Genomic instability in scleroderma

Scleroderma is an enigmatic rheumatic disorder of uncertain etio-pathogenesis. Cancer has an approximately two-fold higher incidence in scleroderma patients than in the general population. There are preliminary data of acquired genetic damage in scleroderma but the significance of these observations are uncertain. To determine somatic mutation frequency at the glycophorin-A (GPA) locus in patients with limited and diffuse cutaneous scleroderma. The GPA assay measures the total somatic mutation frequency (Vf), composed of gene inactivating mutations (NO) and mutations arising from mitotic recombination (NN) in individuals heterozygous for the GPA MN blood group. Mutation frequency was determined using a validated GPA flow cytometric assay using fluorescent labeled monoclonal antibodies specific for the GPA blood groups M and N. This assay detects and enumerates progeny of red blood cell (rbc) precursor cells which have acquired genetic damage resulting in a loss of expression of one of the GPA alleles. It was found that patients with scleroderma (n = 23) had significantly elevated Vf as compared with young healthy controls (p < 0.001) and elderly controls (p = 0.03). Patients with diffuse scleroderma had higher mean Vf as compared with limited scleroderma (p = 0.055). In comparison with controls, patients with scleroderma exhibit a higher proportion of mitotic recombinant mutations than inactivating mutations (p < 0.002). There was no correlation between Vf and disease duration, age at onset or autoantibody status. We have documented evidence of acquired genetic damage at the GPA locus in scleroderma. Evidence of acquired genetic damage in this disorder may be importance in explaining both the etio-pathogenesis of scleroderma and the association of scleroderma with cancer.     

Maternal scleroderma: Placental findings and perinatal outcome

Pregnancy after the onset of scleroderma is uncommon; therefore, placental findings and perinatal outcome have rarely been correlated. The histopathologic features of placentas from 13 pregnancies in eight women with scleroderma were recorded and correlated with the clinical features of the mother and fetus. Adverse perinatal outcome included intrauterine fetal demise in five, and previable or preterm delivery in four. A decidual vasculopathy was seen in 5 of the 13 placentas, four of which were associated with intrauterine fetal demise. Decidual blood vessels in the scleroderma patients were evaluated immunohistochemically for platelet-derived growth factor (PDGF), transforming growth factor β1 (TGF-β1), T-helper and T-suppressor lymphocytes, macrophages, immunoglobulin (Ig) M, and IgG, and compared with those from hypertensive and uncomplicated third-trimester pregnancies. The atherotic blood vessels in scleroderma were characterized by mural macrophages and IgM and IgG deposition and were similar to those seen in placentas from hypertensive pregnancies. CD8-positive T cells predominated in normal and hypertensive decidua compared with scleroderma, in which CD4-positive T cells were more frequent. No difference in PDGF or TGF-β1 staining was found between scleroderma and control groups. In conclusion, decidual vasculopathy is common in scleroderma, is similar to that seen in hypertension, and is associated with poor perinatal outcome. A trend toward a reversed ratio of decidual CD4- to CD8-positive T cells is seen in scleroderma compared with hypertension and uncomplicated pregnancies. PDGF and TGF-β1 do not appear to be involved in the pathogenesis of decidual vasculopathy in scleroderma.     

Cardiac repolarization abnormalities and increased sympathetic activity in scleroderma

BACKGROUND: Cardiac involvement in scleroderma is a poor prognostic sign and is usually underdiagnosed, particularly in asymptomatic patient. This paper focuses on QT dynamicity and heart rate variability (HRV) in patients with scleroderma and controls in an attempt to investigate the cardiac autonomic system and ventricular repolarization. METHODS: Sixty patients with scleroderma and 30 age- and sex-matched healthy controls who had no cardiovascular risk factors were included in this study. All patients and the controls underwent a 24-hour holter recording as well as a transthoracic echocardiography. HRV and QT dynamicity parameters were calculated. RESULTS: In HRV analysis, autonomic balance was changed in favor of the sympathetic system in patients with diffuse scleroderma. In QT dynamicity analysis, QT/RR slopes were significantly steeper in patients with diffuse scleroderma compared to patients with limited scleroderma and controls (QTapex/RR: 0.24 +/- 0.16, 0.15 +/- 0.03, 0.14 +/- 0.03 respectively p < 0.001; QTend/RR: 0.26 +/- 0.17, 0.14 +/- 0.04, 0.13 +/- 0.05, respectively p < 0.001). CONCLUSIONS: Patients with diffuse scleroderma may have asymptomatic cardiac repolarization abnormalities and autonomic dysfunction. Our results may indicate that QT dynamicity and HRV can be useful noninvasive methods that may detect impaired state of autonomic balance and cardiac repolarization in patients with diffuse scleroderma.     

Spontaneous production of, and defective response to, interleukin-1 by peripheral blood mononuclear cells from patients with scleroderma.

Interleukin-1 (IL-1) is a monocyte derived factor that participates in immune regulation and in the regulation of fibroblast proliferation and collagen deposition. It therefore, seems particularly pertinent to study in scleroderma, a disorder of immune regulation where increased collagen deposition is a hallmark. The production of IL-1 by lipopolysaccharide stimulated monocytes from 18 untreated scleroderma patients was akin to that of their normal matched controls. However, the unstimulated monocytes from six of the 18 scleroderma patients released IL-1 activity spontaneously into their supernatants. All six patients with spontaneous IL-1 release had less than 5 years disease duration. The response to IL-1 by T lymphocytes from patients with scleroderma was low as compared to those from controls. The presence of spontaneous IL-1 production with decreased response to IL-1 in scleroderma may indicate an in vivo pre-activation of monocytes to produce this factor that might have a bearing in the pathogenesis of collagen deposition in scleroderma.     

Nephrotic range proteinuria: rare manifestation of scleroderma renal crisis

The nephrotic range of proteinuria is uncommon in scleroderma renal crisis. This 46-yr-old woman with a medical history of scleroderma presented with very high blood pressure, a sudden elevation of serum creatinine, and proteinuria in the nephrotic range. Renal biopsy revealed onion-skin type of arterial changes with necrosis, confirming the presence of scleroderma nephropathy. Electron microscopy showed diffuse fusion of foot processes. Immunohistochemical staining (IHC) revealed increased expression in glomeruli of phosphorylated mammalian target of rapamycin (p-mTOR). These findings suggest that fusion of foot processes and activation of mammalian target of rapamycin-dependent pathways in podocytes are most likely responsible for the severe proteinuria in this patient with scleroderma nephropathy.     

鼻硬结病的临床特点及病理诊断研究

目的 探讨鼻硬结病的临床特点及病理诊断价值。方法 收集2014年4月~2018年12月复旦大学附属眼耳鼻喉科医院10例硬结病患者资料进行回顾性分析,对硬结病临床、病理学特征及六胺银染色结果进行分析研究。结果 9例患者病变累及鼻部（1例同时累及气管,1例同时累及软腭）,另1例侵犯会厌。最常见的症状为鼻塞（9例）,其次为流涕（2例）,鼻出血（2例）,头痛（1例）,嗅觉下降（1例）,呼吸不畅（1例）及咽部异物感（1例）。通过六胺银染色显示,5例形态不典型硬结病病例中有4例短杆状菌体。结论 硬结病常累及上呼吸道,鼻腔是常见发病部位,六胺银特殊染色在硬结病病理诊断有较大作用,是诊断硬结病的重要辅助手段。     

Antinuclear Antibodies and Anti-DNA Antibodies in Scleroderma

Antinuclear antibodies (ANA), including anti-DNA antibodies, and rheumatoid factors (RAT, Waaler-Rose) were determined prospectively during a 3-year period in 40 patients with localized scleroderma (LS) compared with 77 patients with generalized scleroderma (GS). ANA were increased in 26% of patients with LS, and in 47% with GS, anti-DNA antibodies in 23% of patients with LS, and in 34% with GS. Thus, the anti-DNA antibody level was lower compared with the known level in systemic lupus erythematosus. Rheumatoid factors were present in 6-7% of patients with LS, and in 14-15% of patients with GS. Increased antinuclear antibodies were not associated with any specific type of localized scleroderma, nor with internal disorders, and no case of clinical overlap to discoid or systemic lupus erythematosus was observed. However, six patients with localized scleroderma and complaints of arthralgia all presented increased antibodies, and one patient showed overlap to rheumatoid arthritis. It is suggested that increased ANA and anti-DNA antibodies in localized scleroderma, associated with joint manifestations, represents a systemic component in this type of scleroderma, with activation of the immune system and similarities with generalized collagen diseases.     

Using the polymerase chain reaction to Borrelia burgdorferi infection in localized scleroderma injure (morphea), in Venezuelan patients

Borrelia burgdorferi is the causative agent of Lyme Borreliosis, an infectious multisystemic disease transmitted to humans by the Ixodes ticks bite. A possible association of Borrelia burgdorferi with localized scleroderma has been postulated. However, published data do not provide unequivocal results. Previous serologic analysis of patients with localized scleroderma in South American countries (including Venezuela), have been reported as yielding some reactivity. The present study looked for evidence of Borrelia burgdorferi infection in venezuelan patients with localized scleroderma, using the polymerase chain reaction to analyze 21 skin samples of patients with this skin condition. The results were negative in all the samples studied. Our data do not support an association of Borrelia burgdorferi infection and the sclerotic lesions of localized scleroderma; but do not rule out the possibility of a relationship between localized scleroderma and an unknown geno-specie of Borrelia burgdorferi sensu lato complex, a different Borrelia specie or a different spirochetal organism, as the etiological agents of the skin lesions in this area.     

Stimulatory autoantibodies to the PDGF receptor: a link to fibrosis in scleroderma and a pathway for novel therapeutic targets

Systemic sclerosis (scleroderma) is a complex disease characterized by excessive deposition of collagen and abnormalities of blood vessels. In addition, activation of the immune system is a central feature of scleroderma as shown by mononuclear cell infiltration of the skin, autoantibody production and release of inflammatory cytokines. The pathogenesis of the disease is poorly understood and the molecular events underlying the main clinical features are not known. The detection of agonistic autoantibodies targeting PDGF receptor in serum of patients with scleroderma may indicate a novel link between phenotypic features of the disease and a specific signalling pathway. Agonistic PDGF receptor antibodies induce in vitro the scleroderma phenotype in normal human fibroblasts and, thus, link autoimmunity to fibrosis. These findings pave the way to novel therapeutic strategies.     

硬皮病患者甲襞微循环的特点

利用“甲襞微循环加权积分法”观测了11例硬皮病患者的甲襞微循环,发现硬皮病患者甲襞微循环的主要特点是管襻数目减少,畸形管襻增多,血流缓慢,出现不同程度的红血球聚集,以及乳头波纹浅平等。硬皮病患者甲襞微循环的总积分属于中度异常。     

Pathogenic autoantibodies in systemic sclerosis

Systemic sclerosis, scleroderma, is a disease characterized by widespread vascular injury and fibrosis of the skin and visceral organs. Circulating autoantibodies against several intracellular antigens are common in scleroderma patients. The specificities of such autoantibodies correlate with distinct clinical manifestations. However, till date there is no evidence that these autoantibodies, though helpful in diagnosis and prognosis, are linked to the pathogenesis of scleroderma nor that they may cause any feature of the disease. Recently, the discovery of novel agonistic autoantibodies targeting the PDGF receptor has provided important insight into the molecular pathogenesis of scleroderma and the intracellular mechanisms leading to fibrosis. Although their pathogenic role awaits validation in in vivo models, these antibodies represent the molecular link between the immune system and fibrosis.     

The TGF beta receptor endoglin in systemic sclerosis

Immunohistochemical, flow cytometric and ELISA studies were performed to examine the expression of endoglin (CD105, a TGF beta receptor) on dermal endothelial cells, peripheral blood monocytes and free and bound serum levels in patients with systemic sclerosis as compared with appropriate controls. Endoglin was found to be significantly upregulated on dermal blood vessels in patients with scleroderma (and in patients with inflammatory skin disorders) as compared to healthy skin (p < 0.05). In contrast, there was no significant difference in endoglin expression on circulating blood monocytes between scleroderma patients and patients with a rheumatic disoder or healthy control subjects; however, endoglin expression was upregulated on monocytes in inflammatory joint fluid from patients with rheumatoid arthritis. Endoglin expression on monocytes was also influenced by isolation techniques and during whole blood culture. No differences were found in circulating free or bound endoglin levels between scleroderma patients and healthy controls. In conclusion, endoglin expression on dermal endothelial cells was significantly enhanced in scleroderma but levels on circulating monocytes and in the serum were within normal limits. The functional significance of this upregulation is uncertain but may reflect endothelial activation in scleroderma.     

Anti-neutrophil cytoplasmic autoantibody-associated rapid progressive glomerulonephritis complicated with both limited and diffuse scleroderma]

We report two patients with scleroderma, 73-year-old female and 67-year-old female, who developed anti neutrophil cytoplasmic autoantibody (ANCA) associated rapid progressive glomerulonephritis (RPGN). Both patients have had a long history of scleroderma (23 and 14 years, respectively) when ANCA-associated glomerulonephritis occurred. In the first patient, scleroderma was localized in both fingers. She has been followed-up as CREST syndrome rather than systemic sclerosis. The complaints on admission were leg edema and left chest pain in the first patient, and a pyrexia and dyspnea in the second patient. Both patients showed pulmonary manifestation (pleural effusion in the first patient, interstitial pneumonia and alveolar hemorrhage in the second patient, respectively) and rapid progressive glomerulonephritis. Both patients died in spite of corticosteroid therapy. Autopsy findings in the second patient demonstrated crescentic glomerulonephritis and alveolar hemorrhage. Our cases demonstrated that MPO-ANCA associated glomerulonephritis could be associated with limited scleroderma as well as systemic scleroderma. In these condition, the prognosis will be poor if scleroderma seemed to be stable.     

Mononuclear cell-fibroblast interactions in scleroderma

We studied cell proliferation and collagen biosynthesis in cocultures of dermal fibroblasts with peripheral blood mononuclear cells (MNC) from scleroderma patients and from age-matched normal controls. Autologous one-way mixed MNC-fibroblast cultures revealed that fibroblasts do not stimulate MNC proliferation. Conversely, MNC stimulate autologous fibroblasts from scleroderma patients as well as from normal controls. This effect is increased in cells from scleroderma patients in which it seems to be mediated both by cell-to-cell interaction and through the production of soluble factors by MNC. In normal control cell systems we found no proliferative effect of supernatants of unstimulated cells or from those stimulated in autologous mixed-lymphocyte reactions. Coculture of fibroblasts with autologous MNC resulted in increased [14C]proline incorporation into both collagenic and noncollagenic proteins. This effect was mediated mostly by soluble factors that are released into the culture medium. Protein synthesis by MNC-fibroblast cocultures from scleroderma patients was significantly greater than protein synthesis by those from normal controls. Culture supernatants from unstimulated MNC or from autologous mixed-lymphocyte cultures caused a slight decrease in collagenic protein synthesis by cultured fibroblasts from scleroderma patients but not by those from normal controls. This effect of culture supernatants could be reproduced, and magnified, with purified IL-1 on cells from either patients or controls. Our findings indicate abnormal MNC-fibroblast interactions in scleroderma that could play an important role in the pathogenesis of fibrosis, the hallmark of this condition.     

Pregnancy and scleroderma.

Scleroderma is a rare disease with a marked female excess in incidence. The pattern of age of onset, together with the effects of the disease, are such that the majority of women with scleroderma experience pregnancy prior to diagnosis. There are three questions of interest: (1) Does pregnancy adversely affect the prognosis of scleroderma? Isolated case reports suggest that renal disease, and in particular hypertensive crises, are associated with pregnancy in the absence of any renal abnormality before pregnancy. However, such events are rare. (2) Does scleroderma adversely affect either fertility or the outcome of pregnancy? Women with established scleroderma, again in case series, have a high rate of spontaneous miscarriage which is not found consistently in epidemiological studies. Prematurity and low birth rates are more frequent problems. (3) Does reproductive history influence disease and particularly Raynaud's phenomenon may antedate diagnosis by many years and might influence reproductive outcome, in general reproductive outcome is similar to that seen after diagnosis, although fertility appears to be reduced.     

Renal biopsy findings predicting outcome in scleroderma renal crisis

Scleroderma renal crisis is irreversible in some patients despite aggressive treatment. This study was designed to identify pathologic prognostic features in scleroderma renal crisis. We retrospectively reviewed the pathology and the clinical records of 17 patients who underwent kidney biopsies during scleroderma renal crisis (group A, recovered renal function [n = 7]; group B, remained in renal failure or died [n = 10]). Multiple histologic features were assessed semiquantitatively (0-3) or as percentages. C4d staining of peritubular capillaries and small vessels was assessed semiquantitatively (0-3) in patients with scleroderma (n = 11), normotensive (n = 10), and hypertensive (n = 12) nonscleroderma native kidney controls. The percentage of thrombosed vessels (25.1 +/- 21.0 versus 5.6 +/- 12.3, P = .045) and the severity of glomerular ischemic collapse (2.9 +/- 0.3 versus 1.4 +/- 0.8, P = .001) were significantly higher in group B than in group A. Also, group B patients tended to have more severe acute tubular injury and vascular fibrinoid changes. The peritubular capillary C4d score in patients with scleroderma, normotensive controls, and hypertensive controls were 1.1 +/- 0.9, 0.3 +/- 0.7, and 0.3 +/- 0.5, respectively (P = .018, scleroderma versus other controls). Small vessel C4d score was higher in scleroderma compared to normotensive but not hypertensive controls. Within scleroderma samples, a significantly higher peritubular capillary C4d score (1.6 +/- 0.7 versus 0.3 +/- 0.5, P = .024) but not small vessel score was found in group B compared to group A. This tended to be associated with peritubular capillary leukocyte margination. Vascular thrombosis, severe glomerular ischemic collapse, and peritubular capillary C4d deposits in scleroderma renal crisis kidney biopsies correlated with increased risk of failure to recover renal function.     

Decreased monocyte-mediated angiogenesis in scleroderma.

Scleroderma is a disease characterized by proliferative vascular lesions in which monocytes/macrophages may play a key role. Monocytes were isolated from 14 scleroderma patients and 11 normal controls and cultured with or without lipopolysaccharide (LPS) (5 micrograms/ml). Monocyte-conditioned medium was assayed in the rat corneal bioassay for angiogenesis. Conditioned medium from normal monocytes was nonangiogenic, as was conditioned medium from scleroderma monocytes. While conditioned medium from LPS-activated normal monocytes was potently angiogenic in 11/13 corneas, conditioned medium from LPS-activated scleroderma monocytes was angiogenic in only 3/14 corneas. Levels of the angiogenic cytokine tumor necrosis factor-alpha (TNF-alpha) were measured in conditioned medium from scleroderma and normal monocytes. TNF-alpha levels were not significantly different in patient and control groups and thus do not account for the decreased angiogenic activity exhibited by scleroderma monocytes. As monocytes require activation to produce angiogenic activity, we determined the cell surface binding of monoclonal antibodies to activation-related (HLA-DR, 3D8, and 8D7) and other (Leu-M5) markers on monocytes by radioimmunoassay. Monocytes were cultured alone, with LPS (5 micrograms/ml), or with interferon-gamma (IFN) (200 units/ml). The usual increase in binding of anti-HLA-DR on stimulation of scleroderma monocytes with IFN was slightly less than that of controls. IFN-stimulated monocytes bound less anti-8D7 than controls. Anti-3D8 and anti-Leu-M5 binding was comparable in both groups. These results suggest that scleroderma monocytes do not produce normal levels of angiogenic activity with LPS stimulation, have some altered markers of activation on their cell surfaces, and may thus contribute to the aberrant vascular proliferation found in this disease.