Internal Medicine Correlations and Clinical Scenarios (CCS) USMLE Step 3

CASE 6: Scleroderma

Setting: office

CC: “My face and hands are getting tight.”

VS: BP: 152/94 mm Hg; P: 86 beats/minute; T: 98°F; R: 22 breaths/minute

HPI: A 43-year-old woman with progressive immobility of her fingers and tightening of her face visits you in your office. She is also somewhat short of breath but only with two to three blocks of exertion. She does not notice the dyspnea often because joint pain makes her avoid walking.

PMHX:

Image Hypertension

Image Raynaud disease

Medications:

Image Nifedipine

PE:

Image Chest: fine crepitations throughout

Image Extremities: sclerodactyly, edema of lower extremities

Image Skin: tightening at face and hand, no Raynaud disease now; some telangiectasia present

Which of the following tests is most likely to be positive?

a. SCL-70

b. Anti-centromere antibody

c. ANA

d. Antineutrophil cytoplasmic autoantibody (ANCA)

e. Anti-Jo

Answer c. ANA

As with many autoimmune disorders, ANA is most likely to be positive, but has no specificity. ANA is positive in 80% to 95% of those with scleroderma, which gives it a false negative rate of only 5% to 15%. Anti-Jo reveals lung involvement in polymyositis and dermatomyositis.

Image

Calcinosis: mechanism unknown

Sclerodactyly: mechanism unknown

Scleroderma + High BP = Angiotensin-Converting Enzyme (ACE) Inhibitors

Initial Orders:

Image SCL-70

Image ANA

Image Chest x-ray

Image Oximeter

Image CHEM-7, CBC

Image Enalapril

Nifedipine is best for Raynaud disease.

SCL-70 is an antibody against topoisomerase III.

See the patient as soon as possible after starting the ACE inhibitor. Chemistry should be checked to see there is no worsening of renal function.

Interval History: “Patient has epigastric pain going into chest with sore throat and bad taste in mouth.”

VS: BP: 124/84 mm Hg on enalapril

On CCS, you cannot order medications by class. You have to write “enalapril” or “lisinopril.” You cannot just order “ACE inhibitor.” Do not worry about spelling. CCS automatically checks spelling and asks if you are sure that is the drug or test you wanted.

Reports:

Image SCL-70: positive

Image ANA: positive

Image Chest x-ray: normal

Image Oximeter: 96% saturation on room air

Image CHEM-7, CBC: normal except slight anemia; hematocrit 34%; mean corpuscular value (MCV) normal; no eosinophilia

Eosinophilic Fasciitis

Thick Skin +

Orange Color +

Worse on Exertion +

Eosinophils =

Treat with Steroids

Inform the patient she likely has gastroesophageal reflux disease (GERD). Patients with scleroderma have the skin manifestations before the internal organ involvement.

What is the main difference between CREST and scleroderma?

a. GERD

b. Telangiectasia

c. Lung and heart

d. Pulmonary hypertension

e. Calcinosis and sclerodactyly

Answer c. Lung and heart

Scleroderma or progressive systemic sclerosis has all the manifestations of CREST and also has the involvement of several internal organs. Scleroderma involves the heart, lungs, and kidneys. CREST has a primary pulmonary hypertension, but the lung parenchyma itself is normal. In scleroderma, the pulmonary hypertension is secondary to lung fibrosis. Both disorders have joint pain and skin manifestations.

Scleroderma has:

• Renal

• Heart

• Lung

Orders:

Image Omeprazole

Image Continue ACE inhibitor and nifedipine

Although the underlying pathology and disease progression of scleroderma are not an emergency, the symptoms of GERD, elevated BP, and Raynaud disease can be controlled.

Interval History: “Epigastric pain and bad taste in mouth are improved on PPIs; BP 124/78 mm Hg.”

Which manifestation of scleroderma can be slowed with treatment?

a. Calcinosis and sclerodactyly

b. Pulmonary fibrosis

c. Renal fibrosis

d. Cardiac fibrosis

Answer b. Pulmonary fibrosis

We do not have a clear treatment to stop the progression of skin calcinosis or sclerodactyly. Pulmonary fibrosis may be slowed with cyclophosphamide or mycophenolate. Although we use ACE inhibitors for renal hypertensive crisis, this is not the same as controlling the primary renal fibrosis or the cardiac fibrosis. Pulmonary hypertension can be treated with bosentan and the prostacyclin analogues epoprostenol, treprostinil, and iloprost. Overall, treatment in scleroderma is extremely frustrating. We have symptomatic therapy for Raynaud disease (i.e., calcium channel blockers) and GERD but no clear drugs to stop the underlying pathology of the skin, heart, or kidneys.

Orders:

Image Pulmonary function testing

Penicillamine is not effective in controlling calcinosis.

Bosentan inhibits endothelin-1.

Prostacyclin dilates pulmonary vasculature.

The patient returns for discussion of her pulmonary function tests (PFTs). Symptoms of dyspnea slowly progress.

PFT Report:

Image Decreased forced expiratory volume at 1 second (FEV1); decreased forced vital capacity (FVC)

Image Decreased residual volume; decreased total lung capacity

Which of the following is the most accurate test of lung involvement?

a. PFTs

b. Diffusing capacity of the lungs for carbon monoxide (DLCO)

c. Lung biopsy

d. Right-sided heart catheterization response to vasodilators

e. High-resolution chest computed tomography (CT)

Answer c. Lung biopsy

Pulmonary involvement is present in 70% of those with scleroderma. Lung biopsy is simply the most accurate of all these methods at establishing a diagnosis. Right-sided heart catheterization may be useful to assess response to vasodilatory treatment, but it is not a direct assessment of interstitial lung disease. This is how you are going to tell the need for cyclophosphamide.

The patient undergoes PFTs, high-resolution CT, and ultimately lung biopsy. A trial of cyclophosphamide and bosentan is made. Ultimately, scleroderma does shorten lifespan, but there is no clear therapy to reverse any manifestation on a permanent basis.



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