Normotensive renal failure in a patient with systemic sclerosis and p-antineutrophil cytoplasmic autoantibodies which developed into Paget's disease of bone after immunosuppressive therapy

Systemic vasculitis during the course of systemic sclerosis: report of 12 cases and review of the literature

Although the presence of antineutrophil cytoplasmic antibodies (ANCA) has been reported in patients with systemic sclerosis (SSc), the association of SSc and systemic vasculitis has rarely been described. We obtained information on cases of systemic vasculitis associated with SSc in France from the French Vasculitis Study Group and all members of the French Research Group on Systemic Sclerosis. We identified 12 patients with systemic vasculitis associated with SSc: 9 with ANCA-associated systemic vasculitis (AASV) and 3 with mixed cryoglobulinemia vasculitis (MCV). In all AASV patients, SSc was of the limited type. The main complication of SSc was pulmonary fibrosis. Only 2 patients underwent a D-penicillamine regimen before the occurrence of AASV. The characteristics of AASV were microscopic polyangiitis (n = 7) and renal limited vasculitis (n = 2). Anti-myeloperoxidase antibodies were found in 8 of the 9 patients. The Five Factor Score was above 1 in 3 of the 9 patients. Of the 3 patients with MCV, Sjögren syndrome was confirmed in 2. We compared our findings with the results of a literature review (42 previously reported cases of AASV with SSc). Although rare, vasculitis is a complication of SSc. AASV is the most frequent type, and its diagnosis can be challenging when the kidney is injured. Better awareness of this rare association could facilitate earlier diagnosis and appropriate management to reduce damage.

Scleroderma associated with ANCA-associated vasculitis

We have recently reported on two cases of scleroderma patients with ANCA-associated vasculitis for the first time in Korea. In order to explore the nature of this disease combination, we pooled together all the previously known cases and statistically analyzed them. Out of the 50 selected cases, survival analysis was done for comparison of the scleroderma disease period and the clinical factors associated with ANCA-associated vasculitis (AAV). Kaplan-Meier analysis revealed that patients having anti-topoisomerase antibody (anti-Scl-70) and, probably, PR-3 ANCA are at a higher risk for developing AAV than patients without both anti-topoisomerase antibody and anti-centromere antibody (ACA), and patients with MPO-ANCA. Multivariate Cox regression analysis revealed having anti-topoisomerase antibody as a risk factor for developing AAV [OR 3.1 (95% CI 1.11-8.55), P=0.031]. We suggest that having anti-topoisomerase antibodies may play a role among scleroderma patients in developing AAV.

ANCA-related crescentic glomerulonephritis in a patient with scleroderma without marked dermatological change and malignant hypertension

A 64-year-old woman with scleroderma without marked dermatological change developed anti-neutrophil cytoplasmic autoantibody (ANCA)-related renal failure. She had neither malignant hypertension nor elevation of plasma renin concentration. Renal biopsy showed crescentic glomerulonephritis (pauci-immune type) and the myeloperoxidase-specific anti-neutrophil cytoplasmic autoantibody (MPO-ANCA) titer was found to be elevated to 757 IU/ml. Methylprednisolone pulse therapy followed by oral prednisolone effectively suppressed renal failure and lowered the MPO-ANCA titer. We believe this is a rare case of ANCA-related renal failure in a patient with scleroderma without marked dermatological change.

Antineutrophil cytoplasmic antibodies in scleroderma patients: first report of a case with anti-proteinase 3 antibodies and review of the literature

OBJECTIVE

To evaluate the incidence, the subspecificities and the clinical correlation of antineutrophil cytoplasmic antibodies in scleroderma patients.

METHODS

Sixty-two patients affected by scleroderma in limited or diffuse pattern have been screened for the presence of anti-proteinase 3 and anti-myeloperoxidase antibodies by ELISA method.

RESULTS

Two patients affected by diffuse systemic sclerosis were found to be antineutrophil cytoplasmic antibody-positive. One patient presented a weak positivity for anti-myeloperoxidase antibodies in the absence of renal impairment. One patient which clinical course is characterised by rapidly progressive skin and lung involvement presented a high positivity for anti-proteinase 3 antibody.

CONCLUSION

Our study confirms the low incidence of antineutrophil cytoplasmic antibodies in scleroderma patients (3.2%); we reportthe first case of isolated scleroderma with positivity of anti-proteinase 3 antibodies.