[Endocrine disturbances in circumscribed scleroderma]

AIM

To evaluate prevalence of endocrine pathology in patients with circumscribed scleroderma (CS), baseline immunopathological alterations in CS patients.

MATERIAL AND METHODS

Circulating immune complexes were studied by the Digeon method in a total of 70 CS patients (female 52, 74.3%; male 18, 25.7%; age 16 to 70 years).

RESULTS

Circulating immune complexes assay by Digeon detected evident immune imbalance characteristic for metabolic disturbances of the connective tissue and affection of the endocrine system.

CONCLUSION

CS patients need a combined examination including endocrinological and immunological tests.

Localized scleroderma in childhood is not just a skin disease

OBJECTIVE

Juvenile localized scleroderma is usually considered a disease that is confined to the skin and subcutaneous tissue. We studied the prevalence and clinical features of extracutaneous manifestations in a large cohort of children with juvenile localized scleroderma.

METHODS

Data from a multinational study on juvenile scleroderma was used for this in-depth study. Clinical features of patients with extracutaneous manifestations were compared with those of patients who had exclusively skin involvement.

RESULTS

Seven hundred fifty patients entered the study. One hundred sixty-eight patients (22.4%) presented with a total of 193 extracutaneous manifestations, as follows: articular (47.2%), neurologic (17.1%), vascular (9.3%), ocular (8.3%), gastrointestinal (6.2%), respiratory (2.6%), cardiac (1%), and renal (1%). Other autoimmune conditions were present in 7.3% of patients. Neurologic involvement consisted of epilepsy, central nervous system vasculitis, peripheral neuropathy, vascular malformations, headache, and neuroimaging abnormalities. Ocular manifestations were episcleritis, uveitis, xerophthalmia, glaucoma, and papilledema. In more than one-fourth of these children, articular, neurologic, and ocular involvements were unrelated to the site of skin lesions. Raynaud's phenomenon was reported in 16 patients. Respiratory involvement consisted essentially of restrictive lung disease. Gastrointestinal involvement was reported in 12 patients and consisted exclusively of gastroesophageal reflux. Thirty patients (4%) had multiple extracutaneous features, but systemic sclerosis (SSc) developed in only 1 patient. In patients with extracutaneous involvement, the prevalence of antinuclear antibodies and rheumatoid factor was significantly higher than that among patients with only skin involvement. However, Scl-70 and anticentromere, markers of SSc, were not significantly increased.

CONCLUSION

Extracutaneous manifestations of juvenile localized scleroderma developed in almost one-fourth of the children in this study. These extracutaneous manifestations often were unrelated to the site of the skin lesions and sometimes were associated with multiple organ involvement. The risk of developing SSc was very low. This subgroup of patients with juvenile localized scleroderma should be evaluated extensively, treated more aggressively, and monitored carefully.

Atypical hemodynamic manifestations of cardiac tamponade

Clinical examination and transthoracic echocardiography play a vital role in the management of patients with pericardial effusion and cardiac tamponade physiology. We report patients in advanced phase 3 cardiac tamponade with variant clinical and hemodynamic presentations. These atypical cardiac tamponade cases include: A patient with severe aortic valve regurgitation who lacked pulsus paradoxus; a patient with systemic sclerosis without hypotension; and a patient with pulmonary hypertension lacking right heart collapse on echocardiography. Recognition of these atypical clinical and hemodynamic manifestations of cardiac tamponade will avoid undue delay in the treatment.

Neuroimaging findings in scleroderma en coup de sabre

OBJECTIVES

To describe the neuroimaging and clinical findings in patients with localized scleroderma en coup de sabre (LScs).

METHODS

Patients with LScs were evaluated by high-resolution MRI and CT. The authors performed three-dimensional reconstructions of MRI and CT scans to evaluate brain and bone structures.

RESULTS

Nine patients with LScs were evaluated (five women), with ages ranging from 6 to 53 years (mean, 30.7 years). Brain CT showed bone deformities with thinning of the skull under the skin lesions in six patients. MRI scans showed focal atrophy and blurring of the gray-white matter interface localized under the skin lesion in all patients. In three patients it was associated with hyperintense signal on fluid-attenuated inversion recovery (FLAIR) and T2-weighted images. Follow-up MRI showed extension of the brain lesion in one patient; in the remaining patients, the lesion did not progress. Four of the nine patients had partial epilepsy. One had surgery for management of refractory seizures, and pathologic findings indicated a focal inflammatory process.

CONCLUSION

Localized scleroderma en coup de sabre is associated with focal, and in some progressive, brain lesions underlying the skin atrophy. Epilepsy, when present, is related to these brain lesions. Imaging findings and histopathology indicated that the process, most likely focal inflammatory, may be progressive.

Anti-DNA topoisomerase II? autoantibodies in localized scleroderma

OBJECTIVE

To determine the prevalence and clinical correlation of anti-DNA topoisomerase IIalpha (anti-topo IIalpha) antibody in patients with localized scleroderma.

METHODS

Anti-topo IIalpha antibodies or anti-DNA topoisomerase I (topo I) antibodies were determined by enzyme-linked immunosorbent assay (ELISA) and immunoblotting. Inhibition of topo IIalpha enzymatic activity by the antibodies was evaluated by decatenation assays using kinetoplast DNA as a substrate.

RESULTS

IgG or IgM anti-topo IIalpha antibody was detected in 76% (35 of 46) of patients with localized scleroderma, and in 85% (11 of 13) of patients with generalized morphea, the severest form of localized scleroderma. This prevalence of the antibody in patients with localized scleroderma was much higher than that found in patients with systemic sclerosis (SSc) (5 of 37 [14%]), systemic lupus erythematosus (2 of 26 [8%]), dermatomyositis (2 of 20 [10%]), and in healthy controls (3 of 42 [7%]). Immunoblotting confirmed the presence of IgG anti-topo IIalpha antibody in sera from patients with localized scleroderma and showed no cross-reactivity of anti-topo IIalpha antibody with topo I. Anti-topo I antibody was not detected by ELISA in any sera from patients with localized scleroderma. In addition, anti-topo I antibody from SSc patients did not cross-react with topo IIalpha. The presence of anti-topo IIalpha antibody was associated with a greater total number of sclerotic lesions and number of plaque lesions in patients with localized scleroderma. Furthermore, anti-topo IIalpha antibody was able to inhibit topo IIalpha enzymatic activity.

CONCLUSION

The results of the present study indicate that anti-topo IIalpha is a major autoantibody in localized scleroderma, and is distinct from anti-topo I antibody in SSc.

Progressive facial hemiatrophy: central nervous system involvement and relationship with scleroderma en coup de sabre

OBJECTIVE

To investigate the relationship of progressive facial hemiatrophy (PFH) and scleroderma en coup de sabre by establishing the presence and type of central nervous system (CNS) involvement in both diseases and the possible coexistence of PFH with scleroderma in other body sites.

METHODS

We divided 19 cases of PFH into 2 groups: group 1 in which atrophies were preceded by cutaneous indurations (n = 10) and group 2 with no precedent indurations (n = 9). The third group consisted of 7 cases of scleroderma en coup de sabre with no PFH features. Clinical and laboratory investigations included indirect immunofluorescence for antinuclear antibodies, and routine neurological examination involved electroencephalography, magnetic resonance imaging (MRI) before and after contrast application to evaluate the integrity of blood-brain barrier, angio-MRI to evaluate intracranial blood vessel anomalies, and 99mTc-HM-PAO-SPECT to evaluate regional cerebral blood flow (CBF).

RESULTS

We found similar anomalies in all 3 groups. MRI did not show abnormality in 2 out of 9 PFH cases preceded by indurations, in 5 out of 9 cases not preceded by indurations, and in all 7 cases of scleroderma en coup de sabre, including 5 patients, in whom the CBF was found to be diminished. In single cases of groups 1 and 2, SPECT was normal despite some MRI abnormalities. Angio-MRI was not contributory since the same abnormalities of Willis circle were found in normal controls. In single cases of both PFH groups, MRI with contrast disclosed some damage of the blood-brain barrier.

CONCLUSION

Our results suggest frequent CNS involvement in PFH cases, regardless of the time of presentation of cutaneous indurations, with or without coexistent plaques of localized scleroderma in other locations. This indicates a close relationship between PFH and scleroderma en coup de sabre. The detection of abnormal SPECT by normal MRI in some cases of PFH and scleroderma en coup de sabre is of practical importance. This indicates the usefulness of SPECT in studying both PFH and scleroderma en coup de sabre.

Risk of cancer in patients with scleroderma: a population based cohort study

BACKGROUND

Previous studies have suggested an increased risk of cancer among patients with scleroderma.

OBJECTIVE

To study a population based cohort of patients with scleroderma in South Australia.

METHODS

Subjects with scleroderma were identified from the South Australian Scleroderma Registry established in 1993. All subjects on the scleroderma registry were linked to the South Australian Cancer Registry to identify all cases of cancer until 31 December 2000. Standardised incidence ratios (SIRs) for cancer for subjects with scleroderma were determined using the age- and sex-specific rates for South Australia.

RESULTS

In 441 patients with scleroderma, 90 cases of cancer were identified, 47 of which developed after inclusion on the scleroderma registry. The SIRs for all cancers among these patients were significantly increased (SIR=1.99; 95% confidence interval (95% CI) 1.46 to 2.65) compared with the cancer incidence rates for South Australia. The SIRs for lung cancer (SIR=5.9; 95% CI 3.05 to 10.31) were also significantly increased. The SIRs for all cancers among the subgroups with diffuse scleroderma (SIR=2.73; 95% CI 1.31 to 5.02) and limited scleroderma (SIR=1.85; 95% CI 1.23 to 2.68) were significantly increased.

CONCLUSIONS

This population based cohort study provides evidence that scleroderma is associated with cancer, and in particular, lung cancer. In addition, both diffuse and limited forms of scleroderma are associated with a similarly increased risk of cancer.

Body image dissatisfaction among women with scleroderma: extent and relationship to psychosocial function

Body image dissatisfaction and its relationship to psychosocial function were investigated in 127 women with scleroderma Results indicated elevated body image dissatisfaction, with participants reporting higher levels than a sample of patients with severe burn injuries. Age, skin tightening above the elbows, and functional disability were related to heightened body image dissatisfaction, suggesting that younger patients with more severe disease may be at greatest risk for developing body image concerns. Path analysis revealed that depression mediated the relationship between body image dissatisfaction and psychosocial function. Results suggest that body image dissatisfaction is a significant concern in women with scleroderma and should be assessed routinely. Early identification and treatment of body image dissatisfaction may help prevent the development of depression and psychosocial impairment in this population.

Localized scleroderma in adults and children. Clinical and laboratory investigations on 239 cases

We examined, retrospectively, 239 patients (113 adults and 126 children) with LS, referred to our department from 1980 up to 2001. Clinical parameters evaluated were age, sex, LS variant, extracutaneous manifestations, duration of disease and follow-up. We also considered laboratory findings, most notably erythrocyte sedimentation rate, blood eosinophilia, antinuclear antibodies (ANA) and various circulating autoantibodies. Plaque morphea was the most common form in both groups (74 adults and 61 children). In contrast, linear scleroderma affected children much more frequently than adults (22 children vs 7 adults). When the limbs were involved, this variant could lead to severe orthopedic complications (10 children vs one adult patient). On the other hand, linear scleroderma of the scalp and face comprising scleroderma en coup de sabre and Parry-Romberg syndrome was also more frequent in children (14 children vs 5 adults) causing ocular (8 cases), oral (7 cases) and neurologic (8 cases) abnormalities. Typical of childhood were mixed forms (18 pediatric patients), characterized by combination of different LS variants, which usually followed a more protracted and complicated course and showed ANA positivity (11 cases). Among adults, Raynaud's phenomenon was found in 8 patients; interestingly, anticentromere antibodies were detected in 4 of these subjects, identifying a subset at risk for progression to systemic disease. Children and adults developed LS with analogous clinical and immunological features. However, the prevalence of LS variants differed between adult and pediatric populations, leading to different extracutaneous complications.

Epidemiology and pathogenesis of scleroderma

Scleroderma is a heterogenous connective tissue disorder characterized by fibrosis of the skin, with or without internal organ involvement. The aetiology of scleroderma may involve both environmental and genetic factors. Abnormalities involving the immune system, vascular tissue and extracellular matrix have been demonstrated. Recent research has focused on microchimerism as a risk factor for the development of scleroderma. This article reviews the epidemiology and pathogenesis of this disorder.

Scleroderma in children and adolescents

The scleroderma disorders remain challenging conditions in pediatric rheumatology to understand pathologically and indeed for which to provide care. It is clear that much progress is being made in the clinical approach to understanding this group of group of disorders. It seems likely that the different lesions of LS may represent unique immunopathogenic mechanisms or perhaps reflect unique genetic or other characteristics of the patients themselves. To take advantage of the revolution in therapies now occurring in rheumatology it is critical that controlled clinical trials are developed with appropriate agreed upon outcome measures for both localized and systemic disease.

Lipodermatosclerosis: review of cases evaluated at Mayo Clinic

BACKGROUND

Lipodermatosclerosis describes bound-down, sclerotic skin involving the lower extremities.

OBJECTIVE

Our purpose was to describe the demographic and clinical features of patients with lipodermatosclerosis.

METHODS

This was a retrospective study of patients presenting to Mayo Clinic between 1976 and 1998 with a diagnosis of lipodermatosclerosis.

RESULTS

Of 97 patients, 84 (87%) were women. Mean age was 62 years (range, 25-88 years). Mean body mass index was 34.3 (range, 17.8-71.5). Clinical signs were bilateral involvement in 44 patients (45%), induration localized to a discrete plaque in 49 (51%), erythema in 69 (71%), hyperpigmentation in 57 (59%), ulceration in 13 (13%), concomitant edema in 69 (71%), and varicosities in 55 (57%). Vascular studies performed on 72 patients showed abnormalities in 49: deep venous incompetence in 33 (67%), calf muscle pump abnormality in 19 (39%), abnormal pulsatility in 10 (20%), and obstruction in 1 (2%).

CONCLUSION

Lipodermatosclerosis was associated with female sex, middle age, high body mass index, and venous abnormalities.

Localized and systemic scleroderma

Scleroderma is a broad term encompassing both localized and systemic sclerosis. Localized scleroderma is a cutaneous limited fibrosis that manifests as plaque morphea, generalized morphea, linear scleroderma, and deep morphea. Systemic scleroderma (sclerosis) can manifest as either limited or diffuse disease. Limited systemic sclerosis is typically preceded by Raynaud's phenomenon, involves cutaneous sclerosis distal to the elbows, with gastrointestinal and pulmonary fibrosis, and anticentromere antibody positivity. Diffuse systemic scleroderma is characterized by simultaneous Raynaud's phenomenon, cutaneous skin involvement proximal to the elbow with gastrointestinal, pulmonary, renal and cardiac fibrosis, and positive serology for antitopoisomerase and anti-RNAP III antibodies. This article discusses the classification, epidemiology, pathogenesis, clinical manifestations, treatment, and prognosis of the scleroderma.

Accuracy of alternative approaches to capture-recapture estimates of disease frequency: internal validity analysis of data from five sources

The authors used "internal validity analysis" to evaluate the performance of various capture-recapture methods. Data from studies with five overlapping, incomplete lists generated subgroups whose known sizes were compared with estimates derived from various four-source capture-recapture analyses. In 15 data sets unanalyzed previously (five subgroups of each of three new studies), the authors observed a trend toward mean underestimation of the known population size by 16-25%. (Coverage of the 90% confidence intervals associated with the method found to be optimal was acceptable (13/15), despite the downward bias.) The authors conjectured that (with the obvious exception of geographically disparate lists) most data sets used by epidemiologists tend to have a net positive dependence; that is, cases captured by one source are more likely to be captured by some other available source than are cases selected randomly from the population, and this trend results in a bias toward underestimation. Attempts to ensure that the underlying assumptions of the methods are met, such as minimizing (or adjusting adequately) for the possibility of loss due to death or migration, as was undertaken in one exceptional study, appear likely to improve the behavior of these methods.

Scleromyxoedema-like cutaneous diseases in renal-dialysis patients

15 renal dialysis patients have been identified with a skin condition characterised by thickening and hardening of the skin of the extremities and an increase in dermal fibroblast-like cells associated with collagen remodelling and mucin deposition. The disease closely resembles scleromyxoedema, yet has significant enough clinical and histopathological differences to warrant its designation as a new clinicopathological entity.

[Scleroderma in children: a retrospective study of 70 cases]

BACKGROUND

Scleroderma is uncommon in childhood. The aim of our study was to analyze the frequency of different clinical forms, their prognostic significance, biological features, and co-morbidities and to assess the pertinence of therapeutic options.

PATIENTS AND METHODS

The files of 70 children with primary scleroderma seen from 1980 to 1997 were retrospectively reviewed.

RESULTS

Localized scleroderma was observed in 56 children and diffuse lesions in 14. Localized scleroderma (44 girls, 12 boys) began early at a mean age of 7 years 2 months. The lesions presented as isolated bands (39 p. 100), associated with morphea (36 p. 100), or multiple morphea (5 p. 100). Mean duration of the clinical course was longer in cases with more and deeper lesions. Eosinophilia was observed at onset in 38 p. 100 of the cases and antinuclear antibodies were found in 28 p. 100. Local corticosteroid therapy (level I or II) appeared to be useful in the superficial and active lesions (morphea) but did not halt progression to deep scleroderma. General corticosteroid therapy (1 mg/kg/24 h) did not prevent the development of sequelae in cases with bands (16/16). Diffuse scleroderma corresponded to systemic scleroderma (6 cases), dual morbidity (dermatomyositis, mixed connective tissue disease) (6 cases), or scleroderma after eosinophil fasciitis (2 cases). Age at onset was around 9 years with female predominance. A particular gloves and socks form was observed and cardiac involvement was common, but there was no case of renal involvement. The therapeutic problems were similar to those in adults.

DISCUSSION

Our findings emphasize that scleroderma occurs readily in childhood, unlike what has been reported 10 years ago. Prognosis depends on functional impairment resulting from major sequelae particularly important in localized forms and the life-threatening situations occurring in systemic forms.

Morphea and localized scleroderma in children

Localized scleroderma refers to a diverse spectrum of disorders that involve fibrosis of the skin. Children are more likely than adults to develop localized forms of scleroderma. This condition may have devastating effects on growth and development such as limb asymmetry, flexion contractures, and psychological disability. The pathogenesis of localized scleroderma is unknown but its possible relation to Borrelial infection is discussed. This article reviews associated laboratory and radiologic abnormalities, and discusses implications for monitoring disease activity. There is no universally effective therapy for this idiopathic condition and therapy is limited. A rationale for treatment based on disease subtype and severity is provided.

[Connective tissue diseases in the hospital outpatient service in Lomé (Togo)]

PURPOSE

There have been few studies of connective tissue diseases in Africa.

METHODS

A retrospective study was conducted in order to describe the various connective tissue diseases and their semiological profile in patients attending the dermatology and rheumatology units at Lomé hospital.

RESULTS

Clinical examinations showed that eighty-four (0.2%) out of the 34,169 patients were suffering from connective tissue diseases. Diseases that were encountered were the following: scleroderma (18 cases), systemic lupus erythematosus (four cases), discoid lupus erythematosus (15 cases), rheumatoid arthritis (29 cases), polymyositis and dermatomyositis (16 cases), juvenile rheumatoid arthritis (one case), giant cell arteritis (one case). Raynaud's syndrome was present in six out of the 18 patients suffering from scleroderma. Nephrotic syndrome was observed in a patient suffering from systemic lupus erythematosus. A septicemia caused this patient's death. Two patients suffering from polymyositis had cancer. No etiology was found in the 14 other patients. Hip involvement was present in two patients suffering from rheumatoid arthritis. Patients with rheumatoid arthritis had no systemic involvement (nodulitis, vasculitis).

CONCLUSION

Our results are in agreement with those of previous studies on connective tissue diseases in Africa. However, further studies are required to better understand the epidemiological and semiological profiles of connective tissue diseases in Africa.

[Scleroderma in a hospital setting in Togo]

The purpose of this retrospective study was to determine the epidemiological and semiological profile of scleroderma in Black Africa. Medical records of patients who consulted in the Dermatology Clinic and the Rheumatology Clinic of the Teaching Hospital in Lomé, Togo between 1980 and 1996 and between 1989 and 1996 respectively were reviewed. Scleroderma was diagnosed in 18 of the 34,169 patients seen during the study periods (0,05%). The disease was systemic in 13 cases (8 females, 5 males; mean age: 31 years) and localized in 5 cases (mean age: 20 years). There were no predisposing occupational or therapeutic factors. The clinical manifestations were Raynaud's phenomenon in six of the 13 patients with systemic scleroderma. Extensive cutaneous sclerosis in 10 cases, poikiloderma in seven cases, dysphagia in three cases, pulmonary fibrosis in four cases, and polyarthralgia in two cases. Myalgia and renal involvement were not observed. The findings of this study documents the low incidence of scleroderma in Togo. The high frequency of extensive cutaneous sclerosis, poikiloderma and low frequency of Raynaud's phenomenon which were often mild are the most remarkable features of the disease in Lomé. These features have been pointed out previously but epidemiologic data is still insufficient to confirm the existence of an African form of scleroderma.

Classification and epidemiology of scleroderma

Scleroderma is classified as two separate but related entities, a localized form and a systemic form. The classification scheme for morphea presented here is that of Peterson et al, which divides morphea into five categories: plaque, generalized, bullous, linear, and deep. Using this system, these authors estimated the incidence rate of localized scleroderma to be 27 new cases per million population per year. Overall survival was similar to that of the general population. There was a preponderance of female cases (approximately 3:1) for all forms of morphea except for linear scleroderma, which had an even sex distribution. Systemic scleroderma is divided into limited and diffuse disease based on the extent of skin involvement. Recent estimates have placed the incidence rate of systemic sclerosis in the United States at 19 new cases per million adults per year, with an overall prevalence of 240/million adults. The female-to-male ratio is approximately 5:1. The prevalence of scleroderma varies by geographic region and ethnic background and is higher in the United States than in Europe or Japan. Although systemic sclerosis survival has improved over the past two decades, with 5-year survival over 80%, long-term survival is significantly lower than expected, and morbidity is considerable.

Pediatric scleroderma

Scleroderma is a diverse group of conditions which have in common fibrosis of skin and other tissues. Although less common in children than in adults, these conditions are an important cause of morbidity and occasional mortality when they occur in the pediatric population. Children are more likely than adults to develop localized forms of scleroderma, and because of the impact on growth, these can result in major facial or limb asymmetry, flexion contractures, and disability. Management approaches must take into consideration the effect of medications on the child (for example, growth failure and osteoporosis from corticosteroids) as well as the psychosocial impact of chronic illness and physical deformity on the child and family. This article describes the types of scleroderma identified in children, reviews epidemiologic and etiologic factors, and discusses management options. Because this is a rare group of diseases managed by both dermatologists and rheumatologists, large series of patients are rare, and controlled studies of management are not available.