Nora Sandorfi

Role of protein kinase C-δ in the regulation of collagen gene expression in scleroderma fibroblasts

Working with cultured dermal fibroblasts derived from control individuals and patients with systemic sclerosis (SSc), we have examined the effects of protein kinase C-delta (PKC-delta) on type I collagen biosynthesis and steady-state levels of COL1A1 and COL3A1 mRNAs. Rottlerin, a specific inhibitor of PKC-delta, exerted a powerful, dose-dependent inhibition of type I and type III collagen gene expression in normal and SSc cells. Optimal rottlerin concentrations caused a 70-90% inhibition of type I collagen production, a >80% reduction in COL1A1 mRNA, and a >70% reduction in COL3A1 mRNA in both cell types. In vitro nuclear transcription assays and transient transfections with COL1A1 promoter deletion constructs demonstrated that rottlerin profoundly reduced COL1A1 transcription and that this effect required a 129-bp promoter region encompassing nucleotides -804 to -675. This COL1A1 segment imparted rottlerin sensitivity to a heterologous promoter. Cotransfections of COL1A1 promoter constructs with a dominant-negative PKC-delta expression plasmid showed that suppression of this kinase silenced COL1A1 promoter activity. The results indicate that PKC-delta participates in the upregulation of collagen gene transcription in SSc and suggest that treatment with PKC-delta inhibitors could suppress fibrosis in this disease.

Connective tissue disease related interstitial lung diseases and idiopathic pulmonary fibrosis: provisional core sets of domains and instruments for use in clinical trials

Rationale Clinical trial design in interstitial lung diseases (ILDs) has been hampered by lack of consensus on appropriate outcome measures for reliably assessing treatment response. In the setting of connective tissue diseases (CTDs), some measures of ILD disease activity and severity may be confounded by non-pulmonary comorbidities. Methods The Connective Tissue Disease associated Interstitial Lung Disease (CTD-ILD) working group of Outcome Measures in Rheumatology—a non-profit international organisation dedicated to consensus methodology in identification of outcome measures—conducted a series of investigations which included a Delphi process including >248 ILD medical experts as well as patient focus groups culminating in a nominal group panel of ILD experts and patients. The goal was to define and develop a consensus on the status of outcome measure candidates for use in randomised controlled trials in CTD-ILD and idiopathic pulmonary fibrosis (IPF). Results A core set comprising specific measures in the domains of lung physiology, lung imaging, survival, dyspnoea, cough and health-related quality of life is proposed as appropriate for consideration for use in a hypothetical 1-year multicentre clinical trial for either CTD-ILD or IPF. As many widely used instruments were found to lack full validation, an agenda for future research is proposed. Conclusion Identification of consensus preliminary domains and instruments to measure them was attained and is a major advance anticipated to facilitate multicentre RCTs in the field.

Improvement of severe systemic sclerosis-associated gastric antral vascular ectasia following immunosuppressive treatment with intravenous cyclophosphamide.

Objective. We describe 3 patients with systemic sclerosis (SSc) with severe, transfusion-dependent gastric antral vascular ectasia (GAVE) refractory to laser ablation who showed remarkable clinical and endoscopic improvement following intravenous (IV) pulse cyclophosphamide (CYC) treatment. Methods. Review of clinical records and upper gastrointestinal endoscopy images from 3 patients with SSc and severe GAVE before and after treatment with IV pulse CYC. Results. IV CYC was followed by improvement and stabilization of hemoglobin levels, and marked reduction in blood transfusion requirements and the number and frequency of endoscopic laser treatments. Conclusion. IV pulse CYC immunosuppression was followed by remarkable clinical and endoscopic improvement of SSc-associated GAVE.

Inhibition of type I collagen gene expression in normal and systemic sclerosis fibroblasts by a specific inhibitor of geranylgeranyl transferase I

OBJECTIVE To examine the effects of specific inhibition of geranylgeranyl transferase I on the expression of types I and III collagen genes in normal and systemic sclerosis (SSc) dermal fibroblasts in vitro. METHODS Fibroblasts from 2 normal subjects and 4 SSc patients were incubated with 2-10 microM of GGTI-298, a specific geranylgeranyl transferase inhibitor. Type I collagen and fibronectin production were determined by enzyme-linked immunosorbent assay. Steady-state messenger RNA (mRNA) levels for alpha1(I), alpha2(I), and alpha1(III) collagens and fibronectin were assessed by Northern hybridization, and the transcription of the alpha1(I) collagen gene was examined by transient transfections with a reporter construct containing -5.3 kb of the gene. RESULTS GGTI-298 caused a dose-dependent inhibition of type I collagen production and a reduction in the steady-state levels of alpha1(I), alpha2(I), and alpha1(III) mRNA in normal and SSc cells. A 60-70% inhibition of type I collagen production and a 70-80% reduction in the mRNA levels for alpha1(I), alpha2(I), and alpha1(III) were observed at 10 microM GGTI-298. In contrast, the expression of fibronectin, cyclooxygenase 1, and GAPDH was not affected. The effects on alpha1(I) collagen mRNA resulted from a profound reduction in transcription of the alpha1(I) collagen gene promoter. GGTI-298 did not affect cellular viability or morphology. CONCLUSION These results demonstrate that specific inhibition of geranylgeranyl prenylation causes a potent and selective inhibition of expression of the genes encoding types I and III collagens, without affecting cellular viability. The findings indicate that inhibition of geranylgeranyl prenylation should be further studied as a potential therapeutic approach for SSc and other fibrosing diseases.

Mortality, Recurrence, and Hospital Course of Patients with Systemic Sclerosis-related Acute Intestinal Pseudo-obstruction

Objective. Acute intestinal pseudo-obstruction is a rare gastrointestinal manifestation of systemic sclerosis (SSc) with few data existing as to its demographics, clinical course, outcomes, and mortality. Methods. We undertook a case-control study to describe 64 cases in 37 unique patients, of whom 70% had spontaneous resolution with conservative measures of intravenous hydration and bowel rest, 9% underwent surgical resection, and 25% required prolonged total parenteral nutrition (TPN). Results. Hospital course was for a mean of 12 ± 12.5 days and there was a 16% patient mortality in our population. In a subgroup analysis, patients who had recurrent episodes of pseudo-obstruction were less likely to have esophageal involvement from SSc, and more likely to need prolonged TPN. Mortality tended to be higher in male patients and patients who did not have SSc-related esophageal involvement, and also in patients who had low hemoglobin and serum albumin at presentation. The need for a nasogastric tube for decompression and a surgical intervention correlated with a more prolonged hospital stay. Conclusion. To the best of our knowledge, ours is the largest study looking at this rare manifestation of SSc.

Sarcoid-Reaction Mimicking Metastatic Malignant Hepatopancreatobiliary Tumors: Report of Two Cases and Review of the Literature

IntroductionSarcoidosis is a multisystem chronic granulomatous disease found predominantly in the lungs and lymph nodes. Its pathologic hallmark is the presence of systemic non-caseating granulomas; however, a variation of this disease known as “sarcoid-like reaction” has been described in patients with underlying cancer.ReportSarcoid-like reactions in patients with hepatopancreatobiliary (HPB) tumors are rare findings, with only 15 cases having been reported in the English language literature. These reactions can be found in local lymph nodes or in distant organs, and when present in patients with cancer, they can mimic metastatic disease on imaging, potentially resulting in incorrect cancer staging and management.DiscussionWe describe two cases of patients with HPB tumors who had distant organ disease on cross-sectional imaging suspicious for metastases, which on further workup were found to be sarcoid-like reactions. We also discuss malignancy-induced sarcoid-like reactions and provide a review of the literature of sarcoid-like reactions in the setting of HPB tumors.

Primary amyloidosis causing diffuse alveolar hemorrhage.

Diffuse alveolar hemorrhage is a serious complication that has been described in various disease states including several vasculitic syndromes as well as conditions that may resemble vasculitis clinically. In this article, we present a case of 79-year-old man, who was admitted with productive cough, blood-tinged sputum, and a positive atypical antineutrophil cytoplasmic antibody pattern on indirect immunofluorescence microscopy. He subsequently developed frank hemoptysis and respiratory failure. Open lung biopsy demonstrated amyloid deposition within blood vessels. He was treated with 1 g of intravenous methylprednisolone over 3 days with rapid improvement in hemoptysis and hypoxemia. This case report and a review of literature illustrate unusual clinical manifestations of vascular amyloidosis that may be confused with vasculitis. Accurate diagnosis of this condition may improve clinical outcome and spare the patient from unwarranted, potentially harmful treatments.

Inhibition of collagen gene expression in systemic sclerosis dermal fibroblasts by mithramycin

Background: The anti-tumour antibiotic mithramycin is also a potent inhibitor of fibrosis after glaucoma surgery. This drug displays high affinity binding to GC-rich sequences in DNA, including those present in the promoter of the gene encoding the α1 chain of type I collagen (COL1A1). Objective: To evaluate the effects of mithramycin on COL1A1 expression in systemic sclerosis fibroblasts. Methods: Confluent cultures of dermal fibroblasts from patients with recent onset diffuse systemic sclerosis were treated with mithramycin in vitro. Cell viability and protein expression were examined by fluorescence and confocal imaging. Type I collagen production was analysed by confocal imaging and metabolic labelling. COL1A1 messenger RNA levels and stability were assessed by northern hybridisation, and COL1A1 transcription was examined by transient transfections. Results: Treatment of systemic sclerosis fibroblasts with mithramycin (10–100 nmol/l) did not cause significant cytotoxicity. Type I collagen biosynthesis decreased by 33–40% and 50–70% in cells cultured with mithramycin at 10 nmol/l and 100 nmol/l, respectively. Mithramycin at 50 nmol/l decreased COL1A1 mRNA levels by 40–60%. The effects of mithramycin on collagen gene expression were mediated by transcriptional and post-transcriptional mechanisms as shown by the reduction of COL1A1 promoter activity and by a decrease in the stability of these transcripts, respectively. Conclusions: Mithramycin causes potent inhibition of collagen production and gene expression in systemic sclerosis dermal fibroblasts in vitro in the absence of cytotoxic effects. These results suggest that this drug may be an effective treatment for the fibrotic process which is the hallmark of systemic sclerosis.

46, XX SRY-positive male syndrome presenting with primary hypogonadism in the setting of scleroderma.

OBJECTIVE To describe a case of SRY gene translocation in a man with scleroderma presenting with primary hypogonadism. METHODS We present the clinical, physical, laboratory, and pathologic findings of the study patient and discuss the cytogenetic analysis and the cause of the sexual dysfunction. Relevant literature is reviewed. RESULTS A 35-year-old man with a recent diagnosis of diffuse cutaneous sclerosis was referred by his rheumatologist because of a low testosterone level. His medical history was notable for right cryptorchidism corrected after birth. He had no history of sexual activity, but reported normal erectile function before his current presentation. Physical examination findings were remarkable for a height of 157.5 cm; weight of 72.7 kg; extensive, diffuse thickening of the skin; mild gynecomastia; little axillary and pubic hair; and soft testes (1-2 mL bilaterally). Initial laboratory testing revealed the following values: follicle-stimulating hormone, 22.1 mIU/mL (reference range, 1.4-18.1 mIU/mL); luteinizing hormone, 19.7 mIU/mL (reference range, 1.5-9.3 mIU/mL); total testosterone, 25 ng/dL (reference range, 241-827 ng/dL); and free direct testosterone, 0.8 pg/mL (reference range, 8.7-25.1 pg/mL). Laboratory test results were consistent with primary hypogonadism. A urologist performed testicular biopsy, which showed severe testicular atrophy with absent spermatogenesis. Primary hypogonadism due to Klinefelter syndrome or testicular fibrosis secondary to scleroderma was suspected. Karyotype analysis showed a 46, XX karyotype, and fluorescence in situ hybridization was consistent with a 46, XX, Xp22.3(SRY+) gene translocation. After a normal prostate-specific antigen level was documented, testosterone replacement therapy was initiated, and he was referred for genetic counseling. CONCLUSIONS The 46, XX SRY-positive male syndrome is rare. Adult diagnosis can be challenging because of normal sexual development. Scleroderma, which rarely can occur in Klinefelter-type syndromes, further complicated the diagnosis in this case.

Mortality, length of stay and cost of hospitalization among patients with systemic sclerosis: results from the National Inpatient Sample

Objectives To evaluate the hospitalizations and define the factors associated with in-hospital mortality, longer length of stay (LOS) and higher hospital costs among SSc hospitalizations. Methods We used the National Inpatient Sample (2012-13) to identify adult hospitalizations with SSc, excluding patients with concomitant diagnosis of RA and systemic lupus. We calculated rates of hospitalization, in-hospital mortality, LOS and hospital costs. Factors associated with these outcomes were evaluated by univariate and backward stepwise multivariate logistic regression. Results There were 9731 hospitalizations in the sample representing an estimated 48 655 hospitalizations nationwide with SSc (0.09%), and the inpatient mortality rate was 5%. Patients were predominantly older (mean age 63.2 years), female (82.2%) and Caucasian (71.5%). Infections were the most common primary diagnoses among SSc hospitalizations (17.4%) and among those who died (32.7%). Acute renal failure [adjusted odds ratio (aOR) = 4.3, 95% CI: 3.3, 5.6] and aspiration (aOR= 3.5, 95% CI: 2.5, 4.9) were strongly associated with in-hospital mortality. The median (interquartile range) LOS was 4 days (-2, 7), and the median (interquartile range) cost was