Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Comparar e caracterizar, por intermédio dos protocolos de avaliação da deglutição, os achados fonoaudiológicos na fase preparatória oral e oral da deglutição nos pacientes avaliados nos dois grupos de doenças (DM/PM e ES). Foram identificados 80 pacientes com diagnóstico de dermatopolimiosite e esclerose sistêmica, de ambos os sexos, atendidos no ambulatório de Colagenoses do serviço de Reumatologia do Hospital Universitário Pedro Ernesto (HUPE-UERJ). Foram excluídos os indivíduos abaixo de 18 anos e acima de 60 anos (24) e com outras doenças e/ ou comorbidades. Dos 56 pacientes restantes, 73,2% (41) apresentavam ES e 26,8% (15) DM/PM. Após a assinatura do termo de consentimento livre e esclarecido, os indivíduos foram submetidos à avaliação clínica estrutural e funcional da deglutição pelo pesquisador, que é fonoaudiólogo. O estudo revelou elevada prevalência de alterações oromiofuncionais e da deglutição na fase preparatória oral e oral propriamente dita nos pacientes com ES para a consistência sólida, que geram disfagia oral e alta, e não somente uma disfagia baixa como tem sido apresentado na literatura médica. O estudo reforçou que as mulheres são as mais acometidas pelas doenças autoimunes e que os homens são em menor número. O fonoaudiólogo deve ser parte integrante da equipe interdisciplinar que atende esses pacientes. / Compare and Characterize by means of evaluation protocols of swallowing, speech-language findings in oral and oral preparatory phase of swallowing in patients evaluated in both groups of diseases (DM / PM and SS). We identified 80 patients with dermatomyositis and systemic sclerosis, of both sexes, Collagen outpatient clinic of the Rheumatology Service of Hospital Universitário Pedro Ernesto (HUPE-UERJ). We excluded individuals below 18 years and above 60 years (24) and other diseases and / or comorbidities. Of the 56 remaining patients, 73.2% (41) had SS and 26.8% (15) DM / PM. After signing an informed consent, subjects underwent structural and functional clinical assessment of swallowing, the researcher who is a speech and audiologist therapist. The study revealed high prevalence of oromiofunctionals and oral phase swallowing in patients with SS to solid food dysphagia and oral generating not only a high and low dysphagia as has been shown in medical literature. The study reinforced that women are more affected by autoimmune diseases, and that men are fewer. The speech and audiology therapist must be part of the interdisciplinary team that deals with these patients

Recentemente, descobrimos que coelhos, Nova Zelândia, imunizados com colágeno tipo V humano mais adjuvante de Freund apresentavam fibrose e vasculite de órgãos normalmente afetados na esclerose sistêmica. Deste modo, nós estudamos o processo de fibrilogênese para identificar possíveis fatores envolvidos na alteração do remodelamento observado neste modelo de esclerodermia. Adicionalmente, fizemos uma comparação preliminar com pele humana obtida de pacientes com esclerodermia (n=3). Coelhos fêmeas, Nova Zelândia (n=14), foram imunizados subcutaneamente com duas doses de 1mg de colágeno V mais adjuvante completo de Freund, com intervalo de 30 dias, seguido de duas imunizações em adjuvante incompleto de Freund, via intramuscular, com intervalo de 15 dias. Os animais do grupo controle (n- 14) foram inoculados somente com adjuvante completo e incompleto de Freund, nas mesmas condições dos imunizados. Foram realizadas análises histológicas das peles dos animais e pacientes através da coloração com tricrômico de Masson e imunofluorescêcia, a fim de detectar fibras de colágeno e interação dos colágenos I, III e V. A análise da pele dos animais demonstrou depósito precoce de fibras de colágeno na derme após 7 dias da sensibilização, com aumento destes depósitos após 75 e 120 dias respectivamente. Depósito de colágeno na pele e atrofia de anexos foram mais intensos nos animais sacrificados em 120 dias e se correlacionaram com a quantidade aumentada de colágeno. Surpreendentemente, o colágeno V foi expresso em animais e pacientes, formando fibras densas e atípicas na derme. Sugerimos que esta expressão anômala de colágeno V, morfologicamente diferente, possa justificar o remodelamento observado na placa esclerodérmica / Recently, we discovered that New Zealand rabbits immunized with human type V collagen plus Freund`s adjuvant presented fibrosis and vasculitis of organs usually affected in systemic sclerosis. In this way, we studied the fibrillogenesis process regarding to identify any possible factor involved in altered remodeling observed in this scleroderma-like model. Additionally, we done a very preliminary comparison with human skins obtained from scleroderma patients (N=3). Female New Zealand rabbits (N=14) were immunized subcutaneously with two doses of 1mg collagen V plus complete Freunds adjuvant at a 30 days interval, followed by two additional intramuscular booster immunizations in incomplete Freunds adjuvant at a 15-day interval. Animals from control group (N=14), were only inoculated with complete and incomplete Freunds adjuvant given at same conditions of collagen type V group. Histological analysis of skins from animals and patients were done by Massons trichrome staining, and immunofluorescence method used to detect collagen fibers and interactions of types I, III and V collagen in the remodeling process. The analysis of animal skins showed precocious collagen fibril deposits in the dermis after 7 days of immunization and increase of this process in 75 and 120 days. Skin collagen deposit and atrophy of annexes were progressively more intense in late sacrificed animals and correlated with increased amount of collagen deposition. Surprisingly, type V collagen was over expressed both in animals and patients, forming dense and atypical collagen fibers in the dermis. We suggest that this anomalous expression of morphologically different type V collagen could justify the remodeling observed in scleroderma plaque

Objetivo: Verificar o remodelamento da pele e produção de anticorpos em modelo experimental de esclerodermia em coelhos, após indução de tolerância nasal com colágeno tipo V. Métodos: Coelhas Nova Zelândia (N=12) foram imunizadas com 1mg/ml de colágeno V (Col V) em adjuvante completo de Freund e dois reforços com adjuvante incompleto de Freund. Seis coelhas imunizadas receberam uma dose diária de 25ug de Col V, iniciado via nasal (grupo tolerado) 150 dias do começo das imunizações e seis animais foram somente imunizadas (grupo imunizado). Um grupo imunizado com adjuvante de Freund serviu como controle. Biopsias de pele foram coletadas em 0, 75, 120, 150 e 210 dias e coradas pelo H&E, tricrômico de Masson e Sírius red para analise morfológica e morfométrica. Os colágenos I, III e V, além de TGFbeta e PDGF foram imunomarcados por imunofluorescência. Os soros dos animais foram coletados em 0, 150 e 210 dias para determinar anticorpos anti-colágenos I, III, IV e V e anti-nucleares. Resultados: Os animais imunizados mostraram progressivo decréscimo da derme papilar, atrofia de anexos, aumento no depósito dos colágenos I, III e V e aumento da expressão de TGFbeta e PDGF. Os tolerados apresentaram aumento dos anexos cutâneos e significante diminuição no depósito dos colágenos I, III e V, TGFbeta e PDGF. O grupo de imunizados e de tolerados apresentaram anticorpos anti-colágenos III e IV e antinucleares. Conclusões: A indução de tolerância nasal com Col V diminuiu o remodelamento da pele observado no modelo experimental de esclerodermia e inibiu a síntese de citocinas fibrogênicas. Portanto, a tolerância nasal com Col V pode ser uma opção terapêutica promissora para o controle do remodelamento cutâneo em pacientes com esclerodermia. / Objective: Our aim was to verify the skin remodeling and antibody production in experimental model of scleroderma in rabbits, after induction of tolerance by daily nasal administration of human type V collagen (Col V). Methods: Female New Zealand rabbits (N=12) were immunized with 1mg/ml of Col V in complete Freund\'s adjuvant, followed by more two boosters in incomplete Freund\'s adjuvant. Six immunized rabbits received daily nasal administrating of 25ug of Col V (tolerated group), started 150 days after the first immunization, and the others animals (N=6) were only immunized (immunized group). Finally a group of rabbits immunized with Freund\'s adjuvant served as control. Skin biopsies were collected at 0, 75, 120, 150 and 210 days, and stained with H&E, Masson\'s trichrome and Sirius red for morphological and morphometric analysis. Types I, III and V collagen, TGFbeta and PDGF were immunostained by immunofluorescence. The sera of animals were colleted at 0, 150 and 210 days to determine anti types I, III, IV and V collagen and antinuclear antibodies. Results: The immunized animals showed progressive decrease of papillary dermis, appendages atrophy, increase of types I, III and V collagen deposition and increased expression of TGF-beta and PDGF. The tolerated rabbits presented increase of cutaneous appendages and significant decrease of types I, III and V and TGF-beta and PDGF. Both immunized and tolerated rabbits presented anti types III and IV antibodies and antinuclear antibodies. Conclusions: Col V nasal tolerance reduced skin remodeling in experimental model of scleroderma and inhibited synthesis of fibrotic cytokines. Therefore, the nasal tolerance with type V collagen can be a promising therapeutic option to control the skin remodeling in patients with scleroderma.

Introdução: A doença intersticial pulmonar é um importante fator prognóstico na esclerose sistêmica (ES). O prognóstico das pneumonias intersticiais não específicas (NSIP) associadas às colagenoses tem sido descrito como melhor do que o da forma idiopática. Levanta-se a hipótese de que o processo de remodelamento e reparo do parênquima pulmonar nessas duas formas da doença sejam diferentes. Objetivos: Comparar os mecanismos de reparo e remodelamento entre a NSIP associada a ES e a NSIP idiopática. Observar o impacto dos mesmos nas provas de função pulmonar e na sobrevida. Métodos: Foram analisadas 40 biópsias de pacientes com o diagnóstico de NSIP (18 biópsias de NSIP associada a ES e 22 na forma idiopática). As informações clínicas e as provas de função pulmonar foram obtidas através da revisão dos prontuários. As lâminas foram revisadas por três patologistas. Foram comparadas as densidades epitelial, vascular, bem como a atividade vascular dos dois grupos utilizando o método de imuno-histoquímica. Para isso foram utilizados os anticorpos anti- citoqueratina 7 (CK-7), anti- proteína-a do surfactante (SP-A), antimarcador de célula endotelial CD-34 (CD34), e anti-molécula da adesão vascular 1 (VCAM-1). Também foi comparado o padrão de remodelamento da matriz septal e vascular, usando os métodos histoquímicos da resorcina (fibras elásticas) e picrosírius (colágeno). Uma análise estatística foi realizada comparando os resultados dos dois grupos, o impacto do remodelamento nas provas de função pulmonar e a influência na sobrevida. Resultados: A densidade das células epiteliais foi menor na NSIP-ES, do que na forma idiopática (p<0,0001). Já os pneumócitos tipo II e as células de Clara encontraram-se diminuídos no grupo idiopático (p=0,02). Uma diminuição na densidade vascular foi encontrada na NSIP-ES quando comparada à forma idiopática (p<0,0001); no entanto, a atividade vascular medida pelo VCAM-1 foi maior no grupo da NSIP-ES (p<0.0001). O conteúdo das fibras elásticas e colágeno septal, bem como o das fibras elásticas na parede vascular, estavam aumentados no grupo da ES quando comparados à forma idiopática (p=0,01; p=0,001 e p<0,0001, respectivamente). Não houve diferença estatística entre o colágeno da parede vascular, no grau de obstrução vascular ou associação entre os parâmetros de remodelamento e reparo do parênquima pulmonar na sobrevida dos dois grupos. Dentre as provas de função pulmonar, a DCO/Hb foi mais afetada no grupo da ES (59% do valor predito na ES e 97% no grupo idiopático). Foi observada uma associação direta entre a densidade vascular e a DCO/Hb (p=0,02). Após o seguimento de 36 meses, não foi observada diferença no prognóstico dos dois grupos. Conclusão: Os processos de remodelamento e reparo do parênquima pulmonar parecem ser diferentes entre os dois grupos. Apesar de o processo fibrótico ser mais intenso na NSIP-ES, isso parece não estar associado a um pior prognóstico, como tem sido descrito na forma idiopática. Como o processo de elastose e a expressão do VCAM-I são mais intensos na ES, isso sugere que o processo inflamatório tem um papel mais importante na patogênese e no processo de remodelamento e reparo da ES do que na forma idiopática. No entanto, outros estudos são necessários para validar a importância desses resultados e sua utilização para fins terapêuticos e de prognóstico / Background: The presence of Interstitial lung disease is a well recognized prognostic factor in systemic sclerosis (SSc). As the prognosis in nonspecific interstitial pneumonia (NSIP) has been described to be better in collagen vascular disorders compared to the idiopathic forms, it is conceivable that the mechanisms of repair and remodeling are different between these two forms of the disease. Objectives: To compare the mechanisms of repair and remodeling between SSc associated nonspecific pneumonia and the idiopathic form, as well as their impact on pulmonary function tests and survival rates. Methods: Biopsies from 18 patients with SSc-associated NSIP and 22 with idiopathic NSIP were analyzed. Clinical data and pulmonary function test results were obtained by retrospective chart review. All H&E slides were reviewed by three pathologists. The epithelial and vascular densities and vascular activity were compared between the two groups by immunohistochemistry with antibodies directed against cytokeratin-7, surfactant protein-a, CD34, and VCAM-1, as well as septal and vascular matrix remodeling using histochemical stains (picrosirius and resorcin). Statistical analyses were performed to compare the results of these various studies with clinical parameters (e.g. pulmonary function tests) and survival between the groups. Results: Epithelial cell density was lower in SSc-NSIP when compared with idiopathic-NSIP (p<0.0001). Type II pneumocytes and Clara cells were reduced in idiopathic NSIP (p=0.02). A decrease in microvessel density was found in SSc-NSIP compared to idiopathic-NSIP (p<0.0001). The vascular activity measured by VCAM-1 expression was higher in NSIP-SSc when compared to the idiopathic group (p<0.0001). A direct association between vascular density and DLCO/HB was found (p=0.02). Among pulmonary function tests the DLCO/HB was affected to a greater extent in the SSc group (59% of the predicted value in SSc and 97% in the idiopatic group). The content of septal collagen and elastic fibers, as well as the elastic fibers in the vascular wall, were higher in the SSc group (p=0.01, p=0.001 and p<0.0001, respectively). There were no differences in the collagen content of the vascular wall, vascular grade, or survival between the two groups. There was no difference in the survival rate between the two groups after a follow-up of 36 months. Conclusions: Alterations in the pulmonary epithelium and vasculature seem to differ in the SSc-NSIP when compared to the idiopathic form of the disease. Although the fibrotic process is more intense in the SSc group, it does not seem to affect the prognosis of these patients, contrary to what has been described in idiopatic lung fibrosis. Because the elastotic process and VCAM-1 expression are higher in the SSc group, this might suggest that inflammatory mechanisms affecting the elastic fiber system and vasculature could play a greater role in the pathogenesis and pulmonary remodeling process of SSc-NSIP than in idiopathic-NSIP. Further studies may be required to assess the significance of these findings and explore if they can provide prognostic and/or treatment information

Introdução: A imunização de coelhos saudáveis com colágeno do tipo V (COLV) reproduz as principais manifestações da esclerose sistêmica (ES), incluindo fibrose, vasculopatia e produção de autoanticorpos específicos da doença. Estudos preliminares mostraram que, tanto na derme de animais imunizados com COLV (COLV-IM), como na derme de pacientes com ES, observa-se deposição aumentada de COLV anômalo, mas não se sabe qual a relevância clínica deste achado. O remodelamento da matriz extracelular é precoce nos animais COLV-IM, ocorrendo já no sétimo dia após a imunização, o que sugere que o COLV esteja relacionado com a injúria endotelial, evento primário envolvido na patogênese da ES. Desta forma, os objetivos do presente estudo foram avaliar a expressão de COLV na derme de controles saudáveis e de pacientes com ES e sua correlação com espessamento cutâneo, atividade e duração da doença; assim como pesquisar uma possível associação entre a deposição deste colágeno na derme com a expressão de marcadores de apoptose e de ativação endotelial em pacientes e no modelo animal induzido pela imunização com COLV. Pacientes e Métodos: Biópsias de pele de pacientes com ES (N=18, 6 com doença precoce e 12 com doença tardia) e de controles (N=10) pareados por idade e sexo, assim como biópsias de pele de coelhos imunizados com COLV + adjuvante de Freund (COV-IM, N=6) ou adjuvante de Freund (N=6) foram avaliadas. Nos pacientes com ES, o espessamento cutâneo foi avaliado por meio do escore de Rodnan Modificado (MRSS) e a atividade da doença foi calculada pelo índice de atividade de Valentini. Para realizar a quantificação por histomorfometria, o COLV na derme foi identificado por imunofluorescência. Caspase-3, endotelina-1, CTGF, TGF e VEGF nas células endoteliais dérmicas foram marcados por imunohistoquímica. Nos pacientes e nos controles, o COLV proveniente da cultura de fibroblastos dérmicos foi quantificado por PCR RT em tempo real e caracterizado por eletroforese, imunoblotting e reconstrução tridimensional, por meio da microscopia confocal. Resultados: O depósito de COLV foi maior na derme de pacientes com doença precoce, quando comparados aos controles e aos pacientes com doença tardia. A atividade e a duração da ES estiveram associadas com o depósito de COLV. A expressão de RNA mensageiro das cadeias COLV1 COLV2 foi aumentada em relação aos controles e a reconstrução tridimensional confirmou a presença de fibras anômalas de COLV. Observou-se maior expressão de caspase-3, endotelina-1, CTGF, TGF e VEGF nas células endoteliais dos pacientes com ES, quando comparados aos controles. Houve correlação positiva entre o depósito de COLV e a expressão de caspase-3, endotelina-1 e CTGF. Ao comparar-se os coelhos COLV-IM com os controles, observou-se aumento significativo da expressão de COLV aos 7 dias e de endotelina-1 aos 210 dias após a imunização. Embora de maneira não significativa, verificou-se maior expressão de caspase-3, CTGF e VEGF nos animais COLV-IM e, quando os animais foram comparados ao longo do tempo, percebeu-se maior expressão de COLV no sétimo dia após a imunização na derme dos animais COLV-IM, diminuindo no trigésimo dia e voltando a subir aos 75 dias e aos 210 dias. A caspase-3 e a endotelina-1 comportaram-se de maneira semelhante. Conclusão: Estes resultados sugerem que o COLV possa agir como um possível gatilho envolvido na patogênese da ES, agindo como um indutor de ativação e de apoptose endotelial, que por sua vez poderia resultar em maior expressão de COLV, perpetuando o processo de remodelamento observado na pele dos pacientes com ES / Introduction: The immunization of healthy rabbits with type V collagen (COLV) reproduces the main characteristics of systemic sclerosis (SSc), such as fibrosis, vasculopathy and specific auto-antibodies. Preliminary studies demonstrated that both COLV-immunized rabbits (COLV-IM) and SSc patients exhibit increased expression of abnormal COLV in the dermis, but the clinical relevance of this finding is unknown. The remodeling of the extracellular matrix is an early event in COLV-IM rabbits that can be detected by the seventh day after immunization; this observation suggests that COLV is involved in endothelial injury, one of the first manifestations of the disease. Thus, the objectives of this study were to evaluate COLV expression in the dermis of healthy controls and SSc patients and to determine the correlation of this expression with skin thickness, disease activity and duration and search for a possible association between this collagen with apoptosis and activation of endothelial cells markers in patients and in animal model induced by immunization with COLV. Patients and Methods: Skin biopsies from 18 patients (6 early-stage and 12 late-stage) and 10 healthy controls as well as skin biopsies from rabbits immunized with COLV (COLV-IM) and Freund adjuvant (N=6) or Freund adjuvant alone (N=6) were evaluated. Skin thickening assessment was performed with the Modified Rodnan Skin Score (MRSS), and activity was calculated using the Valentini Disease Activity Index. To perform quantification by histomorphometry, COLV was identified by immunofluorescence, and caspase-3, endothelin-1, CTGF, TGF and VEGF in dermal endothelial cells were labeled by immunohistochemistry. In SSc patients and healthy controls, COLV from dermal fibroblast culture was quantified by real-time RT-PCR and characterized by electrophoresis, immunoblotting and tridimensional reconstruction by confocal microscopy. Results: COLV deposition was increased in the dermis of the patients with early disease compared with the healthy controls and the patients with late disease. SSc activity and disease duration were associated with dermal COLV deposition. COLV1 and COLV2 mRNA expression levels were higher in SSc, and a tridimensional reconstruction of SSc dermal heterotypic fibers confirmed the presence of abnormal COLV. The dermal endothelial cell expression of caspase-3, endothelin-1, CTGF, TGF and VEGF was higher in the SSc patients than in the controls. There was a positive correlation between COLV deposition and caspase-3, endothelin-1 and CTGF expression. When the COLV-IM rabbits were compared with the controls, there was a significant increase in the expression of COLV 7 days after the immunization and a significant increase in the expression of endothelin-1 210 days after the immunization. The expression of caspase-3, CTGF and VEGF was higher in the COLV-IM animals than in the control rabbits, although not significantly, and when the rabbits were compared over time, the expression of COLV was higher in the dermis of the COLV-IM animals 7 days after immunization, decreasing at 30 days and increasing again at 75 and 210 days. Caspase-3 and endothelin-1 exhibited similar behavior. Conclusion: these results suggest that COLV can be a possible trigger involved in the pathogenesis of SSc, acting as an inducer of endothelial apoptosis and activation that could result in higher expression of COLV, perpetuating the remodeling process observed in SSc skin

As células Natural Killer (NK) fazem parte da resposta imune inata, sendo a primeira linha de defesa do organismo contra vírus, bactérias, tumores e microorganismos. Estas células induzem a morte da célula-alvo quando não há o reconhecimento das moléculas de antígenos leucocitários humanos (HLA) de classe I, através de seus receptores, chamados Killer cell Immunoglobulin-like Receptor (KIR). Vários estudos demonstram o envolvimento dos genes KIR na patogênese das doenças auto-imunes. Acredita-se que combinações desses genes possam ser favoráveis para o desenvolvimento da esclerose sistêmica (ES). Portanto, o conhecimento destes genes relacionados às células NK poderiam ser úteis para o entendimento da patogênese da ES. O objetivo deste estudo é investigar o polimorfismo dos genes KIR em um grupo de pacientes com ES, incluindo a forma difusa e limitada da doença. A freqüência do receptor inibidor KIR2DL2 foi significantemente menor nos pacientes comparada com a do grupo controle (28,7% versus 65,2%; P<0,001; OR=0,21; IC95% 0,11–0,38). Quando analisamos a combinação do receptor inibidor 2DL2, com a presença do ativador 2DS2 (KI2DS2+/KIR2DL2-), encontramos uma maior freqüência nos pacientes (26,1% versus 1,7%; P<0,001; OR=19,94; IC95% 4,7–175,1). Por outro lado, a presença de ambos KIR2DL2 e KIR2DS2 foi mais freqüente no grupo controle (26,9% versus 57,3%; P<0,001; OR=0,27; 95%CI 0,1–0,4). Nenhuma diferença estatística no polimorfismo dos genes KIR foi encontrada entre a forma difusa e a forma limitada. A combinação KIR2DS2+/KIR2DL2– parece ser um fator de risco para o desenvolvimento da ES enquanto a alta freqüência do gene inibidor KIR2DL2 no grupo controle parece ter uma função protetora. Estes resultados indicam um potencial papel dos genes KIR na patogênese da ES. / Natural killer (NK) cells have an important role in the early responses to viral infections. They kill diverse target cells with decreased or absent expression of major histocompatibility complex (MHC) class I molecules through the Killer Cell Immunoglobulin-Like Receptors (KIR). Many studies have reported association of KIR genes with autoimmune diseases. The objective of this study is to investigate possible associations of KIR polymorphisms with systemic sclerosis (SSc), including the limited (lSSc) and diffuse (dSSc) forms of the disease. The frequency of inhibitory KIR2DL2 was significantly decreased among patients with SSc compared with healthy controls (28.7% versus 65.2; P<0.001, odds ratio [OR] 0.21, 95% confidence interval [95% CI] 0.11–0.38). When activatory and inhibitory KIR genes were analyzed in combination, the concomitant presence of KIR2DS2 and absence of KIR2DL2 (KI2DS2+/KIR2DL2-) phenotype was more frequent in SSc patients than in the control group (26.08% versus 1.75%; P<0.001, OR=19.94, 95%CI [4.78–175.10]). On the other hand, the presence of both KIR2DS2 and KIR2DL2 was more frequent in the control group (26.96% versus 57.39%; P=0.000005, OR=0.27, 95%CI [0.15–0.49]). No significant difference in KIR genes polymorphisms was found between lSSc and dSSc disease subsets. The combination of KIR2DS2+/KIR2DL2– may be a risk factor for development of SSc while the higher frequency of the inhibitory KIR2DL2 gene in the control group suggest to a protective effect. These results indicate a potential role of KIR genes in the SSc pathogenesis.

Introdução: A doença intersticial pulmonar é um importante fator prognóstico na esclerose sistêmica (ES). O prognóstico das pneumonias intersticiais não específicas (NSIP) associadas às colagenoses tem sido descrito como melhor do que o da forma idiopática. Levanta-se a hipótese de que o processo de remodelamento e reparo do parênquima pulmonar nessas duas formas da doença sejam diferentes. Objetivos: Comparar os mecanismos de reparo e remodelamento entre a NSIP associada a ES e a NSIP idiopática. Observar o impacto dos mesmos nas provas de função pulmonar e na sobrevida. Métodos: Foram analisadas 40 biópsias de pacientes com o diagnóstico de NSIP (18 biópsias de NSIP associada a ES e 22 na forma idiopática). As informações clínicas e as provas de função pulmonar foram obtidas através da revisão dos prontuários. As lâminas foram revisadas por três patologistas. Foram comparadas as densidades epitelial, vascular, bem como a atividade vascular dos dois grupos utilizando o método de imuno-histoquímica. Para isso foram utilizados os anticorpos anti- citoqueratina 7 (CK-7), anti- proteína-a do surfactante (SP-A), antimarcador de célula endotelial CD-34 (CD34), e anti-molécula da adesão vascular 1 (VCAM-1). Também foi comparado o padrão de remodelamento da matriz septal e vascular, usando os métodos histoquímicos da resorcina (fibras elásticas) e picrosírius (colágeno). Uma análise estatística foi realizada comparando os resultados dos dois grupos, o impacto do remodelamento nas provas de função pulmonar e a influência na sobrevida. Resultados: A densidade das células epiteliais foi menor na NSIP-ES, do que na forma idiopática (p<0,0001). Já os pneumócitos tipo II e as células de Clara encontraram-se diminuídos no grupo idiopático (p=0,02). Uma diminuição na densidade vascular foi encontrada na NSIP-ES quando comparada à forma idiopática (p<0,0001); no entanto, a atividade vascular medida pelo VCAM-1 foi maior no grupo da NSIP-ES (p<0.0001). O conteúdo das fibras elásticas e colágeno septal, bem como o das fibras elásticas na parede vascular, estavam aumentados no grupo da ES quando comparados à forma idiopática (p=0,01; p=0,001 e p<0,0001, respectivamente). Não houve diferença estatística entre o colágeno da parede vascular, no grau de obstrução vascular ou associação entre os parâmetros de remodelamento e reparo do parênquima pulmonar na sobrevida dos dois grupos. Dentre as provas de função pulmonar, a DCO/Hb foi mais afetada no grupo da ES (59% do valor predito na ES e 97% no grupo idiopático). Foi observada uma associação direta entre a densidade vascular e a DCO/Hb (p=0,02). Após o seguimento de 36 meses, não foi observada diferença no prognóstico dos dois grupos. Conclusão: Os processos de remodelamento e reparo do parênquima pulmonar parecem ser diferentes entre os dois grupos. Apesar de o processo fibrótico ser mais intenso na NSIP-ES, isso parece não estar associado a um pior prognóstico, como tem sido descrito na forma idiopática. Como o processo de elastose e a expressão do VCAM-I são mais intensos na ES, isso sugere que o processo inflamatório tem um papel mais importante na patogênese e no processo de remodelamento e reparo da ES do que na forma idiopática. No entanto, outros estudos são necessários para validar a importância desses resultados e sua utilização para fins terapêuticos e de prognóstico / Background: The presence of Interstitial lung disease is a well recognized prognostic factor in systemic sclerosis (SSc). As the prognosis in nonspecific interstitial pneumonia (NSIP) has been described to be better in collagen vascular disorders compared to the idiopathic forms, it is conceivable that the mechanisms of repair and remodeling are different between these two forms of the disease. Objectives: To compare the mechanisms of repair and remodeling between SSc associated nonspecific pneumonia and the idiopathic form, as well as their impact on pulmonary function tests and survival rates. Methods: Biopsies from 18 patients with SSc-associated NSIP and 22 with idiopathic NSIP were analyzed. Clinical data and pulmonary function test results were obtained by retrospective chart review. All H&E slides were reviewed by three pathologists. The epithelial and vascular densities and vascular activity were compared between the two groups by immunohistochemistry with antibodies directed against cytokeratin-7, surfactant protein-a, CD34, and VCAM-1, as well as septal and vascular matrix remodeling using histochemical stains (picrosirius and resorcin). Statistical analyses were performed to compare the results of these various studies with clinical parameters (e.g. pulmonary function tests) and survival between the groups. Results: Epithelial cell density was lower in SSc-NSIP when compared with idiopathic-NSIP (p<0.0001). Type II pneumocytes and Clara cells were reduced in idiopathic NSIP (p=0.02). A decrease in microvessel density was found in SSc-NSIP compared to idiopathic-NSIP (p<0.0001). The vascular activity measured by VCAM-1 expression was higher in NSIP-SSc when compared to the idiopathic group (p<0.0001). A direct association between vascular density and DLCO/HB was found (p=0.02). Among pulmonary function tests the DLCO/HB was affected to a greater extent in the SSc group (59% of the predicted value in SSc and 97% in the idiopatic group). The content of septal collagen and elastic fibers, as well as the elastic fibers in the vascular wall, were higher in the SSc group (p=0.01, p=0.001 and p<0.0001, respectively). There were no differences in the collagen content of the vascular wall, vascular grade, or survival between the two groups. There was no difference in the survival rate between the two groups after a follow-up of 36 months. Conclusions: Alterations in the pulmonary epithelium and vasculature seem to differ in the SSc-NSIP when compared to the idiopathic form of the disease. Although the fibrotic process is more intense in the SSc group, it does not seem to affect the prognosis of these patients, contrary to what has been described in idiopatic lung fibrosis. Because the elastotic process and VCAM-1 expression are higher in the SSc group, this might suggest that inflammatory mechanisms affecting the elastic fiber system and vasculature could play a greater role in the pathogenesis and pulmonary remodeling process of SSc-NSIP than in idiopathic-NSIP. Further studies may be required to assess the significance of these findings and explore if they can provide prognostic and/or treatment information

Pour beaucoup d’entre nous, y compris pour de nombreux immunologistes, le rôle du système immunitaire est restreint à un rôle de défense contre différents pathogènes, tels que les bactéries et les virus. Pourtant, il devient de plus en plus incontestable que le système immunitaire est impliqué dans de nombreux autres phénomènes que peuvent être le cancer, l’obésité et la réparation tissulaire. Au cours de cette thèse, nous nous sommes intéressés à l’implication des cellules immunitaires, et plus particulièrement des cellules immunitaires innées, dans le mécanisme de réparation tissulaire. Par la suite, nous avons approfondi ce travail en nous focalisant sur les dérégulations de la réparation tissulaire. Ces dérégulations peuvent donner lieu notamment à des phénomènes de « sur-réparation » telle que la fibrose. La fibrose est définie comme un dépôt excessif de matrice extracellulaire par les fibroblastes en réponse à des molécules profibrotiques tels que le TGFβ ou l’IL-13. Nous nous sommes donc intéressés au rôle de la réponse immunitaire innée dans la fibrose en nous concentrant sur deux types de cellules immunitaires innées : les macrophages et les cellules lymphoïdes innées de type 2 (type 2 innate lymphoïde cells, ou « ILC2 »). Nous avons choisi comme modèle d’étude la sclérodermie systémique, maladie auto-immune caractérisée principalement par la fibrose pouvant toucher la peau et/ou les organes internes. Outre la fibrose, cette pathologie est également associée à des anomalies vasculaires et immunitaires. Les mécanismes liant ces trois caractéristiques sont encore mal définis et mal connus. Il est donc nécessaire de comprendre la physiopathologie de cette maladie et d’établir précisément l’implication de la réponse immunitaire dans la fibrose afin d’offrir un traitement thérapeutique pour les patients sclérodermiques et plus généralement pour toutes les maladies fibrotiques. Dans un premier temps, nous montrons, en cytométrie de flux, une diminution des ILC2 dans le sang des patients sclérodermiques par rapport aux témoins (0,007 ± 0,007% vs. 0,01 ± 0,01%, p=0,001). Chez les sujets sclérodermiques, cette baisse de la fréquence des ILC2 circulantes est inversement corrélée à l’atteinte de la fibrose cutanée définie par le score de Rodnan (R=-0,35, p=0,0062). Nous observons une augmentation de ces cellules dans la peau sclérodermique comparé à celle des contrôles (5,015 ± 2,8% vs. 2,816 ± 1,8%). Ce résultat est positivement corrélé au score de Rodnan (r=0,58, p=0,01). Nous obtenons des résultats similaires en immunofluorescence. Un phénotypage des ILC2 dermales nous a permis d’observer une diminution de l’expression de KLRG1 dans la peau des malades. En collaboration avec l’équipe du Pr. Batteux, nous avons étudié le rôle des ILC2 dans un modèle murin de sclérodermie. Nous observons une augmentation cutanée des ILC2 et cela même avant l’établissement de la fibrose au niveau de la peau des souris sclérodermiques (16677 ± 3068 vs. 9091 ± 474). Puis, nous montrons, in vitro, que les ILC2 stimulées par le TGFb perdent l’expression de KLRG1. Au contact des ILC2 stimulées par le TGFb, les fibroblastes deviennent pro-fibrotique en comparaison à l’incubation avec des ILC2 non stimulées. Ces résultats apportent de nouvelles connaissances dans la physiopathologie de la sclérodermie systémique et plus particulièrement dans la fibrose caractérisant cette maladie, ce qui offre des perspectives thérapeutiques potentielles. L’approche conceptuelle du rôle du système immunitaire dans la réparation tissulaire proposée dans cette thèse renouvelle notre vision de l’immunité et ouvre potentiellement un nouveau champ, encore sous-estimé, de thérapies ciblant le système immunitaire. / For many of us, including many immunologists, the role of the immune system is limited to a defense role against different pathogens such as bacteria and viruses. Yet it is becoming increasingly clear that the immune system is involved in many other phenomena such as cancer, obesity and tissue repair.During this thesis, we were interested in the involvement of immune cells, and more particularly innate immune cells, in the tissue repair mechanism. Subsequently, we deepened this work by focusing on the deregulations of tissue repair. These deregulations can lead to "over-repair" phenomena such as fibrosis. Fibrosis is defined as an excessive deposition of extracellular matrix by fibroblasts in response to profibrotic molecules such as TGFβ or IL-13. We therefore focused on the role of the innate immune response in fibrosis by focusing on two types of innate immune cells macrophages and innate lymphoid cells of type 2 (ILC2). We chose systemic scleroderma, an autoimmune disease characterized mainly by fibrosis that can affect the skin and/or internal organs, as our study model. In addition to fibrosis, this pathology is also associated with vascular and immune abnormalities. The mechanisms linking these three characteristics are still poorly defined and poorly understood.It is necessary to understand the physiopathology of this disease and to establish precisely the involvement of the immune response in fibrosis in order to offer therapeutic treatment for scleroderma patients and more generally for all fibrotic diseases.First, we show, in flow cytometry, a decrease of ILC2 in the blood of scleroderma patients compared to controls (0.007 ± 0.007% vs. 0.01 ± 0.01%, p=0.001). In scleroderma subjects, this decrease in the frequency of circulating ILC2 is inversely correlated with skin fibrosis defined by Rodnan's score (R=-0.35, p=0.0062). We observe an increase in these cells in the scleroderma skin compared to controls (5.015 ± 2.8% vs. 2.816 ± 1.8%). This result is positively correlated to Rodnan's score (r=0.58, p=0.01). We obtain similar results in immunofluorescence. In collaboration with Prof. Batteux's team, we studied the role of ILC2 in a mouse model of scleroderma. We observe an increase in cutaneous ILC2 even before fibrosis is established in the skin of scleroderma mice (16677 ± 3068 vs. 9091 ± 474). Then, we show, in vitro, that ILC2 stimulated by TGFb lose the expression of KLRG1. Upon contact with TGFb-stimulated ILC2, fibroblasts become pro-fibrotic compared to incubation with unstimulated ILC2.These results bring new knowledge in the physiopathology of systemic scleroderma and more particularly in the fibrosis characterizing this disease, which offers potential therapeutic prospects.The conceptual approach to the role of the immune system in tissue repair proposed in this thesis renews our vision of immunity and potentially opens up a new and still underestimated field of therapies targeting the immune system.STAR

In systemic sclerosis (SSc), interstitial lung disease (ILD) and engagement of the vascular system lead to increased morbidity and mortality. The aim of this thesis was to elucidate, in a consecutively included cohort of SSc (limited and diffuse) patients (n = 33), the T cell cytokine profile driving the disease in ILD and to explore the role of matrix metalloproteinase 9 (MMP-9) and its inhibitor: tissue inhibitor of metalloproteinase 1 (TIMP-1) in the extracellular matrix (ECM) degrading process leading to fibrous scarring and honey combing. Moreover, to characterize the role of nitric oxide (NO) in vascular engagement. Peripheral arterial changes cause Raynaud’s phenomenon and digital ulcers. Nitric oxide (NO) a main inducer of vasodilation is produced by endothelial nitric oxide synthase (eNOS) in response to changes in blood flow or by inflammatory cytokine inducible (i) NOS. In the vascular smooth muscle cell (VSMC) NO activates guanylate cyclase to produce cGMP, causing relaxation. We showed elevated plasma nitrate, a degradation product of NO, and increased urinary excretion of nitrate and cGMP. Plasma nitrate correlated with elevated levels of endothelial adhesion molecules: endothelial (E) selectin and vascular adhesion molecule 1, indicating that the activated endothelium is the site of NO synthesis by iNOS. Endothelial staining for E-selectin and the finding of iNOS and eNOS in SSc skin biopsies supported this notion. In SSc increased vascular stiffness may limit the NO vasodilatory effects. We found normal endothelium-dependent (i.e. flow mediated (FMD%)) and endothelium-independent (i.e. nitroglycerin-induced (NTG%)) vasodilation in the brachial artery. Radial arterial wall stiffness measured as maximum increase in pulse pressure (dP/dtmax) was increased. FMD% and especially NTG% correlated negatively and dP/dtmax positively to measures of endothelial inflammation: plasma- nitrate and adhesion molecule levels. Thus inflammatory vascular wall changes may interfere with dilation as may the presence of nitrate tolerance. We found elevated alveolar MMP-9 in both its pro- and active form in ILD. The levels correlated to decline in lung capacity, pointing at a causal relation. We suggest that neutrophils secrete MMP-9, which may degrade collagen IV, (the main constituent of basal membranes), collagen V, gelatins, proteoglycans and elastin. MMP-9 activity is partly regulated by the binding of pro- and active form to TIMP-1. Alveolar TIMP-1, which even stimulates fibroblast ECM synthesis, was increased independent of ILD. The inflammatory process in ILD is orchestrated by activated T helper (h) lymphocytes. We found a mixed Th1/Th2 reaction in SSc alveolar T cells expressing messenger for interferon gamma (Th1), IL-6 and IL-10 (both Th2). No particular cytokine mRNA profile distinguished alveolar T cells in ILD. Neutrophils invaded the bronchial epithelium, which seemed otherwise inert as levels of inflammatory cytokine sensitive transcription factors and their nuclear translocation tended to be low. The neutrophil recruitment pathway is uncertain as chemoattractants and endothelial adhesion molecules were normally expressed. In conclusion, MMP-9 probably causes degradation of lung tissue in ILD and may represent a future therapeutic target. Alveolar T cells show a mixed Th1/Th2 cytokine profile independent of ILD. Neutrophils invade the bronchial epithelium. Activated endothelium produces increased amounts of NO and adhesion molecules and the level of activation influences brachial arterial FMD% and NTG% and radial arterial compliance. Nitrate tolerance may be present.

La sclérose systémique est une maladie autoimmune dont l’une des complications majeures est la fibrose. La DNA topoisomérase I (topo) est l’un des principaux autoantigènes associés à cette maladie. Toutefois, aucun lien n’a encore pu être établi entre la présence des anti-topo et le développement de la fibrose. Les travaux antérieurs du laboratoire d’accueil ont montré une interaction directe de la topo avec la surface des fibroblastes et la matrice extracellulaire. Nous avons voulu caractériser ces interactions du point de vue moléculaire. La topo a donc été exprimée sous forme de 5 fragments, déterminés à partir de ses principaux domaines structuraux et de ses épitopes majeurs, chez E. coli. Les fragments purifiés ont été analysés pour leur interaction avec l’héparine, représentant les héparane sulfates de la surface des fibroblastes, et avec des protéines purifiées de la matrice extracellulaire. Nous avons montré que le fragment topo-N est le principal responsable de l’interaction avec l’héparine, ce qui suggère donc l’implication potentielle de ce domaine dans l’interaction de la topo avec la surface des fibroblastes. Le fragment topo-DIDII est responsable de l’interaction avec la plupart des protéines de la matrice extracellulaire étudiées, alors que le fragment topo-H15 n’interagit qu’avec la vitronectine. Aucune interaction des fragments topo-DIII et topo-C n’a été décelée. Ces résultats pourront maintenant servir à mieux comprendre le rôle potentiel de la topo et des autoanticorps circulants anti-topo dans la fibrose présente chez les personnes atteintes de sclérose systémique en contribuant à l’identification de la cible de la topo sur les fibroblastes. / Systemic sclerosis is an autoimmune disease in which one of the major complications is fibrosis. DNA topoisomerase I (topo) is a major autoantigen associated with this disease. However, no link has yet been established between the presence of anti-topo and the development of fibrosis. Previous work of the host laboratory showed a direct interaction of the topo with the surface of fibroblasts and extracellular matrix. We wanted to characterize these interactions at the molecular level. Topo was expressed in 5 fragments, determined from its main structural domains and its major epitopes, in E. coli. The purified fragments were analyzed for their interaction with heparin, representing heparan sulfates on the surface of fibroblasts, and with purified proteins of the extracellular matrix. We have shown that the topo-N fragment is responsible for interaction with heparin, suggesting hence, potential involvement of this domain in the interaction of topo with the surface of fibroblasts. The topo-DIDII fragment is responsible for the interaction with most proteins of the extracellular matrix studied, whereas the topo-H15 fragment only binds to vitronectin. No interaction of fragments topo-DIII and topo-C was found. These results can now be used to better understand the potential role of topo and circulating anti-topo autoantibodies in the fibrosis present in patients with systemic sclerosis in helping to identify the target of topo on fibroblasts.