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AlMehmadi BA, To FZ, Anderson MA, Johnson SR. Epidemiology and treatment of peripheral neuropathy in systemic sclerosis. J Rheumatol 2021; 48:1839-1849. [PMID: 34210833 DOI: 10.3899/jrheum.201299] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The epidemiology and treatment of peripheral neuropathy in systemic sclerosis (SSc) is poorly understood. The objectives of this study were to evaluate the incidence, prevalence, risk factors, and treatments of peripheral neuropathy in SSc. METHODS A systematic review of Medline, Embase and CINAHL databases for literature reporting peripheral neuropathy in SSc was performed. Studies evaluating incidence, prevalence, risk factors, and treatments were synthesized. Meta-analysis using a random effects model was used to evaluate the prevalence of peripheral neuropathy. RESULTS 113 studies reported 949 subjects with at least one type of peripheral neuropathy out of 2143 SSc patients studied. The mean age was 48.5 years. The mean time between SSc onset and detection of peripheral neuropathy was 8.85 years. The pooled prevalence of neuropathy was 27.4% (95%CI 22.4% - 32.7%). Risk factors for peripheral neuropathy in SSc included advanced diffuse disease, anticentromere antibodies, calcinosis cutis, ischemia of the vasa nervosum, iron deficiency anemia, metoclopramide, pembrolizumab, silicosis and uremia. There were 73 subjects with successful treatments (n=36 restoring sensation, n=37 restoring motor or sensorimotor function). Treatments included decompression surgery, prednisone, cyclophosphamide, carbamazepine, transcutaneous electrical nerve stimulation, tricyclic antidepressants and IVIG. CONCLUSION All-cause peripheral neuropathy is not uncommon in SSc. Compression neuropathies can be treated with decompression surgery. Observational data reporting immunosuppressive and anticonvulsants to treat peripheral neuropathy in SSc is limited and conflicting. This data provides the signal of effect to justify RCT to evaluate the efficacy of these interventions.
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Affiliation(s)
- Bader A AlMehmadi
- Toronto Scleroderma Program, Mount Sinai Hospital, Toronto Western Hospital, Division of Rheumatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; College of Medicine, Majmaah University, Saudi Arabia; Toronto Scleroderma Program, Mount Sinai Hospital, Toronto Western Hospital, Division of Rheumatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Medical Library, University Health Network, University of Toronto, Toronto, Ontario, Canada; Toronto Scleroderma Program, Mount Sinai Hospital, Toronto Western Hospital, Division of Rheumatology, Department of Medicine; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada. Corresponding Author. Sindhu Johnson MD PhD, Division of Rheumatology, Ground Floor, East Wing, Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario, Canada, M5T 2S8.
| | - Fergus Z To
- Toronto Scleroderma Program, Mount Sinai Hospital, Toronto Western Hospital, Division of Rheumatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; College of Medicine, Majmaah University, Saudi Arabia; Toronto Scleroderma Program, Mount Sinai Hospital, Toronto Western Hospital, Division of Rheumatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Medical Library, University Health Network, University of Toronto, Toronto, Ontario, Canada; Toronto Scleroderma Program, Mount Sinai Hospital, Toronto Western Hospital, Division of Rheumatology, Department of Medicine; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada. Corresponding Author. Sindhu Johnson MD PhD, Division of Rheumatology, Ground Floor, East Wing, Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario, Canada, M5T 2S8.
| | - Melanie A Anderson
- Toronto Scleroderma Program, Mount Sinai Hospital, Toronto Western Hospital, Division of Rheumatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; College of Medicine, Majmaah University, Saudi Arabia; Toronto Scleroderma Program, Mount Sinai Hospital, Toronto Western Hospital, Division of Rheumatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Medical Library, University Health Network, University of Toronto, Toronto, Ontario, Canada; Toronto Scleroderma Program, Mount Sinai Hospital, Toronto Western Hospital, Division of Rheumatology, Department of Medicine; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada. Corresponding Author. Sindhu Johnson MD PhD, Division of Rheumatology, Ground Floor, East Wing, Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario, Canada, M5T 2S8.
| | - Sindhu R Johnson
- Toronto Scleroderma Program, Mount Sinai Hospital, Toronto Western Hospital, Division of Rheumatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; College of Medicine, Majmaah University, Saudi Arabia; Toronto Scleroderma Program, Mount Sinai Hospital, Toronto Western Hospital, Division of Rheumatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Medical Library, University Health Network, University of Toronto, Toronto, Ontario, Canada; Toronto Scleroderma Program, Mount Sinai Hospital, Toronto Western Hospital, Division of Rheumatology, Department of Medicine; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada. Corresponding Author. Sindhu Johnson MD PhD, Division of Rheumatology, Ground Floor, East Wing, Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario, Canada, M5T 2S8.
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Driouach S, Mounir A, Elkhader S, Zinebi A, El Baaj M, Moudden MK. [Pseudotumoral calcinosis of the wrist compressing the radial nerve in systemic sclerosis]. Ann Dermatol Venereol 2020; 147:366-369. [PMID: 31952956 DOI: 10.1016/j.annder.2019.09.612] [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] [Received: 02/01/2019] [Revised: 04/19/2019] [Accepted: 09/03/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pseudotumoral calcinosis, a rare complication of systemic scleroderma, is characterized by the presence in extra-articular tissue, but rarely intra-articular tissue, of large masses made up of hydroxyapatite crystals. PATIENTS AND METHODS We report an original case of intra- and extra-articular pseudotumoral calcinosis of the wrist diagnosed in a patient followed for mild systemic scleroderma. The calcinosis was revealed in a highly unusual way via ductal syndrome secondary to compression of the radial nerve in the wrist. Surgical treatment resulted in marked clinical and functional improvement. COMMENT Although subcutaneous calcinoses are a fairly common complication of systemic scleroderma, the pseudo-tumoral form remains extremely rare. It may be complicated by pain, recurrent infection, and functional restriction, but literature contains only very rare reports of its revelation via ductal syndrome.
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Affiliation(s)
- S Driouach
- Service de médecine interne, hôpital militaire Moulay Ismail, BP S15, Meknès, Maroc.
| | - A Mounir
- Service de médecine interne, hôpital militaire Moulay Ismail, BP S15, Meknès, Maroc
| | - S Elkhader
- Service de médecine interne, hôpital militaire Moulay Ismail, BP S15, Meknès, Maroc
| | - A Zinebi
- Service de médecine interne, hôpital militaire Moulay Ismail, BP S15, Meknès, Maroc
| | - M El Baaj
- Pôle médical, hôpital militaire Moulay Ismail, BP S15, Meknès, Maroc
| | - M K Moudden
- Service de médecine interne, hôpital militaire Moulay Ismail, BP S15, Meknès, Maroc
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Deeb K, Eby J, Labault-Santiago J. Demyelinating syndrome in systemic sclerosis and neuromyelitis optica. BMC Neurol 2019; 19:234. [PMID: 31607267 PMCID: PMC6790997 DOI: 10.1186/s12883-019-1472-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 09/20/2019] [Indexed: 12/16/2022] Open
Abstract
Background This article reports a case diagnosis of a 44-year-old female who presented with intractable hiccups and vomit complicated with an acute onset of paraplegia. Transverse myelitis was evident on MRI and serological studies were consistent with Neuromyelitis Optica (NMO) based on NMO-IgG sero-positivity. Further studies revealed positive ANA, anti-RNA polymerase III autoantibodies, and Scl-70, leading to a concurrent diagnosis of systemic sclerosis (SSc). The coexistence of these two disease processes and their underlying clinical manifestations and therapeutic interventions are seldom reported in literature and are worth reporting. Case presentation The patient was treated with high dose steroids, and subsequently developed malignant hypertension and acute renal failure, later identified on biopsy as steroids-induced scleroderma renal crisis. Although Neuromyelitis Optica spectrum disorder (NMOSD) has often been associated with various collagen and autoimmune diseases, the coexistence of NMOSD and SSc presented a challenge where the patient underwent aggressive physical therapy and necessitated an intervention with Rituximab to achieve an appropriate clinical response. We have received a written consent forms from the participant in our study, and we have them on file in case they are requested. We have also received the patient’s written consent for the data and images presented in this article. Conclusion This article expands on NMOSD associated autoimmune diseases. Systemic Sclerosis is an insidious disease that is often diagnosed late as not all patients often report skin manifestation. The finding suggests that patients presenting with acute neurological manifestations get tested for NMO-IgG/AQP-4 antibodies and other immunological studies based on clinical findings.
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Affiliation(s)
- Khaled Deeb
- Miller School of Medicine, Internal Medicine Residency, University of Miami, 5301 S Congress Aven, Atlantis, FL, 33426, USA.
| | - Jessika Eby
- Miller School of Medicine, Palm Beach Regional Campus, University of Miami, Atlantis, FL, USA
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Amaral TN, Peres FA, Lapa AT, Marques-Neto JF, Appenzeller S. Neurologic involvement in scleroderma: a systematic review. Semin Arthritis Rheum 2013; 43:335-47. [PMID: 23827688 DOI: 10.1016/j.semarthrit.2013.05.002] [Citation(s) in RCA: 128] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Revised: 04/24/2013] [Accepted: 05/02/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To perform a systematic review of neurologic involvement in Systemic sclerosis (SSc) and Localized Scleroderma (LS), describing clinical features, neuroimaging, and treatment. METHODS We performed a literature search in PubMed using the following MeSH terms, scleroderma, systemic sclerosis, localized scleroderma, localized scleroderma "en coup de sabre", Parry-Romberg syndrome, cognitive impairment, memory, seizures, epilepsy, headache, depression, anxiety, mood disorders, Center for Epidemiologic Studies Depression (CES-D), SF-36, Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Patient Health Questionnaire-9 (PHQ-9), neuropsychiatric, psychosis, neurologic involvement, neuropathy, peripheral nerves, cranial nerves, carpal tunnel syndrome, ulnar entrapment, tarsal tunnel syndrome, mononeuropathy, polyneuropathy, radiculopathy, myelopathy, autonomic nervous system, nervous system, electroencephalography (EEG), electromyography (EMG), magnetic resonance imaging (MRI), and magnetic resonance angiography (MRA). Patients with other connective tissue disease knowingly responsible for nervous system involvement were excluded from the analyses. RESULTS A total of 182 case reports/studies addressing SSc and 50 referring to LS were identified. SSc patients totalized 9506, while data on 224 LS patients were available. In LS, seizures (41.58%) and headache (18.81%) predominated. Nonetheless, descriptions of varied cranial nerve involvement and hemiparesis were made. Central nervous system involvement in SSc was characterized by headache (23.73%), seizures (13.56%) and cognitive impairment (8.47%). Depression and anxiety were frequently observed (73.15% and 23.95%, respectively). Myopathy (51.8%), trigeminal neuropathy (16.52%), peripheral sensorimotor polyneuropathy (14.25%), and carpal tunnel syndrome (6.56%) were the most frequent peripheral nervous system involvement in SSc. Autonomic neuropathy involving cardiovascular and gastrointestinal systems was regularly described. Treatment of nervous system involvement, on the other hand, varied in a case-to-case basis. However, corticosteroids and cyclophosphamide were usually prescribed in severe cases. CONCLUSIONS Previously considered a rare event, nervous system involvement in scleroderma has been increasingly recognized. Seizures and headache are the most reported features in LS en coup de sabre, while peripheral and autonomic nervous systems involvement predominate in SSc. Moreover, recently, reports have frequently documented white matter lesions in asymptomatic SSc patients, suggesting smaller branches and perforating arteries involvement.
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Affiliation(s)
- Tiago Nardi Amaral
- Rheumatology Division, Faculty of Medical Science, State University of Campinas, Campinas, Brazil; Rheumatology Lab, Faculty of Medical Science, State University of Campinas, Campinas, Brazil
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Savarino E, Bazzica M, Zentilin P, Pohl D, Parodi A, Cittadini G, Negrini S, Indiveri F, Tutuian R, Savarino V, Ghio M. Gastroesophageal reflux and pulmonary fibrosis in scleroderma: a study using pH-impedance monitoring. Am J Respir Crit Care Med 2008; 179:408-13. [PMID: 19096004 DOI: 10.1164/rccm.200808-1359oc] [Citation(s) in RCA: 178] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
RATIONALE Interstitial lung disease (ILD) in patients with systemic sclerosis (SSc) is associated with increased morbidity and mortality. Gastroesophageal reflux (GER) is considered a contributing factor in the pathogenesis of ILD. OBJECTIVES To characterize GER (acid and nonacid) in patients with SSc with and without ILD. METHODS Patients with SSc underwent pulmonary high-resolution computer tomography (HRCT) scan and 24-hour impedance-pH monitoring off-proton pump inhibitor therapy. The presence of pulmonary fibrosis was assessed using validated HRCT-scores. Reflux monitoring parameters included number of acid and nonacid reflux episodes, proximal migration of the refluxate, and distal esophageal acid exposure. Unless otherwise specified, data are presented as median (25th-75th percentile). MEASUREMENTS AND MAIN RESULTS Forty consecutive patients with SSc (35 female; mean age, 53 yr; range, 24-71; 15 patients with diffuse and 25 with limited SSc) were investigated; 18 (45%) patients with SSc had pulmonary fibrosis (HRCT score >or= 7). Patients with SSc with ILD had higher (P < 0.01) esophageal acid exposure (10.3 [7.5-15] vs. 5.2 [1.5-11]), higher (P < 0.01) number of acid (41 [31-58] vs. 19 [10-23]) and nonacid (25 [20-35] vs. 17 [11-19]) reflux episodes, and higher (P < 0.01) number of reflux episodes reaching the proximal esophagus (42.5 [31-54] vs. 15 [8-22]) compared with patients with SSc with normal HRCT scores. Pulmonary fibrosis scores (HRCT score) correlated well with the number of reflux episodes in the distal (r(2) = 0.637) and proximal (r(2) = 0.644) esophagus. CONCLUSIONS Patients with SSc with ILD have more severe reflux (i.e., more reflux episodes and more reflux reaching the proximal esophagus). Whether or not the development of ILD in patients with SSc can be prevented by reflux-reducing treatments needs to be investigated.
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Affiliation(s)
- Edoardo Savarino
- Division of Gastroenterology, University of Genoa, Genoa, Italy.
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