Scleroderma

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

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Synonyms and keywords: Systemic sclerosis

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Overview

Epidemiology

Pathophysiology

Etiology

Types of Scleroderma

Diagnosis

Diagnosis is by clinical suspicion, presence of autoantibodies (specifically anti-centromere and anti-scl70/anti-topoisomerase antibodies) and occasionally by biopsy. Of the antibodies, 90% have a detectable anti-nuclear antibody. Anti-centromere antibody is more common in the limited form (80-90%) than in the systemic form (10%), and anti-scl70 is more common in the diffuse form (30-40%) and in African-American patients (who are more susceptible to the systemic form).[1]

In 1980 the American College of Rheumatology agreed upon diagnostic criteria for scleroderma.[2]

Diffuse scleroderma can cause musculoskeletal, pulmonary, gastrointestinal, renal and other complications.[3]Patients with larger amounts of cutaneous involvement are more likely to have involvement of the internal tissues and organs.

Cardiovascular Symptoms

Skin Symptoms

Musculoskeletal System Related Symptoms

Image courtesy of RadsWiki

Respiratory System Symptoms

Gastrointestinal System Related Symptoms

Diffuse scleroderma can affect any part of the gastrointestinal tract.[4] The most common manifestation in the esophagus is reflux esophagitis, which may be complicated by peptic stricturing, or benign narrowing of the esophagus.[5] This is best initially treated with proton pump inhibitors for acid suppression,[6] but may require bougie dilatation in the case of stricture.[4]

Scleroderma can decrease motility anywhere in the gastrointestinal tract.[4] The most common source of decreased motility involvement is the esophagus and the lower esophageal sphincter, leading to dysphagia and chest pain. As Scleroderma progresses, esophageal involvement from abnormalities in decreased motility may worsen due to progressive fibrosis (scarring). If this is left untreated, acid from the stomach can back up into the esophagus causing esophagitis, and GERD. Further scarring from acid damage to the lower esophagus many times leads to the development of fibrotic narrowing, also known as strictures which can be treated by dilatation, and Barrett's esophagus. The small intestine can also become involved, leading to bacterial overgrowth and malabsorption, of bile salts, fats, carbohydrates, proteins, and vitamins. The colon can be involved, and can cause pseudo-obstruction or ischemic colitis.[3]

Rarer complications include pneumatosis cystoides intestinalis, or gas pockets in the bowel wall, wide mouthed diverticula in the colon and esophagus, and liver fibrosis. Patients with severe gastrointestinal involvement can become profoundly malnourished.[5]

Scleroderma may also be associated with gastric antral vascular ectasia (GAVE), also known as watermelon stomach. This is a condition where atypical blood vessels proliferate usually in a radially symmetric pattern around the pylorus of the stomach. GAVE can be a cause of upper gastrointestinal bleeding or iron deficiency anemia in patients with scleroderma.[5]


Renal Symptoms

Renal involvement, in scleroderma, is considered a poor prognostic factor and not infrequently a cause of death in patients with scleroderma.[7]

The most important clinical complication of scleroderma involving the kidney is scleroderma renal crisis. Symptoms of scleroderma renal crisis are malignant hypertension (high blood pressure with evidence of acute organ damage), hyperreninemia (high renin levels), azotemia (kidney failure with accumulation of waste products in the blood) and microangiopathic hemolytic anemia (destruction of red blood cells).[8] Apart from the high blood pressure, hematuria (blood in the urine) and proteinuria (protein loss in the urine) may be indicative.[9]

In the past scleroderma renal crisis was almost uniformily fatal.[10] While outcomes have improved significantly with the use of ACE inhibitors[11][12] the prognosis is often guarded, as a significant number of patients are refractory to treatment and develop renal failure. Approximately 10% of all scleroderma patients develop renal crisis at some point in the course of their disease.[13] Patients that have rapid skin involvement have the highest risk of renal complications.[13]

Therapy

There is no cure for every patient with scleroderma, though there is treatment for some of the symptoms, including drugs that soften the skin and reduce inflammation. Some patients may benefit from exposure to heat.[14]

Digital ulcerations and pulmonary hypertension can be helped by prostacyclin (iloprost) infusion. Iloprost being a drug which increases blood flow by relaxing the arterial wall.[15]

Topical/symptomatic

Topical treatment for the skin changes of scleroderma do not alter the disease course, but may improve pain and ulceration. A range of NSAIDs (nonsteroidal anti-inflammatory drugs) can be used to ease painful symptoms, such as naproxen. There is limited benefit from steroids such as prednisone. Episodes of Raynaud's phenomenon sometimes respond to nifedipine or other calcium channel blockers; severe digital ulceration may respond to prostacyclin analogue iloprost, and the dual endothelin-receptor antagonist bosentan may be beneficial for Raynaud's phenomenon.[16] The skin tightness may be treated systemically with methotrexate and cyclosporin.[16] If there is esophageal dysmotility (in CREST or systemic sclerosis), care must be taken with NSAIDs as they are gastric irritants, and so a proton pump inhibitor (PPI) such as omeprazole can be given in conjunction.

Kidney disease

Scleroderma renal crisis, the occurrence of acute renal failure and malignant hypertension (very high blood pressure with evidence of organ damage) in people with scleroderma, is effectively treated with drugs from the class of the ACE inhibitors. The benefit of ACE inhibitors extends even to those who have to commence dialysis to treat their kidney disease, and may give sufficient benefit to allow the discontinuation of renal replacement therapy.[16] ACE inhibitors are also used for prophylaxis,[13][12] and renal transplantation. Transplanted kidneys are known to be affected by scleroderma and patients with early onset renal disease (within one year of the scleroderma diagnosis) are thought to have the highest risk for recurrence.[17]

Lung disease and pulmonary hypertension

Active alveolitis is often treated with pulses of cyclophosphamide, often together with a small dose of steroids. The benefit of this intervention is modest.[18][19]

Pulmonary hypertension may be treated with epoprostenol, bosentan and possibly aerolized iloprost.[16]

Experimental treatments

Given the difficulty in treating scleroderma, treatments with a smaller evidence base are often tried to control the disease. These include antithymocyte globulin and mycophenolate mofetil; some reports have reported improvements in the skin symptoms as well as delaying the progress of systemic disease, but neither of them have been subjected to large clinical trials.[16]

While still experimental (given its high rate of complications), hematopoietic stem cell transplantation is being studied in patients with severe systemic sclerosis; improvement in life expectancy and severity of skin changes has been noted.[20]

Case Examples

Case #1

Clinical Summary

A 29-year-old black female had a history of scleroderma involving the lung, kidney, heart, and skin. Her main clinical problems centered on her restrictive lung disease. She was able to live at home with supplemental oxygen but recently she had developed edema, chest pain, weakness, lightheadedness, and a loss of appetite. The patient was admitted to the hospital with a working diagnosis of congestive heart failure brought on by her lung disease.

Echocardiographic evaluation revealed a pericardial effusion that was tapped. Soon after this procedure her respiratory status degenerated and she required intubation. Despite aggressive supportive treatment for her cardiac and pulmonary problems, she could not be weaned from the ventilator. Two weeks after admission she became febrile and Gram positive cocci were isolated from sputum culture. She was placed on antibiotics but her condition deteriorated and she developed bradycardia followed by electromechanical dissociation (EMD).

Autopsy Findings

Upon opening the thorax there was 600 cc of cloudy serous fluid in each hemithorax and 100 cc of similar fluid in the pericardial sac. The heart weighed 530 grams and there was thickening of both the left and right ventricular walls. The liver weighed 1880 grams and was congested. The spleen weighed 200 grams and was also congested. The combined lung weight was 1875 grams; the lungs were markedly fibrotic with severe emphysema. In addition, dermal thickening was evident throughout the body and the wall of the esophagus was thickened and firm.

Histopathological Findings

Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology

This is a gross photograph of cut section of the lungs from this patient. Note the extensive fibrosis of the lung parenchyma.


This is a gross photograph of a cut section of one lung from this patient. Note the extensive fibrosis lower lobe (arrows).


This is a closer view of the cut section of lung from this patient. Note the extensive fibrosis and the severe emphysematous changes.


This is a closer view of the cut section of lung from this patient showing the extensive fibrosis and the severe emphysematous change.


This is a gross photograph of the heart from this case. There is thickening of the left ventricular wall and some thickening of the right ventricle as well.


References

  1. Jimenez SA, Derk CT (2004). "Following the molecular pathways toward an understanding of the pathogenesis of systemic sclerosis". Ann. Intern. Med. 140 (1): 37–50. PMID 14706971.
  2. "Preliminary criteria for the classification of systemic sclerosis (scleroderma). Subcommittee for scleroderma criteria of the American Rheumatism Association Diagnostic and Therapeutic Criteria Committee". Arthritis Rheum. 23 (5): 581–90. PMID 7378088. Text "year:1980 " ignored (help) Available online at "Criteria for the Classification of Systemic Sclerosis 1980". Text " accessdate:5 August 2007" ignored (help)
  3. 3.0 3.1
  4. 4.0 4.1 4.2 Sallam H, McNearney TA, Chen JD (2006). "Systematic review: pathophysiology and management of gastrointestinal dysmotility in systemic sclerosis (scleroderma)". Aliment. Pharmacol. Ther. 23 (6): 691–712. doi:10.1111/j.1365-2036.2006.02804.x. PMID 16556171.
  5. 5.0 5.1 5.2 Rose S, Young MA, Reynolds JC (1998). "Gastrointestinal manifestations of scleroderma". Gastroenterol. Clin. North Am. 27 (3): 563–94. PMID 9891698.
  6. Hendel L, Hage E, Hendel J, Stentoft P (1992). "Omeprazole in the long-term treatment of severe gastro-oesophageal reflux disease in patients with systemic sclerosis". Aliment. Pharmacol. Ther. 6 (5): 565–77. PMID 1420748.
  7. Ruangjutipopan S, Kasitanon N, Louthrenoo W, Sukitawut W, Wichainun R (2002). "Causes of death and poor survival prognostic factors in thai patients with systemic sclerosis". Journal of the Medical Association of Thailand. 85 (11): 1204–9. PMID 12546318.
  8. Steen VD, Mayes MD, Merkel PA (2003). "Assessment of kidney involvement". Clin. Exp. Rheumatol. 21 (3 Suppl 29): S29–31. PMID 12889219.
  9. Steen VD (1994). "Renal involvement in systemic sclerosis". Clin. Dermatol. 12 (2): 253–8. PMID 8076263.
  10. Steen VD (2003). "Scleroderma renal crisis". Rheum. Dis. Clin. North Am. 29 (2): 315–33. PMID 12841297.
  11. Rhew EY, Barr WG (2004). "Scleroderma renal crisis: new insights and developments". Current rheumatology reports. 6 (2): 129–36. PMID 15016343.
  12. 12.0 12.1 Steen VD, Medsger TA (2000). "Long-term outcomes of scleroderma renal crisis". Ann. Intern. Med. 133 (8): 600–3. PMID 11033587.
  13. 13.0 13.1 13.2 Jimenez S, Koenig AS. Scleroderma. eMedicine.com. Accessed: May 22, 2006.
  14. Oliver GF, Winkelmann RK (1989). "The current treatment of scleroderma". Drugs. 37 (1): 87–96. PMID 2651089.
  15. Zandman-Goddard G, Tweezer-Zaks N, Shoenfeld Y (2005). "New therapeutic strategies for systemic sclerosis--a critical analysis of the literature". Clin. Dev. Immunol. 12 (3): 165–73. PMID 16295521.
  16. 16.0 16.1 16.2 16.3 16.4 Zandman-Goddard G, Tweezer-Zaks N, Shoenfeld Y (2005). "New therapeutic strategies for systemic sclerosis--a critical analysis of the literature". Clin. Dev. Immunol. 12 (3): 165–73. PMID 16295521. PMC 2275417
  17. Pham PT, Pham PC, Danovitch GM, Gritsch HA, Singer J, Wallace WD, Hayashi R, Wilkinson AH. Predictors and risk factors for recurrent scleroderma renal crisis in the kidney allograft: case report and review of the literature. Am J Transplant. 2005 Oct;5(10):2565-9. PMID 16162209.
  18. Tashkin DP, Elashoff R, Clements PJ; et al. (2006). "Cyclophosphamide versus placebo in scleroderma lung disease". N. Engl. J. Med. 354 (25): 2655–66. doi:10.1056/NEJMoa055120. PMID 16790698. Unknown parameter |month= ignored (help)
  19. Hoyles RK, Ellis RW, Wellsbury J; et al. (2006). "A multicenter, prospective, randomized, double-blind, placebo-controlled trial of corticosteroids and intravenous cyclophosphamide followed by oral azathioprine for the treatment of pulmonary fibrosis in scleroderma". Arthritis Rheum. 54 (12): 3962–70. doi:10.1002/art.22204. PMID 17133610. Unknown parameter |month= ignored (help)
  20. Nash RA, McSweeney PA, Crofford LJ; et al. (2007). "High-dose immunosuppressive therapy and autologous hematopoietic cell transplantation for severe systemic sclerosis: long-term follow-up of the U.S. multicenter pilot study". Blood. 110 (4): 1388–96. doi:10.1182/blood-2007-02-072389. PMID 17452515.

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