Systemic Sclerosis

Pro.Ali Alkazzaz

2017

Babylon collge of medicine

Systemic Sclerosis

• Multisystem disorder

• Unknown etiology

• Thickening of skin caused by accumulation of connective tissue (collagen types I and III)

• Involvement of visceral organs

Epidemiology

• Peak age range: 35-64• Younger age in women and with diffuse disease.

• Female:Male = 3:1

• Incidence: 20/million per year in US

• Prevalence: 240/million in US.

Etiology

• Unknown

• Environmental Exposures• Silica exposure in men conferred increased risk

• Silicone breast implants: no definite risk identified

• Aniline laced Contaminated rapseed oil in Spain

• Vinyl chloride exposure increased risk of SSc like disorder: Eosinophilic Fasciitis

• Bleomycin therapy

• L-tryptophan: Eosinophilia Myalgia syndrome

Etiology

• Genetic Factors• Familial Clustering: 1.5-2.5% of those with 1st degree

relative

• HLA-haplotypes: there are higher risk haplotypes in certain populations

Pathogenesis: general principles

• Endogenous or exogenous pathogen stimulates antigen presenting cells.

• Antigen presenting cells stimulate CD4+ T cells• Cytokines are produced by both of these cells.• Cytokines stimulate growth factors to stimulate fibroblasts

to produce collagen• Vascular damage occurs with thickened intima and

narrowing of the lumen. • Narrowing of the lumen leads to ischemia. • Ischemia leads to prostacyclin production which is a

platelet aggregant and platelets bind to endothelium and release PDGF which is chemotactic and mitogenic for fibroblasts.

Pathogenesis

Pathogenesis of Scleroderma

Up to Date

Forms of Systemic Sclerosis

• Limited Scleroderma• Skin thickening is distal to elbows and knees, not involving

trunk• Can involve perioral skin thickening (pursing of lips)• Less organ involvement• Seen in CREST syndrome• Isolated pulmonary hypertension can occur

• Diffuse Scleroderma• Skin thickening proximal to elbows and knees, involving the

trunk• More likely to have organ involvement• Pulmonary fibrosis and Renal Crisis are more common.

2013 ACR Diagnostic Criteria

Limited Scleroderma

• More gradual process• Can have Raynaud’s for years (even up to decade)

• Skin involvement distal to elbows and knees• Often with perioral involvement (pursing of lips)

• Capillaroscopy • with dilated capillary loops but without dropout.

• Less organ involvement• though 10-15% with isolated pulmonary hypertension.

• Renal involvement is rare.

• Anti-centromere Ab in 70-80%

Limited Scleroderma

• CREST Syndrome• Calcinosis

• Raynaud’s

• Esophageal Dysmotility

• Sclerodactyly

• Telangiectasisa

A.D.A.M. Images

CREST Syndrome

ACR and Mayo Foundation

Calcinosis on x-ray

Gupta E., et al. Malaysian Family Physician. 2008;3(3):xx-xx ACR

Nailfold Capillaroscopy

Diffuse Scleroderma

• More Rapid Process• Often with onset of skin thickening within a year of

Raynaud’s symptoms

• Skin involvement proximal to elbows and knees• Often can involve the trunk

• Capillaroscopy reveals dropout• With capillary dilatation and dropout.

• Early organ involvement• Renal, interstitial lung disease, myocardial, diffuse

gastrointestinal – often within the first 3 years.

• Antibodies• Anti-Scl-70, anti-RNA Polymerase III.

Diffuse Scleroderma

ACR

American Osteopathic College of Dermatology, Grand Rounds

Netter

Organs Involved

• Skin

• Musculoskeletal

• Pulmonary

• Renal

• Gastrointestinal

• Cardiac

Skin Involvement

• Early stages:• Perivascular infiltrate which are primarily T cells.• Skin swelling which eventually becomes skin thickening.• Involves the hands and/or feet (distal).

• Late Stages: • Finger-like projections of collagen extend from the dermis to

the subcutaneous tissue to anchor skin deeper. • Skin becomes firm, thick and tight. • Skin thickening moves proximally. • Fibroblasts and collagen deposition. • Hair and wrinkles overlying area of skin thickening

disappears.

Skin involvement in Scleroderma

• May regress on its own over years• reverse pattern (ie, starting with regression of skin

thickening in the trunk, then proximal extremities, then more distal).

• Digital Ulcers: • on extensor surface of PIP’s and elbows; may become

secondarily infected.

• Digital ischemia: • with pits in the distal aspect of the digits related to

prolonged Raynaud’s.

• Thinning of the lips, beak-like nose.

Skin Manifestations

Kahaleh B. Rheum Dis Clin N Amer 2008:57-71

Sclero.orgInternational Scleroderma Network

ACR

Musculoskeletal

• Arthritis • in > 50% with swelling, stiffness, and pain in the joints

of the hands.

• Carpal Tunnel Syndrome.

• Contractures • related to skin thickening.

• Polymyositis • may occur as part of mixed connective tissue disease or

overlap.

Pulmonary

• leading cause of death • since we are better at control of renal disease.

• Symptoms: • exertional dyspnea

• Types of lung Involvement:• Interstitial lung disease.

• Isolated pulmonary hypertension.

Interstitial Lung Disease

• Inflammatory phase• with ground glass opacities and linear infiltrates • lower 2/3 of the lung fields on CT scan.

• Fibrosis: • Late phase with honeycombing.

• Diagnosis– Pulmonary function tests

• restrictive pattern with low FVC, low residual volume, low DLCO.

– High Resolution CT Scan– BAL: often not required– Lung biopsy: often not required

• ILD is most commonly associated with diffuse scleroderma.• Anti-Scl-70

Interstitial Lung Disease

Up to Date 2005 Up to Date 2005

Primary Pulmonary Hypertension

• Symptoms:• exertional dyspnea.

• Frequency• 10-15% of patients with systemic sclerosis

• Definition: • Mean PA blood pressure >25mmHg at rest or >30mmHg with

exercise on right heart catheterization.• Estimated systolic pulmonary artery pressure of >35mmHg

on Echocardiogram

• Pathogenesis• Intimal fibrosis and medial hypertrophy of the pulmonary

arterioles and arteries.

Pulmonary Hypertension

Up to Date 2005

Doppler Echocardiogram to estimate pulmonary artery pressure. Roberts JD. Pulm Circ 2011;1:160-181.

Other Pulmonary Associations

• Pneumonia: • due to aspiration secondary to GERD; skin thickening of

chest may reduce effectiveness of cough.

• Alveolar carcinoma: increased incidence

• Bronchogenic carcinoma: increased incidence.

Renal Manifestations of Systemic Sclerosis

• Scleroderma Renal Crisis• Abruptly developing severe hypertension

– Rise in SBP by > 30 mmHg, DBP by > 20 mm Hg

• One of the following: – Increase in serum creatinine by 50% over baseline or creatinine > 120%

of upper limit.

– Proteinuria > 2+ by dipstick.

– Hematuria > 2+ by dipstick or > 10 RBC/HPF

– Thrombocytopenia < 100

– Hemolysis (schisctocytes, low platelets, increased reticulocyte count).

• Can cause headache, encephalopathy, seizures, LV failure.

• 90% with blood pressure > 150/90.

• Can occur also with lower blood pressures < 140/90 and this confers worse prognosis.

Steen et al., ClinExp. Rheumatol. 2003

Scleroderma Renal Crisis

Up to Date 2012

Risk Factors for Renal Crisis

• Rapidly progressive skin thickening within the first 2-3 years.

• Steroid use (prednisone > 15 mg)

• Anti-polymerase III Ab.

• Pericardial Effusion.

Treatment of Scleroderma Renal Crisis

• Medical Emergency: generally with admission.

• Initiation of ACE inhibitors such as captopril; lifelong treatment with ACE inhibitors.

• Dose escalation of captopril.

Treatment of Scleroderma Renal Crisis

Steen, Clinics in Dermatology, 1994

Without

Renal Crisis - Prognosis

• Improved overall with ACE-inhibitors.

• Even with ACE-inhibitors 20-50% will progress to ESRD.

• Among patients who required dialysis during the acute phase, an appreciable proportion (40-50%) will be able to discontinue dialysis.

Gastrointestinal Manifestations

• Esophageal dysmotility: in up to 90%. • Pathophysiology:

– reduced tone of gastroesophageal sphincter and distal dilatation of the esophagus.

– Lamina propia and submucosal tissue with Inflammatory changes and increased collagen on pathology.

• Symptoms– Dysphagia, GERD; many asymptomatic.

• Diagnosis:– Esophageal manometry, Esophagram, CT scan.

• Treatment– Proton Pump Inhibitors– Elevation of head of the bed.

• Complications:– Barret’s Esophagus.

Gastrointestinal Manifestations

• Gastric Involvement:• Symptoms: Early satiety. • Diagnosis: Nuclear Gastric Emptying Test. • Treatment: promotility agents• Watermelon Stomach: dilated vessel which can cause bleeding.

• Small Intestinal involvement• Symptoms: distension, pain, bloating, steatorrhea• nutritional deficiencies secondary to bacterial overgrowth.

» Vitamin B6/B12/folate/25-OH Vit D, low albumin

• Diagnosis: – glucose hydrogen breath test– Low D-xylose absorption test – small bowel aspiration (only if resistance to rotating antibiotics)

• Treatment: Rotating antibiotics, Reglan, Erythromycin

Image of Watermelon Stomach: University of Michigan Rheumatology Website

Gastrointestinal Manifestations

• Colon Involvement: • Can cause symptoms of constipation due to decreased

peristalsis.

• Fecal incontinence can occur due to alterations of internal and external sphincter.

Cardiac Manifestations

• Forms of cardiac involvement

• Pericardial Effusion– symptomatic pericarditis in 20%

• Microvascular CAD:– recurrent vasospasm of coronary arteries – Necrosis– patchy myocardial fibrosis; leads to diastolic > systolic

dysfunction.

• Myocarditis– Inflammation which leads to fibrosis

• Arrhythmias and conduction abnormalities– Fibrosis of cardiac conduction system. – AV conduction defects and arrhythmias.

Cardiac Involvement

Adapted from Desai, et al; Curr Opin Rheumatol 2011m 23:545-554

Cardiac Manifestation Prevalence Diagnosis Treatment

Myocarditis Rare Cardiac MRI, Biopsy Cytoxan + steroids

Pericardial effusion 5-16% Echocardiogram None; NSAIDs if symptomatic

Microvascular CAD > 60% MRI/nuclear medicine Calcium channel blockers

Macrovascular CAD 25% Coronary Angiogram Stenting/medical tx

Bradyarrhythmias Rare EKG/Holter Pacemaker

Tachyarrhythmias 15% EKG/Holter Diltiazem, ablation,defibrillator

Scleroderma AutoantibodiesAntigen ANA

PatternFrequency Clinical

AssociationsOrgans Involved

Scl-70(topoisomerase 1)

Speckled 10-40 dcSSC Lung fibrosis

RNA Polymerase III Speck/Nuc 4-25 dcSSC Renal, Pulmonary HTN

Centromere Centromere 15-40 lcSSc, CREST Pulmonary HTNEsophageal

U1-RNP Speckled 5-35 lcSSC, MCTD Muscle

U3 RNP (fibrillarin) Nucleolar 1-5 dcSSC, poor prognosis MusclePulmonary HTN

PM-SCL Nucleolar 3-6 Overlap, mixed Muscle

Th/To Nucleolar 1-7 lcSSc Pulmonary HTN,Lung fibrosis,Small bowel

Anti U11/U12 Nucleolar 1-5 lcSSc & dcSSC Lung Fibrosis

Anti-Ku 1-3 Overlap Ssc Muscle, Joint, SLE overlap

Adapted from: Nihtyanova SI, Denton CP. Nat Rev Rheumatol 2010; 6:112

Scleroderma Treatment

• Depends on clinical manifestations• Aggressive disease versus stable disease

• Reversible inflammation vs Vasoconstriction.

• Organ Involvement• Treatment is directed at organ involved.

Raynaud’s

• Calcium Channel Blockers: nifedipine

• Nitroglycerin patches

• Sildenafil (Viagra) (but not in combination with nitroglycerine) –usually for refractory Raynaud’s.

• Parental vasodilators (iloprost) – for severe disease with impending digital ischemia.

Gastrointestinal Involvement

• GERD• Proton pump inhibitor.

• Delayed Gastric Emptying and peristalis disorders

• Supportive

• Promotilants are sometimes used.

Pulmonary Involvement

• Interstitial Lung Disease: with active inflammation

• Mycophenolate

• Azithioprine

• Cytoxan - IV

• plus lower dose of steroids if RNA Poly III neg (ie 10 mg daily); avoid steroids if RNA Poly III positive.

• Pulmonary Hypertension• Vasodilators: bosentan, sildenafil, epoprostenol,

treprostinil, iloprost.

• Lung Heart Transplant

Myositis

• Polymyositis overlap or MCTD• Similarly to myositis alone with methotrexate,

azathioprine in combination of low dose steroids.

• Tend to keep prednisone dose at around 10 mg or less to avoid risk of renal crisis.

Cardiac Involvement

• Pericarditis: • NSAIDs

• Drainage of effusion if tamponade

• Myocarditis with elevated CK-MB & troponin• If CAD is excluded, MRI and biopsy confirms, then

treatment would generally be with low dose prednisone (10 mg/day) and cytoxan; nifedipine may also be helpful.

Skin Disease

• Stable disease: no treatment

• Advancing diffuse skin involvement:• Methotrexate

• Mycophenolate

• Current trial with Tocilizumab (Actemra)

• D-penicillamine 125 mg/day.

• Research on various anti-fibrosis therapies is being performed (imatinib, Gleevac).

Differential Diagnosis

• Scleredema• No Raynauds, negative antibodies, seen in IDDM• Proximal skin thickening (trunk, shoulders, back)

• Scleromyxedema• Skin thickening/induration on head, neck, arms, trunk• Monoclonal gammopathy (multiple myeloma/AL amyloid)• Skin biopsy differentiates.

• Endocrinologic: diabetes and hypothyroid myxedema• Can be associated with skin induration. • In diabetes can have sclerodactyly (Diabetic Cheiroarthropathy) - dorsal• POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, skin thickening).

• Nephrogenic Systemic fibrosis• Chronic kidney disease and gadolinium MRI contrast• Can involve hands and feet.

• Eosinophilic fasciitis: • Hands and feet are spared, peripheral blood eosinophilia, peau de orange appearance• Diagnosis is via skin biopsy.

• Graft versus Host disease• History of bone marrow transplant, no Raynaud’s symptoms. • Diagnosis is via skin biopsy.

Cases

Case 1

• 50 year old female who has CREST syndrome with anti-centromere antibody:

• Raynaud’s controlled with nifedipine• only digital skin thickening of the hands which is unchanged• GERD on omeprazole• telangiectasia. • She currently has no complaints.

• Labs: • CMP, CBC, ESR, CRP, total CK all normal, anti-centromere Ab positivity.

• Echocardiogram and PFT’s 1 month ago: • Echo: normal with normal estimated PA pressures. • PFT’s: normal lung volumes, normal DLCO.

• What is next step:

Case 1

• Renew medications• Nifedipine and omeprazole

• This case highlights the most typical case seen in clinics with stable disease.

• Things to watch for: • Change in skin disease

• Periodic echocardiogram and PFT’s.

• General exam

Case 2

• 60 year old male with Raynaud’s for 4 months prior to onset of skin involvement

• Skin thickening has ascended to involve proximal extremities, chest, and abdomen within 1 year.

• The patient reports mild shortness of breath recently.

• Exam: • Vitals: T 98.9, BP 124/73, pulse 80, resp rate 18• Raynaud’s is noted without digital ulcer. • Cardiovascular exam normal. • Gastrointestinal exam is normal. • Dry crackles noted at both bases. • Extremities: no edema.

• Labs: • CBC, CMP, total CK are all normal• ESR 35, CRP 1.8 (upper limit of normal is 1.0). • Anti-Scl-70 Ab positive, RNA Pol III negative.

• What is next step?

Case 2

• PFT’s: TLC decreased 80% to 55%, VC decreased 85% to 50%, RV decreased 83% to 62%, DLCO decreased 75% to 45%.

• Bronchoscopy performed: all cultures & cytology negative (neutrophils and eosinophils are present).

• Echocardiogram: no pulmonary hypertension. • Lung Biopsy shown on right. • What is the diagnosis? What is the treatment?

Learningradiology.com Oikonomou A, Prassopoulos P - Insights Imaging (2012)

Strek, ME. Amer Col Chest Physicians 2012

Case 2

• Interstitial lung disease associated with scleroderma with active inflammation.

• Mycophenolate, Cytoxan, or Azathioprine

• Prednisone (low dose) 10 mg daily; gradual taper

Case 3

• 50 year old female presents with • onset of Raynaud’s for 1 year, • developed skin thickening from the digits of the hands to just distal to the

elbows. • She has noticed difficulty getting out of chairs and lifting objects overhead.

• Exam:• VS: Temp 98.2, BP 124/72, pulse 78, respiratory rate 16• Cardiovascular and pulmonary exams normal. • Gastrointestinal exam is normal. • Muscle weakness of thighs and shoulder regions is noted. • No skin lesions other than skin thickening.

• Labs:• CBC, chem-7, ESR, CRP all normal, PM-SCL Ab positivity• Total CK 3000 (mostly CKMM), AST 158, ALT 105, GGT normal.

• What is the next step?

Case 3

• MRI of the thigh• Biopsy of thigh musculature• What is the diagnosis? What is the treatment?

EMG, Nerve Conduction Studies

Olsen NJ, et al. Rheum Dis Clin N. Amer 1996;22(4):783-796

Seidman, RJ. Medscape

Case 3

• Scleroderma/Myositis overlap.

• Methotrexate or Azathioprine

• Low dose prednisone: 10 mg daily

• Over the next few months, CK levels normalize and prednisone dose is gradually tapered, and the patient’s strength improves.

Case 4

• 35 year old female with • limited scleroderma for 3 years, anti-centromere Ab positive.

• with stable skin disease involving the digits of the hands only; new “rash” appeared 1 month ago, gradually worsening, no change in last week.

• Raynaud’s have been quite severe, but not on therapy.

• Exam• VS: Temp 97.9, BP 123/76, pulse 82, RR 16

• Cardiac, pulmonary, gastrointestinal exams normal, no edema

• Skin: see next slide

Case 4

• Labs: • CBC, CMP, ESR, CRP all normal; anti-centromere Ab

positive, anti-phospholipid Ab neg, echo with bubble study negative

• What is the diagnosis? What is next step?

Sclero.orgInternational Scleroderma Network

Case 4

• Digital Ischemia due to Raynaud’s

• Start calcium channel blocker• Nifedipine 30 mg PO daily.

• Close follow-up and increase dose of nifedipine as blood pressure tolerates.

• If not responding:• Can start nitroglycerin patch or can start sildenafil (not

both).

Case 5

• 58 year old male with:• Rapid onset scleroderma with Raynaud’s for 6 months then

skin thickening that spread to proximal arm, proximal thigh, chest, and abdomen within 1.5 years.

• Blood pressure generally runs 110/70

• has mild headache, and has noticed some swelling of the legs.

• Exam: • VS: Temp 98.4, BP 160/105, pulse 70, RR 16.

• Cardiac, pulmonary, gastrointestinal exam all normal; neurologic exam is non-focal.

• There is only mild bilateral lower extremity edema.

Case 5

• Labs• Creatinine 2.0 (baseline is 0.6), CBC normal, ESR and

CRP normal, urine with 1+ protein, no RBC or WBC; known to be RNA Pol III positive.

• What is the diagnosis? What is the next step.

Case 5

• Scleroderma Renal Crisis

• Treatment:• Hospitalization

• Start ACE-inhibitor: captopril with dose escalation.

References

• Medscape

• Up To Date

• Desai, et al; Curr Opin Rheumatol 2011; 23:545-554

• Curr Opin Rheumatol 23;505-510

• Fischer A; CHEST 2006; 130:976 –981

• Rheum Dis Clin N Am;2003;29:293–313

• Arthritis Rheum 2006;54:3962-3970

• Rheumatology 2009;48:iii32–iii35

• Steen VD; Rheum Dis Clin N Am 2003;29:315–333

• Hudson M, et al; Medicine 2010;89:976-981

• Bon LV; Curr Opin Rheumatol 2011;23:505–510

• Barnes J; Curr Opin Rheumatol 2012, 24:165–170

Definition of Criteria

Skin Scoring

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