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Transcript crest - UNC School of Medicine
CREST
J. Ryan Altman, MD
AM REPORT
9 December 2009
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What’s my diagnosis?
Other findings: picture 6
Systemic Sclerosis and Scleroderma Disorder
Definitions
Scleroderma: presence of tight, thickened skin
Anatomic distribution of sclerodermatous skin defines
subtypes and disease associations
Localized scleroderma: morphea, linear, en coup de saber
Systemic sclerosis: multiorgan involvement
SSc with diffuse cutaneous involvement
SSc with limited cutaneous involvement (CREST)
SSc sine scleroderma (visceral disease without skin
involvement)
Peak onset: age 30-50, Female>Male
Systemic Sclerosis and Scleroderma Disorder
Classification criteria (1 maj. or 2 min.)
Major: skin findings extend prox to MCT or MTP joints
Minor: sclerodactyly (limited to fingers), digital pitting
scars (from loss of substance on finger pad), bibasilar
pulmonary fibrosis (mechanism: stimulatory
autoantibodies against PDGF receptor activating collagen
gene expression)
Proposed additions: presence of Reynaud's phenomenon,
dropout or dilatation on nailfold capillaroscopy, and
serologies
Systemic Sclerosis and Scleroderma Disorder
Diagnostic studies
+ anti-Scl-70 (anti-topoisomerase 1): 40% diffuse, 15% limited
+ anti-centromere pattern (kinetochore): 60-80% limited, <5%
diffuse
+ ANA (>90%)
+ RF (30%)
HLA Association: DR1 (DQ5), DQB1/DR4 (D13 subtypes)
If renal involvement: incr BUN and Cr, proteinuria
If pulm involvement: interstitial pattern on CXR/chest CT,
restriction and/or decr DLCO on PFTs; Pulm HTN revealed by
ECHO
Skin bx not routine, but helpful to assess other possible causes
for skin thickening
Systemic Sclerosis and Scleroderma Disorder
Limited involvement findings
Skin: thickening on distal extremities and face only
Nails: capillary dropout +/- dilitation
Pulm: Pulm HTN>Fibrosis
Renal: none (diffuse: renovascular HTN)
Cardiac: none (diffuse: restrictive cardiomyopathy)
Other: CREST (Calcinosis cutis, Raynaud’s, Esophageal
dysmotility, Sclerodactyly, Telangiectasias)
Antibodies: Anticentromere (diffuse: Anti-Scl 70)
Prognosis: survival >70% at 10yr (diffuse: 40-60% at 10yr)
Systemic Sclerosis and Scleroderma Disorder
Treatment
Pulmonary
Renal
APAP, NSAIDS, PT
Myositis
NSAIDS or steroids for pericarditis
Arthritis
PPI/H2 for GERD, Abx for malabsorption, hypomotility metoclopramide or erythromycin
Cardiac
Monitor BP, ACE-I (not ARB) for HTN crisis
GI
Fibrosis: cyclophosphamide
Pulm HTN: vasodilators
MTX, AZA, steroids
Skin
PUVA for morphea, emollients or oral steroids (caution can precipitate HTN renal
crisis) for pruritis, immunosuppressants only minimal to modest benefit for fibrosis
Bibliography
Dry gangrene:
http://images.google.com/imgres?imgurl=http://www.wsiat.on.ca/images/mlo/diabetic_fig5.jpg&imgrefurl=http://www.wsiat.on.ca/english/
wsiatDocs/mlo/diabetic_screen.htm&usg=__WP71rmUnUCfoMaE095mQ2utCjkA=&h=385&w=288&sz=63&hl=en&start=7&tbnid=jUjPkZ
wMzCQT8M:&tbnh=123&tbnw=92&prev=/images%3Fq%3Ddry%2Bgangrene%26gbv%3D2%26hl%3Den%26safe%3Doff
Raynaud Phenomenon: www.csmc.edu/images/354016_Raynaudsphenomenon.jpg
Sclerodactyly: bestpractice.bmj.com/.../295-10-tn_default.jpg
Scleroderma: www.scleroderma.org/.../diffuse-hands_jpg.jpg
Capillary telangiectasias: http://www.aafp.org/afp/2004/0315/p1417.html
Calcinosis cutis: www.dermis.net/bilder/CD051/100px/img0063.jpg
Connective Tissue Disorders: Pocket Medicine 3rd ed., Marc Sabatine
Uptodateonline.com: Classification of scleroderma disorders