Giuseppina Abignano

Ultrasonographic features of the hand and wrist in systemic sclerosis

OBJECTIVES To investigate ultrasonographic hand and wrist features in patients with SSc and their correlation with clinical and X-ray examinations. METHODS All the patients and controls underwent clinical examination, X-ray and ultrasonography (US) evaluations of the hands and wrists. Forty-five SSc patients all of whom satisfied the ACR criteria and 45 controls-15 patients with RA, 15 patients with FM syndrome and 15 healthy subjects were assessed. US was performed by a General Electric Logiq-5 PRO using a 7-12 MHz linear array transducer. RESULTS Joint effusion was found in 22 (49%) SSc patients; synovial proliferation in 19 (42%), which was associated with a power Doppler signal in 11 of them; marginal bone erosions in 5 (11%); joint space narrowing in 8 (18%); periarticular calcinosis in 12 (27%); and osteophytosis in 26 (59%). In SSc patients, the prevalence of synovitis as detected by US (i.e. effusion and/or synovial proliferation) was found to be significantly higher than that found by clinical examination (i.e. tenderness and/or swelling) (26 vs 15 out of 45 cases; P = 0.03). US indicated a significantly higher number of joints with osteophytes than X-rays (59 vs 27%; P < 0.005). CONCLUSIONS Our study depicts the main sonographic abnormalities of the SSc hand. Using US, we found an unexpectedly high prevalence of joint pathology in SSc without clinically involved hands. The clinical usefulness of US in the assessment of SSc articular involvement either in clinical practice or in therapeutic trials is yet to be defined.

Early systemic sclerosis: assessment of clinical and pre-clinical organ involvement in patients with different disease features

OBJECTIVE To assess internal organ involvement in early SSc at presentation. METHODS One hundred and fifteen patients admitted to a tertiary centre because of RP, who did not present any routinely detectable scleroderma-related internal organ involvement, were investigated for ANA and videocapillaroscopy, and underwent history and physical examination to detect symptoms/signs suggestive of SSc. Patients were then subdivided into three groups: (i) early SSc, constituted by patients without clinical manifestations other than RP, but with scleroderma marker autoantibodies and/or typical capillaroscopic abnormalities; (ii) probable SSc, constituted by patients with the same autoantibody and/or capillaroscopic status as early SSc patients, but with any of the following manifestations: digital ulcers/scars, puffy fingers, arthritis, telangiectasia, dysphagia/heartburn, shortness of breath; (iii) UCTD, constituted by patients with a specific (i.e. disease antibody marker) ANA and capillaroscopic findings plus any disease manifestation. All patients were investigated by lung functional study and B-mode echo-Doppler-cardiography. Patients who consented underwent oesophageal manometry. RESULTS An inverted mitral E : A ratio (i.e. early scleroderma cardiac involvement) and/or a diffusing lung capacity for CO <80% of the predictive value (i.e. early lung involvement) and/or basal low oesophageal sphincter pressure <15 mmHg (i.e. early oesophageal involvement) were detected in 37/51 probable SSc patients (72%), 8/19 early SSc patients (42%) and 12/45 UCTD patients (27%). CONCLUSION A scleroderma-related internal organ involvement was detected in patients from each group and, more importantly, was pre-clinical in a number of cases.

Virtual skin biopsy by optical coherence tomography: the first quantitative imaging biomarker for scleroderma

Background Skin involvement is of major prognostic value in systemic sclerosis (SSc) and often the primary outcome in clinical trials. Nevertheless, an objective, validated biomarker of skin fibrosis is lacking. Optical coherence tomography (OCT) is an imaging technology providing high-contrast images with 4 μm resolution, comparable with microscopy (‘virtual biopsy’). The present study evaluated OCT to detect and quantify skin fibrosis in SSc. Methods We performed 458 OCT scans of hands and forearms on 21 SSc patients and 22 healthy controls. We compared the findings with histology from three skin biopsies and by correlation with clinical assessment of the skin. We calculated the optical density (OD) of the OCT images employing Matlab software and performed statistical analysis of the results, including intraobserver/interobserver reliability, employing SPSS software. Results Comparison of OCT images with skin histology indicated a progressive loss of visualisation of the dermal–epidermal junction associated with dermal fibrosis. Furthermore, SSc affected skin showed a consistent decrease of OD in the papillary dermis, progressively worse in patients with worse modified Rodnan skin score (p<0.0001). Additionally, clinically unaffected skin was also distinguishable from healthy skin for its specific pattern of OD decrease in the reticular dermis (p<0.001). The technique showed an excellent intraobserver and interobserver reliability (intraclass correlation coefficient >0.8). Conclusions OCT of the skin could offer a feasible and reliable quantitative outcome measure in SSc. Studies determining OCT sensitivity to change over time and its role in defining skin vasculopathy may pave the way to defining OCT as a valuable imaging biomarker in SSc.

The enhanced liver fibrosis test: a clinical grade, validated serum test, biomarker of overall fibrosis in systemic sclerosis

Objectives The absence of a serological surrogate outcome measure of fibrosis in systemic sclerosis (SSc) is a major deficiency for intervention studies and clinical management. An algorithm including the serum concentration of procollagen-III aminoterminal-propeptide, tissue inhibitor of matrix metalloproteinase-1 and hyaluronic acid, has recently been validated as predictive of severity and clinical outcome in chronic liver diseases (enhanced liver fibrosis (ELF) test) and implemented as a clinical grade test available for physicians. We evaluated the ELF test as a surrogate outcome measure in SSc. Methods The ELF score was determined blindly in 210 patients with SSc. Results were correlated with clinical, functional and instrumental variables including disease severity, activity and disability. Results The ELF test was above normal range in 83% of SSc patients (175/210). The ELF score showed a significant correlation (p<0.0001) with extent of skin involvement (r=0.28), diffusing lung capacity of carbon monoxide (DLCO) (r=−0.32), health assessment questionnaire–disability index (HAQ-DI) (r=0.32), disease severity score (r=0.3) and age (r=0.41). In addition, ELF correlated with disease activity (r=0.23; p=0.02). Using regression analysis, the extent of skin involvement, age, DLCO and gender were independently associated with the ELF score. The ELF score did not correlate with the presence of pulmonary artery hypertension, digital ulcers or any other measure of vasculopathy. Conclusions The ELF test is a clinical-grade serum test that significantly correlates with several measures of fibrosis in SSc and with overall disease activity, severity and HAQ-DI. The specific correlation with fibrosis and its face validity, together with the feasibility of the test, warrant its further development as a surrogate outcome measure of fibrosis in SSc.

Cell-free DNA in the plasma of patients with systemic sclerosis

The aim of the present study was to evaluate the concentration of cell-free DNA (cf-DNA) in the plasma of patients with systemic sclerosis (SSc) and to examine the correlation of cf-DNA with clinical variables of the disease. The study population consisted of 122 SSc patients and 16 healthy controls. Epidemiological and clinical data were collected by direct assessment. The β-globin gene was used to determine the total amount of DNA in the plasma by real-time quantitative PCR analysis. cf-DNA was found in all patients (mean concentration 1,420.7 copies/ml) and controls (mean concentration 1,462.5), with no significant difference. In SSc patients, no correlation was found between cf-DNA and the type of organ involvement, but patients with active disease presented significantly higher cf-DNA concentrations than those with inactive disease (p < 0.05). Our data suggest that cf-DNA could provide a useful biomarker for the assessment of disease activity in SSc patients.

Biomarkers in the management of scleroderma: an update.

Scleroderma, or systemic sclerosis, is a clinically heterogeneous disease characterized by fibroproliferative vasculopathy, tissue fibrosis affecting the skin and internal organs, and autoimmune activation. Many biomarker candidates have been identified in the past two decades; however, fully validated measures are still lacking with regard to aiding in the early diagnosis and reflecting the disease activity, severity, prognosis, and response to therapy. An ideal biomarker should be highly sensitive and specific, reflecting the current status of disease; should be related to the disease activity and/or severity in accordance with the clinical evolution; should anticipate clinical changes before they occur; and should add independent information about the risk or prognosis that is reproducible and feasible. This review focuses on the most recent and innovative approaches to identify biomarkers, such as extensive gene expression analysis and proteomics, and on markers and surrogate outcome measures closer to clinical practice, and attempts to evaluate them through the OMERACT (Outcome Measures in Rheumatology Clinical Trials) filter.

Potential Use of Optical Coherence Tomography and High-Frequency Ultrasound for the Assessment of Nail Disease in Psoriasis and Psoriatic Arthritis

Background: Psoriatic nail disease is increasingly recognised to be of major clinical and research relevance. Clinical assessment remains the current gold standard for its evaluation. Objective: We compared optical coherence tomography (OCT) and ultrasound (US) for nail disease assessment in psoriatic disease. Methods: 18 patients with at least one involved nail and 12 healthy controls were scanned using OCT; psoriatic patients also had an US scan (using a linear probe at 9-14 MHz). Nail and contour abnormalities were documented. Clinical onychopathy was scored independently using the modified Nail Psoriasis Severity Index. Results: Among 180 nails, 67.8% had clinical findings whereas 33.9% were abnormal by US and 44.4% had abnormalities on OCT. A positive OCT had a sensitivity and specificity of 44.4 and 95.8%, respectively, with a positive likelihood ratio of 10.7 for nail disease. OCT demonstrated 76.3% absolute agreement compared with clinical assessment and 65% with US. OCT detected subtle abnormalities in 12 clinically normal nails and in 41 nails with normal US findings. Conclusion: These findings show that OCT has a potential for the systematic characterisation of psoriatic nail changes and could be useful in diagnosis and more objective assessment of treatment response.

Quantitating Skin Fibrosis: Innovative Strategies and Their Clinical Implications

Skin fibrosis is the final outcome of a variety of pathologic processes ranging from aberrant wound healing (keloids) to environmentally induced conditions (nephrogenic systemic fibrosis) to idiopathic or autoimmune conditions (morphea and systemic sclerosis). The quantitative assessment of skin fibrosis has been a major burden of clinical and biomarker research in the field for the past three decades. Here, we review the efforts that reached some sort of validation and the ones we envisage have the potential for further development focusing on systemic sclerosis as prototype of fibrotic disease.

OP0228 Optical coherence tomography validation: A new quantitative imaging biomarker for affected skin in scleroderma

Background Skin involvement in systemic sclerosis (SSc) is often primary outcome in clinical trials but it is still orphan of a quantitative imaging technique. Optical Coherence Tomography (OCT) is an emerging imaging technology for clinical examination employing a low-intensity infra-red laser beam and providing high-contrast 2 mm deep skin images with a 4 micron resolution. Objectives The aim of this study was to evaluate face validity and reliability of OCT in SSc. Methods Dorsal aspect of forearms was assessed employing topical probe “VivoSight” (Michelson Diagnostics) and optics of Swept-source Fourier-Domain type with a laser wavelength of 1305±15 nm. Clinical skin involvement was determined using the mRSS. The study included 8 foreams from 8 healthy controls (HC) and 5 forearms for each group scored from “0” to “3” from 13 SSc patients. Hematoxylin-Eosin (H&E) staining was performed from forearm skin biopsy, within 1 cm of OCT scanned region, in one HC and one SSc patient (mRSS=3 on the site of analysis). Matlab software was employed to calculate mean optical density (OD) of the scans. Signal changes within epidermis (ED), Dermal-Epidermal Junction (DEJ) and dermis of SSc patients and HC were analysed and collated to a unique graph. To investigate the intraobserver and interobserver reproducibility, intraclass correlation coefficient (ICC) and limits of agreement (LoA) were calculated for the minimum value after the first peak and the maximum value of the second peak of the averaged A-scans. Results OCT images collected in HC showed a regular hyper-reflective border of the skin surface and a homogeneous hypo-reflective epidermal layer. The papillary dermis (PD) was visualized as hyper-reflective area compared to the adjacent ED allowing the visualization of the DEJ. Mean OD data showed that DEJ was a OD nadir region between 60 and 70 micron from the surface, the PD a high density region (OD range:0.64-0.72; micron range:60-100) and the reticular dermis (RD) had a OD ranging from 0.72 and 0.4. In contrast SSc affected tissues (mRSS=3) showed no DEJ and no increase in OD in the PD which appeared with a range density of 0.61-0.56. Interestingly in SSc non-affected tissues (mRSS=0), the valley corresponding to DEJ was still visible with an almost normal OD range of the PD (OD=0.64-0.67) and an OD of the second peak lower than healthy subjects. In the remaining cases (mRSS=1 and 2) the valley after the entrance peak was still visible, however with a weaker second peak compared to healthy skin and SSc non-affected skin. Validation with H&E staining confirmed the localisation of the above mentioned density areas.In addition the results showed excellent intraobserver reliability (ICC >0.98; LoA=0.94-0.99) in both parameters measured by the same clinician on the two separate occasions. The interobserver reliability was also excellent with ICC>0.89 (LoA=0.61-0.97) in both parameters assessed by two investigators. Conclusions This is a proof of concept validation of face validity of OCT as quantitative imaging technique of scleroderma skin. The potential of this tool is supported by an excellent reliability. Sensitivity to change ability of OCT is under evaluation to determine whether the technique could be used as outcome measure of skin involvement in SSc. Disclosure of Interest None Declared

Early onset neutropenia after mycophenolate mofetil in systemic sclerosis

Mycophenolate mofetil (MMF), by inhibiting the de novo synthesis of purines, displays potent immunosuppressive properties on B and T lymphocytes and is now widely used in transplant medicine [1, 2] and lupus nephritis [3, 4]. Moreover, MMF inhibits the proliferation of vascular smooth muscle cells [5] and Wbroblasts [6], thereby suggesting that the drug might be eVective in diseases such a scleroderma [7–9], in which Wbrotic process are prominent. In this report, we describe a case of early onset neutropenia after MMF therapy in systemic sclerosis (SSc). A 63-year-old white woman was diagnosed, 7 years ago, as having SSc. Disease duration, from Raynaud’s phenomenon, is 20 years. In 2000, the patients developed scleredema; 2001 skin sclerosis, weight loss, dysphagia; 2003 alveolitis; 2006 heart failure. Concomitant diseases: hypertension, nodular goiter, osteoporosis. Remission of alveolitis was achieved with steroids and cyclophosphamide in 2003. New onset of alveolitis appeared in January 2008. On physical examination, the blood pressure was 130/ 70 mmHg, skin score 5. She refers: dyspnea III functional class NHYA, palpitations, dysphagia. Laboratory studies show: hemoglobin 10.5 g/dl, white blood cell count 4,520 l¡1 (nv 4,000–11,000), neutrophils 3,910 l¡1, lymphocytes 1,200 l¡1, platelets 197,000 l¡1, creatinine 0.98 mg/dl, C3 108 mg/dl, C4 27 mg/dl, ESR 75 mm, ANA 1:320 with a nucleolar pattern. The echocardiography shows left ventricular ejection fraction 30%, E/A ratio <1, PAPs 35 mmHg. The respiratory function test shows: forced vital capacity (FVC) 104% and carbon monoxide diVusing capacity (DLCO) 60%. On high resolution, chest computerized tomography scan (HRCT) pointed out a ground glass and Wbrosis. Concomitant medication: low dose of aspirin, proton pump inhibitors, domperidone, angiotensin II antagonists, diuretic, bis-phosphonate. Mycophenolate mofetil was started at dose of 1,000 mg/ day; previous white blood cell count and neutrophils was normal. After 20 days MMF was increased at the dose of 2,000 mg/day; white blood cell count was 5,270 l¡1 and neutrophils were 3,920 l¡1. Twenty days after MMF 2,000 mg/day therapy developed neutropenia (white blood cell count was 2,090 l¡1 with 1,530 l¡1 neutrophils), without clinical eVects; hemoglobin and platelet count remained normal. MMF was discontinued. Within 15 days the white blood cell and the neutrophils level rose to normal (WBC 5,550 l¡1, N 4,230 l¡1). MMF was started again at dose of 1,000 mg/day, after 3 months the level of WBC and neutrophilis was normal; the FVC and DLCO 100% and 62, respectively. The incidence of neutropenia appears to be rare in patients treated with MMF. However, recently four cases of neutropenia associated with MMF have been reported [10]. In this report, neutropenia was developed when the plasma level of mycophenolate was in the therapeutic range; the mean time from starting MMF until development of neutropenia is variable. In our case discontinued of MMF was followed by a rapid and spontaneous rise in neutrophils (20 days). In conclusion, we reported one case of neutropenia in SSc patient, considered to be secondary to the use of MMF. We recommend caution when using MMF as well as monitoring levels and cell counts during treatment. G. Cuomo (&) · G. Abignano · G. Valentini Rheumatology Unit, Second University of Naples, Policlinico Via Pansini, 5, 80131 Naples, Italy e-mail: giovanna.cuomo@unina2.it