Clinical rheumatology, 1983, 2, N ~ 4, 375-380

Overlapping connective tissue diseases in children

D. ITZKOWITCH*, M. ALEXANDER**
J.P. FAMAEY***, T. APPELBOOM*

* Division of Rheumatology, HOpital Erasme, University of Brussels, ** Department of

Pediatry, *** Department of Rheumatology, HOpital St-Pierre, University of Brussels,
Rue Haute, 322, 1000 Brussels, Belgium.

SUMMARY O f 18 children with different connective tissue diseases four were

f o u n d to have overlaps. T w o presented features of SLE and PSS or SLE and P M
and 2 had features o f SLE, PSS and J R A . In two o f them antiribonucleoprotein
antibodies were detected by radical immunodiffusion. But these antibodies were
also detected in a few children suffering from a single connective tissue disease. On
the other hand, the six children with anti-RNP were not characterized by a particu-
lar clinical picture or a 'better prognosis ; when compared to adults, no significant
difference could be observed except that the R a y n a u d phenomenon, sausage fingers
and myositis seemed less frequent in childhood. ~t m a y be concluded that combi-
nations o f connective tissue disease can occur in children but anti-RNP does not
appear ~as a good biological marker.

Key words: M C T D , Anti-ENA, Children.

INTRODUCTION (PM) but also by the detection of an antiri-

Since 1972, mixed connective tissue dis-
ease (MCTD) has been determined, at least
in adults, by overlapping features of syste-
mic lupus erythematosus (SLE), progressive
systemic sclerosis (PSS), and polymyositis
Received 21 December 1982
Revised 7 April 1983
Accepted 18 April 1983
Correspondence to :
DR. D. ITZKOWITCH
Division of Rheumatology
H6pital Erasme
Route de Lennik, 808,
B-1070 Brussels, Belgium.
bonucleoprotein (RNP) antibody which is
directed against the ribonuclease sensitive
antigen of an extractable nuclear antigen
(ENA) from thymus (1,2,3,4,). Whether this
disease presents similarly in children remains
poorly documented and questionable. For
example, systemic onset juvenile rheumatoid
arthritis (JRA) is characterized by a high
fever, rash and leucocytosis and the rheu-
matoid factor is rarely present (5). SLE in
childhood can be differentiated from SLE in
adults by the high frequency of rash, fever,
hepatosplenomegaly and renal dysfunction.
The characteristic skin lesion of the face
and the extremities is much more frequent in
dermatomyositic children than in adults.
However, scleroderma is similar in adults
376 Itzkowitch, Alexander, Famaey, Appelboom
and in children (malignant hypertension has,
nevertheless, not been reported in
childhood). Therefore, the questions arise
which overlaps can be observed in
childhood, what is their clinical profile and
whether children with overlaps are also de-
fined by the presence of anti-RNP. The pe-
diatric literature does not provide much in-
formation concerning M C T D . In adults, low
titers of anti-RNP antibodies can be found
additionally in SLE, RA, PSS an P M with a
good prognosis (7).
Can anti-RNP antibodies in children be
detected additionally in conditions different
f r o m overlaps ?
Are anti-RNP antibodies associated with a
lower incidence of renal manifestations also
in childhood (8) ?
MATERIAL AND METHODS
Anti-RNP
Anti-RNP antibodies were detected by a
double immunodiffusion technique using a
calf thymic extract prepared according to
Mattioli(9,10). A fresh thymus obtained
f r o m the slaughterhouse was homogenized
with a Virtis homogenizer, then centrifuged
at 20,000 g during 1 h. The supernatant was
collected and used as E N A in the precipi-
tation system; 5 m m wells were performed
in a 0.5 % agarose 4 m m layer covering a
5 cm diameter Petri dish. The central well
was filled with E N A and the surrounding
wells with the sera for testing. The Petri dish
was kept at r o o m temperature over a 48h
period. Then the gels were washed with neu-
tral salt solutions to eliminate nonspecific
lines. Sera used previously and containing
anti-RNP antibodies, as demonstrated by
the sensitivity of the precipitating line of the
digestion of the thymic extract by ribonu-
clease and trypsine, were used as reference
sera for all the tests (10).
The presence of anti-RNP antibodies was
defined as a precipitating line identical with
the reference line. Other lines were not char-
acterized.
Patients
The cases of 18 children with connective
disease f r o m the Department of Pediatrics at
the H6pital St Pierre (Universit6 Libre de
Bruxelles) were followed by one of us
(M.A.), analyzed and their clinical characte-
ristics recorded. Our findings were analyzed
for the presence of anti-RNP antibodies and
compared to the series of children with anti-
R N P antibodies discussed by other authors
from the literature and to our series of adults
with anti-RNP. Criteria for the diagnosis
were established according to Brewer f o r
JRA(6) and according to the American
Rheumatism Association for RA, PSS and
SLE. Polymyositis was defined by the use of
the following criteria : symmetrical weakness
of proximal muscles and local evidence of
necrosis of the skeletal muscle assessed by
elevation of creatinine phosphokinase, lactic
dehydrogenase, transaminase and aldolase.
RESULTS
In order to know whether combinations
of connective tissue diseases can exist in
childhood, overlaps have been investigated
a m o n g our group of 18 patients shown in
Table I.
First, features suggesting the coexistence
of two diseases were found in 2 children:
one child (AL) exhibited simultaneously
features of SLE and PSS, and another (Me)
showed signs of SLE and PM. Moreover, in
two children (Br and Ga) an overlap of three
connective tissue diseases, JRA, SLE and
PSS could be distinguished. On the other
hand, criteria proposed for the definition of
JRA(6), SLE and PSS can also (without
exclusion criteria) be used to evoke the pos-
sible diagnosis of these diseases, in which
case the four children can be classified as
having a combination of J R A + PSS (AL),
J R A + SLE (Me), and J R A + PSS (Br and
Ga) (11,12).
Secondly, it was determined that the pre-
sence of anti-RNP antibodies might be relat-
 Overlapping connective tissue diseases in children 377

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378 Itzkowitch, Alexander, Famaey, Appelboom

Table II : Comparison of features in children and adults with anti RNP-antibodies

Adults with Adults with Children with Children with

anti-RNP anti-RNP anti-RNP anti-RNP
Characteristics from from Appelboom from Singsen recent
Sharp et al (13) et al (10) et al (14) studies

Number of subjects 308 15 14 6

Polyarthralgia 95o70 12/15 13/14 6/6
ANF 90% 15/15 14/14 6/6
Raynaud phenomenon 81o70 13/15 11/14 2/6
Hypere-ammaglobulinaemia 74o70 4/6
Polyarthritis 74% 12/15 !3/14 6/6
Positive rheumatoid factor 60o70 9/14 1/6
Esophageal hypomobility 58% 5/15 8/12
Sclerodactyly 50% 10/15 11/14 2/6
Myositis 50% 6/15 0/6
Cutaneous rash ? 8/14 3/6
Technique for anti-ENA detection hemagglutination immunodiffusion hemagglutination immuno-
diffusion

ed to overlapping syndromes. These anti- Cardiac signs (2/6) consisted of pericardi-

bodies could be demonstrated by immuno-
diffusion in 2 out of the 4 children with
combination features but also in children
with only one connective tissue disease : SLE
(2/3), JRA (1/9) and hypergammaglobuli-
naemic purpura (HGP) (1/1). The problems
of the girl with HGP started with purpura
affecting the abdomen and lower bimbs fol-
lowed by several episodes of arthritis of
ankles and knees. Moreover, she exhibites
signs of hepatomegaly and generalized lym-
phadenopathies. Chest X-rays revealed en-
larged mediastinal glands and nodular opa-
cities in the lungs. The striking laboratory
findings included ESR 138 mm/h, latex fix-
ation test, mixed IgG and IgM cryoglobulins
and antinuclear factors. Despite vigorous
treatment, she developed chronic Salmonella
infection and died from septicaemia.
Whether in our series the presence of anti-
RNP antibodies was associated with specific
symptoms was the next point to be investiga-
ted: only cutaneous manifestations seemed
to occur more frequently in t h e anti-RNP
group, but these signs were dissimilar, exhi-
biting two cases of facial butterfly lupus-like
rash, one case of purpura and two cases of
sausage fingers.
tis. Respiratory manifestations were pleuritis
(2/6) complicated by an alteration of CO
diffusion (1/6). Renal signs with hematuria
occurred in two cases without renal insuf-
ficiency, and proteinuria was present in one
of them. In both, the biopsy showed a glom-
erulonephritis. The only renal involvement
in the group without anti-RNP antibodies
was hematuria, proteinuria and nephrotic
syndrome with an impairment of renal
function. A diffuse proliferative glomeru-
lonephritis was demonstrated at the biopsy.
While age was not contributive to differen-
tiation, most of the children with anti-RNP
were girls (5/6).
After a follow-up of 5 years, all but one
with anti-RNP were clinically symptom-free
except for mild arthritis. Unfortunately, the
girl who suffered from HGP died.
Finally, children with anti-RNP anti-
bodies have been compared with two series
of adults with similar antibodies detected by
passive hemagglutination(13) or by immu-
nodiffusion(10) (Table II): Raynaud phe-
nomenon, sausage fingers, sclerodactyly and
myositis seem to occur less frequently
among children than among adults.
 Overlapping connective tissue diseases in children
DISCUSSION
The purpose of this paper was not to
survey in detail a population of children
with defined or mixed connective tissue dis-
ease, studies already available in the litera-
ture (15;16,17), but to look for the existence
of overlaps with and without anti-RNP and
to approach the significance of this marker
in children with a u t o i m m u n e disease.
Our work seems to indicate that overlap-
ping connective tissue diseases can occur in
childhood but that they are not specifically
characterized by the presence of anti-RNP
anti-bodies. Indeed, overlaps with and
without anti-RNP antibodies are observed.
These can additionally be detected in the se-
rum of children with other conditions : sys-
temic lupus erythematosus (SLE), JRA,
H G P (this latter condition has so far not
been reported in association with anti-RNP
antibodies). We have also noted that anti-
R N P is not characterized by a particular
clinical picture or a better prognosis.
Anti-RNP was also detected when antinu-
clear antibodies were present and speckled
staining was always observed. This does not
exclude but renders less likely the location of
the antigen in the r rather than in
the nucleus. However, this technique has en-
abled us to detect previously anti-RNP in
M C T D and in other conditions (when the
titre is generally much lower) and our data
were similar to Sharp's series (1,9). This con-
sideration suggests that the possible absence
o f detection o f anti-RNP in some cases of
the present study is not due to a lack of sen-
sitivity of the assay. That the marker is iden-
tical in all the tested sera is indicated by the
identity reaction.
In fact, in our series children differ from
adults(10,13) by a lower frequency of
Raynaud phenomenon, sclerodactyly and
myositis as shown in Table II. However, in
both conditions (children and adults), anti-
R N P antibodies more often seem to be pre-
sent a m o n g females. Unfortunately, our
study is limited to 18 patients.
379
It is rather difficult to assert the specificity
of anti-RNP antibodies since several tech-
niques can be employed to detect them.
Moreover, E N A contains at least a series of
ribonucleic acids coupled or not with pro-
teins ; the significance o f the reaction in the
literature and of its sensitivity to digestion
by ribonuclease remains questionable (14).
In this work immunodiffusion has been
chosen to demonstrate the identity of the
precipitation lines between E N A and the se-
rum whereas most of the other series have
used hemagglutination which does not per-
mit discrimination between the different an-
tigens sensitive to R N A ase. On the other
hand, the sensitivity of our assay is relatively
poor. When our results are compared to
those of the literature, most of the clinical
signs of our cases are also found in the other
series of children with anti-RNP antibodies.
Singsen et al. reported 14 children with
M C T D characterized by the presence of high
titers of speckled antinuclear factors, anti-
bodies to R N P , as well as by significant car-
diac and renal involvement and thrombocy-
topenia. Four of them d i e d of generalized
infections o f cerebral hemorrhage (15). Bal-
dass~tre et al. described 5 children with
M C T D and anti-ENA sensitive to R N A ase
who were similar to our children with anti-
R N P antibodies except that fever and rash
were more frequent in their series; the be-
nign course remains to be seen(16). Rosen-
berg documented pulmonary hypertension,
mucocutaneous ulcerations and other lung
and oesophageal involvements in a child
with M C T D (18). (Unfortunately, we are un-
able to provide information on the Sm-anti-
gen in our group of children). Our follow-up
is too short to give data on the outcome ex-
cept for one patient who died f r o m Salmon-
ella septicaemia.
In conclusion, the literature and our
experience do not confirm the favourable
course and the good prognosis described for
adults with M C T D .
These studies also point out the difficulty
(in adults as well as in children) in differen-
380 Itzkowitch,Alexander, Famaey, Appelboorn
tiating the concepts of MCTD, undifferen-
tiated connective tissue diseases and the
combination of connective tissue di-
s e a s e s (19). S y m t o m s e x c l u s i v e t o o n e s p e c i -
fic d i s e a s e h a v e n e v e r b e e n s t r e s s e d i n c o n -
nective tissue diseases. Criteria now exist,
b u t t h e i r u s e is l i m i t e d b y t h e i r l a c k o f speci-
f i c i t y (e.g. a r t h r i t i s c a n b e p r e s e n t i n t h e m a -
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