. The patient recovered well after 1 year follow-up and the sequela was urinary incontinence and grade 4/5 lower-extremity muscle strength.

LESSONS

MCTD with multiple neurological complications is extremely rare and poses diagnostic and therapeutic challenges. Our experience suggests a combination of low-dose corticosteroids and hydroxychloroquine sulfate may be an effective therapeutic approach.

Facts and controversies in mixed connective tissue disease

Mixed connective tissue disease (MCTD) is a systemic autoimmune rheumatic disease (SARD) characterised by the combination of clinical manifestations of systemic lupus erythematosus (SLE), cutaneous systemic sclerosis (SSc) and polymyositis-dermatomyositis, in the presence of elevated titers of anti-U1-RNP antibodies. Main symptoms of the disease are polyarthritis, hand oedema, Raynaud's phenomenon, sclerodactyly, myositis and oesophageal hypomobility. Although widely discussed, most authors today accept MCTD as an independent entity. Others, however, suggest that these patients may belong to subgroups or early stages of certain definite connective diseases, such as SLE or SSc, or are, in fact, SARD overlap syndromes.

Mixed connective tissue disease

Mixed connective tissue disease (MCTD) was first described in 1972 as a disease syndrome with overlapping features of systemic sclerosis, systemic lupus erythematosus (SLE) and polymyositis associated with antibodies to RNAse sensitive extractable nuclear antigen. When the antigen was subsequently characterized as polypeptides on the U1 ribonuclear protein component of the splicesosome (U1RNP), MCTD became the first rheumatic disease syndrome to be defined by a serologic test. Clinical features include a high frequency of Raynaud’s syndrome, swollen hands, sclerodactyly, arthritis, polymyositis and interstitial lung disease. Over the last 30 years there has been a continuing debate as to whether MCTD constitutes a ‘distinct clinical entity’. Here, I will review the pathological, immunogenetic and clinical features of MCTD and conclude that the debate remains unresolved. The early misconception that it has a relatively good prognosis has not stood the test of time with long-term follow-up studies. These have identified a tendency for MCTD to evolve into SLE or systemic sclerosis and highlighted pulmonary hypertension and scleroderma renal crisis as important causes of death. Providing it is realized that our appreciation of the clinical features associated with anti-U1RNP have evolved over time, MCTD remains a useful concept in clinical practice. Whether it can be credited with the term ‘disease’ awaits the demonstration of common etiopathological events underlying the development of antibodies to U1 RNP and their associated clinical features.

Cardiac involvement in autoimmune myositis and mixed connective tissue disease

The clinical cardiac manifestations most frequently reported in idiopathic inflammatory myopathies, myositis, are congestive heart failure, conduction abnormalities, that may lead to complete heart block and coronary artery disease. Although clinically overt cardiac involvement is rarely reported in myositis patients, subclinical manifestations are frequently observed and are predominated by conduction abnormalities and arrhythmias detected by ECG. Furthermore, cardiovascular manifestations constitute a major cause of death in myositis, thus cardiac involvement maybe overlooked in these patients. Also children with juvenile dermatomyositis may develop cardiac involvement although the frequency seems to be low. The underlying pathophysiologic mechanisms that may cause cardiac manifestations could involve myocarditis and coronary artery disease as well as involvement of the small vessels of the myocardium. In patients with mixed connective tissue disease (MCTD) clinically significant cardiac involvement is also rare, the most frequently reported manifestations being pericarditis and pulmonary hypertension, the latter often attributable to small vessel disease, and often a prognostic unfavourable manifestation.

Undifferentiated Connective Tissue Disease, Mixed Connective Tissue Disease, and Overlap Syndromes in Rheumatology

Autoimmune diseases often have overlapping symptoms and laboratory somewhat unfamiliar to the non-rheumatologist. Characteristic signs, symptoms, and autoantibodies define specific connective tissue diseases. Some patients have some characteristic symptoms, but cannot be definitively classified. Still other patients meet criteria for more than one specific connective tissue disease. These patients can be confusing with regard to diagnosis and prognosis. Clarification of each patient's condition can lead to improved patient care.

Profile of gastrointestinal involvement in patients with systemic sclerosis

Systemic sclerosis (SSc) is a chronic autoimmune connective tissue disease. Of the numerous organ manifestations, involvement of the upper and lower gastrointestinal tract (GIT) appears to be the most frequent with regard to the clinical symptoms. However, as the frequency and clinical relevance of GI involvement in patients with SSc are not known in detail, the German network of the systemic sclerosis (DNSS) has developed a detailed questionnaire to evaluate the extent and profile of gastrointestinal involvement in SSc patients. The multi-symptom questionnaire was used at baseline and after 1 year in registered patients of the DNSS. In addition, the results were compared with gastrointestinal disorders in patients with SSc and other rheumatic diseases, as well as with the medical history of the patients. In total, 90 patients were included in the study. The results of the study show that in reality, a much higher (nearly all) percentage of (98,9%) patients than expected suffer from GI-symptoms, regardless of the stage of their disease. Of these, meteorism (87,8%) was the most common followed by coughing/sore voice (77,8%), heartburn (daytime 68,9%, nighttime 53,3%), diarrhea (67,8%), stomach ache (68,9%) and nausea (61,1%). Although SSc patients were treated according to the respective recommendations, only limited improvements with regard to GI-symptoms could be achieved after 1 year of follow-up. In addition, the study revealed that the multi-symptom questionnaire is a useful tool to contribute to identify the gastrointestinal sequelae in systemic sclerosis.

Scleroderma overlap syndrome

BACKGROUND

Overlap syndrome is an entity that satisfies the criteria of at least two connective tissue diseases (CTD). These conditions include systemic sclerosis (SSc), dermatomyositis or polymyositis, Sjogren's syndrome, rheumatoid arthritis and systemic lupus erythematosus. A combined pathology has impact on the clinical features, diagnosis and treatment.

OBJECTIVES

To analyze the features of SSc patients with overlap syndrome registered in the European (EUSTAR) database at our center and to review the literature focusing on clinical and diagnostic issues and new treatments.

METHODS

We studied the medical records of 165 consecutive SSc patients and reviewed cases with scleroderma overlap syndrome. A PubMed search for the period 1977 to 2009 was conducted using the key words "overlap syndrome", "systemic sclerosis", "connective tissue disease" and "biological agents."

RESULTS

Forty patients satisfied the criteria for scleroderma overlap syndrome. The incidence of additional connective tissue diseases in the whole group and in the overlap syndrome group respectively was: dermatomyositis or polymyositis 11.5% and 47.5%, Sjogren's syndrome 10.3% and 42.5%, rheumatoid arthritis 3.6% and 15.4%, and systemic lupus erythematosus 1.2% and 5.0%. Coexistence of SSc and another CTD aggravated the clinical course, especially lung, kidney, digestive, vascular and articular involvement. Coexisting non-rheumatic complications mimicked SSc complications. An additional rheumatic or non-rheumatic disease affected treatment choice.

CONCLUSIONS

The definition of scleroderma overlap syndrome is important, especially in patients who need high-dose corticosteroids for complications of a CTD. The use of novel biological therapies may be advocated in these patients to avoid the hazardous influences of high-dose steroids, especially renal crisis. In some overlap syndrome cases, biological agents serve both conditions; in others one of the conditions may limit their use. In the absence of formal clinical trials in these patients a cautious approach is preferred.

[Treatment options of acral ulcers in MCTD]

In patients with systemic sclerosis or mixed connective tissue disease (MCTD) acral ulcers are considered as frequent manifestations that may lead to amputation and loss of function, respectively, as a result of secondary Raynaud's phenomenon. Thus it is necessary to take advantage of all available medical and supportive measures. Adjuvant treatments such as hyperbaric oxygenation and regional sympathetic block represent interdisciplinary treatment options to improve oxygenation of critical ischemia and analgesia and should be subject of further investigation.

A multidisciplinary hand clinic for patients with rheumatic diseases: a pilot study

To describe the characteristics, management strategies and outcomes of patients with rheumatic diseases and complex hand function problems referred to a multidisciplinary hand clinic. Assessments (baseline and after three months of follow-up) included sociodemographic and disease characteristics and various hand function measures. The most frequently mentioned impairments and limitations of the 69 patients enrolled in the study pertained to grip, pain, grip strength, and shaking hands. Fifty-six patients received treatment advice, conservative therapy (n=39), surgery (n=12), or a combination of both (n=5). In 38 of 56 patients (68%) the recommended treatment was performed, and 33 completed the follow-up assessment. On average, patients improved, with an increase in grip strength and the Michigan Hand Outcomes Questionnaire scores reached statistical significance. Two-thirds of patients with rheumatic conditions visiting a multidisciplinary hand clinic reportedly followed the treatment advice (recommendations), with an overall trend toward a beneficial effect on hand function. To further determine the added value of a structured, multidisciplinary approach a controlled comparison with other treatment strategies is needed.

Lunge und Autoimmunerkrankungen - Therapie

Pulmonary manifestations of autoimmune diseases are treated depending on the involved lung structure and the underlying disorder. In this review the therapeutic approach in the case of vascultitis, rheumatoid arthritis and connective tissue disease will be presented.

[Pulmonary arterial hypertension in collagenoses: clinical features, epidemiology, pathogenesis, diagnosis and treatment]

Pulmonary arterial hypertension (PAH) is a severe vasculopathy, which is characterised by progressive narrowing and obliteration of the pulmonary arterioles and increased endothelin-1 levels. The increase of vascular resistance in the lung vessels leads to chronic pressure overload and to right heart failure, if untreated. PAH often occurs in association with rheumatic-inflammatory diseases (e.g., in 15% of patients with systemic sclerosis (SSc), especially in the limited form or in CREST patients) and determines their prognosis: in advanced stages, untreated patients die within a short period. Therefore all SSc patients, particularly the newly diagnosed ones, should be screened for PAH with echocardiography. If PAH is suspected, a right heart catheter should be performed, and if PAH is confirmed, adequate treatment should be initiated. While few years ago lung transplantation was the only option for patients with severe PAH, in recent years enormous progress was seen in drug treatment. Today prostanoids (Ventavis) and the endothelin receptor antagonist bosentan (Tracleer) are available for patients with PAH in WHO/NYHA stage III: they have substantially improved the prognosis of PAH in the last years. Since few months, also the phosphodiesterase inhibitor sildenafil (Revatio) is available. The combination of drugs with different mode of action will likely further improve the prognosis of PAH patients.

Glomerulonephritis in children with mixed connective tissue disease

AIMS

Mixed connective tissue disease (MCTD) has overlapping clinical features with systemic lupus erythematosus (SLE). Renal biopsy is necessary for all children with SLE to evaluate the prognosis, because they are at a quite high risk of developing renal complications. Furthermore, lupus nephritis and hypocomplementemia usually precede the appearance of clinical manifestations. Immune complex-mediated nephritis is one of the major complications of MCTD. Juvenile MCTD is known to be associated with a higher risk of nephritis than adult MCTD. However, it is uncertain whether all children with MCTD should be subjected to a renal biopsy, and whether most of those with hypocomplementemia present nephropathy, as in patients with SLE. We examined the histopathological characteristics of juvenile MCTD nephritis, the importance of renal biopsy and the implications of hypocomplementemia in our patients and reported cases of MCTD.

MATERIAL AND METHODS

We performed renal biopsy in 11 children with MCTD and found 6 patients with glomerulonephritis. In addition, we studied the frequency and the characteristics of glomerulonephritis in 71 cases of juvenile MCTD (our 11 patients and 60 reported cases). We also analyzed the relationship between hypocomplementemia and pathological features in 41 cases of MCTD nephritis (23 adults, 18 children).

RESULTS

6 of our 11 patients had glomerulonephritis, but of them four had no abnormality in urinalysis at the time of biopsy. In 5 patients renal biopsy showed normal findings. Review of 71 cases of juvenile MCTD showed that of them 28% presented latent asymptomatic nephritis at the time of biopsy. Membranous nephropathy (MN) and mesangial proliferative glomerulonephritis (MPG) were common in MCTD. Interestingly, hypocomplementemia was more frequently observed in patients with MN or mixed form of MN and MPG (MPG/MN) than simple MPG based on our review of 41 cases (p < 0.01).

CONCLUSION

A more aggressive indication of renal biopsy should be considered in children with MCTD because of the high incidence of non-clinical nephritis. The hypocomplementemia observed in patients with MCTD suggests the high frequency of glomerulonephritis, including membranous lesions.

Treatment of mixed connective tissue disease

Mixed connective tissue disease (MCTD) is believed to be incurable and seems to have a variable prognosis. Some patients have a mild self-limited disease, whereas others develop major organ involvement that requires aggressive treatment. Because no controlled clinical trials have been performed to guide therapy in MCTD, treatment strategies must rely largely upon the conventional therapies that are used for similar problems in other rheumatic conditions (systemic lupus erythematosus, scleroderma, polymyositis). Given the heterogeneous clinical course of MCTD, therapy should be individualized to address the specific organ involved and the severity of underlying disease activity. Corticosteroids, antimalarials, methotrexate, cytotoxics (most often cyclophosphamide), and vasodilators have been used in the treatment of MCTD with varying degrees of success.

Effectiveness of intravenous immunoglobulin therapy for skin disease other than toxic epidermal necrolysis: a retrospective review of Mayo Clinic experience

OBJECTIVE

To examine retrospectively the use and effectiveness of intravenous immunoglobulin (IVIg) treatment of various skin diseases, primarily immunobullous disease.

PATIENTS AND METHODS

We identified patients who had received IVIg therapy for skin disease between 1996 and 2003 at the Mayo Clinic in Rochester, Minn, Scottsdale, Ariz, and Jacksonville, Fla, and retrospectively reviewed their medical records.

RESULTS

Eighteen patients were treated with IVIg for various skin diseases: immunobullous disease in 11 adults (pemphigus vulgaris [7 patients], bullous pemphigold [3], and cicatricial pemphigoid [1]); dermatomyositis (2); mixed connective tissue disease (1); chronic urticaria (1); scleromyxedema (1); leukocytoclastic vasculitis (1); and linear IgA bullous disease (1). Responses of patients by type of disease were as follows: pemphigus vulgaris, 1 partial response (PR) and 6 no response (NR); bullous pemphigoid, 1 complete response (CR) and 2 NR; cicatricial pemphigoid, 1 NR; dermatomyositis, 1 CR and 1 PR; mixed connective tissue disease, 1 CR; chronic urticaria, 1 CR; scleromyxedema, 1 CR; leukocytoclastic vasculitis, 1 PR; and linear IgA bullous disease, 1 CR. Six patients (33%) experienced CR, 3 (17%) had PR, and 9 (50%) had NR to IVIg therapy. All 9 nonresponders were adult patients with immunobullous disease.

CONCLUSION

Although this was a retrospective study of a small cohort of a mixture of patients, the findings emphasize that our experience with IVIg treatment for skin disease, particularly immunobullous disease, is less favorable than that reported previously. Further studies are needed to verify the efficacy of IVIg for skin disease.

A teenager with mixed connective tissue disease presenting with an acute coronary syndrome

Mixed connective tissue disease (MCTD) manifests as a number of cardiovascular diseases; however, myocardial infarction secondary to coronary artery disease has not been well documented. We present a case of a teenager with MCTD and known cardiac risk factors who developed an acute coronary syndrome.

Thrombotic thrombocytopenic purpura associated with mixed connective tissue disease

We report a male case of thrombotic microangiopathy with mixed connective tissue disease (MCTD). Thrombocytopenia and hemolytic anemia developed despite steroid treatment for acute interstitial pneumonitis. The patient became confused and eventually developed coma. Diffusion-weighted MRI revealed high intensity at the brainstem, frontal lobes, basal nuclei, and insula, findings compatible with multiple brain edema due to microthrombosis. Despite the treatment of successive plasma exchange and steroid pulse therapy, he eventually died by multiple organ failure. This rare case suggested that diffusion-weighted MRI is very sensitive at detecting early alterations of thrombotic thrombocytopenic purpura (TTP)-induced ischemic lesions in the brain. Neuropsychiatric symptoms due to thrombotic microangiopathy could be some of the fatal complications in MCTD patients.

Autologous peripheral blood stem cell transplantation in a patient with severe mixed connective tissue disease

A 65-year old man with mixed connective tissue disease (MCTD) and severe therapy resistant polymyositis was considered for high-dose cyclophosphamide (200 mg/kg) supported by autologous stem cell transplantation (ASCT). During a 21 months follow-up there has been a significant subjective, but objectively only a slight improvement in muscle strength. Initially the levels of serum creatine kinase and serum aldolase normalised, but are at 21 months at about the same level as before ASCT. Based on histopathological examination there is still active myositis. Our case would suggests that this treatment may have some efficacy in MCTD with severe polymyositis although longer follow-up is needed.

Mixed connective tissue disease with multiple organ damage: successful treatment with plasmapheresis

A 24-year-old-woman with mixed connective tissue disease (MCTD) developed multiple organ failure, disseminated intravascular coagulation (DIC), metabolic acidosis, and respiratory and renal failure resulting from visceral vasospasm, so-called visceral Raynaud's phenomenon. After plasmapheresis, the condition of multiple organ failure was markedly improved. The successful treatment with plasmapheresis was dependent upon the removal of immune complexes in serum and improvement of visceral circulation. Thus plasma exchange is recommended as a possible a treatment for multiple organ damage in MCTD.

Autologous hemopoietic stem-cell transplantation for children with refractory autoimmune disease

Autologous stem cell transplantation (ASCT) has been proposed as a possible treatment for severe autoimmune diseases such as rheumatoid arthritis (RA), multiple sclerosis (MS), systemic sclerosis, and systemic lupus erythematosus (SLE). To date, more than 250 patients with various autoimmune disorders have undergone an ASCT since 1996. Among them, there is a very limited number of children. This review summarizes the experience with ASCT for pediatric rheumatic diseases. Most reported cases concern juvenile idiopathic arthritis (JIA). Experience with ASCT for childhood SLE, Scleroderma, or Dermatomyositis is very limited. To date, 12 children with severe systemic or polyarticular JIA, all with progressive disease activity despite the use of corticosteroids, MTX, CsA, or Cyclophosphamide were treated in our center with ASCT. Rheumatologic follow-up at 3-month intervals up to 36 months showed a marked decrease in arthritis severity as expressed by the core-set criteria for juvenile chronic arthritis (JCA) activity. However, these children remain at risk for severe viral infections due to the prolonged lymfopenia. ASCT in this severely ill patient group induces a very significant and drug-free remission of the disease, but carries a significantly risk of developing fatal MAS.

Childhood mixed connective tissue disease

Two girls with mixed connective tissue disease (MCTD) were treated in our hospital in the past 5 years. Patient 1, a 10-year-old girl presenting with migratory arthralgia, had an initial diagnosis of juvenile rheumatoid arthritis. Muscle weakness with elevated levels of creatine kinase and liver enzymes, sclerodactyly, Raynaud's phenomenon and heliotrope sign developed subsequently in the following 3 years. Patient 2, a 13-year-old girl, had been treated for suspected systemic lupus erythematosus since 9 years of age. She presented with lymphadenopathy, arthralgia, pericardial effusion, and paralytic ileus. The symptoms waxed and waned. Sclerodactyly, Raynaud's phenomenon, proteinuria, and hypertension were also noted. Both patients had high serum titers of antinuclear antibody (speckled pattern, 1:5120) and were seropositive for antiribonuclear protein antibody. Intravenous immunoglobulin, prednisolone, cyclosporine A, and nonsteroidal anti-inflammatory drugs (NSAIDs) were given to patient 1. Patient 2 received cyclosporine A, prednisolone, and methylprednisolone pulse therapy. The disease has been well controlled for 2 years by low-dose immunosuppressants and NSAIDs. MCTD is a rare juvenile rheumatic disease: early identification and appropriate treatment can improve the disease outcome.

[Mixed connective tissue disease--etiology, pathogenesis, clinical significance, treatment]

Some patients have features of more than one rheumatic disease and thus do not fit into traditional classification. Patients with combination of clinical finding similar to those of systemic lupus erythematosus (SLE), progressive systemic sclerosis (PSS), polymyositis, rheumatoid arthritis (RA) and with unusually high titers of circulating antinuclear antibody with specificity for nuclear ribonucleoprotein (RNP) are considered to have mixed connective tissue disease (MCTD). The overlap was described by Sharp and colleagues in 1972. During the post 20 years many studies exposed the clinical correlates of this antibody system (now called anti U1RNP). Controversy arose about whether MCTD was a distinct entity or would be better defined as subset of SLE. Anti RNP antibodies precipitate three proteins uniquely associated with U1RNP. Clinical correlates considered to be distinctive of MCTD are associated with 68 kD antigen specificity. Its to be expected that T cells receptors and HLA molecules are involved in the generation of these antibodies. Several observations have indicated, that 68 kD anti U1RNP antibody response in associated with HLA DR 4 and DR2 phenotype. Several studies have pointed a role of viruses initiating an antibody response against URNPs. Initial observations of MCTD suggested infrequent renal disease, a good response to corticosteroids and favourable prognosis. Future study has shown that some patients may require aggressive and prolonged pharmacologic therapy and that pulmonary involvement is common. Pulmonary hypertension associated proliferative vascular lesions may be serious complication with not always favourable prognosis.

[Mixed connective tissue disease and overlap syndrome]

Clinical features of mixed connective tissue disease and overlap syndrome were described. Especially, importance of diagnosis and treatment in early stage of pulmonary hypertension in patients with MCTD were stressed.

ABC of rheumatology. Raynaud's phenomenon, scleroderma, and overlap syndromes

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Mixed connective tissue disease: recurrent episodes of optic neuropathy and transverse myelopathy. Successful treatment with plasmapheresis

Severe neuropsychiatric manifestations in mixed connective tissue disease (MCTD) are thought to be quite rare. We report an unusual case of MCTD with recurrent optic neuropathy and transverse myelopathy suggestive of a relapsing-remitting demyelinating disorder. Symptoms responded dramatically to a treatment with plasmapheresis and immunosuppressive medication.

[MCTD (mixed connective tissue disease)]

Mixed connective tissue disease (MCTD) was proposed by Sharp and others in 1972. MCTD is a unique disease in which the presence of nuclear RNP antibody is characteristic and the patient shows partial symptoms of SLE, PSS and or PM/DM. Among them, Raynaud's phenomenon and sausage like finger or swollen hand are the most common symptoms. Although patients with MCTD generally respond to small amount of corticosteroid and the prognosis is not so bad, some patients with MCTD especially those with pulmonary hypertension show high mortality.

[Pulmonary edema as a complication during pericardial puncture in "mixed connective tissue disease"]

A 22-year-old female patient with an 8-year history of mixed connective tissue disease (systemic sclerosis overlapping with systemic lupus erythematosus) presented with marked respiratory distress, sinus tachycardia (135 bpm), and pulsus paradoxus. The chest x-ray showed an enlargement of the cardiac silhouette, which was due to a 3-cm-wide, circular pericardial effusion, as demonstrated by two-dimensional echocardiography. Pericardiocentesis performed to decompress cardiac tamponade did not lead to clinical improvement. The increase in dyspnea was caused by a rise in pulmonary wedge pressure from 21 to 40 mm Hg following an acute increase of mitral valve regurgitation. In the presence of global hypokinesia of the left ventricle, cardiac output decreased from 3.25 to 2.63 l/min. Intensive care including hemodialysis and plasmapheresis as well as high-dose application of cyclophosphamide and steroids led to a stabilization of the hemodynamic situation over a period of days. The case report presented here supports the general recommendation to perform pericardiocentesis in a stepwise manner under hemodynamic monitoring. This holds true primarily for patients with mitral valve regurgitation and/or cardiac involvement in connection with an underlying disease.

[Superposition syndrome of connective tissue diseases: current view with special focus on mixed connective tissue disease]

Attention is called to mixed connective tissue disease which, twenty years after it's original description, has now reached the syndromic individualization with important therapeutic and prognostic implications. In particular the discussion concerns the pulmonary complications (hypertension and fibrosis) responsible frequently for fatal outcome.