Sclérodermie Systémique: bilan initial, examens de...
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Sclérodermie Systémique:
bilan initial, examens de surveillance
Eric Hachulla
Scleroderma National Centre
Department of Internal Medicine
Lille University, France
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• Prévalence
– USA : 260 millions d’habitants
– UK : 13 à 48/million d’habitants
– Australie : 86/million d’habitants
– France (Seine-Saint-Denis) : 158/million d’adultes
6 à 8 000 SSc adultes en France
• Incidence aux USA et en Europe : 4,5 à 18,5 nouveaux cas/million d’habitants
Gaubitz M. Rheumatology 2006;45:ii3 Le Guern. Rheumatology 2004;43:1129
Epidemiology
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Erasmus LD. Scleroderma in gold
miners on the Witwatersrand
with particular reference to pulmonary
manifestations. S Afr J Lab
Clin Med 1957; 3: 209–31
Epidemiology
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Epidemiology
Erasmus LD. Scleroderma in gold
miners on the Witwatersrand
with particular reference to pulmonary
manifestations. S Afr J Lab
Clin Med 1957; 3: 209–31
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Kettaneh J Rheumatol 2007;34:97
Epidemiology
Organic solvents
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Adapted from Varga J and Abraham D. J Clin Invest 2007;117:557
iv
Progenitor cells
Pericytes, BM- &
monocyte-derived MSCs,
Epithelial cells?
ECM synthesis, deposition,
contractions, and remodeling FIBROSIS
i
Vascular injury
Endothelial cell activation
Leukocyte adhesion
Vascular obliteration
Defective vasculogenesis
Tissue hypoxia
Endothelin
Tissue injury ii Inflammation
T cell & monocyte activation, TH2, TH17 cytokine production:
IL17, IL13
Autoimmunity B cell activation
Autoantibodies iii
Fibroblast activation
and differentiation
Recruit
-ment
Myofibroblast
Fibroblast
v
Courtesy Pr Alan Tyndall
Scleroderma physiopathology
PDGF, TGFb IL1, IL4
PDGF, TGFb IL1, IL4
VASCULOPATHY
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Delay between RP onset and first non-RP clinical symptom : 6 ± 9 years
(Hachulla E. Arthritis Rheum 2005;52:3792)
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Hachulla E. Arthritis Rheum 2005;52:3792
All dcSSc lcSSc p
Patients 599 165 434
Male 16% 22% 14% 0.01
Age (years) 55 ± 13 53 ± 13 55 ± 13 0.10
Occupational risks 11% 13% 10% 0.23
Delay between RP onset and
first non-RP clinical symptom
(years)
6 ± 9 3 ± 6 7 ± 10 <0.0001
Time since first non-RP
symptom onset (years)
7 ± 7 8 ± 7 7 ± 7 0.09
Age at first non-RP symptom
onset
46 ± 14 44 ± 14 47 ± 14 0.008
Raynaud’s phenomenon: first sign of SSc?
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Mean age at first non-RP symptom onset: 46 ± 14 years
(Hachulla E. Arthritis Rheum 2005;52:3792)
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Mean age at first non-RP symptom onset: 46 ± 14 years
(Hachulla E. Arthritis Rheum 2005;52:3792)
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Mean age at first non-RP symptom onset: 46 ± 14 years
(Hachulla E. Arthritis Rheum 2005;52:3792)
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Arthritis Rheum 1980;23:581
Classification criteria
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Arthritis Rheum 1980;23:581
Classification criteria
10 to 30% of SSc patients do not fulfill the 1980 preliminary criteria!
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LeRoy EC. J Rheumatol 1988 ;15 :202
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LeRoy EC. J Rheumatol 1988 ;15 :202
Classification criteria
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LeRoy EC. J Rheumatol 1988 ;15 :202
Classification criteria
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A
A] Ac anticentromères : L'aspect en IFI est très évocateur avec une fluorescence d'une trentaine de grains, réguliers, sur les noyaux de toutes les cellules à l’interphase. Ces grains s'alignent le long du fuseau de mitose en phase mitotique (plaque équatoriale, flèches). Cet examen suffit à l'identification de cette spécificité d'auto-anticorps. B] Ac antiScl 70 : La fluorescence est homogène dite en « verre dépoli » pour l’ensemble du noyau. Un marquage du nucléole peut être observé. Les cellules en mitose sont plus fluorescentes. .
B
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C et D] Ac antiPmScl et antiU3 RNP (antifibrillarine) : l'IFI montre un marquage nucléolaire.
C D
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natural history Diffuse versus limited scleroderma
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Hachulla E. Arthritis Rheum 2005;52:3792
All dcSSc lcSSc p
Patients 599 165
(27.5%)
434
(72.5%)
Male 16% 22% 14% 0.01
Age (years) 55 ± 13 53 ± 13 55 ± 13 0.10
Occupational risks 11% 13% 10% 0.23
Delay between RP onset and
first non-RP clinical symptom
(years)
6 ± 9 3 ± 6 7 ± 10 <0.0001
Time since first non-RP
symptom onset (years)
7 ± 7 8 ± 7 7 ± 7 0.09
Age at first non-RP symptom
onset
46 ± 14 44 ± 14 47 ± 14 0.008
Diffuse versus limited scleroderma
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Alamanos Y. Semin Arthritis Rheum 2005; 34: 714
Diffuse versus limited scleroderma survival
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ILD and lung fibrosis
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ILD and lung fibrosis
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ILD extent on HRCT scan Interest in clinical practice
Goh NS. Am J Respir Crit Care Med 2008; 177: 1248
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ILD extent on HRCT scan Interest in clinical practice
Goh NS. Am J Respir Crit Care Med 2008; 177: 1248
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Heart involvement
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Heart involvement
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Hachulla AL. Ann Rheum Dis 2009; 68: 1878
Localized thinning of LV in 29% T2 delayed contrast enhancement in 12%
Heart involvement
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Digital arteriopathy
Intimal and medial hyperplasia & proliferation
Adventitial fibrosis
Compromised lumen
Pulmonary arterial
hypertension
Scleroderma renal crisis1
1. Image courtesy of Luc Mouthon
Microangiopathy
Gut involvement
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Penn H Q J Med 2007; 100: 485
Scleroderma renal crisis
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Pulmonary Arterial Hypertension
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Pulmonary Arterial Hypertension
Arthritis Rheum 2005; 52: 3792 Arthritis Rheum 2009; 60: 1831
PAH prevalence: 8 % PAH incidence: 0.6 per 100 patients-year
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Time between SSc diagnosis and PAH diagnosis
n=78
time from first none RP symptom to PAH diagnosis
Event
free p
atients
Hachulla E. Chest 2009; 136: 1211
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55.1% during the 5 first years 22% dSSc and 78% lSSc
Time between SSc diagnosis and PAH diagnosis
n=78
time from first none RP symptom to PAH diagnosis
Event
free p
atients
Hachulla E. Chest 2009; 136: 1211
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Doppler echocardiography = PAH screening tool
ItinerAIR study
TJV< 2.8 m/s TJV ≥ 3 m/s
Dyspnea (not
explained by another
cause)
No dyspnea (or
dyspnea explained
by another cause)
TJV 2.8-3 m/s
No PAH
Suspected PAH
TJV= tricuspid jet velocity
Hachulla E. Arthritis Rheum 2009; 60: 1831
RHC
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DLCO: a PAH predictive factor ?
Mean DLCO at diagnosis: 52%
Steen V, Medsger TA Jr. Arthritis Rheum 2003 ;48 :516
10-15
0
5-10 0-5 PH diagnosis
Controls (n = 14)
Cases (n = 19) 20
40
60
80
100
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Ischemic DUs
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ne concernent pas que le CREST syndrome:
- 1/3 des formes limitées,
- 1/4 des formes diffuses
Calcifications sous-cutanées
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February 2005
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All population (n = 101)
DUs
45% Recurrence 66%
Patients with DUs (n = 44)
Hachulla E et al. J Rheumatol 2007; 34:2423-30
Ischemic DUs: prevalence
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Hachulla E et al. J Rheumatol 2007; 34:2423-30.
Time to first Ischemic DUs after first SSc non RP symptom
First DU <1 year 19/44 (43%)
<5 years 32/44 (73%)
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Délai entre les 2 premiers épisodes d’ulcères digitaux*
Patients n Incidence annuelle des ulcères digitaux
(moyenne SD)
p
< 1 an 10 0.96 0.61 0.048
≥ 1 an 19 0.50 0.28
< 2 ans 14 0.850.57 0.04
≥ 2 ans 15 0.480.26
* Chez les patients ayant fait au moins 2 épisodes d’ulcères digitaux
Hachulla E. J Rheumatol 2007, 34: 2423
Yearly incidence of DU
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Échelle de la main de Cochin
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Mouthon L. Ann Rhem Dis 2008; 67: 110
Échelle de bouche de Cochin
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Sclérodermie systémique: quelles explorations systématiques?
- Bilan clinique: peau, articulations, nécroses digitales, auscultation pulmonaire, RGO, recherche d’un syndrome de Sjögren - 6MWT, classe de dyspnée - Capillaroscopie - AAN, bilan hépatique, créatinine, BU, NFS, fer ferritine, TSH FT4, CPK - ECG, thorax - Echocardiographie - EFR (CPT, CVF, VEMS, DLCO) - scanner thoracique en coupes fines - fibroscopie haute, Manométrie œsophagienne, selon clinique
- Clinique - EFR (CPT, CVF, DLCO) - Echocardiographie, VIT - bilan hépatique, créatinine, BU, NFS, fer ferritine, BNP?
Initial
Annuel, tous les 6 mois les 3 premières années si dcSSc