Radiation toxicity in patients with collagen vascular disease and intrathoracic malignancy treated with modern radiation techniques

BACKGROUND AND PURPOSE

There is concern that patients with collagen vascular disease (CVD) are at higher risk of developing radiation toxicity. We analyzed radiation toxicities in patients with intrathoracic malignancy and CVD treated using modern radiotherapy.

MATERIALS AND METHODS

This single-institution retrospective study included 31 patients with CVD and 825 patients without CVD treated from 1998 to 2014. Radiation esophagitis (RE) and radiation pneumonitis (RP) were scored by RTOG scales. RE was analyzed with logistic regression and RP with Cox regression.

RESULTS

CVD patients experienced similar grade ≥3 RE compared to control patients (23% vs. 19%, p = 0.64) but more grade ≥3 RP (26% vs. 10%, p = 0.01). There was no significant association between CVD subtype and toxicities. In multivariate analysis, CVD and lung V20 >30% were associated with grade ≥3 RP. We identified V20 ≤30%, V5 ≤50%, and MLD ≤18 Gy as dose thresholds in patients with CVD. CVD patients with mild severity disease and only 1 organ system involved were at low risk for RP.

CONCLUSIONS

Patients with CVD may be at higher risk of RP. However, CVD patients may be offered curative thoracic RT with particular attention to risk-reduction strategies and maintaining recommended dose constraints as described in this study.

NK cell populations in collagen vascular disease

OBJECTIVES

Pulmonary involvement of varying etiology is common in collagen vascular diseases (CVDs). Bronchoalveolar lavage fluid (BALF) cell differentials reveal information on the immune mechanisms involved in the CVDs. The aim of the present study was to evaluate BALF cell populations in CVD-associated ILD and to investigate possible correlation with pulmonary function.

METHODS

Fifty-seven patients (26 male and 31 female, mean age ± SD: 54.68±12.18 years) with CVD-associated interstitial lung disease were studied. Patients were divided into 6 groups based on underlying CVD. The study population also included a group of 10 healthy controls. BALF was examined in all individuals. Cell density, total cell number and differential cell count were recorded. BALF lymphocyte subsets were analysed by dual flow cytometry. Pulmonary function was assessed in all patients.

RESULTS

BALF differential cell count did not differ significantly among the different groups. Scleroderma patients showed the highest percentage of CD19 cells (p<0.001). The NK and NKT cell percentages were significantly higher in systemic lupus erythematosus and in Sjögren, respectively, compared to other CVDs and controls (p=0.001 and p<0.001). Also BALF neutrophil percentage correlated negatively with FVC (r=-0.356, p=0.011) and FEV1 (r=-0.336, p=0.017) and BALF NKT cell percentage correlated negatively with pO2 (r=-0.415, p=0.003).

CONCLUSIONS

Important variations observed in BALF cell populations suggest the implication of NK and NKT cells in the pathogenesis of lung involvement in CVDs.

The spectrum of lung involvement in collagen vascular-like diseases following allogeneic hematopoietic stem cell transplantation: report of 6 cases and review of the literature

Multisystem autoimmune diseases occurring after allogeneic hematopoietic stem cell transplantation are infrequent, late-onset manifestations that resemble well-defined collagen vascular disorders. Because the lung is frequently involved in the course of connective tissue disorders, we focused on lung manifestations occurring in autoimmune diseases following allogeneic stem cell transplantation. In the present series, we report 6 patients with systemic lupus erythematous, mixed connective tissue disease, Sjögren syndrome, polymyositis, and ANCA-positive vasculitis who presented with a spectrum of pulmonary manifestations affecting the airways, lung parenchyma, and probably respiratory muscles. We identified 3 different histopathologic patterns of interstitial pneumonia consistent with the underlying autoimmune disorder: lymphocytic interstitial pneumonia and non-specific interstitial pneumonia in 2 patients with Sjögren syndrome and diffuse alveolar damage in 1 patient with ANCA-positive vasculitis. These lung manifestations had poor prognoses. Further studies are needed to determine the optimal therapy for these complications.

[How to find a collagen-vascular disease patient in an early stage and when to let her/him visit a rheumatologist]

Collagen-vascular diseases could be defined as 'chronic', 'inflammatory', 'multiorgan diseases' 'with immunological derangement'. It is important to know that these diseases frequently involve locomotorium, skin, and vessels, of which symptoms or signs are easily sensed by patient herself or observed by herself or a doctor from her body surface. Even among routine laboratory findings, cytopenia, lymphocytopenia, inflammatory reactant level increase, serum total protein level increase could be indicative of these diseases. When considering a substantial number of patients with these diseases or with their subclinical status, routine medical check for rheumatoid factor or anti-nuclear antibody would be better recommended. In case that differential diagnosis is difficult or a strong intervention may be necessary, visiting a rheumatologist at least once would be a choice for early diagnosis or to avoid iatrogenic adverse events induced by irrelevant steroid, disease-modifying anti-rheumatic drug or immunosuppressant. Socio-economically, the early diagnosis and early treatment for these diseases would be very effective showing a good cost-performance.

Angiogenic activity of sera from patients with systemic autoimmune diseases in relation to clinical, radiological, and functional pulmonary status

Systemic autoimmune diseases, such as vasculitis and collagen diseases, are characterized by chronic inflammation. Mutual interrelationship between angiogenesis and chronic inflammation has already been demonstrated. The aim of the study was to examine the effect of sera from patients with systemic autoimmune diseases on angiogenesis induced by human mononuclear cells. The study population consisted of 43 patients with a systemic autoimmune disease associated with pulmonary manifestations, divided into three groups: 14 with Wegener's granulomatosis (WG), 13 with systemic sclerosis (SS), and 16 with collagen vascular diseases (CVD) such as rheumatoid arthritis, systemic lupus erythematosus, and dermatomyositis. The control group consisted of 15 healthy volunteers. Clinical status was evaluated using a questionnaire. Standard chest radiographs were performed in all patients. Pulmonary function tests were performed according to the ERS standards. An animal model of a leukocyte-induced angiogenesis assay was used as an angiogenic test. Sera from WG and CVD patients significantly stimulated angiogenesis compared with healthy subjects (P<0.001). On the other hand, sera from healthy donors exerted a proangiogenic effect compared with PBS. In contrast, sera from SS patients significantly (P<0.001) inhibited angiogenesis compared with sera from healthy subjects and PBS. Proangiogenic effect of sera from systemic diseases patients depended on radiological changes. No significant correlation between a degree of dyspnea or functional pulmonary tests and the number of new vessels or angiogenesis index was found. Sera from patients with systemic autoimmune diseases and healthy people constitute the source of mediators modulating angiogenesis. These modulatory effects differ depending on the disease entity.

[Pathogenesis of systemic sclerosis]

Systemic sclerosis is a complex multi-systemic disease with a mostly unresolved pathogenesis. Following an inflammatory reaction, overproduction of collagen and other extra-cellular matrix components leads to a characteristic fibrosis. It remains unclear why this overproduction by fibroblasts and myofibroblasts occurs. Micro-vascular disturbances and endothelial cells, as well as immunomodulation and inflammation are central factors. Besides intrinsic influences, such as genetic polymorphisms, multiple mediators with fibrotic effects such as Platelet Derived Growth Factor, Transforming Growth Factor-beta and Connective Tissue Growth Factor have been characterized. These have become targets for innovative therapeutic strategies that might lead to specific treatments for systemic sclerosis.

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.

Collagenoses and cutaneous manifestations of hepar diseases

The authors discuss cutaneous manifestations of some systemic diseases (collagenoses) and their connection with diseases of liver cells.

Adjuvant hydrodistension under epidural anesthesia for interstitial cystitis

BACKGROUND

Hydrodistension is the first choice of treatment for interstitial cystitis because it allows for diagnosis, bladder biopsy and treatment. However, the method and efficacy of hydrodistension are variable. We performed adjuvant hydrodistension and examined the efficacy and factors that influence prognosis.

METHODS

Fifty-two patients participated in the present study as subjects; they satisfied the diagnostic inclusion and exclusion criteria established by the National Institute of Diabetes, Digestive and Kidney Disease (NIDDK) in 1987, USA. Under epidural anesthesia, the bladder was repeatedly distended up to the maximal bladder capacity for treatment, diagnosis and biopsy. Hydrodistension was performed again on the following day for approximately 30 min under epidural anesthesia in a ward until macroscopic hematuria disappeared.

RESULTS

Five patients were classified into the good, 30 into the moderate and 17 into the poor response group. In the good response group, three patients had type I allergy and one patient did not fulfil all of the positive factors in the NIDDK criteria. The poor response group included one patient with collagen disease. The poor response group was further divided into two subgroups based on bladder capacity. One subgroup included eight patients with a bladder capacity of less than 100 mL and vesicoureteral reflux (VUR). The other subgroup included nine patients with a bladder capacity of more than 100 mL. Among these nine patients there were five patients who lacked one or two positive factors in the NIDDK criteria.

CONCLUSION

Adjuvant hydrodistension under epidural anesthesia is effective for about 70% of patients for more than 3 months. It can be performed in a ward without any serious complications. It was observed that patients lacking one or two positive factors were included in the good and poor response groups.

Tuberculosis or systemic lupus erythematosus? A diagnostic and therapeutic dilemma

The diagnosis of patients with fever of unknown origin (FUO) is often problematic because the range of possible differential diagnoses is broad. We report on a case in which a patient presented with FUO and was subsequently found to have both a collagen vascular disease and an intercurrent infection. Treatment for the collagen vascular disease with corticosteroids exacerbated the intercurrent infection. The problems in the diagnosis and management of such cases are discussed.

Pulmonary ventilatory function in premenopausal women with and without genital descensus

A hypothesis on the existence of link between the changes in connective tissue in patients with genital descensus and impairments of their pulmonary function was made. In the sample of 40 patients, admitted to hospital for surgical correction of their genital descensus, their pulmonary ventilatory function was examined and compared with 40 matched female examinees without genital descensus. All the examinees were in premenopausis, nonsmokers and without history or clinical signs of the diseases that could affect their pulmonary function. Patients exhibited highly significant decrements in all expiratory flows, especially in the peak expiratory flow (-26%) and other flows at large lung volumes. The forced vital capacity and forced expired volume at 1 second were also decreased (-9% and -16%, respectively). The findings were typical for reduced strength of the expiratory muscles, suggesting the possible link between the lack of collagen and the impairments of pulmonary function in women with genital descensus.

The effect of nonmalignant systemic disease on tolerance to radiation therapy

PURPOSE

Some patients with nonmalignant systemic diseases, like collagen vascular disease (CVD), hypertension, diabetes mellitus, and inflammatory bowel disease (IBD), tolerate radiation therapy poorly. Although the mechanisms of each of these disease processes are different, they share a common microvessel pathology that is potentially exacerbated by radiotherapy. This article reviews and evaluates available data examining the effects of these benign disease processes on radiation tolerance.

METHODS

We conducted a thorough review of the Anglo-American medical literature from 1960 to 2001 on the effects of radiotherapy on CVD, hypertension, diabetes mellitus, and IBD.

RESULTS

Fifteen studies were identified that examined the effects of radiation therapy for cancer in patients with CVDs. Thirteen of 15 studies documented greater occurrences of acute and late toxicities (range 7%-100%). Higher rates of complications were noted especially for nonrheumatoid arthritis CVDs. Nine studies evaluated the effects of hypertension and diabetes on radiation tolerance. All nine studies documented higher rates of late toxicities than in a "control" group (range 34%-100%). When patients had both diabetes and hypertension, the risk of late toxicities was even higher. Six studies examined radiation tolerance of patients with IBD irradiated to the abdomen and pelvis. Five of these six studies showed greater occurrences of acute and late toxicities for patients with IBD, even with precautionary measures like reduced fraction size and volume and patient immobilization (13%-29%).

CONCLUSION

The majority of published studies documented lower radiation tolerance for patients who have CVD, diabetes mellitus, hypertension, and IBD. This may reflect a publication bias, as the majority of these studies are retrospective with small numbers of patients and use different scoring scales for complications. These factors may contribute to an overestimation of true radiation-induced morbidity. Although the paucity of data makes precise estimates difficult, a subset of patients, in particular, those with active CVD, IBD, or a combination of uncontrolled hypertension with type I diabetes, is likely to be at higher risk. Future prospective trials need to document these disease entities when reporting treatment-related complications and also must monitor toxicities associated with quiescent versus active IBD and CVD, type I versus type II diabetes, and levels of hypertension (controlled versus uncontrolled) matched for radiation-specific treatment sites, field size, fractionation, and total dose.

Collagens and collagen-related diseases

The collagen superfamily of proteins plays a dominant role in maintaining the integrity of various tissues and also has a number of other important functions. The superfamily now includes more than 20 collagen types with altogether at least 38 distinct polypeptide chains, and more than 15 additional proteins that have collagen-like domains. Most collagens form polymeric assemblies, such as fibrils, networks and filaments, and the superfamily can be divided into several families based on these assemblies and other features. All collagens also contain noncollagenous domains, and many of these have important functions that are distinct from those of the collagen domains. Major interest has been focused on endostatin, a fragment released from type XVIII collagen, which potently inhibits angiogenesis and tumour growth. Collagen synthesis requires eight specific post-translational enzymes, some of which are attractive targets for the development of drugs to inhibit collagen accumulation in fibrotic diseases. The critical roles of collagens have been clearly illustrated by the wide spectrum of diseases caused by the more than 1,000 mutations that have thus far been identified in 22 genes for 12 out of the more than 20 collagen types. These diseases include osteogenesis imperfecta, many chondrodysplasias, several subtypes of the Ehlers-Danlos syndrome, Alport syndrome, Bethlem myopathy, certain subtypes of epidermolysis bullosa, Knobloch syndrome and also some cases of osteoporosis, arterial aneurysms, osteoarthrosis, and intervertebral disc disease. The characterization of mutations in additional collagen genes will probably add further diseases to this list. Mice with genetically engineered collagen mutations have proved valuable for defining the functions of various collagens and for studying many aspects of the related diseases.

Clinical significance of ventilation/perfusion scans in collagen disease patients

The purpose of this study was to detect disturbances in pulmonary circulation in collagen disease patients by means of a non-invasive technique.

METHODS

Ventilation/perfusion scans with 133Xe gas and 99mTc-macroaggregated albumin (MAA) were performed in 109 patients with various collagen diseases. Functional images of V, Vol, Q and V/Q ratio were obtained at total lung capacity. Wash-out time was calculated from the wash-out curve. Whole body scans were performed in 65 patients to evaluate intra-pulmonary shunts.

RESULTS

Increased V/Q areas were observed in 74 patients (67.9%), suggesting some impairment of pulmonary perfusion. Decreased perfusion, probably due to vasculitis or intravascular microcoagulation, was observed often, even in patients without pulmonary fibrosis. Shunt ratios over 10% were observed in 8 of the 65 patients (12.3%), indicating formation of PA-PV shunts secondary to peripheral vascular impairment. Wash-out time was prolonged in 37 patients (33.9%), shortened in 18 (16.5%), and within the normal range in 54 (49.6%). The prolonged and normal wash-out times in the patients with pulmonary fibrosis may represent obstructive changes in the small airways superimposed on the fibrosis.

CONCLUSION

Ventilation/perfusion scans are a very useful tool for evaluating collagen lung diseases, and they might contribute to treatment decisions for the patients.

Role of carbohydrate antigens sialyl Lewis (a) (CA19-9) in bronchoalveolar lavage in patients with pulmonary fibrosis

BACKGROUND

It has been reported that carbohydrate antigen sialyl Lewis (a) (CA19-9) levels are elevated in serum as well as in bronchoalveolar lavage fluid (BALF) of patients with pulmonary fibrosis. However, the biological significance of CA19-9 is unclear.

OBJECTIVE

The purpose of the present study was to evaluate correlations between CA19-9 levels in BALF and several biochemical as well as clinical parameters in patients with pulmonary fibrosis. In addition, biological functions of CA19-9 were also examined.

METHODS

We studied 24 patients with a diagnosis of pulmonary fibrosis: 16 with idiopathic pulmonary fibrosis (IPF) and 8 with pulmonary fibrosis associated with a collagen vascular disorder (PF-CVD). In BALF, carbohydrate antigens sialyl Lewis (a) (CA19-9), elastase: alpha(1)-proteinase inhibitor complex (E-PI), hepatocyte growth factor (HGF), LDH, IgG, IgA, albumin, and cell differentiation were measured. We also evaluated the effects of CA19-9 on neutrophil functions.

RESULTS

CA19-9/albumin levels in BALF significantly correlated with HGF/albumin, elastase/albumin, LDH/albumin, total number of alveolar macrophages, and total number of neutrophils. Purified CA19-9 had a chemotactic activity for neutrophils. In addition, neutrophil chemotactic activity to C5a, fMLP, and interleukin 8 was significantly stimulated after incubation with purified CA19-9. Furthermore, CA19-9 increased the expression of CD15s on neutrophils.

CONCLUSIONS

Our data demonstrated (i) CA19-9 in BALF correlated with other markers of inflammation in pulmonary fibrosis, and (ii) CA19-9 can modify neutrophil functions. These results suggest that CA19-9 may play a role in the process of lung injury in patients with pulmonary fibrosis.

Nonlinear analysis of blood flux in human vessels

Laser Doppler fluxmetry (LDF) is frequently used in research on microcirculation of blood. Usually LDF time series are analysed by conventional linear methods, mainly Fourier analysis. These methods may not be optimal for the investigation of nonlinear effects of vasomotion, heartbeat or vessels. Nonlinear methods are based on a reconstruction of the system trajectory in an embedding space describing not only the measured time series but the behaviour of the whole system. The fill factor is a tool for displaying the main properties of this attractor in two dimensions and for determining diverse parameters for further analysis. A quantitative characterization of the system is possible by the distribution of correlation dimensions in the embedding space. The singular value decomposition (SVD) can be used to display and characterize individual degrees of freedom. These methods were applied to LDF time series from nine healthy controls and nine patients with Raynaud's phenomenon due to connective tissue disease. The fill factor and the SVD indicate qualitatively that in the controls vasomotion and heartbeat are the main influences on blood flow and act fairly independently of each other. In the patients there was a mixture of strong but irregular degrees of freedom. The mean and the maximal local correlation dimensions were significantly higher in the patient group. Nonlinear analysis of LDF time series provides additional information which cannot be detected using conventional approaches.

[Pulmonary hemodynamic and gas exchange effects of various oxygen concentrations in patients with severe pulmonary hypertension primarily affecting the pulmonary vasculature]

The aim of this study was to evaluate pulmonary hemodynamic and gas exchange response to oxygen inhalation in patients with severe pulmonary hypertension primarily affecting the pulmonary vasculature. This study included 7 patients with primary pulmonary hypertension (PPH), 11 with pulmonary hypertension related to collagen vascular diseases (CoPH), and 18 with chronic thromboembolic pulmonary hypertension (CTEPH). All patients had mean pulmonary arterial pressure (PPAm) of greater than 25 mm Hg. We divided the patients into two groups: a PPH + CoPH group comprising the 7 PPH and 11 CoPH patients, and the CTEPH group. We measured cardiopulmonary variables after 10 min inhalation of various oxygen concentrations (FiO2 0.24, 0.28, 0.4, 1.0). In the PPH + CoPH group, PPAm significantly decreased after the inhalation of oxygen concentrations of 40% or more. This was associated with a significant reduction in pulmonary arteriolar resistance (PAR), and suggested active pulmonary vasodilation was caused by oxygen inhalation. In the CTEPH group, on the other hand, PPAm significantly decreased after the inhalation of oxygen concentrations of 28% or more, apparently in association with a significant fall of cardiac output. However, PAR was unchanged regardless of the inspired oxygen concentration, indicating an absence of pulmonary vasodilation in the CTEPH group. When breathing room air, 7 patients in the PPH + CoPH group (38.9%) and 10 in the CTEPH group (55.6%) demonstrated mixed venous oxygen tension (PvO2) values of less than 35 Torr. Extra attention should be paid to PvO2 when administering oxygen therapy to patients with severe pulmonary hypertension.

[Renal disorders in patients with collagen vascular diseases]

Membranous nephropathy, mesangial proliferative glomerulonephritis and renal amyloidosis are common renal pathology in RA patients. However, IgA nephropathy and diffuse thinning of glomerular basement membrane are described as common and characteristic renal lesions in Japanese RA patients. Glomerular filtration rate may decrease significantly in active lupus nephritis, but renal plasma flow does not change or even increase. These findings seem to be characteristic of SLE patients with active renal disorders. Therefore, filtration fraction may be a useful clinical parameter to evaluate SLE patients. Scleroderma renal crisis(SRC) has been believed to be the most serious renal disorder in systemic sclerosis (SSc). Recently, the presence of an antibody to RNA polymerase has been associated with a high prevalence of SRC.

Collagen vascular diseases

Collagen vascular diseases are multisystem disorders that frequently affect the skin. At times, cutaneous disease is the initial manifestation. This article focuses on lupus erythematosus, dermatomyositis, and sclerodermoid syndromes.

In vitro spontaneous and UVB-induced lymphocyte apoptosis are not specific to SLE

We studied in vitro spontaneous and ultraviolet light (UV)-induced lymphocyte apoptosis in patients with systemic lupus erythematosus (SLE, n = 11), cutaneous lupus erythematosus (CLE, n = 8), and other collagen diseases (n = 6), as well as normal individuals (n = 6). Apoptosis was confirmed by the presence of a 180 bp DNA ladder on gel electrophoresis. UVB-induced apoptosis was observed in 4 of 11 patients with SLE (36.3%), 3 of 8 patients with CLE (37.5%) and 2 of 6 patients (33.3%) with other collagen diseases. There was no clinical correlation between clinical photosensitivity and UV-induced apoptosis. Similarly, spontaneous apoptosis was also found in lymphocytes from patients with diseases other than SLE. No apoptosis was found in normal subjects with or without UVB irradiation (25 mJ/cm2). These data suggest that UV-induced lymphocyte apoptosis may not be specific to SLE but may be common in collagen diseases.

Collagen types VIII and X, two non-fibrillar, short-chain collagens. Structure homologies, functions and involvement in pathology

Collagens can be divided into two groups, i.e., fibrillar and non-fibrillar collagens. Short-chain collagens, a subgroup of non-fibrillar collagens, comprises collagen type VIII and type X. These two collagen types show several similarities in structure and possibly also in function. Type VIII collagen appears to be secreted by rapidly proliferating cells. It can be found in basement membranes and may serve as a molecular bridge between different types of matrix molecules. In different tissues this collagen type may serve different functions. Stabilization of membranes, angiogenesis, and interactions with other extracellular matrix molecules. Since collagen type X is produced by hypertrophic chondrocytes, this collagen type can only be found in matrix of the hypertrophic zone of the epiphyseal growth plate cartilage. Collagen type X is probably involved in the process of mineralization, endochondral ossification, and is also proposed to play a role in angiogenesis. Collagen types VII and X may be involved in matrix and bone disorders. Their structure, function, and involvement in pathology are discussed in this review.

HTLV-I env-pX transgenic rats: prototype animal model for collagen vascular diseases

To evaluate the function of HTLV-I env-pX gene in vivo, we developed two lines of transgenic rats (env-pX rats) that expressed env-pX gene products, under control of own LTR promotor. In various tissues of the rats, env and pX mRNAs were constitutively expressed, irrespective of age. At age 5 weeks, swelling of the bilateral ankle joints histologically showing synovial lining hyperplasia, severe chronic inflammation, erosion of the joint cartilage, and bone destruction with pannus formation began to develop in these env-pX rats. These histologic features resemble those of rheumatoid arthritis (RA) in man. High titered rheumatoid factors and low anti-dsDNA antibodies and hyper-gamma globulinemia were detected. Necrotizing arteritis resembling polyarteritis nodosa, polymyositis, myocarditis and Sjögren syndrome-like sialoadenitis developed, together with RA-like arthritis even in one individual animal. Thymic atrophy with low body weight was also observed. The evidence indicates that env-pX rats appear to be suitable animal models for elucidating pathogenetic mechanisms involved in not only HTLV-I related diseases but also various collegen vascular and autoimmune diseases of unknown etiology in man.

Neurologic abnormalities in the skeletal dysplasias: a clinical and radiological perspective

The neurologic manifestations of the skeletal dysplasias are reviewed. Three important major groups are identified: Achondroplasia (cranio-cervical junction problems in infancy, spinal stenosis and neurogenic claudication in the adult). Type II collagenopathies (upper cervical spine anatomic and functional problems), and craniotubular and sclerosing bone dysplasias (osseous overgrowth with foraminal obstruction problems). The remainder of the well-identified 150 or so bone dysplasias are also evaluated in depth for their diverse neurologic abnormalities. The findings discussed are important both for the diagnosis and management of these patients.

[A comparative study of pulmonary elasticity and diffusion through the alveolocapillary membrane in major collagenoses with lung involvement]

We studied 60 patients with collagen-vascular diseases with pulmonary manifestations (SLE-25; SSc-13; mixed connective tissue disease-12; RA-6; PD-DM-3; ankylosing spondylitis-1), 54 females and 6 males, mean age 42.4 +/- 9.9 years. We measured lung volumes (total lung capacity-TLC) by spirography (Flowscreen Jaeger) and body plethysmography (Bodyplethismograph Jaeger); compliance of the lungs (CL) and elastic recoil pressures at 100%, 80% and 70% TLC (PL,el 100%, 80%, 70% TLC) by the esophageal catheter method; diffusing capacity of the lungs by the single-breath method (DL,COSB) (Alveo-Diffusionstest Jaeger). DL,CO was diminished in 45 (75%) of cases. 11 patients (18.3%) had an increased elastic recoil, equally distributed between mild and severe decrease of DL,CO. Statistical significant correlations were found between TLC-DL,CO (r = 0.63; p < 0.001) and TL-CL (r = 0.49; p < 0.001). No correlations were found between DL,CO and PL,el 100, 80, 70% TLC. The results are expressed as percent of predicted value (% pred.). The mean values and standard deviation (X +/- sd) were calculated.

CONCLUSIONS

I) DL,CO is the most frequent altered pulmonary function test in collagen-vascular diseases with pulmonary manifestations; it seems to be a sensible parameter for diagnosing these diseases. 2) The alteration of DL,CO,CL and PL,el appears to be rather as a result of "shrinking lungs" due to respiratory muscle involvement than to an interstitial lung disease. 3) Elastic recoil pressures and compliance should be considered as routine pulmonary function test, important for the evaluation of treatment and prognosis.

Pediatric rheumatology clinic populations in the United States: results of a 3 year survey. Pediatric Rheumatology Database Research Group

OBJECTIVE

To describe the patient population referred to pediatric rheumatology centers (PRC) across the US 1992-95; and to compare these results to data on regional PRC populations.

METHODS

A Pediatric Rheumatology Disease Registry was established in 1992. Data on new patients seen at 25 PRC across the US were submitted to the registry for a 36 month period from 1992 through 1995.

RESULTS

A total of 12,939 patients were submitted to the registry. Of these patients, 5245 (40.5%) had rheumatological diagnoses. Patients with juvenile rheumatoid arthritis were the largest group of the patient population (2071 patients-16% of total diagnoses). There were 1568 patients with other forms of childhood arthritis (12%), 1172 with collagen vascular diseases (9%), and 434 with vasculitis (3.3%). Over 50% of the patients had nonrheumatologic diagnoses, including 1577 with idiopathic pain syndromes (12%). Other diagnoses included infections, orthopedic conditions, and malignancies. Fourteen percent of the patients were not given a diagnosis at the time of the initial visit.

CONCLUSION

PRC see a wide variety of patients. Although the majority do have rheumatologic conditions, over 50% of new patients have conditions not autoimmune in origin. Fourteen percent of the patients cannot be diagnosed at the time of their first clinic visit, requiring time to see the evolution of their symptoms before a definitive diagnosis can be assigned.

The connective tissue diseases and the overall influence of gender

The autoimmune diseases are more common in women than men. The actual prevalence ranges from the high of 10 to 15 females for each male for systemic lupus erythematosus to four females for every male with rheumatoid arthritis. Though these diseases are found in the very young and the aged, the high prevalence is observed after puberty in most patients. These diseases vary with regard to severity, and most investigators suspect that the signs and symptoms of these diseases vary with menstrual cycle and change severity during pregnancy. The collagen diseases are devastating to the health of young women. Rheumatoid arthritis occurring at a mean age of 40 years results in debilitating erosive changes in bone with morning stiffness and eventual crippling. Systemic lupus erythematosus, Sjögren's syndrome and others, common to women of the childbearing years, act in several ways to destroy organ systems of the body. Virtually any organ system of the female anatomy can be affected by these illnesses. In the case of lupus, the disease has protean manifestations, such as procoagulation, renal destruction, skin disease, unrelenting arthropathy and arthritis, and encephalopathy (to name only a few). The underlying mechanisms are not known; however, the immune system acts to destroy tissue via immune complex deposition and through the action of cytotoxic lymphocyte activity. There is an association of both clinical signs and autoantibody subpopulations with markers of the HLA-D or MHC II locus on chromosome 6. No constitutive gene for any of the collagen vascular diseases has been identified in the human. Evidence exists to support an altered metabolism of estrogens and androgens in patients with these diseases. Recent data also indicate that increased estrogen levels might initiate autoimmune diseases in many women and men. Estrogen hydroxylation is increased in both men and women with autoimmune diseases like lupus. The mechanisms are unknown, although estrogenic metabolites have been shown to increase B cell differentiation and activate T cells. Moreover, isolated cases of hyperprolactinemia have been observed in association with these hyperestrogenic states, and treatment of hyperprolactinemia has been shown to ameliorate diseases like lupus. Androgen oxidation is also increased in patients with autoimmune disease, but this abnormality has been observed only in patients with lupus, and only women at that. The result is that women with autoimmune diseases like lupus and rheumatoid arthritis have lower plasma androgens than control cases. These data have supported the use of weak androgens, e.g., DHEA, for the treatment of lupus.

[Pulmonary involvement of collagen vascular diseases: studies on prognostic factors from basic and clinical viewpoints]

In 715 patients with collagen vascular diseases, interstitial lung disease and pulmonary hypertension were found to be important causes of death (37.5% and 6%, respectively). The prognosis of interstitial lung disease associated with collagen vascular disease was better than that of idiopathic interstitial pneumonia; patients with the latter were more likely to experience exacerbations. A distinct subgroup of patients with dermatomyositis and interstitial lung disease with a rapidly progressive course was characterized by mild muscle symptoms, low levels of creatine phosphokinase and negative tests for anti-Jo-1 antibody. CT scores and analysis of bronchoalveolar lavage fluid proved to be of some value in predicting outcome. Measurement of IL-6 in bronchoalveolar lavage fluid and local immunostaining for this pro-inflammatory cytokine were helpful in evaluating responses to therapy.

Eosinophil activation in patients with pulmonary fibrosis

The eosinophil count and concentrations of eosinophil cationic protein (ECP) were measured in bronchoalveolar lavage fluid (BALF) from patients with idiopathic pulmonary fibrosis (IPF), pulmonary fibrosis associated with a collagen vascular disorder (PF-CVD), sarcoidosis, and healthy controls. The patients with IPF and PF-CVD showed significant increased eosinophil count and ECP levels in BALF compared with the controls. When the patients with IPF and PF-CVD were subclassified into chronic stable, progressive, and acute progressive subgroups in accordance with the observed progression of pulmonary dysfunction during the preceding 3- to 6-month period, those in the acute progressive subgroup showed significantly elevated recovered eosinophil count and ECP level, as well as recovered lymphocyte count and total protein, albumin, and type III procollagen aminoterminal peptide-related antigens (pIIIp) in BALF, compared with either of the other two subgroups. Multivariate stepwise logistic regression analysis revealed that, among these variables, only ECP and pIIIp significantly contributed to discrimination among the three subgroups differing in disease activity. These findings suggest that eosinophils are involved in the inflammatory process in pulmonary fibrosis and that the released ECP and other cytotoxic eosinophil products may contribute to the lung injury and development of fibrosis.

[Dysfunction of the posterior tibial muscle due to tendon insufficiency]

The mechanical integrity of the arch of the foot depends on static and dynamic factors. The posterior tibial tendon in particular is situated to provide dynamic support along the medioplantar aspect of the foot and arch. Tibialis posterior dysfunction is a progressive condition leading to a painful flatfoot deformity. To understand changes that occur in the pathological state, a clear analysis of the normal function of the tibialis posterior is necessary. Early diagnosis of posterior tibialis dysfunction is crucial for preventing a progressive deformity. For diagnosis, clinical findings are predominant. When passive correction of the foot deformity is still possible, a reconstruction of the tendon should be attempted. As retraction of the tendon ends or degeneration prevents primary repair, tendon transfer may substitute for the posterior tibial tendon. When a fixed flatfoot has developed, realignment by arthrodesis is advised. Triple arthrodesis may be appropriate to correct hindfoot valgus as well as forefoot abduction.

[The Achilles tendon in sports]

Achillodynia is a generic term for various types of ailments in the region of the Achilles tendon. For adequate therapy a specific diagnosis is absolutely necessary. Besides an accurate anamnesis and the right choice of terrain and shoes, as well as a clinical examination where one has to specifically keep an eye on muscular imbalance between the gastrocnemius and the soleus muscle and disorders of the ligamentous control of the calcaneus caused by fibular ligament instabilities, a procedure such as radiology, ultrasound, and MR imaging is inevitable. From the differential diagnosis point of view a distinction between peritendinitis, mechanically triggered bursitis (calcaneal and subachilles), bony alterations of the calcaneus (calcaneus spur, Haglund exostosis persistent nucleus of the apophysis, fatigue fracture, etc) and a partial or total rupture (a one-time occurrence or multiple occurrences) has to be made. Occasionally, entrapment of the ramus calcaneus of the sural nerve causes calcaneal pain. If clinically not confirmed, lumbar pain ought to be taken into consideration (discopathy, Bechterew disease, etc). Metabolic disorders (especially uric acid) and underlying rheumatic diseases must be excluded. The therapy of achillodynia includes local and peroral antiphlogistic medication as a concomitant measure. More important is the causal influence of etiological factors, i.e., the correction of muscular imbalance, ensuring control of the calcaneus through bandages and adjustment of sport shoes, changes in training buildup and exercise intensity, just to mention a few. If necessary, surgically splitting the peritendineum, sanitation of a partial rupture, bursectomy and removal of mechanically obstructive exostosis must be done.

[Spontaneous tendon ruptures. Etiology, pathogenesis and therapy]

Spontaneous tendon ruptures are ascribed to recurrent microtrauma resulting from continuous mechanical loading in a critical zone, to muscular imbalance combined with poor coordination as a result of inappropriate training, and also to deteriorating circulation with increasing age. Ruptures of the rotator cuff occur more frequently with increasing age, and the size of the rupture also correlates with age. The frequency of the complaint in men, the predominant involvement of the dominant shoulder, and also the above-average occurrence in occupations involving strenuous physical work indicate that degenerative change plays a role. In about 50% of patients presenting with a ruptured rotator cuff, the genesis is clearly traumatic. A trauma will almost always be the cause of an isolated rupture of the subscapularis tendon. The choice of reconstruction technique for a ruptured rotator cuff depends on the patient's age and level of activity in daily life. In the case of young patients, further surgical measures to repair the defect are indicated following failure of primary suture of the tendon, but in older patients subacromial debridement alone is considered the appropriate procedure. Rupture of the long head of the biceps tendon is usually a sequela of a rotator cuff rupture and the resulting loss of protective cover. Isolated ruptures of the long head of the biceps tendon are much rarer. They tend to occur in middle-aged patients and are usually the result of a relatively minor trauma. Ruptures of the distal biceps tendon are also relatively rare (3%) and are always of traumatic origin. There is no absolute indication for surgical intervention for a ruptured long head of the biceps tendon. Surgical repair is essential in the case of rupture of the distal biceps tendon. Transosseous reinsertion at the tuberosity of the radius is the recommended method of repair. Today's frequent cases of rupture of the Achilles tendon in the framework of sports activities are ascribed to inappropriate training procedures in combination with poor muscular coordination. An exogenous cause is the administration of local injections for pain relief in the form of a so-called tendon anesthetic. Today an increasingly important role is assigned to functional therapy with ultrasound support, although suturing the tendon is still the intervention of choice to meet the high functional demands imposed in the framework of top-level sports.(ABSTRACT TRUNCATED AT 400 WORDS)

Collagenous colitis

Collagenous colitis is characterized clinically by chronic watery diarrhea and pathologically by colonic mucosal subepithelial collagen deposition. We report a 72-year-old woman who had collagenous colitis associated with chronic watery diarrhea. She received a non-steroidal anti-inflammatory agent (sulindac) because of rheumatoid arthritis. Histological examination of biopsy showed a thick subepithelial collagen layer with lymphocytes, plasma cells, and infiltration of a few eosinocytes in the lamina propria. These findings led to the diagnosis of collagenous colitis. After treatment with salazosulfapyridine, her bowel movement became normalized and mucosal subepithelial collagen deposition disappeared.

Cardiac involvement in collagen diseases

The purpose of this study is to evaluate the early morphological and functional abnormalities of the heart in patients with collagen disease. The study population was free of risk factors for coronary artery disease and without any clinically evident cardiac manifestations. In 62 patients with collagen disease (25 with progressive systemic sclerosis, 19 with systemic lupus erythematosus, 15 with rheumatoid arthritis, three with dermatomyositis) and in 40 healthy subjects an echocardiographic study was performed. Echocardiographic examination from the apical four-chamber view was performed at rest and during the end of a 3 min isometric exercise with handgrip. Global and regional ejection fraction of the left ventricle were calculated. In the group with progressive systemic sclerosis the left ventricular mass index was significantly higher than in the control group (110.78 +/- 48.61 vs 82.18 +/- 28.46 g.m-2) and the ejection fraction (53.61 +/- 7.95%) was the lowest of all groups (control: 61.47 +/- 8.52%, systemic lupus erythematosus: 59.04 +/- 8.58%, rheumatoid arthritis: 62.38 +/- 6.88%). Regional ejection fraction analysis revealed a major dysfunction of the proximal segment of the interventricular septum, in all groups. During isometric exercise, the global and regional ejection fraction did not change significantly, although differences between groups disappeared. In rheumatoid arthritis, mitral and aortic valve leaflet separation appeared to be reduced. In the group with systemic lupus erythematosus, mild abnormalities were noticed, although the mean age and duration of the disease were the smallest compared with the other groups. In conclusion, patients with progressive systemic sclerosis mainly present left ventricular hypertrophy with a reduced ejection fraction while rheumatoid arthritis patients show a predominant valve dysfunction.(ABSTRACT TRUNCATED AT 250 WORDS)

Fibroelastolytic patterns of intrinsic skin aging: pseudoxanthoma-elasticum-like papillary dermal elastolysis and white fibrous papulosis of the neck

BACKGROUND

Cutaneous aging is due to intrinsic and extrinsic factors. While the pathologic hallmark of extrinsic aging (photoaging) is solar elastosis, intrinsic aging lacks any specific feature. Only a progressive thinning and loss of the dermal elastic network occasionally associated with focal thickening of the collagen bundles may be observed. In contrast to the different clinical patterns of solar elastosis, only one distinctive disorder has been related so far to intrinsic aging: the temporary wrinkles.

OBJECTIVE

Pseudoxanthoma-elasticum-like papillary dermal elastolysis (PDE) and white fibrous papulosis of the neck (WFP) are further clincopathologic patterns of intrinsic aging.

MATERIAL AND METHODS

Review of the literature and clinical and histologic studies of patients of our files.

RESULTS

PDE and WFP share some peculiar clinical and histologic features, namely their occurrence in late adulthood and thinning or loss of the elastic fibers, mainly in the papillary dermis. Moreover, elastolysis in PDE and focal fibrosis in WFP, along with the abnormal elastic fibers, immature elastogenesis and activation of fibroblasts observed in PDE, are quite similar to the changes described in intrinsic aging.

CONCLUSIONS

PDE and WFP along with temporary wrinkles and some cases of noninflammatory middermal elastolysis could be classified as 'age-related fibroelastolytic syndromes'.

Can interstitial pneumonia as the sole presentation of collagen vascular diseases be differentiated from idiopathic interstitial pneumonia?

We prospectively followed 68 patients diagnosed as idiopathic interstitial pneumonia (IIP) over a period of 1-11 years. Thirteen patients (19%) subsequently developed systemic manifestations of collagen vascular diseases (CVD) and were diagnosed as having had interstitial pneumonia as the sole presentation of CVD (CVD-IP). Compared with the 55 IIP patients, the 13 CVD-IP patients were relatively younger, predominantly female, and had a lower incidence of dust inhalation in their history. They also had a higher erythrocyte sedimentation rate, higher incidence of the x-ray finding of discoid atelectasis in the lower lung fields, and a better prognosis than the IIP patients. However, these features did not clearly distinguish the two groups. We conclude that the patients clinically and/or histologically defined as suffering from IIP cannot be distinguished from CVD-IP patients before systemic signs of CVD appear in the latter group.

Lung function in patients with collagen vascular diseases: a study of non-smokers with normal chest roentgenograms

Lung function was assessed in 52 patients with collagen vascular diseases (CVD) who had neither a smoking history nor an abnormality in their chest x-ray films. Values of the maximum mid-expiratory flow and the maximum expiratory flow after 50% or 75% of the forced vital capacity had been exhaled were decreased and the ratio of closing capacity to total lung capacity was increased in 36-100% (varied among categories of CVD) of patients with CVD, and the carbon monoxide diffusing capacity was decreased in 27-56% of the patients. These findings indicate that small airway diseases and a decrease in diffusing capacity are not rare in CVD patients, even if they had neither a smoking history nor abnormal findings in their chest x-ray films. Regular and routine tests on lung functions are thought to be effective to detect early pulmonary involvement in patients with CVD.