Efficacy and safety of intravenous cyclophosphamide pulse therapy with oral prednisolone in the treatment of interstitial lung disease with systemic sclerosis: 4-year follow-up.

Interstitial lung disease (ILD) is a noteworthy condition in the treatment of systemic sclerosis (SSc) because of its associated mortality and morbidity; however, the efficacy of various treatments for ILD has been controversial in previous reports. In this study, we examined the efficacy and safety of intravenous cyclophosphamide (IVCY) pulse therapy with prednisolone (PSL) for the treatment of ILD with SSc. A total of 121 patients with SSc were screened and evaluated for ILD, using high-resolution computed tomography of the chest, pulmonary function testing, and bronchoalveolar lavage. Thirteen patients with active ILD were enrolled in this study. The treatment protocol for ILD was 0.4 g/m(2) of body surface area of IVCY monthly plus 0.8 mg/kg of body weight of PSL daily. Two to six doses of IVCY were administered, depending on the remission of ILD. Initial PSL doses were maintained for a month and then gradually tapered to 10 mg daily. An activity index of ILD showed improvements in all patients in the 12 months after the initial intervention; however, four patients experienced recurrence of ILD after 24 months, and one additional patient had recurrence of ILD after 36 months. Seven patients reached the 48-month point with no recurrence of ILD. This long observational study for 48 months showed the efficacy of IVCY with PSL for active alveolitis in the first year. However, because five patients had recurrence of ILD more than 1 year after the treatment, it would be necessary to consider maintenance therapy for ILD beyond 1 year.

A patient with urinary tract tuberculosis during treatment with etanercept.

BACKGROUND: Tumor necrosis factor (TNF)-α inhibitors are widely used for rheumatoid arthritis (RA). However, there are several risks to use TNFα inhibitors. Given the properties of TNF-α inhibitors, prevention and early detection of tuberculosis (TB) are especially important. Even among TNF-α inhibitors, the risk of TB infection differs according to each drug. The incidence of TB is lowest with etanercept (ETN). We present a case of urinary tract TB during treatment with ETN. CASE REPORT: A 58-year-old woman was receiving ETN for RA. Before starting ETN, isoniazid (INH) prophylaxis was started. RA was well controlled by ETN. However, 32 months after starting ETN, she noticed urinary frequency and a sensation of residual urine. The diagnosis was elusive, and it took 3 months until urinary tract TB was finally diagnosed. The TB resolved with antituberculosis medication, but RA disease activity flared up after ETN was discontinued. ETN was resumed with careful monitoring for TB recurrence. After resuming ETN, the RA was again well controlled, with no recurrence of TB. CONCLUSIONS: Patients should be monitored for development of TB during ETN treatment, but ETN can be used safely with careful management.

Characteristics of patients with early systemic sclerosis and severe gastrointestinal tract involvement.

OBJECTIVE: To clarify the clinical features of patients with systemic sclerosis (SSc) who developed severe gastrointestinal tract (GIT) involvement in the early stage of the disease. METHODS: Three hundred two consecutive Japanese patients with SSc were investigated: Group 1 comprised 14 patients with severe GIT involvement (malabsorption syndrome and/or pseudo-obstruction) within 2 years of onset of SSc; group 2 consisted of all patients without severe GIT involvement (n = 288); and group 3 consisted of 117 patients without severe GIT involvement within 2 years of onset of SSc. Autoantibodies were evaluated using double immunodiffusion, ELISA, and immunoprecipitation. RESULTS: We found significant differences in clinical features among the 3 groups. Diffuse cutaneous type, erosive esophagitis, and myositis were more common in group 1 than in group 2 (p = 0.007, 0.003, and 0.003, respectively) or group 3 (p = 0.04, 0.002, and 0.01, respectively), whereas interstitial lung disease (ILD) was more frequent in group 2 (p = 0.005) and group 3 (p = 0.02) versus group 1. Antinuclear antibodies showed a nucleolar pattern significantly more frequently in group 1. Myositis-related autoantibodies, including anti-U1RNP, anti-U3RNP, anti-Ku, and anti-signal recognition particle antibodies, were observed in 57% of group 1. CONCLUSION: Our findings strongly suggest the existence of a subgroup of SSc patients with severe GIT involvement in the early stage. Among the Japanese individuals, these patients never developed severe ILD, even though they were classified as having diffuse cutaneous SSc.

Intracellular IL-1alpha-binding proteins contribute to biological functions of endogenous IL-1alpha in systemic sclerosis fibroblasts.

The aberrant production of precursor IL-1alpha (pre-IL-1alpha) in skin fibroblasts that are derived from systemic sclerosis (SSc) is associated with the induction of IL-6 and procollagen, which contributes to the fibrosis of SSc. However, little is understood about how intracellular pre-IL-1alpha regulates the expression of the other molecules in fibroblasts. We report here that pre-IL-1alpha can form a complex with IL-1alpha-binding proteins that is translocated into the nuclei of fibroblasts. Immunoprecipitation that used anti-human IL-1alpha Ab and (35)S-labeled nuclear extracts of fibroblasts showed three specific bands (approximately equal to 31, 35, and 65 kDa). The 31-kDa molecule was identified as pre-IL-1alpha, and the 35- and 65-kDa molecules might be pre-IL-1alpha-binding proteins. A partial sequencing for the 10 aa from the N-terminals of the molecules showed 100% homology for HAX-1 (HS1-associated protein X-1) and IL-1 receptor type II (IL-1RII). Suppression of the genes of HAX-1 or IL-1RII induced the inhibitory effects of IL-1 signal transduction, including production of IL-6 and procollagen, by fibroblasts. In particular, pre-IL-1alpha was not translocated into the nucleus by an inhibition of HAX-1. These findings reveal that nuclear localization of pre-IL-1alpha depends on the binding to HAX-1 and that biological activities might be elicited by the binding to both HAX-1 and IL-1RII in SSc fibroblasts.

Classification of systemic sclerosis in the Japanese population based on rapid progression of skin thickening.

In general, patients with systemic sclerosis (SSc) have been classified in two clinical subsets (diffuse and limited) based on the extent of skin thickening, and the extent of skin fibrosis is closely related to the severity of organ involvement and mortality rates. In addition, there is a rapid progression of skin thickening in diffuse cutaneous SSc (dcSSc). In this study, we classified a novel subset of SSc based on the rate of skin thickening progression, and evaluated the relationship of the subset to disease severity and laboratory markers. Thirty-three patients with dcSSc were included in the study. Participants who had a modified Rodnan's total skin thickness score higher than 15 points within a year from the first symptoms were defined as having rapidly progressive SSc (RPSSc; group 1), while all the other dcSSc patients were defined as having non-RPSSc (group 2). The frequencies of interstitial lung disease and renal crisis were significantly higher in group 1 than in group 2. The frequencies of anti-topoisomerase I antibody (anti-topo I) and anti-SS-A antibody were significantly higher in group 1 than in group 2. Conversely, the frequency of anticentromere antibody was significantly higher in group 2 than in group 1. This study demonstrates the clinical significance of a new subset of SSc (defined as RPSSc), which is characterized by a markedly rapid progression of skin thickening. This new classification may be useful for predicting the prognosis of SSc at an early stage, so that patients who should receive aggressive therapy with immunosuppressants might be identified.

Angiotensin II in the lesional skin of systemic sclerosis patients contributes to tissue fibrosis via angiotensin II type 1 receptors.

OBJECTIVE: Tissue fibrosis in systemic sclerosis (SSc) is attributed to excessive deposition of extracellular matrix components produced by fibroblasts in skin lesions. Angiotensin II (Ang II), a vasoconstrictive peptide, is reported to have profibrotic activity as a result of induction of the extracellular matrix. The aim of the present study was to examine the expression of Ang II and its type 1 (AT(1)) and type 2 (AT(2)) receptors in affected skin and dermal fibroblasts from patients with SSc and to study the role of Ang II in collagen production by SSc dermal fibroblasts. METHODS: Levels of Ang II in sera from SSc patients and normal subjects were measured by a solid-phase immobilized-epitope immunoassay. Expression of angiotensinogen (Angt) in the skin was evaluated by immunohistochemistry. Expression of Angt, AT(1), and AT(2) in cultured dermal fibroblasts was analyzed by reverse transcription-polymerase chain reaction and immunohistochemistry. Levels of type I procollagen produced by cultured dermal fibroblasts were measured by enzyme-linked immunosorbent assay. RESULTS: Serum Ang II levels in patients with diffuse cutaneous SSc were significantly higher than those in patients with limited cutaneous SSc and in healthy donors. Immunohistochemical and immunoblotting analyses showed that Angt was present in skin from SSc patients, but not in normal skin. Angt messenger RNA (mRNA) was expressed in fibroblasts from patients with diffuse cutaneous SSc who had high levels of serum Ang II, but not in normal fibroblasts. AT(1) mRNA expression was found in both SSc and normal fibroblasts, whereas AT(2) mRNA was found only in SSc fibroblasts. Exogenous Ang II augmented the production of type I procollagen and transforming growth factor beta1 by cultured fibroblasts via activation of AT(1). CONCLUSION: Aberrant Ang II production may be involved in tissue fibrosis through excessive production of the extracellular matrix components in SSc dermal fibroblasts. This suggests that the use of AT(1) receptor antagonists may be a novel strategy for the treatment of tissue fibrosis in SSc patients.

Expression of hepatocyte growth factor and its receptor (c-met) in skin fibroblasts from patients with systemic sclerosis.

OBJECTIVE: To determine the effect of excessive induction of hepatocyte growth factor (HGF)/c-met signaling in fibroblasts derived from patients with systemic sclerosis (SSc). METHODS: Fibroblasts were obtained from skin of patients with SSc and healthy controls. The 2.4 kb interleukin 1alpha (IL-1alpha) cDNA was subcloned into pcDNA3 expression vector, which was stably transfected into normal fibroblasts by lipofection. HGF production in cultured fibroblasts was measured by ELISA. C-met protein (a receptor for HGF) in cultured fibroblasts was evaluated by immunocytochemistry using polyclonal anti-c-met antibody. Production of procollagen type I was estimated by an ELISA system using antibodies against procollagen type I C-peptide. RESULTS: Cultured skin fibroblasts expressed mRNA and protein of HGF constitutively in both SSc and control cultures. However, HGF production in SSc fibroblasts was significantly higher than in normal fibroblasts. In both SSc and normal fibroblasts, HGF production was dose dependently increased by the addition of recombinant IL-1alpha. Immunocytochemical staining revealed that c-met was spontaneously expressed in SSc fibroblasts, whereas no expression of c-met was detected in normal fibroblasts. C-met mRNA was expressed in normal fibroblasts transfected with the IL-1alpha gene. Addition of recombinant HGF (100 ng/ml) to cultured SSc fibroblasts significantly decreased procollagen type I production. CONCLUSION: High concentration of HGF inhibited collagen production in cultured fibroblasts derived from patients with SSc. Overexpression of HGF/c-met appears to be a biological feedback response to the fibrotic process of SSc, suggesting that the antifibrotic effect of HGF might be used as a novel strategy for treatment of SSc.