Clinical Subset, Skin Manifestations And Th17 Cell In Systemic Sclerosis

PartⅠClinical relevance between two clinical subset and serum antinuclear antibodies in Systemic sclerosisBackground and Objective Systemic sclerosis (SSc) is a rare, heterogeneous disease, with excessive fibrosis of the skin and various internal organs. Based on the skin involvement, SSc is divided into two clinical subset:diffuse cutaneous Systemic sclerosis (dcSSc) and limited cutaneous Systemic sclerosis (lcSSc). It has been reported that the particular antinuclear antibodies (ANA) are often indicative of clinical diagnosis, clinical subset and prognosis. Currently there are little clinical study on a large sample of SSc patients, more of analytical data on SSc skin lesion. This study aimed to observe comprehensively the skin lesion,other clinical manifestations and laboratory features of SSc patients, trying to explore the relevance between two clinical subsets and serum ANA (anti-Scl-70 autoantibodies and anticentromere antibody) in SSc patients in China.Methods We studied 171 Chinese patients with SSc. A questionnaire was developed to collect a core set of clinical data to determine the current disease status. Comprehensive examinations and pictures were given to the skin involvement in SSc patients. Patients were grouped into tow descriptive disease subsets, i.e. diffuse cutaneous Systemic sclerosis (dcSSc) limited cutaneous Systemic sclerosis (lcSSc). Patients also classified into two-based subgroups according two types of ANA: anti-Scl-70 autoantibodies (AT-Scl-70ab) and anticentromere antibody (ACA).Results for 171 patients with SSc(female/male 6.4:1.), the average age is 51.4±14 years old and the average age of RP (Raynaud's phenomenon) onset was 38.4±13.2 years old with the interval of 4.7±4.3 years from RP onset to primary skin sclerosis or organ injury.89.9% of 171 SSc patients presented with Raynaud's phenomenon and 81% with Raynaud's phenomenon as initial manifestations. The occurence of other skin lesions were:61.2% poikeloderma,51.7% telangiectasia,5.6% skin calcinosis,27.5% Sjogren's syndrome,39.9% finger ulcers,32% joint contractures,28.7% bone absorption and 17.4% patients with limitation of mouth opening or ankyloglossia. Of the 171 patients,66.1% of patients had lcSSc and 33.9% dcSSc. Patients positive for ACA mostly (83.3%) had lcSSc, whereas only 55.1% of those carrying Scl70 autoantibodies had dcSSc; 44.9% of Scl70-positive patients were classified as lcSSc. On one hand, the presence of autoantibodies (Scl70 and ACA) distinguished the frequency of clinical manifestations very similarly to the distinction of dcSSc and lcSSc subsets. Scl70 positivity, like diffuse skin involvement, was associated with significant differences in the prevalence of pulmonary fibrosis, tendon friction rubs, joint contractures. Pulmonary fibrosis for instance, which was significantly more frequent in dcSSc(71.7%) than in lcSSc(50%, P<0.05), was also more common in patients carrying Scl70 autoantibodies than ACA. However, there were some differences. Most notably, isolated pulmonary hypertension was more common in in patients with ACA (13.4%) than Scl70 autoantibodies (3.4%, P<0.05). The prevalence of oesophageal involvement, elevated acute-phase reactants (>30 mm/h), high C reactive protein (CRP), hypocomplementaemia was associated with diffuse skin involvement, but not with autoantibody status.Conclusion Our analysis confirms the importance of dcSSc and lcSSc scleroderma subdivision in their association with particular organ manifestations. Clearly, both clinical and laboratory parameters must be combined and evaluated longitudinally in the prognostication of SSc.PartⅡNailfold videocpillaroscopic patterns and its clinical significance in systemic sclerosisBackground and objective Nailfold microcirculation changes play an important role on the diagnosis and differential diagnosis of SSc. In this study we used nailfold videocapillaroscopy (nailfold videocapillaroscopy, NVC) to observe nailfold microcirculation changes in a group of SSc patients and try to grade scleroderma microangiophathy into four NVC patterns. By comparing the NVC patterns in all enrolled subjects, we expect to find out the common and specific features of NVC patterns among different types of connective tissue diseases(CTDs) and assess the role of NVC examination on the diagnosis and differential diagnosis of CTDs like SSc,SLE,UCTD etc.Method A colour digital video camera attached to a stereomicroscope was used to capture nailfold capillary images. Computerised image processing was used to analyse and store data. Subsequent quantitative and qualitative morphological analysis was performed in the following connective tissue diseases (CTDs) patient and control groups:120 patients with systemic sclerosis(SSc),31 with systemic lupus erythematosus(SLE),13 with dermatomyositis (DM),5with mixed connective tissue disease (MCTD), undifferentiated connective tissue disease (UCTD) and 20 healthy adults. Based on LeRoy's criteria,120 patients with SSc (102women and 18men) were clinically defined into two subsets:81 1cSSc (limited cutaneous SSc) and 39 dcSSc (diffuse cutaneous SSc). The age at onset of Raynaud's phenomenon (RP) and SSc, the durations of RP and SSc, antitopoisomerase (anti-Scl70) and anticentromere (ACA) autoantibodies were recorded and analyzed in all patients. We analyzed NVC data under the five variables (enlargement of capillary, number of abnormal capillary, hemorrhage of capillary, loss of capillary, disorganization of capillary) for semi-quantitative classification based on which the SSc patients were grouped into four NVC patterns:early NVC Group, inactive NVC Group, active NVC Group, and late NVC Group. The relevance of the NVC patterns and clinical features was also studied.ResultsNVC patterns in 120 SSc patients:enlarged capillary loops were observed in 75.8%(91 cases), giant capillary loops in 66.7%(80 cases), bushy capillary in 33% (41 cases), avascularity in 53%(64 cases), and disorganized vascularity in 61.7%(74 cases).NVC patterns in 30 SLE patients:enlarged capillary loops were observed in 93.5%(91 cases), giant capillary loops in 6.5%(2 cases), bushy capillary in 16.1%(5 cases), avascularity in 9.7%(3 cases), and disorganized vascularity in 22.6%(7 cases).NVC patterns in 13 DM patients:enlarged capillary loops were observed in 76.9%(10 cases), giant capillary loops in 23.1%(10 cases), bushy capillary in 46.2% (6 cases), avascularity in 30.8%(4 cases), and disorganized vascularity in 46.2%(6 cases).NVC patterns in 5 MCTD patients:enlarged capillary loops were observed in 80.0%(4 cases), giant capillary loops in 20.0%(1 cases), bushy capillary in 20.0%(1 cases), avascularity in 40.0%(2 cases) and disorganized vascularity in 40.0%(2 cases).NVC patterns in 14 UCTD patients:enlarged capillary loops were observed in 71.4%(10 cases), giant capillary loops in 42.9%(6 cases), bushy capillary in 28.6% (4 cases), avascularity in 21.4%(3 cases), and disorganized vascularity in 21.4%(3 cases).NVC patterns in 20 healthy adults:only four had enlarged capillary loops. giant capillary loops,bushy capillary,avascularity and disorganized vascularity were not observed.Universality and particularity:Enlarged capillary loop and capillary hemorrhage were more frequent in CTD patients in contrast to healthy adults. However giant capillary loops,bushy capillary,avascularity and disorganized vascularity were in SSc patients with more frequency than other CTDs and the first two signs could also be found in DM patients。Enlarged capillary loop was prominent in SLE patients.The features of NVC patterns in SSc patients:Early NVC Group:mild enlarged capillary; few abnormal capillaries; few hemorrhages; normal organization of vascularity; no capillary loss.Inactive NVC Group:mild to moderate enlarged capillary; moderate abnormal capillaries; few hemorrhages; mild to moderate disorganization of vascularity; no or mild loss of capillary.Active NVC Group:moderate to severe enlarged capillary; moderate to severe abnormal capillaries; moderate to severe hemorrhages; mild to moderate disorganization of vascularity; moderate to severe loss of capillary.Late NVC Group:severe loss of capillary(>50% total area); massive avacularity; severe disorganization of vascularity;The early NVC pattern was observed in 23 (19.17%) patients, the inactive NVC pattern in 37 patients (30.83%),the active NVC pattern 29 (24.17%) and the late NVC pattern 31 (25.83%). The study found the age at onset of SSc was significantly lower in patients with the late NVC pattern characterized by severe capillary architectural disorganization and massive loss of capillary loops. The frequency of anti-Scl70 antibody positivity was significantly less in the early group than both the active group and the late group. ACA antibody positivity were statistically more frequent in both the early group and the inactive group than the late group. In patients with dcSSc, the late NVC pattern was observed more proportionally than other NVC patterns, however there were no significant differences among the four NVC patterns in patients with dcSSc. Conclusion Enlarged capillary loop and capillary hemorrhage were more frequent in CTD patients. However giant capillary loops,bushy capillary,avascularity and disorganized vascularity were in SSc patients with more frequency than other CTDs and the first two signs could also be found in DM patients. By large samples of SSc patients, we explore and establish a method to evaluate microangiophathy and four NVC patterns in SSc patients, which may reflect the evolution of SSc microvascular pathology. The positivity of anti-Scl-70 antibody appears to be more related with both active and late NVC types than NVC types; however the positivity of AC A indicates milder microvascular lesions.PartⅢIncreased Th17 cells in systemic sclerosis correlates with disease activityBackground and Objective A growing number of evidence shows Th17/Treg cells play an important role in the pathogenesis of connective tissue diseases(CTD) such as systemic lupus erythematosus (SLE) and psoriasis with the dominant role of Th17 cells and suppressed Treg cells. However, little is known about the function of Th17/Treg cells in systemic sclerosis (SSc) with scanty research. The purpose of this study is to evaluate the level of Th17/Treg cells, related transcription factors and cytokines in the peripheral blood of SSc patients and analyze their correlations with the disease activity and explore the preliminary mechanisms involved.Methods 45 SSc patients were enrolled with informed consent (36 women and 9 men).13 Patients with Valentini score≥3 were classified as active group. Inactive group comprised 32 Patients with Valentini score<3.24 healthy adults were included in control group. Flow cytometry was used to detect the amount of Th17 and Treg cells in the peripheral blood from all the subjects. The level of IL-17A, RoRyt, FoxP3 mRNA in the peripheral blood mononuclear cells (PMBC) were measured respectively with Quantitative PCR. ELISA assay was performed to discover IL-17 concentration in the serum. Data were statistically analyzed including the correlation between each level of Th17 cells, IL-17A and RoRyt mRNA or serum IL-17 and disease activity index.Results The level of Th17 cells in active group was significantly higher than the other two groups (P<0.05), with no statistical difference between control group and inactive group. The results of the other indicators including IL-17A mRNA RoRyt mRNA and serum IL-17 compared among the three groups were similar to Th17 cells (P values were <0.05). The level of Treg cells in peripheral blood had no significant differences among the three groups (P> 0.05), so did the level of FoxP3 mRNA P> 0.05). Correlation analysis showed that the level of both Th17 cells and serum IL-17 were positively correlated with disease activity.Conclusion This study found that increased level of Th17 cells occurred in patients with SSc, being accompanied with elevated levels of RoRyt mRNA and cytokine IL-17.Disease activity score was positively correlated with the level of Th17 cell and IL-17. However, there is significant difference for Treg cells and FoxP3 between SSc patients and health people. This study again confirmed the role the Th17 cells in the pathogenesis of SSc similar with other connective tissue diseases such as SLE, psoriasis and etc. However, the function of Treg cells in SSc may be somewhat different with one in other connective tissue diseases such as SLE, psoriasis and etc. So, to understand how Th17/Treg cells act in SSc and its clinical significance need further study.