Medicine:Undifferentiated connective tissue disease

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Short description: Maladie auto-immune
Undifferentiated Connective Tissue Disease
Other nameslatent Lupus, incomplete lupus
Symptomsdry eyes, dry mouth, haïr lost, joint inflammation, joint pain, mouth ulcers, positive ANA test, raynaud's phenomenon, sun-sensitive rash, ...

Undifferentiated connective tissue disease (UCTD) is a disease in which the connective tissues are targeted by the immune system. It is a serological and clinical manifestation of an autoimmune disease. When there is proof of an autoimmune disease, it will be diagnosed as UCTD if the disease doesn't answer to any criterion of specific autoimmune disease (such as systemic lupus erythematosus (SLE), la scleroderma,[1] mixed connective tissue disease, Sjögren syndrome, systemic sclerosis, polymyositis, dermatomyositis, or the rheumatoid arthritis). This is also the case of major rheumatic diseases whose early phase was defined by LeRoy et al.[2] in 1980 as undifferentiated connective tissue disease. The latent Lupus and the incomplete lupus are alternative terms used to describe this condition.[3]

The term is sometimes used interchangeably with the mixed connective tissue disease, it is an overlap syndrome. However, some researchers believe that UCTD is a clinically distinct entity and is strongly associated with the presence of titer high in antibodies Ribonucleoproteins (RNP).[4]

It is estimated that up to 25% of people with systemic autoimmune disease could be considered to have UCTD.[5]

Overview

Connective tissue diseases are systemic autoimmune diseases that often involve the joints, cartilage, muscles, and skin. They can also involve any other organ system such as the eyes, heart, lungs, kidneys, gastrointestinal tract, bone marrow, nervous system, and blood vessels. Examples of connective tissue diseases include lupus, scleroderma, rheumatoid arthritis, Sjögren’s syndrome, myositis, and vasculitis.

However there are many people who have features of connective tissue disease, such as blood test results and external characteristics, but do not fulfill the diagnostic criteria established for any one disease. These people are considered to have “undifferentiated” connective tissue disease (UCTD).[6][7]

Stages of disease

  • An initial phase may start years before diagnosis, in which there is an absence of signs, symptoms or serological biomarkers.
  • In the next phase autoantibodies can be detected in the serum despite the absence of clinical manifestations. This phase is variable according to the patients. It is unclear whether the antibodies are causes or markers of this disease. The most frequently detected antibodies are Anti-Ro/SSA[8] and anti-U1-RNP.[9]
  • In the final phase signs and symptoms start to appear. These patients may remain undifferentiated, or evolve later into an identifiable connective tissue disease.

Symptoms and signs

The presentation of the disease varies considerably from one patient to another.[10]

Generally, the symptoms include nonspecific symptoms common to connective tissue diseases such as

  • fatigue. This is common in autoimmune diseases, and is the patient's primary concern.[11]
  • malaise and
  • fever.[12]

These can be the initial presentation for some patients.[7]

Other symptoms associated with UCTD include :[13]

  • joint pain - the most common symptom occurring in up to 86% of patients.[7] The pain is often an aching or arthritis-like pain in the elbows, wrists, hands, and knees, in a symmetrical pattern.[14]
  • dry eyes
  • dry mouth
  • hair loss
  • joint inflammation
  • mouth ulcers
  • Raynaud's phenomenon
  • sun-sensitive rash

Clinical presentation in some people diagnosed with UCTD may show :[15]

Pulmonary involvement, such as nonspecific interstitial pneumonia, can be a complication of the disease.[5]

Diagnosis and assessment

There are no formal diagnostic criteria for UCTD. It is determined by a differential diagnosis. Diagnostic tests are undertaken to determine whether a patient has a disease assured or undifferentiated of the connective tissues.[12]

Patients with UCTD usually have positive antinuclear antibody (ANA), and raised ESR values, without typical autoantibody specificities.[16] Even though up to 15% of healthy people may test positive for ANAs, their presence is regarded as almost always a sign of an autoimmune disorder.

If more specific types of ANAs or other proteins are present, other autoimmune conditions (not UCTD) are implied.[17]

Other mechanisms that may be used[citation needed] are sedimentation rate of erythrocytes, tests for Anti-histone antibodies, Chromatin and vitamin D, and chest X-ray to show signs of pericardial effusion.[citation needed]

Management and treatment

UCTD is normally managed primarily as an outpatient. Meds can be used to manage aspects of the disease.[7]

Treatment depends largely on the progression of the individual disease and the nature of the symptoms presented. The antimalarial medication, the corticosteroid and other medications may be prescribed, as the treating physician considers appropriate:[18]

Possible complications

Complications are present with an affected or injured system, such as the pulmonary system present a lesion and inflammation in the long term, an interstitial lung disease (in 88% of cases, severe interstitial lung disease) or a pulmonary fibrosis. If the heart is affected, a hypertrophy can occur, leading to a cardiomegaly.[2] Organs can also be affected (neurological or renal manifestations) and life-threatening conditions can occur.

Affected pregnant women follow a careful clinical observation because they are more likely to see a progression of the disease. Those with the disease at the beginning of pregnancy will keep the disease undifferentiated against 25% who progress to a defined disease at the end of pregnancy. In addition, 45% of pregnancies with the disease end in preterm birth.

Deterrence and patients education

Early recognition and knowledge of the onset of UCTD can help patients manage and control their disease. Patients should be informed of common agents and triggers to help manage symptoms to shorten the duration of the disease and prevent complications.[citation needed]

Improving health care team outcomes

Undifferentiated connective tissue disease occurs for various reasons, underlying factors may affect several organs depending on individual sensitivity. Coordination of care between primaries clinicians and experts (like rheumatologist) can help achieve optimal patient outcomes.[citation needed]

Prognosis

Development into a defined connective tissue disease

30-40% of UCTD cases may develop into a defined connective tissue disease as more diagnostic criteria are progressively met.[7] This generally happens within 5 years of onset.[19]

Several factors may help predict progression:

  • the presence of cytopenia at the time of the diagnostic.
  • the degree of modification of the capillaroscopy test (skin blood vessel study technique) of nail fold during the follow-up.
  • the presence of antinuclear antibodies.
  • young age.[20]
  • severe vitamin D deficiency.[21]
  • the presence of autoantibodies anti-dsDNA, anti-Sm and anti-cardiolipin correlates with the development of systemic lupus erythematosus in particular.[18]

The rate of progression is higher in the first five years following the onset of the disease and tends to decrease over time. Patients progressing to a defined disease seem to see a slight progression of the disease with a mitigated risk of developing complications.[2]

Remaining undifferentiated

Most UCTD cases will remain undifferentiated. UCTD itself usually has a mild clinical course, particularly if there is low organ involvement. Most patients who remain undifferentiated tend to not experience major organ involvement.[22]

Up to 10-20% of patients diagnosed with UCTD will never progress to a defined disease and their symptoms will decrease or disappear.[2]

About 12% of patients will go into remission.[23][22]

Particular studies

  • In a Bulgarian study, after 5 years, 34% had developed into a defined connective tissue disease (with the highest probability of development being within the first two years after onset of symptoms), 54% continued undifferentiated and 12% were in remission.[22]
  • In a US study, after 10 years, 37% had developed into a defined connective tissue disease, 43% continued undifferentiated and 20% were in remission.[22]
  • In a Spanish study, after a mean follow-up of 11±3 years, 14% had developed a definite CTD, 62% continued undifferentiated, and 24% were in remission.[24]
  • In an Italian study (in which 58% had ANA abnormalities), after 5 years, 6% had developed a defined autoimmune disease. The remaining 94% saw clinical and serological features litte changed in the period and quite stable. 11% of these were and remained asymptomatic.[25]

Patient characteristics

Up to 90% of UCTD cases are females between 32 and 44 years old.[7][2][26] In the United States up to 78% of patients were female, against 93 to 95% in Italy and 94% in Hungary. Higher female prevalence is common in autoimmune diseases.[27]

In the United States, up to 72% of patients diagnosed with UCTD were white skinned.[2]

Prevalence

Prevalence of UCTD has been estimated at 2 people per 100,000 people per year.[28] Annual incidence has been estimated as varying from 41 to 149 per 100,000 adults.[29][30][31] It has also been suggested that UCTD is a relatively common condition seen in rheumatology practice, making up 10-20% of referrals to tertiary care clinics.[32]

Classical epidemiological data for UCTD are not available due to the limited literature exploring the disease. Also, differences in patient selection criteria in existing studies make comparisons between them difficult.[33]

Mechanism

UCTD is caused by genetic and environmental factors. It may be triggered by factors such as:

  • Exposure to harmful products such as cigarette smoke.
  • Exposure to an atmospheric pollutant, there are primaries air pollutants (nitrogen oxides (NOx), sulfur dioxide (SO2), volatile organic compounds (VOCs), hydrocarbons and certain metals (plomb, cadmium…)) or secondaries (created in the atmosphere through chemical reactions between pollutants).
  • Exposure to UV light.

T-cell hypothesis

Populations of regulatory T cells are believed to be responsible[citation needed] for the onset of the disease. When there is a decline of these cells, manifestations of diseases would begin to appear giving an idea of the vital role of these cells in the prevention of autoimmune diseases. Moreover, an additional decrease could unfortunately worsen the pathological state and lead to the differentiation of an undifferentiated connective tissue disease into a differentiated connective tissue disease with a poorer prognosis. Due to the wide range of variation in the inclusion criteria of the disease, up to 50% of patients diagnosed with connective tissue disease may have undifferentiated disease of the underlying connective tissue.

History

The term was first suggested in 1980,[34] as connective tissue disease in patients whose features did not meet other classification criteria.[35] In 1999 a study noted "In recent years there has been growing concern regarding the diagnosis of incomplete forms of the autoimmune diseases."[25] and the first classification criteria were proposed in that year.[33]

Historically the condition was sometimes called undifferentiated connective tissue syndrome, latent lupus or incomplete lupus.[33]

References

  1. ↑ Bodolay, E.; Szegedi, G. (May 2009). "Undifferentiated connective tissue disease" (in Hungarian). Orvosi Hetilap 150 (19): 867–872. doi:10.1556/OH.2009.28610. ISSN 1788-6120. PMID 19403430. 
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Khaled, Marwa; Anjum, Fatima (January 2023). "Undifferentiated Connective Tissue Disease" (in English). StatPearls. PMID 34283427. https://www.ncbi.nlm.nih.gov/books/NBK572061/. 
  3. ↑ Mosca, M.; Neri, R.; Bombardieri, S. (1999). "Undifferentiated connective tissue diseases (UCTD): a review of the literature and a proposal for preliminary classification criteria" (PDF). Clinical and Experimental Rheumatology 17 (5): 615–20. PMID 10544849. http://www.clinexprheumatol.org/article.asp?a=1936. 
  4. ↑ Hoffman, Robert W.; Greidinger, Eric L. (2002). "23: Mixed connective tissue disease". in George C. Tsokos. Modern Therapeutics in Rheumatic Diseases. Humana Press. pp. 347–357. doi:10.1007/978-1-59259-239-5_23. ISBN 978-1-59259-239-5. 
  5. ↑ 5.0 5.1 Lunardi, Francesca; Balestro, Elisabetta; Nordio, Beatrice; Cozzi, Franco; Polverosi, Roberta et al. (June 2011). "Undifferentiated connective tissue disease presenting with prevalent interstitial lung disease: Case report and review of literature". Diagnostic Pathology 6 (50): 50. doi:10.1186/1746-1596-6-50. PMID 21645423. 
  6. ↑ "Undifferentiated connective tissue disease (UCTD)". https://autoimmune.org/disease-information/undifferentiated-connective-tissue-disease-uctd/. 
  7. ↑ 7.0 7.1 7.2 7.3 7.4 7.5 Marwa, Khaled; Anjum, Fatima (January 23, 2023). "Undifferentiated Connective Tissue Disease". StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK572061/. 
  8. ↑ Anti-Ro/SSA are frequently detected, in a very early phase of a pre-clinical stage, in the serum of 30% of systemic lupus. They are also markers of systemic Sjögren syndrome in 50% to 60% of cases and undifferentiated connectivities.[citation needed]
  9. ↑ Marwa, Khaled; Anjum, Fatima (January 23, 2024). "Undifferentiated Connective Tissue Disease". StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK572061/. 
  10. ↑ Owlia, Mohammad Bagher (2006). "Clinical spectrum of connective tissue disorders". Journal, Indian Academy of Clinical Medicine 7 (3): 218. http://medind.nic.in/jac/t06/i3/jact06i3p217.pdf. 
  11. ↑ Zielinski, M. R.; Systrom, D. M.; Rose, N. R. (2019). "Fatigue, Sleep, and Autoimmune and Related Disorders". Frontiers in Immunology 10: 1827. doi:10.3389/fimmu.2019.01827. PMID 31447842. 
  12. ↑ 12.0 12.1 Doria, A.; Mosca, M.; Gambari, P.F.; Bombardieri, S. (February 2005). "Defining unclassifiable connective tissue diseases: incomplete, undifferentiated, or both?" (PDF). The Journal of Rheumatology 32 (2): 213–215. PMID 15693073. http://www.jrheum.org/content/32/2/213.long. 
  13. ↑ Vaz, C.C.; Couto, M.; Medeiros, D.; Miranda, L.; Costa, J. et al. (August 2009). "Undifferentiated connective tissue disease: a seven-center cross-sectional study of 184 patients". Clinical Rheumatology 28 (8): 915–921. doi:10.1007/s10067-009-1175-2. PMID 19390908. 
  14. ↑ Rodgers, Linda (September 27, 2020). "What Is Undifferentiated Connective Tissue Disease? Here's How to Know If You Have It". https://creakyjoints.org/living-with-arthritis/symptoms/what-is-undifferentiated-connective-tissue-disease/. 
  15. ↑ Undifferentiated Connective Tissue Disease - In-Depth Overview. 2017. https://www.hss.edu/conditions_undifferentiated-connective-tissue-disease-overview.asp. 
  16. ↑ 16.0 16.1 Talotta, Rossella (January 1, 2023). "Chapter 7 - the diagnostic laboratory tests in rheumatic diseases". in Rezaei, Nima. Translational Autoimmunity. Translational Immunology. Academic Press. pp. 113–148. doi:10.1016/B978-0-323-85831-1.00007-3. ISBN 978-0-323-85831-1. https://www.sciencedirect.com/science/article/pii/B9780323858311000073. 
  17. ↑ "For example: People with lupus may also test positive for anti-double-stranded DNA antibody (anti-dsDNA) and anti-Smith (anti-Sm) antibody. People with myositis may have elevated levels of a muscle enzyme called creatine kinase (CK) that could be a sign of polymyositis. People with rheumatoid arthritis may test positive for the antibodies anti-cyclic citrullinated peptides (anti-CCP) and rheumatoid factor. People with Sjögren’s may test positive for anti-Ro (SS-A) and anti-La (SS-B) antibodies as well as rheumatoid factor." Rodgers, Linda (September 27, 2020). "What Is Undifferentiated Connective Tissue Disease? Here's How to Know If You Have It". https://creakyjoints.org/living-with-arthritis/symptoms/what-is-undifferentiated-connective-tissue-disease/. 
  18. ↑ 18.0 18.1 Mosca, M; Baldini, C; Bombardieri, S (2004). "Undifferentiated connective tissue diseases in 2004" (PDF). Clinical and Experimental Rheumatology 22 (3 Suppl 33): S14–S18. PMID 15344591. http://www.clinexprheumatol.org/article.asp?a=2414. 
  19. ↑ https://academic.oup.com/book/25283/chapter-abstract/256365091
  20. ↑ Dyball, Sarah; Rodziewicz, Mia; Mendoza-Pinto, Claudia; Bruce, Ian N.; Parker, Ben (November 1, 2022). "Predicting progression from undifferentiated connective tissue disease to definite connective tissue disease: A systematic review and meta-analysis". Autoimmunity Reviews 21 (11): 103184. doi:10.1016/j.autrev.2022.103184. PMID 36031048. https://www.sciencedirect.com/science/article/pii/S1568997222001549. 
  21. ↑ Zold, Eva; Szodoray, Peter; Gaal, Janos; Kappelmayer, Janos; Csathy, Laszlo et al. (2008). "Vitamin D deficiency in undifferentiated connective tissue disease". Arthritis Research & Therapy 10 (5): R123. doi:10.1186/ar2533. PMID 18928561. 
  22. ↑ 22.0 22.1 22.2 22.3 Pepmueller, Peri Hickman (January 23, 2016). "Undifferentiated Connective Tissue Disease, Mixed Connective Tissue Disease, and Overlap Syndromes in Rheumatology". Missouri Medicine 113 (2): 136–140. PMID 27311225. 
  23. ↑ Bodolay, E; Csiki, Z; Szekanecz, Z; Ben, T; Kiss, E et al. (2003). "Five-year follow-up of 665 Hungarian patients with undifferentiated connective tissue disease (UCTD)". Clinical and Experimental Rheumatology 21 (3): 313–320. PMID 12846049. 
  24. ↑ "Undifferentiated connective tissue disease: predictors of evolution into definite disease". https://www.clinexprheumatol.org/abstract.asp?a=11023. 
  25. ↑ 25.0 25.1 https://www.clinexprheumatol.org/article.asp?a=1929
  26. ↑ Autoimmune diseases are typically very weighted towards females.
  27. ↑ "Autoimmune disease". January 25, 2024. https://en.wikipedia.org/w/index.php?title=Autoimmune_disease&oldid=1199053060. 
  28. ↑ Purohit, Richa; Khal, Ravi Shahu; Gokalp, Gizem; Sambandan, Rajan; Bhanusali, Neha; Purohit, Richa; Khal, Ravi Shahu; Gokalp, Gizem et al. (June 16, 2023). "Undifferentiated Connective Tissue Disease With Isolated Diaphragmatic Dysfunction". Cureus 15 (6): e40515. doi:10.7759/cureus.40515. PMID 37461764. 
  29. ↑ Deane, Kevin D.; El-Gabalawy, Hani (April 23, 2014). "Pathogenesis and prevention of rheumatic disease: focus on preclinical RA and SLE". Nature Reviews Rheumatology 10 (4): 212–228. doi:10.1038/nrrheum.2014.6. PMID 24514912. 
  30. ↑ Spinillo, Arsenio; Beneventi, Fausta; Caporali, Roberto; Ramoni, Veronique; Montecucco, Carlomaurizio (December 23, 2017). "Undifferentiated connective tissue diseases and adverse pregnancy outcomes. An undervalued association?". American Journal of Reproductive Immunology 78 (6). doi:10.1111/aji.12762. PMID 28921728. https://onlinelibrary.wiley.com/doi/10.1111/aji.12762. 
  31. ↑ Serena, Caterina; Clemenza, Sara; Simeone, Serena; Zullino, Sara; Ottanelli, Serena; Rambaldi, Marianna Pina; Vannuccini, Silvia; Petraglia, Felice et al. (January 23, 2022). "Undifferentiated Connective Tissue Disease in Pregnancy: A Topic Yet to be Explored". Frontiers in Pharmacology 13. doi:10.3389/fphar.2022.820760. PMID 35126164. 
  32. ↑ Olsen, Nancy J. (January 1, 2019). "48 - Incomplete Lupus, Undifferentiated Connective Tissue Disease, and Mixed Connective Tissue Disease". Dubois' Lupus Erythematosus and Related Syndromes (Ninth ed.). Elsevier. pp. 606–613. doi:10.1016/B978-0-323-47927-1.00048-7. ISBN 978-0-323-47927-1. https://www.sciencedirect.com/science/article/pii/B9780323479271000487. 
  33. ↑ 33.0 33.1 33.2 Mosca, M.; Neri, R.; Bombardieri, S. (1999). "Undifferentiated connective tissue diseases (UCTD): A review of the literature and a proposal for preliminary classification criteria". Clinical and Experimental Rheumatology 17 (5): 615–620. PMID 10544849. https://pubmed.ncbi.nlm.nih.gov/10544849/. 
  34. ↑ Leroy, E. Carwile; Maricq, Hildegard R.; Bashar Kahaleh, M. (1980). "Undifferentiated connective tissue syndromes". Arthritis & Rheumatism 23 (3): 341–343. doi:10.1002/art.1780230312. PMID 7362686. https://onlinelibrary.wiley.com/doi/abs/10.1002/art.1780230312?sid=nlm%3Apubmed. 
  35. ↑ Marwa, K.; Anjum, F. (2024). "Undifferentiated Connective Tissue Disease". StatPearls. https://pubmed.ncbi.nlm.nih.gov/34283427/. 
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