[Pain reduction by radiosynoviorthesis in rheumatism-induced synovitis of the elbow : Results of a retrospective multicenter data analysis]

BACKGROUND

Radiosynoviorthesis (RSO) is a nuclear medical local treatment modality for inflammatory joint diseases. It is indicated in patients with rheumatoid arthritis (RA) in joints with persistent synovitis despite adequate pharmacotherapy. Arthritis of the elbow joint occurs in up to 2/3 of patients with RA. Intra-articular radiotherapy using the beta emitter [186Re] rhenium sulfide leads to sclerosis of the inflamed synovial membrane with subsequent pain alleviation. The clinical efficacy in cubital arthritis, however, has so far only been described in small monocentric studies.

OBJECTIVE

The degree of pain alleviation by RSO was analyzed in patients with rheumatoid cubital arthritis, treated in several nuclear medical practices specialized in RSO.

MATERIAL AND METHODS

The subjective pain intensity before and after RSO was documented in a total of 107 patients with rheumatic cubital arthritis using a 10-step numeric rating scale (NRS). A difference of ≥ -2 is rated as a significant improvement. Follow-up examinations were done after a mean interval of 14 months after RSO (at least 3 months, maximum 50 months).

RESULTS

The mean NRS value was 7.3 ± 2.1 before RSO and 2.8 ± 2.2 after RSO. A significant pain alleviation was seen in 78.5% of all patients treated. The subgroup analysis also showed a significant improvement in the pain symptoms in all groups depending on the time interval between the RSO and the control examination. A significant pain progression was not observed. The degree of pain relief was independent of the time of follow-up.

CONCLUSION

Using RSO for local treatment of rheumatoid cubital arthritis leads to a significant and long-lasting pain relief in more than ¾ of the treated patients.

[Cardiovascular Surgery for Patients Under Immunosuppressive Therapy]

Immunosuppressive agents including steroids are generally given to patients with collagen disease or organ transplant recipients. Cardiovascular surgery for these patients can potentially associate with increased rate of postoperative infection or wound healing complications. Here, some key points for perioperative management in patients under immunosuppressive therapy are reviewed. Before an elective surgery, steroids need to be tapered down as much as possible, because even small amount of steroid can lead to adverse postoperative outcomes. Withholding Biologic disease-modifying antirheumatic drugs (bDMARDs) and Janus kinase (JAK) inhibitors is recommended for stable collagen disease patients. Current guidelines for perioperative management of antirheumatic medication are summarized in Table 1. Perioperative Glucocorticoid management is also required for patients exposed to steroid therapy. Intra-and postoperative steroid cover regimen is shown in Table 2. On the other hand, immunosuppressive therapy should not be discontinued for those after organ transplant and patients with severely active collagen disease. Our experience of kidney transplant recipients who underwent cardiovascular surgery is shown in Table 3. Close monitoring of blood Tacrolimus level is highly important, because it tends to fluctuate after operation and high Tacrolimus level possibly leads to deterioration in renal function. In conclusion, careful perioperative management in cooperation with transplant surgeons and rheumatologists is vital in this clinical setting.

Clinical characteristics of rheumatic disease-associated hypophysitis: A case series and review of literature

Rheumatic diseases have been reported to sometimes involve the pituitary gland. This study aims to characterize the clinical features and outcomes of patients with rheumatic disease-associated hypophysitis. We used the electronic medical record system in our hospital to identify nine patients with pituitary involvement in rheumatoid disease. We summarized the clinical characteristics, radiographic findings, treatments, and clinical outcomes of the 9 patients. We also performed a systematic literature review of systemic lupus erythematosus (SLE) cases with pituitary involvement published in PubMed and Wanfang databases from 1995 to 2021, and eight patients with complete information were selected. In the nine-patient cohort, the median age was 54 years, and the spectrum of rheumatic diseases included immunoglobulin G4-related disease (IgG4RD) (4/9), SLE (2/9), vasculitis (2/9), and Sjögren syndrome (SS) (1/9). All patients had pituitary abnormalities on radiological assessment, 6 developed diabetes insipidus (DI), and 8 presented with anterior pituitary hormone deficiencies in the disease duration. All the patients had multisystem involvement. As compared to hypophysitis with IgG4RD (IgG4-H), the age at onset of hypophysitis with SLE (SLE-H) patients was younger [(30.4 ± 16.4) years vs. (56.0 ± 0.8) years] and the disease duration was shorter [(14.0 ± 17.5) months vs. (71.0 ± 60.9) months] (P < .05). All patients were managed with glucocorticoids (GC) in combination with another immunosuppressant, and the majority of patients improved within 4 months. Six patients achieved disease remission while four required at least one hormone replacement therapy. Hypophysitis is a rare complication secondary to a variety of various rheumatic diseases that can occur at any stage. GC combined with additional immunosuppressants could improve patients' symptoms; however some patients also required long-term hormone replacement therapy in pituitary disorders.

Dupilumab may be an alternative option in the treatment of acquired reactive perforating collagenosis combined with AD

The management of acquired reactive perforating collagenosis (ARPC) is challenging. Here, we shared two cases of ARPC combined with elderly atopic dermatitis (AD) that did not respond well to conventional treatment but responded well to the monotherapy of dupilumab, which suggests that dupilumab may be an alternative option for the treatment.

Acquired reactive perforating collagenosis: A case report and review of the literature

INTRODUCTION

Acquired reactive perforating collagenosis (ARPC) is a rare skin disorder, which is associated with various internal diseases and even malignant neoplasms. A comprehensive knowledge of the concomitant diseases in ARPC patients is helpful to decrease the misdiagnosis. Although the treatment of ARPC is challenging, systemic assessment of existing regimens is not available.

PATIENT CONCERNS

A 50-year-old woman was admitted to the hospital due to cutaneous pruritus and papules all over the body.

DIAGNOSIS

Physical examination showed various sized papules on the lower limbs, buttocks, back, chest, and upper arms with keratotic plugs in the center. Histopathology showed typical collagenous fiber perforation. The diagnosis of ARPC was made according to histopathology, onset age and typical skin lesions. Type 2 diabetes mellitus (T2DM), chronic renal failure (CRF), and hypothyroidism simultaneously presented in this patient.

INTERVENTIONS

This patient was initially treated with topical corticosteroids and oral antihistamines for the skin lesion and pruritus. Medications for glucose control and recovery of renal and thyroid functions were also applied. On the second admission, the combined therapy of topical retinoic acid, Chinese medicinal herb-Qingpeng ointment, and Zinc oxide ointment was added.

OUTCOMES

Papules and pruritus were improved significantly after the second hospitalization.

CONCLUSION

We present a case of ARPC associated with T2DM, CRF, and hypothyroidism, which has rarely been described. There is no standardized treatment for ARPC. Co-administration of two or more agents for dermatologic interventions and treatment for associated diseases may help to improve skin symptoms.

Acquired reactive perforating collagenosis: A report of a typical case

BACKGROUND

Reactive perforating collagenosis (RPC) is a rare form of transepithelial elimination, in which altered collagen is extruded through the epidermis. There are 2 types of RPC, acquired RPC (ARPC) and inherited RPC, while the latter is extremely rare. Here we report on 1 case of ARPC.

METHODS

A 73-year-old female was presented with strongly itchy papules over her back and lower limbs for 3 months. She denied the history of oozing or vesiculation. A cutaneous examination showed diffusely distributed multiple well-defined keratotic papules, 4 to 10 mm in diameter, on the bilateral lower limbs and back as well as a few papules on her chest and forearm. Scratching scars were over the resolved lesions while Koebner phenomenon was negative. The patient had a history of type 2 diabetes for 15 years. Laboratory examinations showed elevated blood glucose level. Skin lesion biopsy showed a well-circumscribed area of necrosis filled with a keratotic plug. Parakeratotic cells and lymphocytic infiltration could be seen in the necrosed area. In dermis, sparse fiber bundles were seen perforating the epidermis. These degenerated fiber bundles were notarized as collagen fiber by elastic fiber stain, suggesting a diagnosis of RPC.

RESULTS

Then a diagnosis of ARPC was made according to the onset age and the history of diabetes mellitus. She was treated with topical application of corticosteroids twice a day and oral antihistamine once a day along with compound glycyrrhizin tablets 3 times a day. And the blood glucose was controlled in a satisfying range. Two months later, a significant improvement was seen in this patient.

CONCLUSION

Since there is no efficient therapy to RPC, moreover, ARPC is considered to be associated with some systemic diseases, the management of the coexisting disease is quite crucial. The patient in this case received a substantial improvement due to the control of blood glucose and application of compound glycyrrhizin tablets.

[USE OF HYALURONIC ACID ALONE AND COMBINED WITH ARGENTIC SULPHADIAZINE IN REACTIVE PERFORATING COLLAGENOSIS. A CASE REPORT]

The dermatosis known since reactive perforating collagenosis (RPC) is an injury that is characterized by the transepidermal elimination of the collagen. Two forms of presentation exist: the inherited one and the acquired one. The acquired form appears in the adult age, principally in diabetics with renal chronic insufficiency. The hyaluronic acid is a glycosaminoglycan of high place molecular weight that is synthesized in the system vacuolar of the fibroblasts and other cells, since they are the keratinocytes, with help of the factors of growth and in other cytokines. The argentic sulphadiazine is a hackneyed medicament of antiinfectious action that is in use for anticipating and treating the infections in wounds and burns of degree the II and IIIrd. His action realizes it on bacteria and fungi.

Reactivation of cytomegalovirus predicts poor prognosis in patients on intensive immunosuppressive treatment for collagen-vascular diseases

Reactivation of cytomegalovirus (CMV) occurs during intensive immunosuppressive therapies. However, the influence of CMV reactivation on prognosis in patients with immunosuppressive therapies for collagen-vascular diseases (CVD) is not fully understood. To determine whether CMV reactivation affects the prognosis of patients with CVD and to identify risk factors of CMV reactivation, we reviewed, retrospectively, the medical records of 109 CVD patients who were treated with glucocorticoid (prednisolone ≥20 mg/day) and were tested for CMV antigen (CMV-Ag). CMV-Ag was detected in 34 of the 109 patients. First-time CMV-Ag detection was within 50 days from the start of intensive immunosuppressive therapy in 82% of the patients. Common manifestations at first-time CMV-Ag detection were fever, arthralgia, and rash, although 52.9% of the patients were asymptomatic. The risk factors for CMV reactivation were old age (>65 years) and high-dose glucocorticoids (PSL ≥50 mg). During the 4-year study period, 18% of patients with positive CMV-Ag and 5% of those without CMV-Ag died. Patients with CMV-Ag (max CMV number ≥5/10(5) WBC) had a significantly poorer prognosis. Multivariate analysis confirmed CMV reactivation as an independent poor prognostic factor in CVD patients. Causes of death were exacerbation of pre-existing interstitial pneumonia and infection other than CMV. Our results demonstrate that CMV reactivation, particularly with a high CMV-Ag number, is a poor prognostic factor in CVD patients. Patients with older age and high-dose glucocorticoids have a high risk of CMV reactivation.

Age dependence of early symptomatic vertebral fracture with high-dose glucocorticoid treatment for collagen vascular diseases

OBJECTIVES

Collagen vascular diseases requiring treatment with high-dose glucocorticoids are frequently complicated by vertebral fracture. We investigated the incidence of symptomatic vertebral fractures for 20 yr among patients who were treated with high-dose glucocorticoids in the Chiba-Shimoshizu Rheumatic Cohort.

METHODS

A total of 2631 patients with collagen vascular diseases (aged >or=18 yr) was registered between 1986 and 2006. The prevalence of symptomatic vertebral fracture was compared between the high-dose glucocorticoid group newly treated with high-dose glucocorticoids (>or=20 mg/d prednisolone equivalent) (n = 700), and the non-glucocorticoid controls not treated with glucocorticoids (n = 194).

RESULTS

During the 20-yr study period, symptomatic vertebral fractures occurred more frequently in the high-dose glucocorticoid group (23.9%) than in the non-glucocorticoid controls (2.6%). According to a Kaplan-Meier analysis, the cumulative incidence of symptomatic vertebral fracture was significantly higher in the high-dose glucocorticoid group than in the non-glucocorticoid controls (P < 0.001). Stratified into age quartiles of the high-dose glucocorticoid group (age 18-31, 32-47, 48-59, and 60-88 yr), the patients had a markedly increased incidence of symptomatic vertebral fracture with aging. The hazard ratios were also significantly higher in the older age quartile of 60-68 than in the younger age quartile of 32-47 (P < 0.001 for trend). The hazard ratio was 26-fold higher in patients aged 60-88 than in patients aged 18-31 (P < 0.01). In the group with fractures, the treatment duration before fracture was negatively associated with the initial age (r = -0.6587; P < 0.001).

CONCLUSIONS

The prevalence of symptomatic vertebral fractures was higher in the patients treated with high-dose glucocorticoids than the untreated controls. Vertebral fractures were age dependent in patients treated with high-dose glucocorticoids. Treatment duration before fracture incidence was significantly shorter in the older patients.

Collagenous colitis

Collagenous colitis is a very rarely recognized disease characterized clinically by watery diarrhoea and histologically by a broad, band-like deposition of collagen under the surface epithelium of the colon and rectum. Two cases of collagenous colitis are reported in this paper. After treatment of one of the patients with metronidazole, the symptoms cleared up and biopsy specimens from the colon showed regression of the pathological picture. The pathogenesis of the diarrhoea is discussed. The aetiological agent seems to be infectious, but is still unknown.

Sequential studies of lymphocytes, neutrophils and serum proteins during prednisone treatment

Seven patients (6 with connective tissue diseases, 1 with bronchial asthma) have been studied before, during, and after prednisone therapy. Maximum dose was 15 mg daily, which was tapered off to zero within three months. All patients showed striking subjective improvement during therapy. The ESR reflected this improvement but the acute phase proteins did not. The serum concentration of prealbumin rose significantly during the period of most intensive steroid treatment. IgE decreased in the patient with bronchial asthma, but otherwise the immunoglobulins did not change, and positive serological tests remained unchanged. Contact sensitization to haptens was induced without impairment during therapy. Prednisone induced rises in blood lymphocyte and neutrophil concentrations. Lymphocyte transformation, both mitogen- and antigen-induced, was not influenced by therapy, but PPD-induced inhibition of leucocyte migration decreased. Neutrophil phagocytosis was unimparied, but bactericidal capacity, stimulated nitroblue tetrazolium reduction, and neutrophil and plasma lysozyme concentrations were all depressed during treatment with prednisone.

[Epidemiology of collagen diseases]

Collagen diseases have been generally thought to be rare, but the number of patients with rheumatoid arthritis(RA) becomes over 700,000 in recent days. In addition, the survival rate has markedly increased, but many lupus patients are still suffering from so called intractable organ involvements such as severe lupus nephritis and CNS lupus, etc. The main purposes of the treatment for RA are to prevent bone/cartilage destruction, to improve the quality of life(QOL) of patients, and to improve prognosis. For these purposes, new type of drugs such as biologic agents are introduced, and showing remarkable effects comparing with conventional DMARDs. But the side effects and cost of these agents are becoming problems. To overcome these problems, the epidemiology that can clearly show the benefits of these agents on daily life of patients is becoming much more important issue.

[Immunosuppressants]

In recent years, novel immunosuppressive drugs applies to various autoimmune diseases and the evidences increase. Since immunosuppressive drugs inhibit nonselectively the whole immune system, there are possibilities that infection may be induced by decreasing the immunity against pathological agents and malignancy may develop by suppressing immune surveillance. In order to use the immunosuppressants safely and effectively, we should obey the indication and dosage, and be familiar with the side effects. It is also important to take informed consent from patients after explaining the benefit and risk. Therefore, the doctors who are going to use immunosuppressive drugs must know well about the indication, the side effects, the metabolism and the action mechanisms of those drugs.

[Intravenous immunoglobulin (IVIG)]

Intravenous immunoglobulin (VIG) was given by Imbach in 1981 to idiopathic thrombocytopenic purpura (ITP). The cure of many of the patients in response to the IVIG expanded the use of IVIG to other autoimmune condition. The diseases proven the efficacy of VIG by controlled trial were ITP, Guillain-Barré syndrome, chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), multiple motor neuropathy, multiple sclerosis, myasthenia gravis, ANCA related vasculitis, Kawasaki disease, autoimmune uveitis and dermatomyositis. There are several uncontrolled trials and case reports about the efficacy of IVIG on the connective tissue diseases, such as systemic lupus erythematosus, systemic sclerosis, Sjögren syndrome, antiphospholipid antibody syndrome and Still's disease. In Japan, only ITP, Kawasaki disease and CIDP are allowed to be use IVIG by health insurance. I would like to summarize the application of VIG on collagen diseases and refer both novel mechanisms as well as to complications of this therapy.

Incidence of symptomatic vertebral fracture with high-dose glucocorticoid treatment in the Chiba-Shimoshizu Rheumatic Cohort between 1986 and 2006

We investigated the incidence of symptomatic vertebral fracture in patients who required long-term high-dose glucocorticoid (GC) treatment. The patients with collagen vascular diseases (aged 18 years or older) were registered to Chiba-Shimoshizu Rheumatic Cohort from 1986 to 2006. The study included the patients who were newly treated with the initial dose more than 20 mg prednisolone equivalent per day at least for more than 6 months. Among 700 patients (female/ male: 539/161, mean age: 46.7 years, mean initial GC dose: 39.9 mg/day), 167 patients (23.8%) had at least one symptomatic vertebral fracture. Age and daily GC dose were significantly higher in the symptomatic fracture group than the no symptomatic fracture group. Cox regression model demonstrated that the relative risk for symptomatic vertebral fracture is independently higher in female patients, and in patients with initial higher age, and in those patients with initial higher GC dose and GC dose-increase, but lower with cumulative higher GC dose. High-dose GC treatment causes significantly high prevalence of symptomatic vertebral fracture in patients with collagen vascular disease. Age, female, higher initial GC dose and GC dose-increase are the risk factors for the symptomatic vertebral fracture in those patients.

[Skin and collagen vascular diseases]

Dermatology and rheumatology have in common that many rheumatologic diseases manifest with distinct clinical presentations on the skin. Since the skin is easily accessible both to physical examination and biopsy, rheumatologists appreciate to consult with dermatologists with experience in the clinical and pathological aspects of the rheumatic diseases with skin manifestations. Though the medical subspecialities show a tendency to an organ-particular focus, dermatologists traditionally have a multidisciplinary approach to patients and tend to communicate in a cross-disciplinary way. The grouping of the chronic inflammatory autoimmune diseases to the so called collagen vascular diseases and their further classification has lead to a synoptic understanding of these diseases. They have in common: inflammatory tissue damage, tendency to chronicity with acute exacerbations, response to high doses of systemic corticosteroids and/or immunosuppressive agents. They comprise: lupus erythematosus, dermatoniyositis, scleroderma, their combinations (mixed connective tissue disease) and the vasculitides. Their heterogeneity translates into a wide range of clinical presentations. The Skin has an important marker function, both for the diagnosis and prognosis, since there are specific correlations between clinical presentation, especially on the skin, autoantibody profiles, disease course, and prognosis. As for the limited forms of cutaneous autoimmune disease, it is important to recoqnize these distinct subsets with their typically favourable prognosis with respective to lesser aggressive therapeutic protocols.

Two cases of refractory thrombotic thrombocytopenic purpura associated with collagen vascular disease were significantly improved by rituximab treatment

Thrombotic thrombocytopenic purpura (TTP) is a rare disorder of small vessels. TTP is associated with deficiency of the von Willebrand factor-cleaving protease, ADAMTS13, and its inhibitor. Low ADAMTS13 activity is present in most of idiopathic TTP patients. The prognosis of TTP was improved by plasma exchange treatment, which replaces the ADAMTS13 and removes ADAMTS13 inhibitor. However, ADAMTS13 activity is normal in some TTP patients. These are found among the secondary TTP patients associated with collagen disease, hematopoietic stem cell transplantation, malignancy, or drugs. In addition, most of them do not respond to plasma exchange. On the other hand, several reports demonstrated that rituximab, which is an anti-CD20 monoclonal antibody, is effective for refractory TTP cases caused by ADAMTS13 deficiency. It is considered that the effect of rituximab is associated with disappearance of ADAMTS13 inhibitor. However, rituximab therapy was effective for the TTP patients with normal ADAMTS13 activity in our cases. We considered another mechanism of rituximab for TTP cases.

Is Interstitial Pneumonia in Patients with Collagen Diseases a Contraindication to Lung Cancer Surgery?

PURPOSE

Lung cancer surgery can be dangerous in patients with interstitial pneumonia (IP) as acute exacerbation of the IP may prove fatal. It remains unclear if patients with collagen diseases (CD), who often suffer from IP, are also at increased risk during lung cancer surgery.

METHODS

We retrospectively examined 17 (3.1%) patients with CD among 545 patients who underwent surgery for lung cancer at our institution.

RESULTS

Nine patients with rheumatoid arthritis, five with systemic sclerosis, two with Sjögren's disease, and one with systemic lupus erythematosus were enrolled in this study. Eleven patients (65%) were taking corticosteroids at the time of surgery. Fourteen patients underwent lobectomy and lymph node dissection, and three patients with pStage IA lung cancer underwent pulmonary wedge resection. Pathologically, 11 (65%) patients had IP with various inflammatory cellular infiltrations, and three (18%) had honeycombing of the lung. Postoperatively, none of the patients suffered acute exacerbation of their IP.

CONCLUSIONS

Despite the high incidence of IP in patients with lung cancer and CD, our results suggest that CD is not a contraindication to the surgical resection of lung cancer.

Incidence and clinical features of cytomegalovirus infection diagnosed by cytomegalovirus pp65 antigenemia assay during high dose corticosteroid therapy for collagen vascular diseases

OBJECTIVE

To investigate the incidence and clinical features in patients with cytomegalovirus (CMV)-positive antigenemia during high dose corticosteroid therapy for collagen vascular diseases, and risk factors associated with it.

PATIENTS AND METHODS

We examined retrospectively 35 consecutive patients for the presence of CMV-positive pp65 antigenemia. The patients were admitted to Saka General Hospital from 2000 to 2003, and were administered more than 0.5 mg/kg of body weight/day of peroral prednisolone for collagen vascular diseases. Characteristics of patients with and without CMV-positive antigenemia were compared.

RESULTS

CMV-positive antigenemia was detected in 14 patients (40.0%), including six with microscopic polyangitis, three with rheumatoid arthritis, and five with other conditions. Three patients (8.6%) were diagnosed as having a CMV disease: pneumonitis or encephalitis. Symptoms and laboratory findings, including slight fever and a low increase in levels of hepatic enzymes and cytopenia, were observed in 10 of the 14 patients. Two patients died of CMV diseases refractory to ganciclovir. Ages of more than 70 years old were associated with the presence of CMV-positive antigenemia (relative risk = 4.5, 95% confidence interval = 1.14-17.6).

CONCLUSION

CMV infection diagnosed by CMV pp65 antigenemia assay is not rare during high dose corticosteroid therapy for collagen vascular diseases, and advanced age is considered a risk factor for it. It has a variety of symptoms and laboratory findings, which are mild and nonspecific to this type of infection, and they may not be clearly noted as clinical signs of CMV infection, even in patients with CMV diseases whose prognoses can be unsatisfactory. During high dose corticosteroid therapy for collagen vascular diseases, careful attention should be paid to CMV infection.

Acquired reactive perforating collagenosis: four patients with a giant variant treated with allopurinol

Reactive perforating collagenosis (RPC) is one of the four essential acquired perforating dermatoses. The condition is characterized by the transepidermal elimination of altered collagen. This paper describes four patients with a giant variant of RPC which has not previously been documented. Three of the patients had associated diabetes mellitus and one had chronic renal failure secondary to fetal scarring. Three of the four patients had a significant improvement in their lesions and symptoms following treatment with allopurinol.

[Acquired reactive perforating collagenosis after curettage of seborrheic keratoses]

Acquired reactive perforating collagenosis (ARPC) developed in an 81-year-old woman two weeks after curettage of seborrheic keratoses. Treatment with allopurinol and antipruritic ointment was given. After four months, there was complete re-epithelialization, leaving atrophic scars.

Non-specific interstitial pneumonia; as the first clinical presentation of various collagen vascular disorders

Recently, we have experienced significant numbers of patients diagnosed with non-specific interstitial pneumonia (NSIP) by open lung biopsy or video-assisted thoracoscopic surgery. The purpose of this work was to describe the clinical features of patients with collagen vascular disorders (CVD) presenting NSIP in the absence of systemic involvement. This study also involved a retrospective review of patients with CVD presenting clinical and pathological evidence of NSIP in the absence of systemic manifestations of CVD. We found seven patients (six from our experience and one from literature review) with histologically proven NSIP who later developed typical CVD more than 6 months after the first presentation of NSIP. In these cases, it was difficult to speculate the development of CVD at the point of first presentation. Therefore, association of CVD should be considered in patients with NSIP even in the absence of classical systemic involvement.

[New therapeutic concepts for vasculitis and collagenosis]

After improvement of the prognosis of the primary systemic vasculitides and systemic lupus erythematosus from a desperate diagnosis with hardly a one year survival after diagnosis to a 5-year-survival-rate of more than 90% actual therapeutic regimes aim at those patients refractory to standard therapeutic regimes, not achieving a remission by standard approaches or having organ damage or contraindications. Furthermore less toxic regimes are looked for with the aim to avoid secondary complications of the standard therapy. New drugs used successfully in rheumatology, transplantation medicine and haematology are used for these purposes in the last years. Recent experiences with Infliximab, Mycophenolate Mofetil, Rituximab und Deoxyspergualin for the treatment of the small vessel vasculitides and systemic lupus erythematosus are reviewed.

The response of skin perfusion and of rheological and immunological variables to intravenous prostanoid administration in Raynaud’s phenomenon secondary to collagenosis

Background: Prostanoids are used in the treatment of Raynaud’s phenomenon and acral perfusion disorders secondary to collagenosis. In subjective terms, intravenous administration of these agents produces success in more than 50% of patients. The therapeutic outcome of clinical administration of alprostadil or iloprost may vary from individual to individual. Patients and methods: The following variables were analysed in a cross-over study in 27 patients with collagenosis and Raynaud’s phenomenon: plasma viscosity and erythrocyte aggregation (rheological variables), partial pressure of oxygen and laser Doppler flowmetry in the finger region, and lymphocyte phenotyping and interleukin (IL) determinations (immunological variables). Results: Laser Doppler flowmetry revealed significant differences between patients with secondary Raynaud’s phenomenon and a control group of 25 healthy subjects. Laser Doppler readings did not change significantly as a result of the treatments. Therapy with iloprost produced a reduction in IL-1beta, L-selectin (CD 62 L) and IL-6. Conclusion: The change in immunological variables due to iloprost may explain the long-term effects of prostaglandins in the treatment of Raynaud’s phenomenon. From our results it is not possible to infer any preference for iloprost or alprostadil.

Glucocorticoidtherapie bei Kollagenosen

Glucocorticoids are irreplaceable for the treatment of connective tissue diseases due to their strong and rapid anti-inflammatory and immuno-modulatory effects. Its use and their dosage depend on the activity of the disease and organ manifestations. There is no alternative to high doses, often even as intravenous pulse therapy, in life-threatening situations with imminent organ failure. Despite an additional immuno- suppressive medication, glucocorticosteroids are mandatory for long-term treatment in most cases. In special situations like high age, gravity or comorbidities like renal failure or hepatosis, glucocorticosteroids are the option with the least possible potential for complications. In the future, new corticosteroids and steroid sparing immuno-suppressants like biologics will be able to reduce the spectrum and the severity of corticoid-induced side effects. Modern state-of-the-art therapeutic regimens for patients with connective tissue diseases should not only be able to sufficiently control the disease activity but also include the prophylaxis of associated comorbidities like arteriosclerosis, osteoporosis or infections.

[Collagen diseases with opportunistic infections]

Treatment of opportunistic infections emerging in collagen diseases is very important as well as the therapy of original diseases. Lung tuberculosis, Pneumocystis carinii and lung fungal infections are main opportunistic infections. There is effective prophylaxis against them, though the cases for their administration should be carefully chosen because of their adverse effects. We have administrated INH and ST (Sulphomethoxazole and Trimethoprim) more than 15 years as the prophylaxis against tuberculosis and P. carinii to the cases who are treated more than 60 mg of prednisolone per day as an initial dose until less than 30 mg per day and completely succeeded. Infliximab treatment has been reported that it often induces tuberculosis in abroad and lots of occurrence was anticipated in Japan where high incidence of tuberculosis is observed. So far, however, there are only few patients, maybe due to the selection of the patients and actively utilizing prophylaxis.

[Collagen diseases with gastrointestinal manifestations]

Collagen vascular diseases are known to present with a diverse array of gastrointestinal manifestations. These can be classified as: 1) gastrointestinal damage due to the collagen vascular disease itself; 2) adverse events caused by pharmacotherapies; or 3) gastrointestinal infections following immunosuppression due to corticosteroid (CS) administration. The first group includes lupus enteritis and protein-losing gastroenteropathy in systemic lupus erythematosus (SLE), reflux esophagitis, chronic intestinal pseudo-obstruction, and pneumatosis cystoids intestinalis in systemic sclerosis, amyloidosis in rheumatoid arthritis, bowel ulcer and bleeding in rheumatoid vasculitis and microscopic polyangiitis, and ileocecal ulcer in Behcet disease. In particular, colonic ulcers associated with SLE represent refractory lesions resistant to CS. Analysis of reported cases showing colonic lesions with SLE (22 cases in Japan) revealed that mean duration of SLE was 9.9 years and 77% of colonic lesions were observed in the rectum and sigmoid colon. Half of the patients developed intestinal perforation or penetration, and 6 of the 11 patients with perforation died. The second group includes lesions in the small and large intestine due to nonsteroidal anti-inflammatory drugs (NSAIDs) and CSs, in addition to peptic ulcers. As perforation in CS-treated patients displays relatively high incidence with poor prognosis, careful attention to such complications is needed. The third group includes candidal esophagitis and cytomegalovirus (CMV) enteritis. Prompt diagnosis is required to prevent colonic bleeding and perforation due to CMV.