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Pediatric Mixed Connective Tissue Disease Clinical Presentation

  • Author: Marisa S Klein-Gitelman, MD, MPH; Chief Editor: Lawrence K Jung, MD  more...
 
Updated: Jan 13, 2015
 

History

See the list below:

  • The most frequent presentation of mixed connective tissue disease (MCTD) is a child with polyarthritis, general malaise, and Raynaud phenomenon.
  • Patients may present with the following:
    • Sclerodermatous skin (usually limited to fingers but can be more extensive).
    • Sausage-shaped fingers
    • Proximal muscle weakness
    • Rash (finger ulcers or pits, Gottren papules)
    • Vasculitic rashes (usually palpable purpuric rashes)
    • Dysphagia
    • Gastroesophageal reflux disease (GERD) symptoms
    • Fever
    • Rheumatoid nodules
    • Lymphadenopathy
    • Alopecia
    • Telangiectasia
    • Headache
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Physical

Detailed physical examination is critical.[8]

  • Classification criteria other than autoantibody status rely on clinical examination and diagnostic tests.
  • Consider the following to make the diagnosis:
    • Alopecia
    • Pleuritic chest pain
    • Pericardial rub
    • Arthritis
    • Raynaud phenomenon
    • Malar rash
    • Petechial rash
    • Muscle weakness
    • Swollen hands (especially dorsal surface)
    • Trigeminal neuropathy
    • Acrosclerosis or sclerodermatous skin changes
    • Epigastric tenderness

The following lists, published by several authors, are the criteria for making a diagnosis of mixed connective tissue disease:[1, 2, 3]

  • Sharp criteria
    • Definite diagnosis requires 4 major criteria with positive anti-U1 RNP greater than 1:4000 and a negative anti-Sm Ab. U1 RNP is the specific RNP protein associated with this syndrome.
    • Probable diagnosis requires either 3 major criteria or 2 major criteria (which must come from the first 3 major criteria listed) and 2 minor criteria plus an anti-U1 RNP greater than 1:1000.
    • Possible diagnosis requires 3 major criteria without serologic evidence of disease or, if anti-U1 RNP is greater than 1:100, 2 major criteria or 1 major and 3 minor criteria.
      • Major criteria include severe myositis, pulmonary involvement (diffusing capacity of lung for carbon monoxide 70% of normal, pulmonary hypertension, proliferating vascular lesions on lung biopsy), Raynaud phenomenon or esophageal hypomotility, swollen hands or sclerodactyly, and highest observed anti-U1 RNP (>1:10,000) with negative anti-Sm Ab.
      • Minor criteria include alopecia, leukopenia (4000 WBC/mL), anemia (< 10 g/dL for females, < 12 g/dL for males), pleuritis, pericarditis, arthritis, trigeminal neuralgia, malar rash, thrombocytopenia (< 100,000/mL), mild myositis, and history of swollen hands.
  • Alarcon-Segovia and Villareal classification
    • Serologic criterion is a positive anti-RNP at a titer of 1:1600 or higher.
    • Clinical criteria (at least 3) are edema of the hands, Raynaud phenomenon (ie, 2 or 3 color changes), acrosclerosis, synovitis, and myositis (laboratory or biopsy evidence).
  • Kasukawa criteria
    • Diagnosis requires the following 3 conditions: (1) positive in either 1 of 2 common symptoms, (2) positive anti-RNP antibody, and (3) positive in 1 or more findings in 2 of 3 disease categories of A, B, and C. The following are disease findings A, B, and C:
      • SLE-like conditions (polyarthritis, lymphadenopathy, facial erythema, pericarditis or pleuritis, leukopenia [< 4000/mL], or thrombocytopenia [< 100,000/mL])
      • Progressive systemic sclerosislike findings (sclerodactyly, pulmonary fibrosis, restrictive lung disease [vital capacity < 80%] or reduced diffusion capacity [< 70%], hypomotility, or dilation of the esophagus)
      • Polymyositislike findings (muscle weakness, increased serum level of myogenic enzymes [creatine kinase], myogenic pattern on electromyogram)
    • Common symptoms include Raynaud phenomenon and swollen fingers or hands.
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Causes

Specific causes of mixed connective tissue disease remain undefined.[9]

  • Research suggests that many factors, including genetics, hormones, and environment, contribute to development of autoimmune syndromes.
  • As mentioned in the Introduction, the hallmark of mixed connective tissue disease is the presence of autoantibodies to U1 small nuclear ribonucleoproteins, in particular a 70-kDa U1 protein. During cell death or apoptosis, the 70-kDa protein is cleaved by caspase-3 into a small 40-kDa protein. Several research groups have described this apoptotic form.
  • Specific anti-RNP autoantibodies that preferentially bind to the apoptotic form of the U1 protein have been demonstrated in a group of patients with mixed connective tissue disease (29 of 53 tested). Furthermore, the concentration of the autoantibody is high early in the disease and decreases over time, suggesting that it correlates or represents an inciting event in disease onset.
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Contributor Information and Disclosures
Author

Marisa S Klein-Gitelman, MD, MPH Professor of Pediatrics, Northwestern University, The Feinberg School of Medicine; Head, Division of Rheumatology, Ann and Robert H Lurie Children's Hospital of Chicago

Marisa S Klein-Gitelman, MD, MPH is a member of the following medical societies: American Academy of Pediatrics, American College of Rheumatology

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Thomas JA Lehman, MD FAAP, FACR, Clinical Professor of Pediatrics, Department of Pediatrics, Division of Pediatric Rheumatology, Weill Cornell Medical College; Chief, Hospital for Special Surgery

Thomas JA Lehman, MD is a member of the following medical societies: PM American Allergy Society

Disclosure: Nothing to disclose.

Chief Editor

Lawrence K Jung, MD Chief, Division of Pediatric Rheumatology, Children's National Medical Center

Lawrence K Jung, MD is a member of the following medical societies: American Association for the Advancement of Science, American Association of Immunologists, American College of Rheumatology, Clinical Immunology Society, New York Academy of Sciences

Disclosure: Nothing to disclose.

Additional Contributors

Barry L Myones, MD Co-Chair, Task Force on Pediatric Antiphospholipid Syndrome

Barry L Myones, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American College of Rheumatology, American Heart Association, American Society for Microbiology, Clinical Immunology Society, Texas Medical Association

Disclosure: Nothing to disclose.

References
  1. Sharp GC, Irvin WS, Tan EM, et al. Mixed connective tissue disease--an apparently distinct rheumatic disease syndrome associated with a specific antibody to an extractable nuclear antigen (ENA). Am J Med. 1972 Feb. 52(2):148-59. [Medline].

  2. Alarcon-Segovia D, Villareal M. Classification and diagnostic criteria for mixed connective tissue disease. Kasukawa R, Sharp GC, eds. Mixed Connective Tissue Disease and Anti-nuclear Antibodies. 1987. 33-40.

  3. Kasukawa R, Tojo T, Miyawaki S. Preliminary diagnostic criteria for classification of mixed connective tissue disease. Kasukawa R, Sharp GC, eds. Mixed Connective Tissue Disease and Anti-nuclear Antibodies. 1987. 41-7.

  4. Mairesse N, Kahn MF, Appelboom T. Antibodies to the constitutive 73-kd heat shock protein: a new marker of mixed connective tissue disease?. Am J Med. 1993 Dec. 95(6):595-600. [Medline].

  5. Nowicka-Sauer K, Czuszynska Z, Majkowicz M, Smolenska Z, Jarmoszewicz K, Olesinska M, et al. Neuropsychological assessment in mixed connective tissue disease: comparison with systemic lupus erythematosus. Lupus. 2012 Mar 20. [Medline].

  6. Michels H. Course of mixed connective tissue disease in children. Ann Med. 1997 Oct. 29(5):359-64. [Medline].

  7. Tsai YY, Yang YH, Yu HH, Wang LC, Lee JH, Chiang BL. Fifteen-year experience of pediatric-onset mixed connective tissue disease. Clin Rheumatol. 2009 Sep 16. [Medline].

  8. Ortega-Hernandez OD, Shoenfeld Y. Mixed connective tissue disease: An overview of clinical manifestations, diagnosis and treatment. Best Pract Res Clin Rheumatol. 2012 Feb. 26(1):61-72. [Medline].

  9. Sharp G. The origin of mixed connective tissue disease: a stimulus for autoimmune disease research. Lupus. 2009. 18(12):1031-2. [Medline].

  10. Malleson PN, Mackinnon MJ, Sailer-Hoeck M, Spencer CH. Review for the generalist: The antinuclear antibody test in children - When to use it and what to do with a positive titer. Pediatr Rheumatol Online J. 2010 Oct 20. 8:27. [Medline]. [Full Text].

  11. Ingegnoli F, Zeni S, Gerloni V, Fantini F. Capillaroscopic observations in childhood rheumatic diseases and healthy controls. Clin Exp Rheumatol. 2005 Nov-Dec. 23(6):905-11. [Medline].

  12. Knight A, Weiss P, Morales K, Gerdes M, Gutstein A, Vickery M, et al. Depression and anxiety and their association with healthcare utilization in pediatric lupus and mixed connective tissue disease patients: a cross-sectional study. Pediatr Rheumatol Online J. 2014. 12:42. [Medline]. [Full Text].

  13. Biro E, Szekanecz Z, Czirjak L, et al. Association of systemic and thyroid autoimmune diseases. Clin Rheumatol. 2006 Mar. 25(2):240-5. [Medline].

  14. Bodolay E, Szekanecz Z, Devenyi K, et al. Evaluation of interstitial lung disease in mixed connective tissue disease (MCTD). Rheumatology (Oxford). 2005 May. 44(5):656-61. [Medline].

  15. Ito S, Nakamura T, Kurosawa R, Miyamae T, Imagawa T, Mori M. Glomerulonephritis in children with mixed connective tissue disease. Clin Nephrol. 2006 Sep. 66(3):160-5. [Medline].

  16. Mier R, Ansell B, Hall MA, et al. Long term follow-up of children with mixed connective tissue disease. Lupus. 1996 Jun. 5(3):221-6. [Medline].

  17. Mier RJ, Shishov M, Higgins GC, et al. Pediatric-onset mixed connective tissue disease. Rheum Dis Clin North Am. 2005 Aug. 31(3):483-96, vii. [Medline].

  18. Mier RJ, Shishov M, Higgins GC, Rennebohm RM, Wortmann DW, Jerath R. Pediatric-onset mixed connective tissue disease. Rheum Dis Clin North Am. 2005 Aug. 31(3):483-96, vii. [Medline].

  19. Singsen BH, Bernstein BH, Kornreich HK, et al. Mixed connective tissue disease in childhood. A clinical and serologic survey. J Pediatr. 1977 Jun. 90(6):893-900. [Medline].

  20. Tiddens HA, van der Net JJ, de Graeff-Meeder ER, et al. Juvenile-onset mixed connective tissue disease: longitudinal follow-up. J Pediatr. 1993 Feb. 122(2):191-7. [Medline].

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Raynaud phenomenon showing demarcation of color difference.
 
 
 
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