EuropeanJournal of
Europ. J. Pediat. 124, 223--230 (1977)
Pediatrics 9 by Springer-Verlag 1977
Immunological Studies in Childhood Scleroderma W. StOgmann, M. Sandhofer, and J. Fritz The Department of Pediatrics (Director: Univ. Prof. Dr. E. Zweymtiller) and The Department of
Dermatology (Director: Univ. Prof: Dr. H. Kresbach) of the University of Graz, A-8036 Graz, Austria
Abstract. The results of immunological studies on 13 children suffering from scleroderma are reported. Antinuclear antibodies with speckled pattern of fluorescence could be found in systemic sclerosis and in 3 patients with scleroderma en bandes. The same patients (except but one with PSS) demonstrated high levels of D N A antibodies. The 2 patients with PSS were found to have a very low percentage of T cells, whereas the percentage of B cells was increased. The results demonstrate the significance of autoimmunity not only in systemic sclerosis but also in focal scleroderma. Beyond this it can be presumed that immune deficiency (with a defect in cellular immunity) may be the predisposing cause of at least progressive systemic sclerosis.
Key words: Progressive systemic sclerosis - Focal scleroderma - Antinuclear antibodies - Antibodies to D N A - T-cell decrease.
Zusammenfassung. An einem Krankengut yon 13 kindlichen Sklerodermiepatienten werden immunologische Untersuchungen durchgefihrt. Bei der progressiven systemischen Sklerodermie (PSS) und bei 3 Patienten mit einer Sklerodermie en bandes waren antinukleire Antik6rper mit fleckigem Kernfluoreszenzmuster nachweisbar. Bei den gleichen Patienten mit bandfSrmigen Skler~ und einem Fall von PSS mit fJbergang in einen Lupus erythematodes visceralis fand sich auch eine stark erh~hte D N A Bindungskapazitit. Schlieglich konnte bei den Fallen mit PSS eine TLymphocytopenie mit relativer B-Lymphocytenvermehrung festgestellt wetden. Aus diesen Untersuchungsbefunden, die mit den wenigen d a r i b e r in der Literatur mitgeteilten ibereinstimmen, li13t sich folgern, dab nicht nut bei PSS, sondern auch bei zirkumskripten Sklerodermieformen Autoimmunprozesse ablaufen, f3ber die itiopathogenetische Relevanz dieserAutoimmunAddress for offprint requests: Univ.-Doz. Dr. W. StSgmann, Univ.-Kinderklinik, Auengruggerplatz, A-8036 Graz, Osterreich
224
W. St6gmann et al. prozesse laBt sich derzeit noch nichts aussagen. Es ist nicht v o n d e r Hand zu weisen, dal~ zumindest bei der systemischen Sklerodermie hinsichtlich dieser Autoimmunprozesse auch eine St6rung des Immunzellgleichgewichtes (TZellverminderung) eine Rolle spielen k/Snnte.
Sclerodermas are a group of skin diseases which are characterised by an initial edemic stage, followed by a second one of sclerosis and a third final stage of total atrophy of the involved skin areas. Two forms of different significance and prognosis are differentiated: circumscript and systemic scleroderma (see Table 1) [15, 22]. Circumscript sclerodermas occur as morphea en plaques, when there exist only one lesion or a few ones, as morphea guttata (disseminated and small patches) or as generalised morphea with many and large lesions. Very interesting are the linear forms of sclerodermas in childhood: scleroderma en coup de sabre and that with facial atrophy may occur in early childhood, whereas scleroderma en bandes is seen especially in girls in puberty; this form usually affects a lower extremity which will show severe mutilation in consequence of atrophy of skin, subcutis and bone after a duration of disease of some years [16]. Progressive systemic sclerosis usually beginning with acral asphyxia, then extending over great areas of the skin and involving the inner organs belongs to the systemic forms of scleroderma. Mixed connective tissue disease and overlap syndrome belong here too. Systemic sclerodermas prefer younger women and girls over 10 years of age. The etiology of sclerodermas is still unknown. They are classified in the socalled collagen diseases, which are thought to be reaction diseases of mostly inflammatory origin [5]. Immunological studies were done on 13 children suffering from scleroderma, who were attended by the Pediatric Clinic in common with the Dermatologic Clinic of the University of Graz, Austria. The purpose of this study was to answer the following questions: are immunological abnormalities in sclerodermas, especially such as autoimmunity, of diagnostic value and of pathomechanical significance, and which similarities a n d / o r differences exist between the circumscript and systemic forms of sclerodermas. Table 1. Classification of sclerodermas
A. Circumscript 1. Morphea a) en plaques b) guttata c) generalised 2. Linear a) en coup de sabre b) with facial atrophy c) en bandes B. Systemic I. progressive systemic sclerosis 2. mixed connective tissue disease
Immunological Studies in Childhood Scleroderma
225
Table 2. Table of patients Case
Patient
Sex
Duration of disease (years)
Age (years)
Form of scleroderma
1 2
F, M. A.E.
F F
5 6
16 14
PSS (transition to LE) PSS (initial M C T D a)
F, A. S.E. K.B. G.M. R, A. W.P.
F F F F F M
3 8 5 4 4 7
14 13 15 12 5 13
en bandes en bandes en bandes en bandes facial atrophy en coup de sabre
S.A. H.P. S.H. D.D. M.B.
F M M F F
4 3 6 3 4
13 8 14 8 10
en en en en en
Linear 3 4 5 6 7 8
Morphea 9 l0 11 12 13
plaques plaques plaques plaqueand guttata plaques
a Mixed connective tissue disease
Materials and Methods Thirteen children with scleroderma comprised the study group (see Table 2). There were 10 females and 3 males, whose age at onset ranged between 1 and 11 years. The duration of disease varied from 3 to 8 years; mean duration at the time of study was 4.7 years. Two of the children had progressive systemic sclerosis: case I showed transition to systemic lupus erythematosus (SLE) after duration of the disease of 5 years (this patient died at 17 years of age); case 2 suffered from mixed connective tissue disease 3 years before the diagnosis of progressive systemic sclerosis (PSS) could be made. Eleven of the children had circumscript (or focal) scleroderma, 5 with patches of skin involvement typical of morphea, 6 with linear forms of the disease. At the time of study therapy was stopped. The following investigations were made: 1. 2. 3. 4. 5. 6. 7. 8.
Erythrocyte sedimentation rate (ESR) (according to Westergren) Blood count Electrophoresis Immunglobulins; quantitatively by radial immunodiffusion Muscle enzymes (GOT, CPK, ALD, LDH) Rheumatoid factor (RF) with Waaler-Rose test LE cell preparation Antinuclear antibodies (ANA) by indirect immunofluorescence; quantitative determination and evaluation of pattern of nuclear fluorescence 9. DNA binding activity (determination of D N A antibodies): by radioimmunoassay according to F A R R as modified by Pincus et al. [17] (in collaboration with the Institute of Biology, Research Center Seibersdorf, Director: Dr. H. Altmann); normal value: DNA binding activity below 25% 10. T-lymphocytes (T-Ly): determination by E-rosette technique. Normal: 50--70% 11. B-lymphocytes (B-Ly): by membrane fluorescence. Normal: 20--27%.
226
W, StOgmann et al.
Table 3. Laboratory findings I Form and patient
ESR
Blood count
G a m m a
Immuno-
globulins
globulins
Muscle enzymes
(%) PSS
1. F, M. 2. A . E .
90/120 15/35
Anemia --
36.2
G+++ G+
++++ ++++
Linear S.
3. F . A .
6/12
Eosin 9%
25
4. S . E . 5. K . B .
19/40 12/28
Eosin 10%
3O
6. G . M . 7. R. A, 8. W . P .
12/27 17/38 9/14
G+++ A+++ M+ A+++ M++
m
m
Morphea
9. 10. 11. 12. 13.
S.A. H. P. S.H. D.D. M.B.
10/26 11/29 2/4 10/19 2/5
G+ A+ A+
m
++
- - = normal; + = increased
Table 4. Laboratory findings II Form and patient
ANA
DNA binding activity
LE cell preparation
RF
T-Ly
B-Ly
(%)
(%)
(%) PSS
1. F. M. 2. A. E.
+++
79
+++
+
+++
25
--
--
25 40
42 40
+++ ++ +++
95 78 68
--
51
21 22 27 24 23 27
Linear S.
3. 4. 5. 6. 7. 8.
F. A. S. E. K. B. G. M. R. A. W. P,
--
64 68 59
--
16
--
29
--
55
--
14
--
49
--
65
--
71
--
Morphea
9. 10. 11. 12. 13.
S. A. H.P. S, H. D. D. M. B.
m
r
15 15 22 6 7
- - = normal or negative; + = increased
--
61
--
47
--
62
21 28 26 19 21
Immunological Studies in Childhood Scleroderma
227
Results Tables 3 and 4 show the results of our study. E S R was normal or only slightly increased except for case 1, who showed transition to SLE. Blood counts were in the normal range; only in cases 3 and 4 could a slight eosinophilia be seen. In three patients an increase of g a m m a globulins in electrophoresis was noted, highest in the SLE transition case. An increase of immunglobnlins, especially of IgG and IgA, but also in two cases of IgM, was found in seven patients (more than 50%) distributed a m o n g each of the three forms of scleroderma (systemic, m o r p h e a and linear). Seven children with systemic or circumscript scleroderma had increased levels of muscle enzymes indicating involvement of muscle tissue in the disease process. A N A could be found in the two cases with PSS and in three patients with scleroderma en bandes. The pattern of immunofluorescence was always a speckled one, therefore showing antibodies to acid nucleoproteins and ribonucleic acids (RNA); two of these patients also had a peripheral and homogeneous pattern of fluorescence. Very high levels of D N A antibodies were noted in the same patients (except for one with PSS); case 3 had the highest level with 95%. LE cells could be found in the SLE transition case only. The two patients with PSS were found to have a very low percentage of T cells whereas the percentage of B cells was relatively increased. In the case with scleroderma en coup de sabre and in one case with morphea T-lymphocytes were decreased to subnormal levels, whereas B-lymphocytes were in the normal range in all cases suffering f r o m circumscript scleroderma.
Discussion The results of our study agree with reports in the literature. In progressive
systemic sclerosis (PSS) positive tests for rheumatoid factor could be found in a third of all patients, without differences between children and adults. LE cells were demonstrable in 4% (ranging between 0 and 22%) of patients with PSS [2, 4]. J o r d o n et al. [12] found antinuclear antibodies in 13 of 27 adult patients with PSS, all with a speckled pattern of immunofluorescence. In children suffering from PSS A N A are demonstrable less c o m m o n l y than in adults: Sandhofer et al. [18] noted A N A in only 15 cases out of 39 patients (children and adults) and Kornreich et al. [14] in only 2 cases out of i2 children. All authors emphasize that there is no correlation between the presence and level of A N A to clinical activity and duration of disease. In typical cases of PSS D N A antibodies have not been found till now [9, 13, 18]; the positive test in case 1 of our study group is probably referable to the transition to SLE. A search of the literature does not reveal any reports about T- and B-lymphocytes in childhood scleroderma. There exist only a few reports on immunological studies in circumscript scleroderma in childhood. Like us (in three cases with scleroderma en bandes) Hanson et al. observed D N A antibodies in 31% of focal scleroderma [9, 10]; the same authors found positive tests for R F in a third of their patients [9].
228
W. St6gmann et al.
Summarizing these results for their diagnostic value it can be said that there can be demonstrated an involvement of the immune system, especially of autoimmunity, in systemic and circumscript scleroderma. It must be emphasized, however, that signs of autoimmunity cannot be found in every case but generally only in a third of patients. To date a specific autoantibody in patients with scleroderma has not been detected. The etiology of scleroderma is unknown. Pathogenetically in systemic scleroderma there is no doubt that immunologic mechanisms, if not the cause, perpetuate the disease. The progressive course of PSS, its possible onset as mixed connective tissue disease and its possible transition to other collagen diseases, especially in SLE, are evidence for this. The finding of ANA and antibodies to DNA by us and, as mentioned above, by other authors demonstrates the significance of autoimmunity in circumscript scleroderma too. The identical histology--in principle--of circumscript and systemic scleroderma [15, 22] and the possible though rare transition of circumscript to systemic disease [8, 24] also bespeak an obviously identical pathogenesis (with different intensity) of circumscript and systemic sclerodermas. Finally the question why autoimmune processes become manifest in patients suffering from scleroderma must be answered. Our interesting finding of a decrease of T-lymphocytes and an increase of B-lymphocytes may provide an answer, because this finding points to a lapse of the immune cell balance. Fudenberg [7] and other authors [20] had identical results in SLE; Fudenberg presumes that immune deficiency with a perhaps genetically determined defect in cellular immunity may be the predisposing cause of SLE and other autoimmunopathies [7, 26]. The often observed occurrence of collagen diseases and atopias and the coexistence of two autoimmunopathies in the same patient, the familial disposition to autoimmunopathies and the finding of antinuclear antibodies in healthy relatives also point to a genetically determined immune deficiency of collagen diseases [1, 4, 6, 21, 25]. Perhaps inborn or acquired deficiency o f T cells may be the cause of occurrence of malignant tumors in patients with collagen diseases [7, 19]. Based on these facts and considerations it can be presumed that a qualitative alteration of the immune system is of importance in the pathogenesis of scleroderma, according to Burnett's hypothesis of a loss of tolerance [23]. Besides a decrease of T-lymphocytes in SLE and PSS ascribed by Currie et al. [3] to the presence of cytotoxic antibodies to T cells, the leucocyte migration inhibition found by Hughes et al. in PSS also speaks for a loss of immune tolerance and for a deficiency of cell-mediated immunity. This decrease of T cells seems to be of clinical importance, as may be concluded from the negative skin tests for P P D and candida antigen in our two patients with PSS. Based on the findings of our study and of those of the references cited above it can be emphasized that circumscript and systemic scleroderma have an identical pathogenesis. Their differentiation rests on practical clinical considerations. It has to be presumed that autoimmunological factors, obviously involved in the pathogenesis, in circumscript scleroderma affect vascular tissue of the skin focally; on the other hand, in systemic scleroderma widespread areas of the vascular tissue of the skin and of other organs are affected. Beyond this it can be
Immunological Studies in Childhood Scleroderma
229
p r e s u m e d t h a t a n i n b o r n deficiency o f c e l l - m e d i a t e d i m m u n i t y m a y be the cause o f f o r m a t i o n o f antibodies. F o r all these new findings the fact r e m a i n s t h a t s c l e r o d e r m a in all of its t y p i c a l forms is a seronegative collagen disease.
References 1. Bl~iker, F., Fischer, K.: Dermatomyositis und Autoantik6rperan~imie bei schwcren Antik6rpermangelsyndromen. Mschr. Kinderheilk. 115, 453 (1967) 2. Burgio, G. R., Vaccaro, R.: Immunologische Befunde bei rheumatischen Erkrankungen im Kindesaltcr. Mschr. Kinderheilk. 117, 553 (1969) 3. Currie, S., Saunders, M., Knowles, M.: Immunological aspects of systemic sclerosis. Brit. J. Dermatology 84, 400 (1971) 4. Dubois, E. L., Chandor, St., Friou, G. J., Bischel, M.: Progressive systemic sclerosis and localized scleroderma with positive LE-cell test. Medicine 50, 199 (1971) 5. Fanconi, G.: Die Kollagenkrankheiten im Rahmen der Autoimmunkrankheiten. Mtinch. med. Wschr. 108, 633 (1966) 6. Fennell, R. H., MacLachlan, M. J., Rodnan, B. P.: The occurrence of antinuclear factors in the sera of relatives of patients with systemic rheumatic disease. Arthritis and Rheumatism 5, 296 (1962) 7. Fudenberg, H. H.: Genetically determined immune deficiency as the predisposing cause of autoimmunity and lymphoid neoplasia. Am. J. Med. 51, 295 (1971) 8. Grabner, K.: Zur Frage der l~bergangsformen zwischen Morphaea und progressiver Sklerodermie. Dermat. Wschr. 154, 625 (1968) 9. Hanson, V., Drexler, E., Kornreich, H.: DNA-Antibodies in Childhood Scleroderma. Arthritis and Rheumatism 13, 798 (t970) 10. Hanson, F., Johnson, G. D., Kornreich, H. K.: Systemic, diffuse and focal forms of scleroderma in children - - a unifying hypothesis. Excerpta Medica 299, Abstract 334 11. Hughes, P., Holt, S., Rowell, N. R.: Leucocyte migration inhibition in progressive systemic sclerosis. Brit. J. Dermatology 91, 1 (1974) 12. Jordon, R. E., Deheer, D., Schroeter, A., Winkelmann, R. K.: Antinuclear antibodies: their significance in scleroderma. Mayo Clin. Proc. 46, 111 (1971) 13. Kerl, H., Sandhofer, M., Klein, G., Altmann, H.: DNS-AntikOrperbestimmungen bei diffusen Bindegewebskrankheiten. Dtsch. med. Wschr. 99, 1626 (1974) 14. Kornreich, H. K., Drexler, E., Hanson, V.: Antinuclear factors in childhood rheumatic diseases. J. Pediat. 69, 1039 (1966) 15. Korting, G. W.: Sklerodermie und sklerodermie~ihnliche Erkrankungen. In: Dermatologie und Venerologie, Gottron, H. A. u. Sch6nfeld, W. (eds.), Vol. II/2/886. Stuttgart: Thieme 1958 16. Kresbach, H.: Zur Kenntnis der Sklerodermien im Kindesalter. Zschr. Haut-u. Geschlechtskr. 27, 343 (1959) 17. Pincus, Th., Schur, P. H., Rose, J. A., Decker, J. L., Talal, N.: Measurement of serum DNA-binding activity in systemic lupus erythematosus. N. Engl. J. Med. 281, 701 (1969) 18. Sandhofer, M., Kerl, H., Klein, G.: Vergleichende Untersuchungeniiber die DNS-Bindungsaktivit~it und das Kernfluoreszenzmuster antinukle~irer Faktoren bei der Sklerodermie. Vortrag bei der Tagung d. Osterreich. Liga zur Bek~impfung des Rheumatismus, Graz, 7.6. 1974 19. Sandhofer, M., Grond, K., Kresbach, H.: Gemeinsames Vorkommen von progressiver Sklerodermie und chronischer Lymphadenose. Wien. klin. Wschr. 87, 183 (1975) 20. Sandhofer, M., Fritz, J., Grond, K., Klein, G.: T- und B-Lymphocyten bei sog. Kollagenosen. Zschr. Rheumatologie 34, 418 (1976) 21. Straub, E., Sachtleben, P.: Autoaggressive Antik6rper bei Antik6rpermangelsyndrom. Mschr. Kinderhcilk. 115, 527 (1967) 22. Tuffanelli, D. L., Reed, W. B., Jablonska, St.: Scleroderma and sclerodermoid conditions. In: La sclerodermie/scleroderma. F. Detbarre (ed.). Paris: Masson 1972 23. Vorlaender, K. O.: Autoantik0rper und Pathogenit~tt. Dtsch. med. Wschr. 87, 887 (1962)
230
W. StSgmann et al.
24. Weidner, P., Braun-Falco, O.: Gleichzeitiges Vorkommen von Symptomen der circumskripten und progressiven Sklerodermie. Hautarzt 19, 345 (1968) 25. Wuthrieh, R. C., Roenigk, H. H., Steck, W. D.: Localized scleroderma. Arch. Dermatol. 111, 98 (1975) 26. Wybran, J., Fu,denberg, H.: How clinically useful is T- and B-cell quantitation? Ann. Intern. Med. 80, 765 (1974)
Received May 7, 1976
Europ. J. Pediat. 124, 223--230 (1977)
Pediatrics 9 by Springer-Verlag 1977
Immunological Studies in Childhood Scleroderma W. StOgmann, M. Sandhofer, and J. Fritz The Department of Pediatrics (Director: Univ. Prof. Dr. E. Zweymtiller) and The Department of
Dermatology (Director: Univ. Prof: Dr. H. Kresbach) of the University of Graz, A-8036 Graz, Austria
Abstract. The results of immunological studies on 13 children suffering from scleroderma are reported. Antinuclear antibodies with speckled pattern of fluorescence could be found in systemic sclerosis and in 3 patients with scleroderma en bandes. The same patients (except but one with PSS) demonstrated high levels of D N A antibodies. The 2 patients with PSS were found to have a very low percentage of T cells, whereas the percentage of B cells was increased. The results demonstrate the significance of autoimmunity not only in systemic sclerosis but also in focal scleroderma. Beyond this it can be presumed that immune deficiency (with a defect in cellular immunity) may be the predisposing cause of at least progressive systemic sclerosis.
Key words: Progressive systemic sclerosis - Focal scleroderma - Antinuclear antibodies - Antibodies to D N A - T-cell decrease.
Zusammenfassung. An einem Krankengut yon 13 kindlichen Sklerodermiepatienten werden immunologische Untersuchungen durchgefihrt. Bei der progressiven systemischen Sklerodermie (PSS) und bei 3 Patienten mit einer Sklerodermie en bandes waren antinukleire Antik6rper mit fleckigem Kernfluoreszenzmuster nachweisbar. Bei den gleichen Patienten mit bandfSrmigen Skler~ und einem Fall von PSS mit fJbergang in einen Lupus erythematodes visceralis fand sich auch eine stark erh~hte D N A Bindungskapazitit. Schlieglich konnte bei den Fallen mit PSS eine TLymphocytopenie mit relativer B-Lymphocytenvermehrung festgestellt wetden. Aus diesen Untersuchungsbefunden, die mit den wenigen d a r i b e r in der Literatur mitgeteilten ibereinstimmen, li13t sich folgern, dab nicht nut bei PSS, sondern auch bei zirkumskripten Sklerodermieformen Autoimmunprozesse ablaufen, f3ber die itiopathogenetische Relevanz dieserAutoimmunAddress for offprint requests: Univ.-Doz. Dr. W. StSgmann, Univ.-Kinderklinik, Auengruggerplatz, A-8036 Graz, Osterreich
224
W. St6gmann et al. prozesse laBt sich derzeit noch nichts aussagen. Es ist nicht v o n d e r Hand zu weisen, dal~ zumindest bei der systemischen Sklerodermie hinsichtlich dieser Autoimmunprozesse auch eine St6rung des Immunzellgleichgewichtes (TZellverminderung) eine Rolle spielen k/Snnte.
Sclerodermas are a group of skin diseases which are characterised by an initial edemic stage, followed by a second one of sclerosis and a third final stage of total atrophy of the involved skin areas. Two forms of different significance and prognosis are differentiated: circumscript and systemic scleroderma (see Table 1) [15, 22]. Circumscript sclerodermas occur as morphea en plaques, when there exist only one lesion or a few ones, as morphea guttata (disseminated and small patches) or as generalised morphea with many and large lesions. Very interesting are the linear forms of sclerodermas in childhood: scleroderma en coup de sabre and that with facial atrophy may occur in early childhood, whereas scleroderma en bandes is seen especially in girls in puberty; this form usually affects a lower extremity which will show severe mutilation in consequence of atrophy of skin, subcutis and bone after a duration of disease of some years [16]. Progressive systemic sclerosis usually beginning with acral asphyxia, then extending over great areas of the skin and involving the inner organs belongs to the systemic forms of scleroderma. Mixed connective tissue disease and overlap syndrome belong here too. Systemic sclerodermas prefer younger women and girls over 10 years of age. The etiology of sclerodermas is still unknown. They are classified in the socalled collagen diseases, which are thought to be reaction diseases of mostly inflammatory origin [5]. Immunological studies were done on 13 children suffering from scleroderma, who were attended by the Pediatric Clinic in common with the Dermatologic Clinic of the University of Graz, Austria. The purpose of this study was to answer the following questions: are immunological abnormalities in sclerodermas, especially such as autoimmunity, of diagnostic value and of pathomechanical significance, and which similarities a n d / o r differences exist between the circumscript and systemic forms of sclerodermas. Table 1. Classification of sclerodermas
A. Circumscript 1. Morphea a) en plaques b) guttata c) generalised 2. Linear a) en coup de sabre b) with facial atrophy c) en bandes B. Systemic I. progressive systemic sclerosis 2. mixed connective tissue disease
Immunological Studies in Childhood Scleroderma
225
Table 2. Table of patients Case
Patient
Sex
Duration of disease (years)
Age (years)
Form of scleroderma
1 2
F, M. A.E.
F F
5 6
16 14
PSS (transition to LE) PSS (initial M C T D a)
F, A. S.E. K.B. G.M. R, A. W.P.
F F F F F M
3 8 5 4 4 7
14 13 15 12 5 13
en bandes en bandes en bandes en bandes facial atrophy en coup de sabre
S.A. H.P. S.H. D.D. M.B.
F M M F F
4 3 6 3 4
13 8 14 8 10
en en en en en
Linear 3 4 5 6 7 8
Morphea 9 l0 11 12 13
plaques plaques plaques plaqueand guttata plaques
a Mixed connective tissue disease
Materials and Methods Thirteen children with scleroderma comprised the study group (see Table 2). There were 10 females and 3 males, whose age at onset ranged between 1 and 11 years. The duration of disease varied from 3 to 8 years; mean duration at the time of study was 4.7 years. Two of the children had progressive systemic sclerosis: case I showed transition to systemic lupus erythematosus (SLE) after duration of the disease of 5 years (this patient died at 17 years of age); case 2 suffered from mixed connective tissue disease 3 years before the diagnosis of progressive systemic sclerosis (PSS) could be made. Eleven of the children had circumscript (or focal) scleroderma, 5 with patches of skin involvement typical of morphea, 6 with linear forms of the disease. At the time of study therapy was stopped. The following investigations were made: 1. 2. 3. 4. 5. 6. 7. 8.
Erythrocyte sedimentation rate (ESR) (according to Westergren) Blood count Electrophoresis Immunglobulins; quantitatively by radial immunodiffusion Muscle enzymes (GOT, CPK, ALD, LDH) Rheumatoid factor (RF) with Waaler-Rose test LE cell preparation Antinuclear antibodies (ANA) by indirect immunofluorescence; quantitative determination and evaluation of pattern of nuclear fluorescence 9. DNA binding activity (determination of D N A antibodies): by radioimmunoassay according to F A R R as modified by Pincus et al. [17] (in collaboration with the Institute of Biology, Research Center Seibersdorf, Director: Dr. H. Altmann); normal value: DNA binding activity below 25% 10. T-lymphocytes (T-Ly): determination by E-rosette technique. Normal: 50--70% 11. B-lymphocytes (B-Ly): by membrane fluorescence. Normal: 20--27%.
226
W, StOgmann et al.
Table 3. Laboratory findings I Form and patient
ESR
Blood count
G a m m a
Immuno-
globulins
globulins
Muscle enzymes
(%) PSS
1. F, M. 2. A . E .
90/120 15/35
Anemia --
36.2
G+++ G+
++++ ++++
Linear S.
3. F . A .
6/12
Eosin 9%
25
4. S . E . 5. K . B .
19/40 12/28
Eosin 10%
3O
6. G . M . 7. R. A, 8. W . P .
12/27 17/38 9/14
G+++ A+++ M+ A+++ M++
m
m
Morphea
9. 10. 11. 12. 13.
S.A. H. P. S.H. D.D. M.B.
10/26 11/29 2/4 10/19 2/5
G+ A+ A+
m
++
- - = normal; + = increased
Table 4. Laboratory findings II Form and patient
ANA
DNA binding activity
LE cell preparation
RF
T-Ly
B-Ly
(%)
(%)
(%) PSS
1. F. M. 2. A. E.
+++
79
+++
+
+++
25
--
--
25 40
42 40
+++ ++ +++
95 78 68
--
51
21 22 27 24 23 27
Linear S.
3. 4. 5. 6. 7. 8.
F. A. S. E. K. B. G. M. R. A. W. P,
--
64 68 59
--
16
--
29
--
55
--
14
--
49
--
65
--
71
--
Morphea
9. 10. 11. 12. 13.
S. A. H.P. S, H. D. D. M. B.
m
r
15 15 22 6 7
- - = normal or negative; + = increased
--
61
--
47
--
62
21 28 26 19 21
Immunological Studies in Childhood Scleroderma
227
Results Tables 3 and 4 show the results of our study. E S R was normal or only slightly increased except for case 1, who showed transition to SLE. Blood counts were in the normal range; only in cases 3 and 4 could a slight eosinophilia be seen. In three patients an increase of g a m m a globulins in electrophoresis was noted, highest in the SLE transition case. An increase of immunglobnlins, especially of IgG and IgA, but also in two cases of IgM, was found in seven patients (more than 50%) distributed a m o n g each of the three forms of scleroderma (systemic, m o r p h e a and linear). Seven children with systemic or circumscript scleroderma had increased levels of muscle enzymes indicating involvement of muscle tissue in the disease process. A N A could be found in the two cases with PSS and in three patients with scleroderma en bandes. The pattern of immunofluorescence was always a speckled one, therefore showing antibodies to acid nucleoproteins and ribonucleic acids (RNA); two of these patients also had a peripheral and homogeneous pattern of fluorescence. Very high levels of D N A antibodies were noted in the same patients (except for one with PSS); case 3 had the highest level with 95%. LE cells could be found in the SLE transition case only. The two patients with PSS were found to have a very low percentage of T cells whereas the percentage of B cells was relatively increased. In the case with scleroderma en coup de sabre and in one case with morphea T-lymphocytes were decreased to subnormal levels, whereas B-lymphocytes were in the normal range in all cases suffering f r o m circumscript scleroderma.
Discussion The results of our study agree with reports in the literature. In progressive
systemic sclerosis (PSS) positive tests for rheumatoid factor could be found in a third of all patients, without differences between children and adults. LE cells were demonstrable in 4% (ranging between 0 and 22%) of patients with PSS [2, 4]. J o r d o n et al. [12] found antinuclear antibodies in 13 of 27 adult patients with PSS, all with a speckled pattern of immunofluorescence. In children suffering from PSS A N A are demonstrable less c o m m o n l y than in adults: Sandhofer et al. [18] noted A N A in only 15 cases out of 39 patients (children and adults) and Kornreich et al. [14] in only 2 cases out of i2 children. All authors emphasize that there is no correlation between the presence and level of A N A to clinical activity and duration of disease. In typical cases of PSS D N A antibodies have not been found till now [9, 13, 18]; the positive test in case 1 of our study group is probably referable to the transition to SLE. A search of the literature does not reveal any reports about T- and B-lymphocytes in childhood scleroderma. There exist only a few reports on immunological studies in circumscript scleroderma in childhood. Like us (in three cases with scleroderma en bandes) Hanson et al. observed D N A antibodies in 31% of focal scleroderma [9, 10]; the same authors found positive tests for R F in a third of their patients [9].
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Summarizing these results for their diagnostic value it can be said that there can be demonstrated an involvement of the immune system, especially of autoimmunity, in systemic and circumscript scleroderma. It must be emphasized, however, that signs of autoimmunity cannot be found in every case but generally only in a third of patients. To date a specific autoantibody in patients with scleroderma has not been detected. The etiology of scleroderma is unknown. Pathogenetically in systemic scleroderma there is no doubt that immunologic mechanisms, if not the cause, perpetuate the disease. The progressive course of PSS, its possible onset as mixed connective tissue disease and its possible transition to other collagen diseases, especially in SLE, are evidence for this. The finding of ANA and antibodies to DNA by us and, as mentioned above, by other authors demonstrates the significance of autoimmunity in circumscript scleroderma too. The identical histology--in principle--of circumscript and systemic scleroderma [15, 22] and the possible though rare transition of circumscript to systemic disease [8, 24] also bespeak an obviously identical pathogenesis (with different intensity) of circumscript and systemic sclerodermas. Finally the question why autoimmune processes become manifest in patients suffering from scleroderma must be answered. Our interesting finding of a decrease of T-lymphocytes and an increase of B-lymphocytes may provide an answer, because this finding points to a lapse of the immune cell balance. Fudenberg [7] and other authors [20] had identical results in SLE; Fudenberg presumes that immune deficiency with a perhaps genetically determined defect in cellular immunity may be the predisposing cause of SLE and other autoimmunopathies [7, 26]. The often observed occurrence of collagen diseases and atopias and the coexistence of two autoimmunopathies in the same patient, the familial disposition to autoimmunopathies and the finding of antinuclear antibodies in healthy relatives also point to a genetically determined immune deficiency of collagen diseases [1, 4, 6, 21, 25]. Perhaps inborn or acquired deficiency o f T cells may be the cause of occurrence of malignant tumors in patients with collagen diseases [7, 19]. Based on these facts and considerations it can be presumed that a qualitative alteration of the immune system is of importance in the pathogenesis of scleroderma, according to Burnett's hypothesis of a loss of tolerance [23]. Besides a decrease of T-lymphocytes in SLE and PSS ascribed by Currie et al. [3] to the presence of cytotoxic antibodies to T cells, the leucocyte migration inhibition found by Hughes et al. in PSS also speaks for a loss of immune tolerance and for a deficiency of cell-mediated immunity. This decrease of T cells seems to be of clinical importance, as may be concluded from the negative skin tests for P P D and candida antigen in our two patients with PSS. Based on the findings of our study and of those of the references cited above it can be emphasized that circumscript and systemic scleroderma have an identical pathogenesis. Their differentiation rests on practical clinical considerations. It has to be presumed that autoimmunological factors, obviously involved in the pathogenesis, in circumscript scleroderma affect vascular tissue of the skin focally; on the other hand, in systemic scleroderma widespread areas of the vascular tissue of the skin and of other organs are affected. Beyond this it can be
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p r e s u m e d t h a t a n i n b o r n deficiency o f c e l l - m e d i a t e d i m m u n i t y m a y be the cause o f f o r m a t i o n o f antibodies. F o r all these new findings the fact r e m a i n s t h a t s c l e r o d e r m a in all of its t y p i c a l forms is a seronegative collagen disease.
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24. Weidner, P., Braun-Falco, O.: Gleichzeitiges Vorkommen von Symptomen der circumskripten und progressiven Sklerodermie. Hautarzt 19, 345 (1968) 25. Wuthrieh, R. C., Roenigk, H. H., Steck, W. D.: Localized scleroderma. Arch. Dermatol. 111, 98 (1975) 26. Wybran, J., Fu,denberg, H.: How clinically useful is T- and B-cell quantitation? Ann. Intern. Med. 80, 765 (1974)
Received May 7, 1976
