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Martins A, Pimenta S, Oliveira D, Miriam Ferreira R, Bernardes M, Costa L, Terroso G. Can microvascular damage predict disease severity in patients with systemic sclerosis? REUMATOLOGIA CLINICA 2024; 20:366-371. [PMID: 39160008 DOI: 10.1016/j.reumae.2024.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 05/09/2024] [Indexed: 08/21/2024]
Abstract
INTRODUCTION Systemic sclerosis (SSc) is characterized by progressive fibrosis of the skin and internal organs, microvascular damage and cellular and humoral immunity abnormalities. Microvascular damage can be easily detected through nailfold videocapillaroscopy (NVC). MATERIALS AND METHODS A retrospective study of patients with SSc and a NVC performed within the first 6 months after diagnosis was conducted. Visceral involvement in the first 3 years of the disease and NVC findings were collected. The severity of microvascular damage was classified into four categories, according to the worsening of the NVC patterns. The severity of organ involvement was assessed by the disease severity scale of Medsger for each organ and as a global measure of disease severity, the simple summation was used. RESULTS A total of 86 patients with SSc were included. A moderate correlation was found between the severity of microvascular damage and the global measure of disease severity (r=0.55, p<0.001), the severity of peripheral vascular involvement (r=0.43, p<0.001) and the severity of skin involvement (r=0.34, p=0.001). The presence of a late scleroderma pattern in NVC were predictive in univariate analysis of digital ulcers (OR 6.03, 95% CI 1.52-23.86, p=0.01), muscular involvement (OR 13.09, 95% CI 1.09-156.78, p=0.04), calcinosis (OR 27.22, 95% CI 5.56-133.33, p<0.001) and worse global disease severity score (OR 1.67, 95% CI 1.17-2.38, p=0.005). Multivariate analysis adjusted for disease duration and gender confirmed late pattern as an independent predictor of calcinosis (OR 42.89, 95% CI 5.53-332.85, p<0.001). DISCUSSION AND CONCLUSION In this study, the worsening of NVC pattern in SSc was associated with the overall disease severity, the severity of peripheral vascular involvement and extension of skin involvement. This study highlights the importance of NVC as a prognostic tool and a possible predictor of systemic visceral involvement.
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Affiliation(s)
- Ana Martins
- Rheumatology Department, Centro Hospitalar Universitário São João, Porto, Portugal.
| | - Sofia Pimenta
- Rheumatology Department, Centro Hospitalar Universitário São João, Porto, Portugal; Medicine Department, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Daniela Oliveira
- Rheumatology Department, Centro Hospitalar Universitário São João, Porto, Portugal; Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
| | - Raquel Miriam Ferreira
- Rheumatology Department, Centro Hospitalar Universitário São João, Porto, Portugal; Medicine Department, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Miguel Bernardes
- Rheumatology Department, Centro Hospitalar Universitário São João, Porto, Portugal; Medicine Department, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Lúcia Costa
- Rheumatology Department, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Georgina Terroso
- Rheumatology Department, Centro Hospitalar Universitário São João, Porto, Portugal
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Róbert L, Németh K, Marschalkó M, Holló P, Hidvégi B. Calcinosis Prevalence in Autoimmune Connective Tissue Diseases-A Retrospective Study. J Clin Med 2024; 13:3428. [PMID: 38929957 PMCID: PMC11204081 DOI: 10.3390/jcm13123428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 06/06/2024] [Accepted: 06/10/2024] [Indexed: 06/28/2024] Open
Abstract
Background/Objectives: Calcinosis cutis is the deposition of insoluble calcium salts, which may cause inflammation, ulceration, pain, and restricted joint mobility. It rarely develops in damaged tissues (dystrophic subtype), most frequently in autoimmune connective tissue diseases (CTDs), but there is very limited data on the prevalence. Also, therapy remains an unsolved issue. In this study, we aimed to collect data on the prevalence of calcinosis in CTD patients to highlight that it is a considerable problem. Methods: A retrospective study was conducted in our department to assess the epidemiology of dystrophic calcinosis in CTDs between January 2003 and January 2024. Results: A total of 839 CTD patients were identified, of whom 56 had calcinosis (6.67%). The mean age of the calcinosis patients at diagnosis of underlying CTD was 41.16 ± 19.47 years. The mean time interval from the onset of calcinosis was 5.96 ± 8.62 years. Systemic sclerosis was the most common CTD complicated by calcinosis (n = 22). Conclusions: Our results are comparable to those reported previously in the literature. Although calcinosis is rare in the overall population, it is a present and unsolved problem in CTD patients. Therefore, further studies are needed on the factors involved in the development and progression of calcinosis as well as its treatment.
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Affiliation(s)
| | | | | | | | - Bernadett Hidvégi
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, H-1085 Budapest, Hungary
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Avanoglu-Guler A, Campochiaro C, De Luca G, Hughes M, Tufan A, Green L, Del Galdo F, Matucci-Cerinic M, Dagna L. Calcinosis in systemic sclerosis: An update on pathogenesis, related complications, and management: A heavy burden still waiting to be lifted off patients' hands. Semin Arthritis Rheum 2024; 66:152431. [PMID: 38537324 DOI: 10.1016/j.semarthrit.2024.152431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/18/2024] [Accepted: 03/06/2024] [Indexed: 05/14/2024]
Abstract
In SSc, dystrophic calcinosis is one of the major clinical manifestations, characterized by the deposition of insoluble calcific substances in tissues, predominantly in the chemical form of calcium hydroxyapatite. Furthermore, calcinosis might lead to compressive neuropathies and severe pain. Current evidence suggests that tissue ischemia and repeated trauma are implicated in the development of calcinosis; however, there are still too many unknown areas that need to be investigated. Detection of calcinosis is commonly performed using X-ray or ultrasound. Moreover, quantification of calcinosis with X-ray and dual-energy computed tomography might be useful for the assessment of disease burden and monitoring of the disease. Despite its prevalence and clinical outcomes, there are no approved disease-modifying treatments for calcinosis in SSc. Debulking or surgical intervention might be preferred for calcinosis complicated with infection, compressive symptoms, or relief of pain. Therefore, innovative investigations and tailored therapeutic approaches are urgently needed to lift the burden of calcinosis from the hands of SSc patients.
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Affiliation(s)
- Aslihan Avanoglu-Guler
- Department of Internal Medicine, Division of Rheumatology, Gazi University, Ankara, Turkey; Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, 20132 Milan, Italy; Vita-Salute San Raffaele University, 20132 Milan, Italy.
| | - Corrado Campochiaro
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, 20132 Milan, Italy; Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Giacomo De Luca
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, 20132 Milan, Italy; Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Michael Hughes
- Department of Rheumatology, Salford Care Organisation, Northern Care Alliance NHS Group, Salford, UK; Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester & Salford Royal NHS Foundation Trust, Manchester, UK
| | - Abdurrahman Tufan
- Department of Internal Medicine, Division of Rheumatology, Gazi University, Ankara, Turkey; Inflammatory Disease Section, National Human Genome Research Institute, Bethesda, Maryland, USA
| | - Lorraine Green
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), University of Leeds and Leeds Teaching Hospitals Trust, Leeds, UK
| | - Francesco Del Galdo
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), University of Leeds and Leeds Teaching Hospitals Trust, Leeds, UK
| | - Marco Matucci-Cerinic
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, 20132 Milan, Italy; Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology AOUC, Florence, Italy
| | - Lorenzo Dagna
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, 20132 Milan, Italy; Vita-Salute San Raffaele University, 20132 Milan, Italy
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Achieng S, Harris J, Samaranayaka M, Herrick AL. A rare form of calcinosis in patients with systemic sclerosis-myositis overlap: report of four cases. Rheumatol Adv Pract 2024; 8:rkae011. [PMID: 38420189 PMCID: PMC10901148 DOI: 10.1093/rap/rkae011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 01/04/2024] [Indexed: 03/02/2024] Open
Abstract
Objectives Calcinosis is a well-described entity that occurs in patients with systemic sclerosis (SSc) and dermatomyositis (DM). Calcinosis in SSc typically occurs over pressure points and is usually nodular. We present a case series of four patients with SSc with a much rarer, diffuse form of calcinosis to illustrate this poorly recognized pattern of extensive and debilitating disease. Methods Four patients with SSc and extensive calcinosis were identified from patients attending a tertiary rheumatology centre in the preceding 3 years. Their electronic case notes, radiographic images and medical photographs were reviewed. Results All four patients had the diffuse cutaneous subtype of SSc (dcSSc) and additionally a myositis overlap. This was in the context of 102 of 461 (22%) patients with SSc whose clinical details had been recorded in the preceding 3 years having dcSSc. Their ages at diagnosis ranged from 27 to 65 years. Three were female, two were anti-Scl70 antibody positive, and two were anti-PMScl antibody positive. Development of calcinosis occurred between 1 and 6 years after onset of SSc. Plain radiography showed very extensive calcinosis in various sites, distributed in a pattern akin to sheets of calcium-containing deposits in the skin and subcutaneous tissue. Conclusions Although calcinosis is common in SSc, extensive sheet-like calcinosis is very rare. Our experience suggests that when this form of calcinosis does occur, this is in the context of the diffuse cutaneous subtype of disease and with myositis overlap. The four cases described should raise awareness of this unusual and extensive pattern of disease.
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Affiliation(s)
- Sheilla Achieng
- School of Biological Sciences, Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Department of Rheumatology, Northern Care Alliance NHS Foundation Trust, Salford Care Organisation, Manchester, UK
| | - Jonathan Harris
- Department of Radiology, Northern Care Alliance NHS Foundation Trust, Salford Care Organisation, Manchester, UK
| | - Muditha Samaranayaka
- Department of Rheumatology, Northern Care Alliance NHS Foundation Trust, Salford Care Organisation, Manchester, UK
| | - Ariane L Herrick
- School of Biological Sciences, Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Department of Rheumatology, Northern Care Alliance NHS Foundation Trust, Salford Care Organisation, Manchester, UK
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Samões B, Guimarães da Fonseca D, Beirão T, Costa F, Vieira R, Terroso G, Ferreira RM, Nicolau R, Saraiva A, Salvador MJ, Duarte AC, Cordeiro A, Vilas-Boas JP, Genrinho I, Bento da Silva A, Gago L, Resende C, Martins P, Madeira N, Dinis S, Couto M, Santos I, Araújo F, Mourão AF, Gomes Guerra M, Oliveira M, Daniel A, Rodrigues M, Dantas Soares C, Parente H, Furtado C, Fontes T, Abelha-Aleixo J. Assessment of calcinosis in Portuguese patients with systemic sclerosis - a multicenter study. Clin Rheumatol 2023:10.1007/s10067-023-06617-5. [PMID: 37154983 DOI: 10.1007/s10067-023-06617-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/21/2023] [Accepted: 04/28/2023] [Indexed: 05/10/2023]
Abstract
INTRODUCTION/OBJECTIVES The study aims to define the clinical and subclinical calcinosis prevalence, the sensitivity of radiographed site and clinical method for its diagnosis, and the phenotype of Portuguese systemic sclerosis (SSc) patients with calcinosis. METHOD A cross-sectional multicenter study was conducted with SSc patients fulfilling Leroy/Medsger 2001 or ACR/EULAR 2013 classification criteria, registered in the Reuma.pt. Calcinosis was assessed through clinical examination and radiographs of hands, elbows, knees, and feet. Independent parametric or non-parametric tests, multivariate logistic regression, and sensitivity calculation of radiographed site and clinical method for calcinosis detection were performed. RESULTS We included 226 patients. Clinical calcinosis was described in 63 (28.1%) and radiological calcinosis in 91 (40.3%) patients, of which 37 (40.7%) were subclinical. The most sensitive location to detect calcinosis was the hand (74.7%). Sensitivity of the clinical method was 58.2%. Calcinosis patients were more often female (p = 0.008) and older (p < 0.001) and had more frequently longer disease duration (p < 0.001), limited SSc (p = 0.017), telangiectasia (p = 0.039), digital ulcers (p = 0.001), esophageal (p < 0.001) and intestinal (p = 0.003) involvements, osteoporosis (p = 0.028), and late capillaroscopic pattern (p < 0.001). In multivariate analysis, digital ulcers (OR 2.63, 95% CI 1.02-6.78, p = 0.045) predicted overall calcinosis, esophageal involvement (OR 3.52, 95% CI 1.28-9.67, p = 0.015) and osteoporosis (OR 4.1, 95% CI 1.2-14.2, p = 0.027) predicted hand calcinosis, and late capillaroscopic pattern (OR 7.6, 95% CI 1.7-34.9, p = 0.009) predicted knee calcinosis. Anti-nuclear antibody positivity was associated with less knee calcinosis (OR 0.021, 95% CI 0.001-0477, p = 0.015). CONCLUSIONS Subclinical calcinosis high prevalence suggests that calcinosis is underdiagnosed and radiographic screening might be relevant. Multifactorial pathogenesis may explain calcinosis predictors' variability. Key Points • Prevalence of subclinical calcinosis in SSc patients is substantial. • Hand radiographs are more sensitive to detect calcinosis than other locations or clinical method. • Digital ulcers were associated with overall calcinosis, esophageal involvement and osteoporosis were associated with hand calcinosis, and late sclerodermic pattern in nailfold capillaroscopy was associated with knee calcinosis. • Anti-nuclear antibody positivity may be a protective factor for knee calcinosis.
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Affiliation(s)
- Beatriz Samões
- Rheumatology Department, Centro Hospitalar de Vila Nova de Gaia E Espinho, Vila Nova de Gaia, Portugal.
| | | | - Tiago Beirão
- Rheumatology Department, Centro Hospitalar de Vila Nova de Gaia E Espinho, Vila Nova de Gaia, Portugal
| | - Flávio Costa
- Rheumatology Department, Centro Hospitalar de Vila Nova de Gaia E Espinho, Vila Nova de Gaia, Portugal
| | - Romana Vieira
- Rheumatology Department, Centro Hospitalar de Vila Nova de Gaia E Espinho, Vila Nova de Gaia, Portugal
| | - Georgina Terroso
- Rheumatology Department, Centro Hospitalar Universitário de São João, Porto, Portugal
| | | | - Rafaela Nicolau
- Rheumatology Department, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | - André Saraiva
- Rheumatology Department, Centro Hospitalar E Universitário de Coimbra, Coimbra, Portugal
| | - Maria João Salvador
- Rheumatology Department, Centro Hospitalar E Universitário de Coimbra, Coimbra, Portugal
| | | | - Ana Cordeiro
- Rheumatology Department, Hospital Garcia de Orta, Almada, Portugal
| | | | - Inês Genrinho
- Rheumatology Department, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | - Ana Bento da Silva
- Rheumatology Department, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
- Comprehensive Health Research Centre (CHRC), NOVA Medical School, Lisbon, Portugal
| | - Laura Gago
- Rheumatology Department, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
- Comprehensive Health Research Centre (CHRC), NOVA Medical School, Lisbon, Portugal
| | - Catarina Resende
- Rheumatology Department, Centro Hospitalar e Universitário de Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Patricia Martins
- Rheumatology Department, Centro Hospitalar e Universitário de Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Unidade de Investigação Em Reumatologia, Instituto de Medicina Molecular, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Nathalie Madeira
- Rheumatology Department, Unidade Local de Saúde da Guarda - Hospital Sousa Martins, Guarda, Portugal
| | - Sara Dinis
- Rheumatology Department, Unidade Local de Saúde da Guarda - Hospital Sousa Martins, Guarda, Portugal
| | - Maura Couto
- Rheumatology Department, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | - Inês Santos
- Rheumatology Department, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | - Filipe Araújo
- Rheumatology and Osteoporosis Unit, Hospital de Sant'Ana, SCML, Cascais, Portugal
| | - Ana Filipa Mourão
- Rheumatology Department, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
- Comprehensive Health Research Centre (CHRC), NOVA Medical School, Lisbon, Portugal
| | - Miguel Gomes Guerra
- Rheumatology Department, Centro Hospitalar Universitário da Cova da Beira, Covilhã, Portugal
| | - Margarida Oliveira
- Rheumatology Department, Centro Hospitalar Universitário da Cova da Beira, Covilhã, Portugal
| | - Alexandra Daniel
- Rheumatology Department, Hospital Distrital de Leiria, Leiria, Portugal
| | - Marília Rodrigues
- Rheumatology Department, Hospital Distrital de Leiria, Leiria, Portugal
| | | | - Hugo Parente
- Rheumatology Department, Unidade Local de Saúde Do Alto Minho, Ponte de Lima, Portugal
| | - Carolina Furtado
- Rheumatology Department, Hospital Do Divino Espírito Santo, Ponta Delgada, Portugal
| | - Tomás Fontes
- Rheumatology Department, Hospital Do Divino Espírito Santo, Ponta Delgada, Portugal
| | - Joana Abelha-Aleixo
- Rheumatology Department, Centro Hospitalar de Vila Nova de Gaia E Espinho, Vila Nova de Gaia, Portugal
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Varjú C, Pauling JD, Saketkoo LA. Multi-Organ System Screening, Care, and Patient Support in Systemic Sclerosis. Rheum Dis Clin North Am 2023; 49:211-248. [PMID: 37028832 DOI: 10.1016/j.rdc.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2023]
Abstract
Systemic sclerosis (SSc) is a heterogenous systemic autoimmune disease of complex multi-organ manifestations with a disease-specific mortality of >50%. The patient journey is fraught with severe, diverse, and diffuse physical impairment, psychological burden, and diminishing health-related quality of life. SSc remains unfamiliar to many clinicians. Delayed/misdiagnosis, inadequate screening, and attention for common complications with potentially preventable disability/death contribute to patients feeling isolated and unsupported. We present actionable standards including screening, anticipatory guidance, and counseling in patient-centered SSc-care emphasizing psycho-social health as the central goal, whereas robust vigilance and efforts to improve biophysical health and survival are imperatives that support this goal.
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Affiliation(s)
- Cecília Varjú
- Department of Rheumatology and Immunology, Medical School, University of Pécs, Pécs, Hungary
| | - John D Pauling
- Department of Rheumatology, North Bristol NHS Trust, Bristol, UK; Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Lesley Ann Saketkoo
- New Orleans Scleroderma and Sarcoidosis Patient Care and Research Center, New Orleans, LA 70112, USA; University Medical Center - Comprehensive Pulmonary Hypertension Center and Interstitial Lung Disease Clinic Programs, New Orleans, LA, USA; Section of Pulmonary Medicine, Louisiana State University School of Medicine, New Orleans, LA, USA; Tulane University School of Medicine, New Orleans, LA, USA.
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Mormile I, Mosella F, Turco P, Napolitano F, de Paulis A, Rossi FW. Calcinosis Cutis and Calciphylaxis in Autoimmune Connective Tissue Diseases. Vaccines (Basel) 2023; 11:vaccines11050898. [PMID: 37243003 DOI: 10.3390/vaccines11050898] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 04/21/2023] [Accepted: 04/23/2023] [Indexed: 05/28/2023] Open
Abstract
Calcinosis represents a severe complication of several autoimmune disorders. Soft-tissue calcifications have been classified into five major types: dystrophic, metastatic, idiopathic, iatrogenic, and calciphylaxis. Autoimmune diseases are usually associated with dystrophic calcifications, including calcinosis cutis, occurring in damaged or devitalized tissues in the presence of normal serum levels of calcium and phosphate. In particular, calcinosis cutis has been described in dermatomyositis, polymyositis, juvenile dermatomyositis, systemic sclerosis, systemic lupus erythematosus, primary Sjögren's syndrome, overlap syndrome, mixed connective tissue disease, and rheumatoid arthritis. Calciphylaxis, a severe and life-threatening syndrome presenting with vascular calcifications and thrombosis, has also been associated with some autoimmune conditions. Due to the potentially disabling character of calcinosis cutis and calciphylaxis, physicians' awareness about the clinical presentation and management of these diseases should be increased to select the most appropriate treatment option and avoid long-term complications. In this review, we aim to analyze the clinical features of calcinosis cutis and calciphylaxis associated with autoimmune diseases, and the main treatment strategies evaluated up to now for treating this potentially disabling disease.
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Affiliation(s)
- Ilaria Mormile
- Department of Translational Medical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Francesca Mosella
- Department of Plastic and Reconstructive Surgery, University of Naples Federico II, 80131 Naples, Italy
| | - Piergiorgio Turco
- Department of Plastic and Reconstructive Surgery, University of Naples Federico II, 80131 Naples, Italy
| | - Filomena Napolitano
- Department of Translational Medical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Amato de Paulis
- Department of Translational Medical Sciences, University of Naples Federico II, 80131 Naples, Italy
- Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, 80131 Naples, Italy
- WAO Center of Excellence, 80131 Naples, Italy
| | - Francesca Wanda Rossi
- Department of Translational Medical Sciences, University of Naples Federico II, 80131 Naples, Italy
- Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, 80131 Naples, Italy
- WAO Center of Excellence, 80131 Naples, Italy
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Song P, Li S, Lewis MA, Fiorentino DF, Chung L. Clinical Associations of Degos-Like Lesions in Patients With Systemic Sclerosis. JAMA Dermatol 2023; 159:308-313. [PMID: 36753129 PMCID: PMC9909573 DOI: 10.1001/jamadermatol.2022.6330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 12/11/2022] [Indexed: 02/09/2023]
Abstract
Importance Degos-like lesions are cutaneous manifestations of a small-vessel vasculopathy that appear as atrophic, porcelain-white papules with red, telangiectatic borders. No study has adequately examined Degos-like lesions in patients with systemic sclerosis (SSc). Objective To characterize the serologic, cutaneous, and internal organ manifestations associated with Degos-like lesions in a large cohort of patients with SSc. Design, Settings, and Participants This retrospective cohort study involved adult patients with SSc who were seen at Stanford Rheumatologic Dermatology Clinic between January 1, 1998, and December 31, 2018. Participants fulfilled the 2013 classification criteria for SSc. Data analysis was conducted from February 1 to June 1, 2019. Main Outcomes and Measures Data on demographic characteristics; autoantibody status; clinical characteristics, including cutaneous and systemic manifestations of SSc; and presence of Degos-like lesions were collected. Results The cohort comprised 506 patients with SSc (447 females [88.3%]; mean [SD] age at first non-Raynaud disease symptoms, 46.1 [15.2] years). Twenty-seven patients (5.3%) had Degos-like lesions, of whom 24 (89.0%) had lesions affecting the fingers. Patients with Degos-like lesions were more likely to have diffuse cutaneous SSc compared with patients without lesions (15 [55.6%] vs 181 [37.8%]; P = .04). Degos-like lesions were also associated with acro-osteolysis (10 [37.0%] vs 62 [12.9%]; P < .01), digital ulcers (15 [55.6%] vs 173 [36.1%]; P = .04), and calcinosis (15 [55.6%] vs 115 [24.0%]; P < .01). While Degos-like lesions were not associated with internal organ manifestations, such as scleroderma renal crisis, interstitial lung disease, or pulmonary arterial hypertension, there was P < .10 for the association with gastric antral vascular ectasia. Conclusions and Relevance Results of this study suggest an association of Degos-like lesions with diffuse cutaneous SSc and other cutaneous manifestations of vasculopathy, including acro-osteolysis, calcinosis, and digital ulcers. A prospective longitudinal study is warranted to examine the onset of Degos-like lesions and to elucidate whether these lesions play a role in SSc.
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Affiliation(s)
- Paula Song
- Division of Rheumatology, Columbia University School of Medicine, New York, New York
| | - Shufeng Li
- Department of Dermatology, Stanford University School of Medicine, Palo Alto, California
- Department of Urology, Stanford University School of Medicine, Palo Alto, California
| | - Matthew A. Lewis
- Department of Dermatology, Stanford University School of Medicine, Palo Alto, California
| | - David F. Fiorentino
- Department of Dermatology, Stanford University School of Medicine, Palo Alto, California
| | - Lorinda Chung
- Division of Immunology and Rheumatology, Stanford University School of Medicine, Palo Alto, California
- Division of Immunology and Rheumatology, Palo Alto Veterans Affairs Healthcare System, Palo Alto, California
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Hughes M, Herrick AL. Diagnosis and management of systemic sclerosis-related calcinosis. Expert Rev Clin Immunol 2023; 19:45-54. [PMID: 36333952 DOI: 10.1080/1744666x.2023.2144835] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Calcinosis is common in patients with systemic sclerosis (SSc) and refers to the sub-epidermal deposition of calcium salts in the skin. SSc-related calcinosis is associated with significant morbidity, including through cutaneous ulceration and predisposition to become infected. AREAS COVERED After briefly addressing aetiopathogenesis, we describe the clinical burden of SSc-associated calcinosis and provide a structured and practical clinical approach to diagnosis and assessment, including discussion of the role of different imaging modalities. The multi-faceted treatment of SSc-associated calcinosis is presented under three broad headings of 'general measures,' and 'medical treatment' and 'surgical treatment.' We adopted a narrative approach to identify relevant manuscripts to inform our review. EXPERT OPINION SSc-related calcinosis is an area of major unmet clinical need and for too long has been a neglected area of research. Safe and effective treatments are badly needed to improve patient quality of life and outcomes. To facilitate future clinical trials, we require increased understanding of pathogenesis (to inform selection of potential targeted therapies) and reliable outcome measures, including those which will measure the impact and severity of calcinosis from the patient perspective. International collaborative research is ongoing to develop outcome measures and treatments for this potentially devastating complication of SSc.
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Affiliation(s)
- Michael Hughes
- Division of Musculoskeletal and Dermatological Sciences, the University of Manchester, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Ariane L Herrick
- Division of Musculoskeletal and Dermatological Sciences, the University of Manchester, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, UK
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10
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Innate Immunity in Calcinosis Cutis. IMMUNO 2022. [DOI: 10.3390/immuno2030027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Calcinosis cutis is the deposition of calcium salts in the skin and subcutaneous tissue, manifesting as variably shaped papules, nodules, and plaques that can substantially impair quality of life. The pathophysiology of calcinosis cutis involves dysregulation of proinflammatory cytokines, leukocytes, and other components of the innate immune system. In some conditions associated with calcinosis cutis, elevated serum calcium, phosphate, and vitamin D may also perturb innate immunity. The mechanisms by which these lead to cutaneous and subcutaneous calcification likely parallel those seen in vascular calcification. The role of aberrant innate immunity is further supported by the association between various autoantibodies with calcinosis cutis, such as anti-MDA5, anti-NXP2, anti-centromere, and anti-topoisomerase I. Treatments for calcinosis cutis remain limited and largely experimental, although mechanistically many therapies appear to focus on dampening innate immune responses. Further research is needed to better understand the innate immune pathophysiology and establish treatment options based on randomized-controlled trials.
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11
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Elahmar H, Feldman BM, Johnson SR. Management of calcinosis cutis in rheumatic diseases. J Rheumatol Suppl 2022; 49:980-989. [PMID: 35569832 DOI: 10.3899/jrheum.211393] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2022] [Indexed: 11/22/2022]
Abstract
Calcinosis (hydroxyapatite and calcium phosphate crystal deposition) within the extracellular matrix of the dermis and subcutaneous tissue is a frequent manifestation of adult and pediatric systemic autoimmune rheumatic diseases, specifically systemic sclerosis, dermatomyositis, mixed connective tissue disease and systemic lupus erythematosus. In this article, we review classification of calcinosis, highlight mechanisms that may contribute to the pathogenesis of calcinosis and summarize the evidence evaluating non-pharmacologic and pharmacologic interventions for the treatment of calcinosis.
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Affiliation(s)
- Hadiya Elahmar
- Hadiya Elahmar MD, Dermatologist at U-turn Dermatology Clinic, Kuwait; Dermatology and Venerology, Ain Shams University, Cairo, Egypt. Brian M Feldman MD MSc, Pediatrics, Medicine, Institute of Health Policy Management and Evaluation, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada. Sindhu R Johnson MD PhD, Toronto Scleroderma Program, Mount Sinai Hospital, Toronto Western Hospital, Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada. Funding: Dr. Johnson is supported by a Canadian Institutes of Health Research New Investigator Award, Gurmej Kaur Dhanda Scleroderma Research Award, and the Oscar and Elanor Markovitz Scleroderma Research Fund. Dr. Feldman holds the Ho Family Chair in Autoimmune Diseases. Corresponding Author. Dr. Sindhu Johnson, Division of Rheumatology, Ground Floor, East Wing, Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario, Canada, M5T 2S8. Phone 1-416-603-6417 Fax.1-416-603-4348.
| | - Brian M Feldman
- Hadiya Elahmar MD, Dermatologist at U-turn Dermatology Clinic, Kuwait; Dermatology and Venerology, Ain Shams University, Cairo, Egypt. Brian M Feldman MD MSc, Pediatrics, Medicine, Institute of Health Policy Management and Evaluation, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada. Sindhu R Johnson MD PhD, Toronto Scleroderma Program, Mount Sinai Hospital, Toronto Western Hospital, Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada. Funding: Dr. Johnson is supported by a Canadian Institutes of Health Research New Investigator Award, Gurmej Kaur Dhanda Scleroderma Research Award, and the Oscar and Elanor Markovitz Scleroderma Research Fund. Dr. Feldman holds the Ho Family Chair in Autoimmune Diseases. Corresponding Author. Dr. Sindhu Johnson, Division of Rheumatology, Ground Floor, East Wing, Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario, Canada, M5T 2S8. Phone 1-416-603-6417 Fax.1-416-603-4348.
| | - Sindhu R Johnson
- Hadiya Elahmar MD, Dermatologist at U-turn Dermatology Clinic, Kuwait; Dermatology and Venerology, Ain Shams University, Cairo, Egypt. Brian M Feldman MD MSc, Pediatrics, Medicine, Institute of Health Policy Management and Evaluation, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada. Sindhu R Johnson MD PhD, Toronto Scleroderma Program, Mount Sinai Hospital, Toronto Western Hospital, Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada. Funding: Dr. Johnson is supported by a Canadian Institutes of Health Research New Investigator Award, Gurmej Kaur Dhanda Scleroderma Research Award, and the Oscar and Elanor Markovitz Scleroderma Research Fund. Dr. Feldman holds the Ho Family Chair in Autoimmune Diseases. Corresponding Author. Dr. Sindhu Johnson, Division of Rheumatology, Ground Floor, East Wing, Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario, Canada, M5T 2S8. Phone 1-416-603-6417 Fax.1-416-603-4348.
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12
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[18F]Sodium Fluoride PET has the potential to identify active formation of calcinosis cutis in limited cutaneous systemic sclerosis. Semin Arthritis Rheum 2022; 55:152027. [DOI: 10.1016/j.semarthrit.2022.152027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 04/11/2022] [Accepted: 05/05/2022] [Indexed: 12/12/2022]
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13
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Kowalska-Kępczyńska A. Systemic Scleroderma-Definition, Clinical Picture and Laboratory Diagnostics. J Clin Med 2022; 11:2299. [PMID: 35566425 PMCID: PMC9100749 DOI: 10.3390/jcm11092299] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/08/2022] [Accepted: 04/18/2022] [Indexed: 02/06/2023] Open
Abstract
(1) Background: Scleroderma (Sc) is a rare connective tissue disease classified as an autoimmune disorder. The pathogenesis of this disease is not fully understood. (2) Methods: This article reviews the literature on systemic scleroderma (SSc). A review of available scientific articles was conducted using the PubMed database with a time range of January 1985 to December 2021. (3) Results and Conclusions: The article is a review of information on epidemiology, criteria for diagnosis, pathogenesis, a variety of clinical pictures and the possibility of laboratory diagnostic in the diagnosis and monitoring of systemic scleroderma.
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Affiliation(s)
- Anna Kowalska-Kępczyńska
- Department of Biochemical Diagnostics, Chair of Laboratory Diagnostics, Medical University of Lublin, 20-081 Lublin, Poland
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14
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Valenzuela A, Chung L. Subcutaneous calcinosis: Is it different between systemic sclerosis and dermatomyositis? JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2022; 7:7-23. [PMID: 35386947 PMCID: PMC8922676 DOI: 10.1177/23971983211053245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 09/27/2021] [Indexed: 02/03/2023]
Abstract
Calcinosis cutis is the deposition of insoluble calcium in the skin and subcutaneous tissues. It is a manifestation of several autoimmune connective tissue diseases, most frequently with systemic sclerosis and juvenile dermatomyositis, followed by adult dermatomyositis. Autoimmune connective tissue disease-associated calcinosis is of the dystrophic subtype, which occurs at sites of damaged tissue in the setting of normal serum calcium and phosphate levels. In juvenile dermatomyositis, calcinosis is considered a marker of ongoing disease activity and possibly inadequate treatment, while in adult dermatomyositis, it is a hallmark of skin damage due to chronic rather than active disease. Calcinosis is associated with long disease duration in systemic sclerosis and dermatomyositis, anti-polymyositis/sclerosis autoantibodies in systemic sclerosis and NXP-2 and melanoma differentiation-associated gene 5 in dermatomyositis. Calcinosis in systemic sclerosis occurs most frequently in the hands, particularly the fingers, whereas in dermatomyositis, it affects mainly the trunk and extremities. The primary mineral component of calcinosis is hydroxyapatite in systemic sclerosis and carbonate apatite in dermatomyositis. Calcinosis in dermatomyositis and systemic sclerosis share some pathogenic mechanisms, but vascular hypoxia seems to play a more important role in systemic sclerosis, whereas the release of calcium from mitochondria in muscle cells damaged by myopathy may be a primary mechanism contributing to dermatomyositis-related calcinosis. Multiple treatment strategies for dermatomyositis and systemic sclerosis-related calcinosis have been used with variable results. Early aggressive treatment of underlying myositis in patients with dermatomyositis may improve long-term outcomes of calcinosis. A better understanding of the pathogenesis of calcinosis is needed to improve treatment options.
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Affiliation(s)
- Antonia Valenzuela
- Division of Clinical Immunology and Rheumatology, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - 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,Lorinda Chung, Division of Immunology and Rheumatology, Stanford University School of Medicine, 1000 Welch Rd Ste 203, MC 5755, Palo Alto, CA 94304, USA.
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15
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Valenzuela A, Stevens K, Chung MP, Rodriguez-Reyna TS, Proudman S, Baron M, Castelino FV, Hsu V, Green L, Galdo FD, Li S, Fiorentino D, Chung L. Change in calcinosis over 1 year using the Scleroderma Clinical Trials Consortium Radiologic Scoring System for Calcinosis of the hands in patients with Systemic Sclerosis. Semin Arthritis Rheum 2022; 53:151980. [DOI: 10.1016/j.semarthrit.2022.151980] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 02/02/2022] [Accepted: 02/03/2022] [Indexed: 10/19/2022]
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16
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Vivekanantham A, Dinsdale G, Heal C, Manning J, Herrick AL. Associations with digital pitting in patients with systemic sclerosis: results of a retrospective analysis. Scand J Rheumatol 2021; 51:159-160. [PMID: 34727825 DOI: 10.1080/03009742.2021.1980980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- A Vivekanantham
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - G Dinsdale
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - C Heal
- Centre for Biostatistics, The University of Manchester, Manchester, UK
| | - J Manning
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - A L Herrick
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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17
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Klifto KM, Cho BH, Lifchez SD. Surgical Debulking for Symptomatic Management of Calcinosis Cutis of the Hand and Upper Extremity in Systemic Sclerosis. J Hand Surg Am 2021; 46:928.e1-928.e9. [PMID: 33795151 DOI: 10.1016/j.jhsa.2021.01.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 11/18/2020] [Accepted: 01/27/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine whether elective calcinosis debulking surgery of the hands and/or upper extremities is a safe and effective treatment for painful symptomatic scleroderma. Our hypothesis was that calcinosis debulking surgery would result in improvement in patient-reported pain and range of motion (ROM) with relatively little postoperative surgical pain for scleroderma patients. METHODS We performed a retrospective review of scleroderma patients who underwent elective calcinosis debulking surgery by a single surgeon between August 2014 and August 2019. Patients were included if they had a documented diagnosis of limited or diffuse scleroderma and underwent elective or nonemergent hand or upper-extremity calcinosis debulking surgery with a minimum final follow-up of 12 months. Primary outcomes measured were preoperative to final follow-up changes in visual analog scale pain scores. Secondary outcomes were changes in numbness and ROM as well as in daily opioid requirements, postoperative opioids used to control surgical pain, and complications. RESULTS Thirty-nine patients underwent calcinosis debulking surgeries on 41 upper extremities. Median final follow-up was 22 months (range, 13-60 months). Significant decreases occurred in visual analog pain scores (preoperative median, 5 [range, 0-10); final follow-up median, 0 [range, 0-8]) and improved patient-reported ROM in 15% (no change, 85%; worse, 0%). There was no significant preoperative to final follow-up difference in patient-reported numbness (improved, 5%; no change, 85%; and worse, 10%). Thirteen patients incurred 17 complications. CONCLUSIONS Elective calcinosis debulking surgery of the hands and/or upper extremities in scleroderma decreased pain scores, improved patient-reported ROM in 15% of patients, and had no effect on patient-reported numbness at final follow-up. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Kevin M Klifto
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Brian H Cho
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Scott D Lifchez
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
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18
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Fairchild R, Chung M, Sharpless L, Li S, Chung L. Ultrasound Detection of Calcinosis and Association With Ulnar Artery Occlusion in Patients With Systemic Sclerosis. Arthritis Care Res (Hoboken) 2021; 73:1332-1337. [PMID: 32475057 DOI: 10.1002/acr.24327] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 05/19/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To investigate the ability of ultrasound (US) compared to radiographs to detect calcinosis in hands/wrists of patients with systemic sclerosis (SSc), and to assess US markers of pathologic perfusion. METHODS Patients with SSc were evaluated for calcinosis in the hands/wrists by radiograph and US. The presence or absence of calcinosis was recorded by patient, hand, and anatomic zone; sensitivity and specificity for calcinosis detection by US versus radiographs was determined. Bilateral US vascular measurements of ulnar artery occlusion (UAO) and finger pulp blood flow (FPBF) were obtained. For each hand, associations between markers of pathologic blood flow (UAO, FPBF, and a composite severity score of UAO and FPBF) and the presence of calcinosis were assessed using generalized estimating equations. RESULTS Of 43 patients with SSc (19 diffuse, 24 limited), 39.5% had calcinosis on radiographs compared to 30.2% on US. Sensitivity and specificity for US, respectively, were 61% and 95% by zone, 78% and 98% by hand, and 76% and 100% by patient. UAO was seen in 30% and 28% of left and right hands, respectively; FPBF was absent in ≥1 digit of the left and right hands in 49% and 44%, respectively. UAO was associated with radiograph-identified calcinosis by hand (odds ratio [OR] 8.08 [95% confidence interval (95% CI) 2.45-26.60], P < 0.001), whereas FPBF and the composite severity score were not significant. UAO was associated with calcinosis even in the absence of digital ulcers (OR 33.00 [95% CI 3.39-321.09], P = 0.003). CONCLUSION US was sensitive and highly specific in detecting calcinosis in SSc. UAO was strongly associated with radiograph-identified calcinosis.
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Affiliation(s)
| | - Melody Chung
- Stanford University School of Medicine, Palo Alto, California
| | | | - Shufeng Li
- Stanford University Medical Center, Palo Alto, California
| | - Lorinda Chung
- Stanford University School of Medicine and Veterans Administration Palo Alto Health Care System, Palo Alto, California
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19
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Jiang W, Yang H, Li S, Tian X, Wang G. Clinical features, treatments and outcomes of calcinosis in adult patients with dermatomyositis: a single cohort study. Rheumatology (Oxford) 2021; 60:2958-2962. [PMID: 33249499 DOI: 10.1093/rheumatology/keaa618] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 08/23/2020] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE The occurrence of calcinosis cutis as a clinical feature of dermatomyositis in adult patients is not well understood. Cohort studies of adult patients with calcinosis are rare. We systematically describe the clinical features, treatments and outcomes of adult patients with calcinosis. METHODS We initially enrolled 627 adult DM patients. Of those enrolled, 35 (5.6%) were found to have calcinosis. We analysed the clinical features associated with calcinosis in this subgroup. The risk factors associated with calcinosis were analysed using the Poisson regression model. RESULTS Multivariate analysis showed that a younger age at disease onset [odds ratio (OR) = 0.945, 95% CI 0.925, 0.966, P < 0.001], dysphagia (OR = 2.609, 95% CI 1.189, 5.728, P = 0.017), skin ulcer (OR = 5.705, 95% CI 3.041, 10.705, P < 0.001) and the presence of anti-nuclear matrix protein 2 antibody (OR = 5.917, 95% CI 2.754, 12.714, P < 0.001) were independently associated with calcinosis. In both the low- and high-dose prednisone treatment groups, no difference in treatment response was seen between the bisphosphonate treatment group and the group not receiving bisphosphonate treatment (P = 1.000 and P = 0.375, respectively). A follow-up study revealed that the mortality rate of the calcinosis group was 5.7%. Additionally, 60.6% of the cases had a chronic polycyclic disease course and 17.1% had mild complications secondary to calcinosis. CONCLUSION Calcinosis is an uncommon, but significant clinical feature in adult patients with DM. Bisphosphonates were not found to effectively treat calcinosis, however, the overall health outcomes of adult DM patients with calcinosis were favourable.
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Affiliation(s)
- Wei Jiang
- Department of Rheumatology, Beijing Key Lab for Immune-Mediated Inflammatory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Hanbo Yang
- Department of Rheumatology, Beijing Key Lab for Immune-Mediated Inflammatory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Sizhao Li
- Department of Rheumatology, Beijing Key Lab for Immune-Mediated Inflammatory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Xiaolan Tian
- Department of Rheumatology, Beijing Key Lab for Immune-Mediated Inflammatory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Guochun Wang
- Department of Rheumatology, Beijing Key Lab for Immune-Mediated Inflammatory Diseases, China-Japan Friendship Hospital, Beijing, China
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20
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Burgess KA, Herrick AL, Watson REB. Systemic sclerosis skin is a primed microenvironment for soft tissue calcification-a hypothesis. Rheumatology (Oxford) 2021; 60:2517-2527. [PMID: 33585894 DOI: 10.1093/rheumatology/keab156] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/26/2021] [Accepted: 02/10/2021] [Indexed: 12/28/2022] Open
Abstract
Calcinosis cutis, defined as sub-epidermal deposition of calcium salts, is a major clinical problem in patients with SSc, affecting 20-40% of patients. A number of recognized factors associated with calcinosis have been identified, including disease duration, digital ischaemia and acro-osteolysis. Yet, to date, the pathogenesis of SSc-related calcinosis remains unknown, and currently there is no effective disease-modifying pharmacotherapy. Following onset of SSc, there are marked changes in the extracellular matrix (ECM) of the skin, notably a breakdown in the microfibrillar network and accumulation of type I collagen. Our hypothesis is that these pathological changes reflect a changing cellular phenotype and result in a primed microenvironment for soft tissue calcification, with SSc fibroblasts adopting a pro-osteogenic profile, and specific driving forces promoting tissue mineralization. Considering the role of the ECM in disease progression may help elucidate the mechanism(s) behind SSc-related calcinosis and inform the development of future therapeutic interventions.
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Affiliation(s)
- Kyle A Burgess
- Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester & Salford Royal NHS Foundation Trust, Manchester, UK
| | - Ariane L Herrick
- Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester & Salford Royal NHS Foundation Trust, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Rachel E B Watson
- Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester & Salford Royal NHS Foundation Trust, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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21
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Takagi K, Kawamoto M, Higuchi T, Tochimoto A, Hirose H, Harigai M, Kawaguchi Y. Characteristics of Japanese patients with systemic sclerosis complicated with calcinosis. Int J Rheum Dis 2021; 24:803-808. [PMID: 33909342 DOI: 10.1111/1756-185x.14121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 03/24/2021] [Accepted: 04/01/2021] [Indexed: 11/28/2022]
Abstract
AIM Calcinosis is often observed in systemic sclerosis (SSc), but its pathogenesis remains unclear. The aim of the present study was to explore the association of clinical features with calcinosis in patients with SSc. METHODS A retrospective cohort study was performed analyzing 416 SSc patients from our SSc database. We examined the clinical features with relation to calcinosis and SSc. RESULTS Calcinosis was observed in 24.0% of patients with SSc. The group with calcinosis comprised more female patients (P < 0.05) and diffuse cutaneous types (P < 0.001) than the group without calcinosis. Complications of Raynaud's phenomenon (P < 0.05), nail fold bleeding (NFB) (P < 0.001), peripheral bone resorption (P < 0.001), myositis (P < 0.001), and pulmonary hypertension (P < 0.05) were more frequently observed in patients with calcinosis compared with those without calcinosis. The group with calcinosis had a higher modified Rodnan total skin-thickness score (mRSS) than the group without calcinosis (P < 0.001). The factors that affected calcinosis in multivariable analysis were peripheral bone resorption (partial correlation coefficient 0.46, 34%), anti-Scl-70 antibody (partial correlation coefficient 0.29, 20%), diffuse type (partial correlation coefficient 0.34, 16%) and NFB (partial correlation coefficient 0.23, 11.2%). CONCLUSIONS Calcinosis in SSc is associated with Raynaud's phenomenon, NFB, and pulmonary hypertension, so peripheral circulatory insufficiency seems to be one of the causes of calcinosis. Furthermore, as it is related to mRSS and the diffuse cutaneous type, common factors related to skin fibrosis are considered to be involved.
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Affiliation(s)
- Kae Takagi
- Department of Medicine, Tokyo Women's Medical University Medical Center East, Tokyo, Japan.,Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Manabu Kawamoto
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Tomoaki Higuchi
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Akiko Tochimoto
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Hikaru Hirose
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Masayoshi Harigai
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Yasushi Kawaguchi
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
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22
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Host LV, Campochiaro C, Afonso A, Nihtyanova SI, Denton CP, Ong VH. High proton pump inhibitor exposure increases risk of calcinosis in systemic sclerosis. Rheumatology (Oxford) 2021; 60:849-854. [PMID: 32829395 DOI: 10.1093/rheumatology/keaa332] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 05/15/2020] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To investigate the association between proton pump inhibitor (PPI) use and the presence and severity of calcinosis in SSc. METHODS We analysed data from two SSc cohorts from a single centre. Cohort 1 included 199 patients reviewed over 10 years, for whom retrospective data on PPI use and calcinosis were available. Cohort 2 was recruited prospectively and included 215 consecutive patients, who underwent clinical assessment. Outcomes of interest were presence of current calcinosis (CC) or calcinosis at any time (CAT). RESULTS The cohort 1 data analysis showed that among patients on standard dose PPI 20% had calcinosis, while in those on high doses of PPI calcinosis was present in 39% (P = 0.003). Analysis of the data from cohort 2 confirmed these findings, demonstrating that the odds of CAT increased significantly with longer PPI exposure [odds ratio (OR) 1.04, 95% CI: 1.02, 1.06; P < 0.001], longer disease duration (OR 1.08, 95% CI: 1.05, 1.12; P < 0.001) and greater age (OR 1.03, CI: 1.01, 1.05; P = 0.010). Multivariable logistic regression showed that higher exposure to PPI remained a significant predictor of calcinosis, with PPI exposure >10 years increasing the risk of CAT >6-fold, compared with no PPI (OR 6.37, 95% CI: 1.92, 21.17; P = 0.003) after adjusting for disease duration and antibodies. CONCLUSION We confirm a significant association between high PPI exposure with severity of calcinosis in SSc. Given the clinical impact of calcinosis and reflux in SSc, PPI exposure as a potentially modifiable risk factor for calcinosis requires further evaluation.
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Affiliation(s)
- Lauren V Host
- Centre for Rheumatology and Connective Tissue Diseases, UCL Medical School, Royal Free Campus, London, UK
| | - Corrado Campochiaro
- Centre for Rheumatology and Connective Tissue Diseases, UCL Medical School, Royal Free Campus, London, UK.,Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UniRAR), San Raffaele Scientific Institute, Milan, Italy
| | - Ana Afonso
- Centre for Rheumatology and Connective Tissue Diseases, UCL Medical School, Royal Free Campus, London, UK.,Internal Medicine Department, Hospital Pedro Hispano, Matosinhos, Portugal
| | - Svetlana I Nihtyanova
- Centre for Rheumatology and Connective Tissue Diseases, UCL Medical School, Royal Free Campus, London, UK
| | - Christopher P Denton
- Centre for Rheumatology and Connective Tissue Diseases, UCL Medical School, Royal Free Campus, London, UK
| | - Voon H Ong
- Centre for Rheumatology and Connective Tissue Diseases, UCL Medical School, Royal Free Campus, London, UK
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23
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Lo Y, Lin LY, Tsai TF. Use of calcium channel blockers in dermatology: a narrative review. Expert Rev Clin Pharmacol 2021; 14:481-489. [PMID: 33612036 DOI: 10.1080/17512433.2021.1894128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Introduction: Calcium channel blockers (CCB) are commonly used for cardiovascular diseases. The evidence supporting the use of CCB in dermatology is mostly anecdotal and limited to case reports or small case series.Areas covered: This review article is divided into two parts. The first part discusses the therapeutic use of CCB in dermatology. The second part focuses on mucocutaneous adverse reactions due to the administration of CCB.Expert opinion: The use of CCB in dermatology is mainly based on its properties as a vasodilator and the inhibition of muscle contractions, such as pernio, anal fissures, facial wrinkles, and painful leiomyoma. However, there remain other modes of action to explain its clinical use in calcinosis, keloid, pressure ulcer, and fibromatosis. Compared to oral CCB, the lack of systemic side effects would make topical use of CCB an attractive alternative in the treatment of skin diseases, but the evidence for topical CCB is still limited, and there is a lack of standardized topical formulation. The main mucocutaneous adverse effects of CCB include gingival hyperplasia, phototoxicity, eczema, psoriasis and risk of skin cancers. Plausible factors for these adverse events include CCB's photoinstability, aldosterone synthesis inhibition, disturbed calcium homeostasis and immunosuppressive properties.
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Affiliation(s)
- Yang Lo
- Department of Dermatology, Cathay General Hospital, Taipei, Taiwan
| | - Lian-Yu Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Tsen-Fang Tsai
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
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Herrick AL, Shukla R, Watson REB. Frontiers in translational systemic sclerosis research: A focus on the unmet 'cutaneous' clinical needs (Viewpoint). Exp Dermatol 2020; 29:1144-1153. [DOI: 10.1111/exd.14179] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 08/06/2020] [Accepted: 08/12/2020] [Indexed: 12/18/2022]
Affiliation(s)
- Ariane L. Herrick
- Division of Musculoskeletal and Dermatological Sciences Salford Royal NHS Foundation Trust Manchester Academic Health Science Centre The University of Manchester Manchester UK
| | | | - Rachel E. B. Watson
- Division of Musculoskeletal and Dermatological Sciences Salford Royal NHS Foundation Trust Manchester Academic Health Science Centre The University of Manchester Manchester UK
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25
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Pseudotumoral calcinosis in systemic sclerosis: Data from systematic literature review and case series from two referral centres. Semin Arthritis Rheum 2020; 50:1339-1347. [DOI: 10.1016/j.semarthrit.2020.03.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 02/28/2020] [Accepted: 03/10/2020] [Indexed: 11/22/2022]
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26
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Barsotti S, Venturini V, Di Battista M, Janowska A, Dini V, Della Rossa A, Mosca M. The impact of skin calcinosis on digital ulcers in patients with SSc: clinical and prognostic stratification using the "wound bed score". Int Wound J 2020; 17:1783-1790. [PMID: 32926570 PMCID: PMC7948997 DOI: 10.1111/iwj.13467] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/02/2020] [Accepted: 07/07/2020] [Indexed: 11/29/2022] Open
Abstract
Digital ulcers (DUs) represent one of the major burdens for patients with systemic sclerosis (SSc), especially when associated with skin calcinosis (SC). The aim of this work is to evaluate the impact of SC in DUs of patients with SSc for clinical characteristics and prognosis assessed by the wound bed score (WBS). We prospectively enrolled 55 patients with DUs and SSc followed in our dedicated wound care clinic. For all the patients we collected clinical and anthropometric data and characteristics of the DU, and we calculated the WBS for each DU. Ninety-nine DUs were evaluated (24 with SC). SC was prevalent in limited cutaneous SSc (75%) and in patients with longer disease duration (P = 0.02). SC-DUs were prevalent at the fingertip (P = 0.04). The healing time was significantly higher in patients with SC (10.4 ± 7.9 weeks) compared with non-SC (7.0 ± 5.7 weeks) P = 0.03. The WBS negatively correlated with the time to achieve complete healing (r = -0.237 P = 0.023) and the correlation was maintained in the non-SC (r = -0.46, P = 0.033). DUs in SSc patients with SC are common and difficult to heal. When DUs are treated in dedicated centres, the prognosis is good. The WBS is fast and easy and maybe commonly applied in clinical practice.
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Affiliation(s)
- Simone Barsotti
- Department of Clinical and Experimental MedicineUniversity of PisaPisaItaly
| | | | - Marco Di Battista
- Department of Clinical and Experimental MedicineUniversity of PisaPisaItaly
| | | | | | | | - Marta Mosca
- Department of Clinical and Experimental MedicineUniversity of PisaPisaItaly
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Manning JB, Marjanovic E, Moore TL, Dinsdale G, Wilkinson S, Dickinson MR, Herrick AL, Murray AK. A pilot study of cutaneous oxygenation and perfusion in systemic sclerosis-related digital calcinosis. Rheumatology (Oxford) 2020; 59:3109-3111. [PMID: 32259842 PMCID: PMC7516112 DOI: 10.1093/rheumatology/keaa131] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 02/18/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Joanne B Manning
- Division of Musculoskeletal and Dermatological Sciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre
| | - Elizabeth Marjanovic
- Division of Musculoskeletal and Dermatological Sciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre
| | - Tonia L Moore
- Division of Musculoskeletal and Dermatological Sciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre
| | - Graham Dinsdale
- Division of Musculoskeletal and Dermatological Sciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre
| | - Sarah Wilkinson
- Division of Musculoskeletal and Dermatological Sciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre
| | - Mark R Dickinson
- Photon Science Institute.,Department of Physics and Astronomy, University of Manchester, Manchester, UK
| | - Ariane L Herrick
- Division of Musculoskeletal and Dermatological Sciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre
| | - Andrea K Murray
- Division of Musculoskeletal and Dermatological Sciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre.,Photon Science Institute
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Nevskaya T, Zheng B, Baxter CA, Ramey DR, Pope JE, Baron M. Skin improvement is a surrogate for favourable changes in other organ systems in early diffuse cutaneous systemic sclerosis. Rheumatology (Oxford) 2020; 59:1715-1724. [PMID: 31774531 DOI: 10.1093/rheumatology/kez529] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 09/26/2019] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES Skin improvement in diffuse cutaneous SSc (dcSSc), measured with modified Rodnan skin score (mRSS), is frequently used as a primary outcome in clinical trials, but it is uncertain whether mRSS changes reflect changes in other organ systems. This aim of this study was to explore if skin changes in early dcSSc over 1 and 2 years are associated with changes in severity of other organ involvement. METHODS Canadian Scleroderma Research Group database patients with dcSSc, disease duration of ≤5 years, no evidence of initial end-stage organ damage and/or significant comorbidity who had 1 year (n = 154) and 2 years (n = 128) of follow-up data were included. mRSS changes of 25% and/or ≥5 points were considered significant. Organ involvement was assessed by Medsger Disease Severity Score and Canadian Scleroderma Research Group definitions using bivariate, chi-square, ANOVA, adjusted regression and longitudinal mixed effect model analyses. RESULTS Improvement in mRSS was found in 41% of patients at 1 year and in 50% at 2 years. Improved patients showed less forced vital capacity decline (P = 0.012) and less frequent new cardiac involvement (P = 0.02) over 1 year, as well as better lung (by both Disease Severity Score, P = 0.006, and Δforced vital capacity%, P = 0.026), peripheral vascular (P = 0.006) and joint/tendon (P = 0.002) involvement over 2 years. mRSS worsening was consistently linked to less favourable lung outcomes at both 1- and 2-year follow-up visits, and more severe gastrointestinal disease at 2 years. CONCLUSION Changes in lung function in early dcSSc closely parallel skin changes. mRSS improvement reflects better prognosis for visceral disease and may be a reliable outcome measure in clinical trials.
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Affiliation(s)
| | - Boyang Zheng
- Division of Rheumatology, McGill University, Montreal, QC, Canada
| | | | | | | | - Murray Baron
- Division of Rheumatology, McGill University, Montreal, QC, Canada.,Department of Medicine, Jewish General Hospital, Montreal, QC, Canada
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29
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Valenzuela A, Baron M, Rodriguez-Reyna TS, Proudman S, Khanna D, Young A, Hinchcliff M, Steen V, Gordon J, Hsu V, Castelino FV, Schoenfeld S, Li S, Wu JY, Fiorentino D, Chung L. Calcinosis is associated with ischemic manifestations and increased disability in patients with systemic sclerosis. Semin Arthritis Rheum 2020; 50:891-896. [PMID: 32898758 DOI: 10.1016/j.semarthrit.2020.06.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 05/12/2020] [Accepted: 06/01/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Calcinosis is a debilitating complication of systemic sclerosis (SSc) with no effective treatments. We sought to identify clinical correlations and to characterize complications and disability associated with calcinosis in a multi-center, international cohort of SSc patients. METHODS We established a cohort of 568 consecutive SSc patients who fulfill 2013 revised ACR/EULAR criteria at 10 centers within North America, Australia, and Mexico. Calcinosis was defined as subcutaneous calcium deposition by imaging and/or physical examination, or a clear history of extruded calcium. All patients completed the Scleroderma Health Assessment Questionnaire Disability Index and Cochin Hand Functional Scale. RESULTS 215 (38%) patients had calcinosis. In multivariable analysis, disease duration (OR=1.24, p = 0.029), digital ischemia (OR=1.8, p = 0.002) and Acro-osteolysis (OR=2.97, p = 0.008) were significantly associated with calcinosis. In the subset of patients with bone densitometry (n = 68), patients with calcinosis had significantly lower median T-scores than patients without (-2.2 vs. -1.7, p = 0.004). The most common location of calcinosis lesions was the hands (70%), particularly the thumbs (19%) with decreasing frequency moving to the fifth fingers (8%). The most common complications were tenderness (29% of patients) and spontaneous extrusion of calcinosis through the skin (20%), while infection was rare (2%). Disability and hand function were worse in patients with calcinosis, particularly if locations in addition to the fingers/thumbs were involved. CONCLUSIONS We confirmed a strong association between calcinosis and digital ischemia. Calcinosis in SSc patients most commonly affects the hands and is associated with a high burden of disability and hand dysfunction.
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Affiliation(s)
| | - Murray Baron
- Division of Rheumatology, Jewish General Hospital, McGill University, Canada
| | - Tatiana S Rodriguez-Reyna
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Department of Immunology and Rheumatology, Mexico
| | - Susanna Proudman
- Royal Adelaide Hospital North Terrace, Rheumatology Unit and Discipline of Medicine, University of Adelaide, Australia
| | - Dinesh Khanna
- University of Michigan Scleroderma Program, Department of internal medicine, Division of Rheumatology, USA
| | - Amber Young
- University of Michigan Scleroderma Program, Department of internal medicine, Division of Rheumatology, USA
| | - Monique Hinchcliff
- Yale University School of Medicine, Section of Rheumatology, Allergy and Clinical Immunology, USA
| | | | - Jessica Gordon
- Hospital for Special Surgery, Department of Rheumatology, USA
| | - Vivien Hsu
- Rutgers-RWJ Medical School, Rheumatology Division, USA
| | | | | | - Shufeng Li
- Stanford University School of Medicine, Department of Dermatology, USA
| | - Joy Y Wu
- Stanford University School of Medicine, Department of Medicine, Division of Endocrinology, USA
| | - David Fiorentino
- Stanford University School of Medicine, Department of Dermatology, USA
| | - Lorinda Chung
- Stanford University School of Medicine and Palo Alto VA Health Care System, Department of Immunology and Rheumatology and Dermatology (by courtesy), USA.
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Abstract
PURPOSE OF REVIEW To provide an update on the available literature regarding the epidemiology, pathophysiology, diagnosis, and treatment of calcinosis cutis in patients with systemic sclerosis (SSc). RECENT FINDINGS We identified observational studies that describe the frequency of calcinosis in SSc and associated clinical features; molecular studies exploring potential pathogenic mechanisms; and case reports and case series describing new diagnostic approaches and treatments. SUMMARY Calcinosis cutis is the deposition of insoluble calcium in the skin and subcutaneous tissues. It represents a major clinical problem in patients with SSc affecting at least one quarter of patients. It is associated with longer disease duration, digital ulcers, acro-osteolysis, positive anticentromere antibody, and positive anti-PM/Scl antibody. Although pathogenesis is unknown, there is evidence supporting local trauma, chronic inflammation, vascular hypoxia, and dysregulation of bone matrix proteins as potential mechanisms. Diagnosis can be made clinically or with plain radiography. Several pharmacologic therapies have been tried for calcinosis with variable and modest results, but surgical excision of calcium deposits remains the mainstay of treatment.
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Affiliation(s)
- Antonia Valenzuela
- Stanford University School of Medicine, Division of Immunology and Rheumatology, Palo Alto, California
| | - Paula Song
- Santa Clara Valley Medical Center, Department of Medicine, San Jose, California
| | - Lorinda Chung
- Stanford University School of Medicine and Palo Alto VA Healthcare System, Division of Immunology and Rheumatology, and Dermatology, Palo Alto, California, USA
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Yehudina Y, Golovach I. Calcinosis in systemic sclerosis: prevalence, clinical picture, management, complications. ACTA ACUST UNITED AC 2019. [DOI: 10.22141/2224-1507.9.2.2019.172122] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Traineau H, Aggarwal R, Monfort JB, Senet P, Oddis CV, Chizzolini C, Barbaud A, Francès C, Arnaud L, Chasset F. Treatment of calcinosis cutis in systemic sclerosis and dermatomyositis: A review of the literature. J Am Acad Dermatol 2019; 82:317-325. [PMID: 31302187 DOI: 10.1016/j.jaad.2019.07.006] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 06/13/2019] [Accepted: 07/07/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND We have limited data on the treatment of calcinosis cutis associated with systemic sclerosis and dermatomyositis. OBJECTIVE To assess the efficacy and tolerance of available treatments for calcinosis cutis based on previously published studies. METHODS We performed a systematic review of studies published in Medline, Embase, and the Cochrane library during 1980-July 2018. The strength of clinical data was graded according to the modified Oxford Centre for Evidence-Based Medicine levels of evidence. RESULTS In all, 30 studies (288 patients) were included. Eleven therapeutic classes, surgery, and physical treatments were identified as potential treatment options for calcinosis cutis. On the basis of results of a small randomized controlled trial and 4 retrospective studies, low-dose warfarin should not be used for calcinosis cutis (level IB evidence). The results of several studies suggest diltiazem and bisphosphonates might be useful treatment options (level IV). Considering biologic therapies, rituximab has shown promising results in treating both dermatomyositis and systemic sclerosis, whereas tumor necrosis factor inhibitors might be useful for treating juvenile dermatomyositis (level IV). Intralesional sodium thiosulfate might be a promising alternative (level IV). LIMITATIONS Few included studies had a high level of evidence. CONCLUSION This study highlights the efficacy and tolerance profiles of available treatments for calcinosis cutis, with a focus on level of evidence.
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Affiliation(s)
- Hélène Traineau
- Sorbonne Université, Faculté de Médecine Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Service de Dermatologie et Allergologie, Hôpital Tenon, Paris, France
| | - Rohit Aggarwal
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jean-Benoît Monfort
- Sorbonne Université, Faculté de Médecine Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Service de Dermatologie et Allergologie, Hôpital Tenon, Paris, France
| | - Patricia Senet
- Sorbonne Université, Faculté de Médecine Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Service de Dermatologie et Allergologie, Hôpital Tenon, Paris, France
| | - Chester V Oddis
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Carlo Chizzolini
- Department of Immunology and Allergy, University Hospital and School of Medicine, Geneva, Switzerland; Department of Pathology and Immunology, School of Medicine, Geneva, Switzerland
| | - Annick Barbaud
- Sorbonne Université, Faculté de Médecine Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Service de Dermatologie et Allergologie, Hôpital Tenon, Paris, France
| | - Camille Francès
- Sorbonne Université, Faculté de Médecine Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Service de Dermatologie et Allergologie, Hôpital Tenon, Paris, France
| | - Laurent Arnaud
- Service de Rhumatologie, Hôpitaux Universitaires de Strasbourg, Laboratoire d'ImmunoRhumatologie Moléculaire, Centre National de Référence des Maladies Systémiques Auto-immunes Rares Est Sud-Ouest, INSERM UMR S1109, Université de Strasbourg, Strasbourg, France
| | - François Chasset
- Sorbonne Université, Faculté de Médecine Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Service de Dermatologie et Allergologie, Hôpital Tenon, Paris, France.
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Sampaio-Barros MM, Castelo Branco LCM, Takayama L, Pontes Filho MAG, Sampaio-Barros PD, Pereira RMR. Acroosteolysis and bone metabolism parameters distinguish female patients with limited systemic sclerosis with and without calcinosis: a case control study. Clin Rheumatol 2019; 38:3189-3193. [DOI: 10.1007/s10067-019-04637-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/23/2019] [Accepted: 06/04/2019] [Indexed: 10/26/2022]
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Lescoat A, Ballerie A, Belhomme N, Cazalets C, de Carlan M, Droitcourt C, Perdriger A, Jégo P, Coiffier G. Synovial involvement assessed by power Doppler ultra-sonography in systemic sclerosis: results of a cross-sectional study. Rheumatology (Oxford) 2019; 57:2012-2021. [PMID: 30053245 DOI: 10.1093/rheumatology/key214] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Indexed: 11/14/2022] Open
Abstract
Objectives To characterize hand synovial manifestations assessed by power Doppler ultrasonography (PDUS) in a cohort of unselected patients fulfilling the 2013 ACR/EULAR classification criteria for SSc and to evaluate the associations of these synovial manifestations with the main general clinical and biological features of SSc. Methods One hundred and three SSc patients were consecutively included and underwent PDUS evaluation of both hands assessing synovial and tenosynovial manifestations according to the OMERACT definitions. Clinical, biological and immunological SSc characteristics were recorded at the same time. Results Thirty-three patients (32%) had ultrasonographic synovial/tenosynovial involvement. The two main PDUS features were Doppler-positive/inflammatory synovitis (n = 18, 17.5%) and sclerosing tenosynovitis (TS) (n = 19, 18.4%). Inflammatory synovitis was more frequent in the wrist and MCP joints. Sclerosing TS was more frequent in men [odds ratio (OR) = 6.32, 95% CI: 2.17, 18.41; P = 0.001] and was associated with anti-RNA polymerase III antibodies (OR = 10.93, 95% CI: 1.84, 65.12; P = 0.01), diffuse SSc (OR = 18.24, 95% CI: 4.80, 69.32; P < 0.0001), interstitial lung disease (OR = 6.09, 95% CI: 1.86, 19.98; P = 0.001) and inflammatory arthralgia (OR = 14.64, 95% CI: 2.58, 83.10; P = 0.002). Inflammatory TS or synovitis were associated with CRP levels >5 mg/l (OR = 5.50, 95% CI: 1.81, 16.70; P = 0.001), pericarditis (OR = 7.81, 95% CI: 1.58, 38.71; P = 0.017) and inflammatory arthralgia (OR = 15.96, 95% CI: 2.80, 91.02; P = 0.002). Inflammatory synovitis and sclerosing TS were not significantly associated within an individual patient (OR = 2.77, 95% CI: 0.88, 8.70; P > 0.05). Conclusions Ultrasonographic synovial involvement is frequent in patients fulfilling the 2013 ACR/EULAR classification criteria and PDUS may have a part to play in a more accurate and precise description of musculoskeletal manifestations of the disease, especially as the question of a treat-to-target approach is arising for SSc.
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Affiliation(s)
- Alain Lescoat
- Department of Internal Medicine, Centre Hospitalier Universitaire de Rennes, Rennes, France.,Universitaire de Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail) - UMR_S, Rennes, France
| | - Alice Ballerie
- Department of Internal Medicine, Centre Hospitalier Universitaire de Rennes, Rennes, France
| | - Nicolas Belhomme
- Department of Internal Medicine, Centre Hospitalier Universitaire de Rennes, Rennes, France
| | - Claire Cazalets
- Department of Internal Medicine, Centre Hospitalier Universitaire de Rennes, Rennes, France
| | - Marine de Carlan
- Department of Internal Medicine, Centre Hospitalier Universitaire de Rennes, Rennes, France
| | - Catherine Droitcourt
- Department of Dermatology, Centre Hospitalier Universitaire de Rennes, Rennes, France.,Centre Hospitalier Universitaire de Rennes, Inserm, CIC, Rennes, France.,REPERES Pharmacoepidemiology and Access to Health Care, University of Rennes 1, Rennes, France.,French School of Public Health, UPRES EA, Rennes, France
| | - Aleth Perdriger
- Department of Rheumatology, Centre Hospitalier Universitaire de Rennes, Rennes, France
| | - Patrick Jégo
- Department of Internal Medicine, Centre Hospitalier Universitaire de Rennes, Rennes, France.,Universitaire de Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail) - UMR_S, Rennes, France
| | - Guillaume Coiffier
- Department of Rheumatology, Centre Hospitalier Universitaire de Rennes, Rennes, France.,UMR INSERM U 1241, University of Rennes, Rennes, France
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Narváez J, Pirola JP, LLuch J, Juarez P, Nolla JM, Valenzuela A. Effectiveness and safety of rituximab for the treatment of refractory systemic sclerosis associated calcinosis: A case series and systematic review of the literature. Autoimmun Rev 2019; 18:262-269. [PMID: 30639647 DOI: 10.1016/j.autrev.2018.10.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 10/01/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To analyze the effectiveness and safety of rituximab (RTX) for the treatment of refractory systemic sclerosis (SSc)-associated calcinosis. METHODS We undertook an observational study of patients with this complication treated with 1 or more cycles of RTX (1 g × 2 weeks) and evaluated for at least 12 months after RTX treatment in a single center. The primary outcome measures of the study were the improvement of calcinosis symptoms (pain, signs of local inflammation, and new episodes of skin ulceration) and the radiologic evolution of the calcification(s). RESULTS We treated 8 patients with refractory SSc-related calcinosis with RTX (off-label use). The main indications for RTX were complicated calcinosis unresponsive to previous therapies with concomitant arthritis in 2 patients and refractory arthritis or interstitial lung fibrosing disease in the remaining 6 patients. The mean number of RTX cycles administered was 3.12 ± 2.1 (range, 1-7), the median duration of RTX treatment was 9 months (interquartile range [IQR], 7.5-36 months), and the median follow-up after the first infusion of RTX dose was 19 months (IQR, http://catsalut.gencat.cat/web/.content/minisite/catsalut/proveidors_professionals/medicaments_farmacia/phf_mhda/informes_camse/esclerosi_sistemica/Dictamen-CAMS_-ES_-web.pdf (n.d.) 5-45 months). Four patients (50%) had a significant improvement in clinical symptoms (sustained improvement in the visual analog scale for pain of at least 50% and no new episodes of local inflammation or skin ulceration). Two of these patients (25%) also had a complete resolution or significant reduction in the size of the calcification(s) on X-ray, according with the radiographical scoring system for calcinosis developed by the Scleroderma Clinical Trials Consortium. In the remaining 4 patients (50%), RTX did not provide any significant clinical or radiologic benefit for calcinosis. The frequency of adverse effects was low, occurring in only 1 patient (12.5%), who developed upper respiratory tract infections not requiring hospitalization. CONCLUSION Our preliminary data suggest that RTX may be helpful as a rescue therapy in selected cases of severe and refractory SSc-related calcinosis.
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Affiliation(s)
- Javier Narváez
- Department of Rheumatology, Hospital Universitario de Bellvitge-IDIBELL, Barcelona, Spain.
| | - Juan Pablo Pirola
- Department of Rheumatology, Hospital Privado Centro Médico de Córdoba, Córdoba. Argentina
| | - Judi LLuch
- Department of Rheumatology, Hospital Universitario de Bellvitge-IDIBELL, Barcelona, Spain
| | - Pablo Juarez
- Department of Rheumatology, Hospital Universitario de Bellvitge-IDIBELL, Barcelona, Spain
| | - Joan Miquel Nolla
- Department of Rheumatology, Hospital Universitario de Bellvitge-IDIBELL, Barcelona, Spain
| | - Antonia Valenzuela
- Department of Clinical Immunology and Rheumatology, Pontificia Universidad Católica de Chile, Chile
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Paxton D, Pauling JD. Does nailfold capillaroscopy help predict future outcomes in systemic sclerosis? A systematic literature review. Semin Arthritis Rheum 2018; 48:482-494. [DOI: 10.1016/j.semarthrit.2018.02.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 01/24/2018] [Accepted: 02/12/2018] [Indexed: 10/18/2022]
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Motegi SI, Sekiguchi A, Yonemoto Y, Mieda T, Chikuda H, Ishikawa O. Demographic and clinical characteristics of spinal calcinosis in systemic sclerosis: Possible association with peripheral angiopathy. J Dermatol 2018; 46:33-36. [PMID: 30447023 DOI: 10.1111/1346-8138.14704] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 10/13/2018] [Indexed: 11/30/2022]
Abstract
The objective was to evaluate the demographic and clinical characteristics of systemic sclerosis (SSc) patients with spinal calcinosis. Paraspinal and intraspinal calcinosis was assessed blindly by orthopedic surgeons specializing in spinal diseases using chest high-resolution computed tomography (CT) that was performed for the screening and prospecting of interstitial lung disease in 159 Japanese SSc patients. Among these patients, we identified 27 (17%) with spinal calcinosis, and the most common site was cervical level at 77.8% (21/27). The frequency of spinal calcinosis in the late stage was higher than in the early stage (44.4% vs 29.6%). Multiple calcinosis was identified in 18.5% (5/27). The frequency of paraspinal calcinosis only was 59.3%, intraspinal calcinosis only 18.5%, and both intraspinal and paraspinal calcinosis 22.2%. Among SSc patients, 4.4% (7/159) had CT-based evidence of spinal cord compression. Among cases with spinal cord compression, only one had neurological symptoms, and surgical removal improved the symptoms. The other six SSc patients with spinal calcinosis (3.8% of 159) had no symptoms. Male sex (29.6%) and severe peripheral vasculopathy such as digital ulcers (55.6%) and acro-osteolysis (33.3%) were significantly more frequent in the SSc patients with spinal calcinosis than in the SSc patients without spinal calcinosis (10.6%, 32.6% and 14.4%, respectively). Our results suggest that severe peripheral vasculopathy may be associated with the development of spinal calcinosis. Because SSc patients are prone to spinal calcinosis, when SSc patients claim symptoms such as pain, numbness and movement disorder of the extremities, spinal calcinosis is a complication that should be taken into consideration.
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Affiliation(s)
- Sei-Ichiro Motegi
- Department of Dermatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Akiko Sekiguchi
- Department of Dermatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Yukio Yonemoto
- Department of Orthopedic Surgery, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Tokue Mieda
- Department of Orthopedic Surgery, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Hirotaka Chikuda
- Department of Orthopedic Surgery, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Osamu Ishikawa
- Department of Dermatology, Gunma University Graduate School of Medicine, Maebashi, Japan
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Frech TM, Machin DR, Murtaugh MA, Stoddard GJ, Bloom SI, Phibbs JV, Donato AJ. Implications of endothelial shear stress on systemic sclerosis vasculopathy and treatment. Clin Exp Rheumatol 2018; 36 Suppl 113:175-182. [PMID: 30277867 PMCID: PMC6542469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 07/30/2018] [Indexed: 02/16/2023]
Abstract
There are no Federal Drug Administration approved drugs for the treatment of systemic sclerosis vascular digital ulcers (DU) in the United States, which are thought to be an end-stage result of prolonged ischaemia due to severe, prolonged Raynaud's phenomenon. Most therapeutics for vasodilation used in SSc work different pathways to target the smooth muscle to induce vessel relaxation. Longitudinal studies of vascular function allow insight into the effects of medications used for Raynaud's phenomenon in the SSc patient population. In this review, we discuss vascular tone, the function of the endothelium in SSc, and provide the rationale for longitudinal studies of vascular function and therapeutics that target the endothelial shear stress in addition to vasodilation for treatment and prevention of DU. This review provides the rationale for vasodilatory medication use for treatment of SSc-related DU and justifies access to non-FDA approved medications for this indication.
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Affiliation(s)
- Tracy M Frech
- University of Utah, Department of Internal Medicine; University of Utah Hospitals and Clinics; and VAMC Salt Lake City, GRECC, Salt Lake City, UT, USA.
| | - Daniel R Machin
- University of Utah, Department of Internal Medicine, Salt Lake City, UT, USA
| | - Maureen A Murtaugh
- University of Utah, Department of Internal Medicine, Salt Lake City, UT, USA
| | - Gregory J Stoddard
- University of Utah, Department of Internal Medicine, Salt Lake City, UT, USA
| | - Samuel I Bloom
- University of Utah, Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, UT, USA
| | - Jessica V Phibbs
- University of Utah Hospitals and Clinics, Salt Lake City, UT, USA
| | - Anthony J Donato
- University of Utah, Department of Internal Medicine; University of Utah, Department of Exercise and Sport Science; University of Utah, Dept. of Nutrition and Integrative Physiology, University of Utah; and VAMC Salt Lake City, GRECC, Salt Lake City, USA
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Abstract
INTRODUCTION Systemic sclerosis (SSc) is a rare autoimmune connective tissue disease characterized by vascular dysfunction, fibrosis, inflammation and autoantibodies. The pathophysiology of SSc is not completely understood, and many patients acquire organ or tissue damage despite advances in treatment. Current treatments target affected organs with modest improvements. Areas covered: This review evaluates several treatment strategies for SSc based on involved organs including skin, pulmonary, cardiac, renal, musculoskeletal, and gastrointestinal. Currently, pulmonary hypertension and interstitial lung disease are the primary causes of increased mortality. We will outline an approach to treatment of SSc based on disease manifestations and current evidence. Expert commentary: This complex disease is currently treated with therapies developed for similar indications such as for vascular manifestations of SSc using idiopathic pulmonary arterial hypertension treatments. Future directions in this field may include combination and maintenance therapy that is currently used in other autoimmune diseases, and tailoring these treatments according to the patients' phenotype. This will hopefully increase the efficacy of available treatments and decrease mortality from SSc.
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Affiliation(s)
- Maysoon Eldoma
- a Division of Rheumatology, St. Joseph's Health Care, Department of Medicine , University of Western Ontario , Ontario , Canada.,b Rheumatologist, Connective Tissue Disease Fellow , University of Western Ontario , Ontario , Canada.,c Division of Rheumatology, Department of Medicine , University of Calgary , Calgary , Alberta , Canada
| | - Janet Pope
- a Division of Rheumatology, St. Joseph's Health Care, Department of Medicine , University of Western Ontario , Ontario , Canada.,d Division Head Rheumatology and Professor of Medicine , University of Western Ontario , Ontario , Canada
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Joven BE, Escribano P, Andreu JL, Loza E, Jimenez C, de Yebenes MJG, Ruiz-Cano MJ, Carmona L, Carreira PE. 2013 ACR/EULAR systemic sclerosis classification criteria in patients with associated pulmonary arterial hypertension. Semin Arthritis Rheum 2018; 47:870-876. [DOI: 10.1016/j.semarthrit.2017.10.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 09/11/2017] [Accepted: 10/11/2017] [Indexed: 01/27/2023]
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Pauling JD. The challenge of establishing treatment efficacy for cutaneous vascular manifestations of systemic sclerosis. Expert Rev Clin Immunol 2018; 14:431-442. [PMID: 29641934 DOI: 10.1080/1744666x.2018.1464390] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION The cutaneous vascular manifestations of systemic sclerosis (SSc) comprise Raynaud's phenomenon, cutaneous ulceration, telangiectasia formation and critical digital ischaemia; each of which are associated with significant disease-related morbidity. Despite the availability of multiple classes of vasodilator therapy, many of which have been the subject of RCTs, a limited number of pharmacological interventions are currently approved for the management of cutaneous vascular manifestations of SSc. Areas covered: A major challenge has been demonstrating treatment efficacy with examples of promising therapies yielding contrasting results in controlled trial settings. Differences between consensus best-practice guidelines, evidence-based recommendations and marketing approvals in different jurisdictions has resulted in geographic variation in clinical practice concerning the management of cutaneous vascular manifestations of SSc. Difficulty demonstrating treatment efficacy risks waning industry engagement for drug development programmes in this field. This article highlights the key challenges in establishing treatment efficacy and barriers that must be overcome to support successful clinical trial programmes across the spectrum of cutaneous vascular manifestations of SSc. Expert commentary: The paucity of approved treatments for cutaneous vascular manifestations of SSc relates as much to challenges in clinical trial design and the need for reliable clinical trial endpoints, as to lack of therapeutic options.
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Affiliation(s)
- John D Pauling
- a Department of Rheumatology, Royal National Hospital for Rheumatic Diseases , Royal United Hospitals NHS Foundation Trust , Bath , UK.,b Department of Pharmacy and Pharmacology , University of Bath , Bath , UK
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Lescoat A, Coiffier G, de Carlan M, Droitcourt C, Ballerie A, Cazalets C, Perdriger A, Jégo P. Combination of Capillaroscopic and Ultrasonographic Evaluations in Systemic Sclerosis: Results of a Cross-Sectional Study. Arthritis Care Res (Hoboken) 2018; 70:938-943. [PMID: 28898558 DOI: 10.1002/acr.23413] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 09/05/2017] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To compare microvascular damages on nailfold capillaroscopy (NFC) with macrovascular manifestations evaluated by hand power Doppler ultrasonography (PDUS) in systemic sclerosis (SSc) patients, and to assess the associations of these damages with the main digital manifestations of the disease: digital ulcers, acroosteolysis, and calcinosis. METHODS NFC, hand radiographs, and PDUS were systematically performed in 64 unselected SSc patients. PDUS evaluation with assessment of ulnar artery occlusion (UAO) and finger pulp blood flow (FPBF) were performed blinded for the results of radiographs and NFC. RESULTS UAO and pathologic FPBF were associated with severe capillary loss (<4 capillaries/mm) on NFC (odds ratio [OR] 4.04 [95% confidence interval (95% CI) 1.23-13.29]; P < 0.05, and OR 3.38 [95% CI 1.03-11.05]; P < 0.05, respectively). Digital ulcer history was associated with UAO (OR 10.71 [95% CI 3.36-34.13]; P < 0.0001), pathologic FPBF (OR 7.67 [95% CI 2.52-23.28]; P < 0.0001), late NFC pattern (OR 6.33 [95% CI 2.03-19.68]; P = 0.001), and severe capillary loss (OR 8.52 [95% CI 2.15-33.78]; P = 0.001). Acroosteolysis was also associated with UAO (OR 15.83 [95% CI 3.95-63.54]; P < 0.0001), pathologic FPBF (OR 5.52 [95% CI 1.71-17.90]; P = 0.003), late NFC pattern (OR 6.86 [95% CI 2.18-21.53]; P = 0.001), and severe capillary loss (OR 7.20 [95% CI 2.16-24.02]; P = 0.001). Calcinosis on radiographs was associated with late NFC pattern (OR 5.41 [95% CI 1.82-16.12]; P = 0.002), severe capillary loss (OR 12.69 [95% CI 3.14-51.26]; P < 0.0001), and UAO (OR 3.19 [95% CI 1.14-8.92]; P = 0.025). Combination of UAO and severe capillary loss in the same patient was especially associated with digital ulcer history (OR 18.60 [95% CI 2.24-154.34]; P = 0.001) and acroosteolysis (OR 10.83 [95% CI 2.56-45.88]; P = 0.001). CONCLUSION Microvascular damages evaluated by NFC and macrovascular features like UAO assessed by PDUS show concordant associations with the main digital manifestations of the disease.
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Affiliation(s)
- Alain Lescoat
- CHU Rennes, University of Rennes, and UMR INSERM U1085, Research Institute in Health, Environment, and Occupation, Rennes, France
| | | | | | | | | | | | - Aleth Perdriger
- CHU Rennes, University of Rennes, and UMR INSERM U991, Rennes, France
| | - Patrick Jégo
- CHU Rennes, University of Rennes, and UMR INSERM U1085, Research Institute in Health, Environment, and Occupation, Rennes, France
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Scleroderma skin ulcers definition, classification and treatment strategies our experience and review of the literature. Autoimmun Rev 2017; 17:155-164. [PMID: 29196241 DOI: 10.1016/j.autrev.2017.11.020] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Skin ulcers (SU) are one of the most frequent manifestations of systemic sclerosis (SSc). SSc-SU are very painful, often persistent and recurrent; they may lead to marked impairment of patient's activities and quality of life. Despite their severe impact on the whole SSc patient's management, the proposed definition, classification criteria, and therapeutic strategies of SSc-SU are still controversial. OBJECTIVE The present study aimed to elaborate a comprehensive proposal of definition, classification, and therapeutic strategy of SSc-SU on the basis of our long-term single center experience along with a careful revision of the world literature on the same topic. METHODS A series of 282 SSc patients (254 females and 28 males; 84% with limited and 16% diffuse cutaneous SSc; mean age of 51.5±13.9SD at SSc onset; mean follow-up 5.8±4.6SDyears) enrolled during the last decade at our Rheumatology Unit were retrospectively evaluated with specific attention to SSc-SU. The SSc-SU were classified in 5 subtypes according to prominent pathogenetic mechanism(s) and localization, namely 1. digital ulcers (DU) of the hands or feet, 2. SU on bony prominence, 3. SU on calcinosis, 4. SU of lower limbs, and 5. DU presenting with gangrene. This latter is a very harmful evolution of both DU of the hands and feet needing a differential diagnosis with critical limb ischemia. RESULTS During the follow up period, one or more episodes of SSc-SU were recorded in over half patients (156/282, 55%); skin lesions were often recurrent and difficult-to-heal because of local complications, mainly infections (67.3%), in some cases associated to osteomyelitis (19.2%), gangrene (16%), and/or amputation (11.5%). SSc-SU were significantly associated with lower patients' mean age at the disease onset (p=0.024), male gender (p=0.03), diffuse cutaneous subset (p=0.015), calcinosis (p=0.002), telangiectasia (p=0.008), melanodermia (p<0.001), abnormal PAPs (p=0.036), and/or altered inflammation reactant (CRP, p=0.001). Therapeutic strategy of SSc-SU included both systemic and local pharmacological treatments with particular attention to complicating infections and chronic/procedural pain, as well as a number of non-pharmacological measures. Integrated local treatments were often decisive for the SSc-SU healing; they were mainly based on the wound bed preparation principles that are summarized in the acronym TIME (necrotic Tissue, Infection/Inflammation, Moisture balance, and Epithelization). The updated review of the literature focusing on this challenging issue was analyzed in comparison with our experience. CONCLUSIONS The recent advancement of knowledge and management strategies of SSc-SU achieved during the last years lead to the clear-cut improvement of patients' quality of life and reduced long-term disability.
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Review of local wound management for scleroderma-associated digital ulcers. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2017; 3:66-70. [PMID: 32099902 DOI: 10.5301/jsrd.5000268] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Digital ulcers (DU) are a common clinical problem in systemic sclerosis (SSc); however, there is no standardization of local wound care protocols for management of these lesions. There is a well-recognized need to develop and standardize non-pharmacological management of DU in patients with SSc, and to adopt these protocols in future clinical trials that focus on DU healing. The purpose of this review is to outline the types of DU that occur in SSc, and provide an update on the principles of wound management for these lesions based on the current literature and expert opinion.
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Abstract
Systemic sclerosis, also called scleroderma, is an immune-mediated rheumatic disease that is characterised by fibrosis of the skin and internal organs and vasculopathy. Although systemic sclerosis is uncommon, it has a high morbidity and mortality. Improved understanding of systemic sclerosis has allowed better management of the disease, including improved classification and more systematic assessment and follow-up. Additionally, treatments for specific complications have emerged and a growing evidence base supports the use of immune suppression for the treatment of skin and lung fibrosis. Some manifestations of the disease, such as scleroderma renal crisis, pulmonary arterial hypertension, digital ulceration, and gastro-oesophageal reflux, are now treatable. However, the burden of non-lethal complications associated with systemic sclerosis is substantial and is likely to become more of a challenge. Here, we review the clinical features of systemic sclerosis and describe the best practice approaches for its management. Furthermore, we identify future areas for development.
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Affiliation(s)
- Christopher P Denton
- UCL Division of Medicine, University College London, London, UK; UCL Centre for Rheumatology and Connective Tissue Diseases, Royal Free Hospital, London, UK.
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Abstract
OBJECTIVES Pathogenesis and risk factors of scleroderma associated calcinosis is poorly understood and there is no effective treatment. This study was performed to better understand the prevalence and clinical features associated with calcinosis in a cohort of SSc outpatients. METHODS In this cross-sectional study, we compared clinical characteristics of SSc patients with (SSc-calcinosis) and without calcinosis (SSc-control) seen in the outpatient Rutgers-RWJ Scleroderma Program between 2012 and 2015. Our analysis included clinical characteristics, comorbidities (i.e. osteoporosis), autoantibodies and imaging results. We performed univariable and multivariable regression analyses to determine common factors associated with calcinosis. RESULTS There were 215 SSc patients, including 65 SSc-calcinosis (81.5% females) and 150 SSc-without calcinosis (controls, 77% females). SSc-calcinosis patients were older (p = .026) with significantly longer disease duration (20 ± 10.5 years versus 12 ± 8 years, p < .0001). Limited cutaneous scleroderma was more common (54%) in the calcinosis group. Longer disease duration from non-Raynaud symptoms (OR 3.77; 95%CI 1.26, 11.27) and osteoporosis (OR 3.43; 95%CI 1.15, 10.36) remained independently associated with calcinosis. CONCLUSIONS Calcinosis was common in both limited and diffuse systemic sclerosis; both longer disease duration and osteoporosis were independently associated with calcinosis. Prospective studies are needed to confirm our findings.
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Affiliation(s)
- Sneha Pai
- a Institute for Rheumatic and Autoimmune Diseases, Overlook Hospital and Medical Center , Summit , NJ , USA
| | - Vivien Hsu
- b Department of Medicine, Division of Rheumatology and Connective Tissue Research , Rutgers-Robert Wood Johnson Medical School , New Brunswick , NJ , USA
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