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This subgroup is positive for anti-topoisomerase 1 antibody &#40;Scl 70&#41; and is at higher risk of internal organ involvement in the initial phases of the disease&#46; The limited form is defined by the development of symmetrical skin thickening confined to the distal regions of the extremities and the face&#46; The patients test positive for the anti-centromere antibody and the prognosis is better except in those with pulmonary hypertension and biliary cirrhosis&#46; The incidence of cardiac involvement is similar in the two forms of presentation&#44; but is more severe in diffuse SS &#40;DSS&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a> It can be a primary cause of &#8211; or secondary to &#8211; pulmonary hypertension&#44; pulmonary interstitial disease and kidney disease&#44; and can affect myocardium&#44; the conduction system&#44; pericardium and the valve apparatus&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Transthoracic echocardiography &#40;TTE&#41; should be a routine evaluation&#44; in combination with electrocardiography and chest X-ray&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">4</span></a> Gadolinium-enhanced nuclear magnetic resonance imaging &#40;MRI&#41; characteristically shows &#8220;late linear and subendocardial enhancement&#8221; corresponding to the pattern of myocardial fibrosis&#46; The T2-weighted images evaluate the presence of myocardial edema&#44; characteristic of &#8220;scleroderma myocarditis&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">5</span></a> Cardiac biopsy is pathognomonic and reveals &#8220;contraction band necrosis and replacement of the myocardial tissue by patchy fibrosis&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Among the treatments administered&#44; calcium antagonists&#44; angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers were found to improve myocardial perfusion&#46; Immunosuppression is proposed as an option in myocarditis&#46; In the case of congestive heart failure &#40;CHF&#41; refractory to drug therapy&#44; heart transplantation should be considered&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">We present the case of a young woman with a diagnosis of DSS&#44; with early progressive cardiac involvement&#46; The importance of this case lies in the form of presentation and its refractoriness to medical treatment&#44; making heart transplantation necessary&#46; We decided to perform a literature review and report this association&#44; taking into account the limited number of references to this condition&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case Report</span><p id="par0025" class="elsevierStylePara elsevierViewall">A 19-year-old woman was referred to our service to be evaluated for DSS&#46; Her medical history included CHF complicated by acute pulmonary edema&#44; for which she had required several hospital stays over the preceding 5 months&#46; Three years earlier&#44; her condition had begun with rapidly progressing&#44; generalized skin thickening&#44; microstomia and Raynaud&#39;s phenomenon&#44; myalgia&#44; muscle weakness&#44; xerostomia&#44; xerophthalmia and dyspnea&#44; which became progressively more marked&#46; There was no evidence of pulmonary&#44; respiratory or renal involvement&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The physical examination revealed arterial blood pressure of 100&#47;70<span class="elsevierStyleHsp" style=""></span>mmHg&#59; heart rate&#44; 80<span class="elsevierStyleHsp" style=""></span>beats&#47;min&#59; respiratory rate&#44; 16<span class="elsevierStyleHsp" style=""></span>breaths&#47;min&#59; body temperature&#44; 36<span class="elsevierStyleHsp" style=""></span>&#176;C&#59; body weight&#44; 63<span class="elsevierStyleHsp" style=""></span>kg&#59; prominent second heart sound localized to pulmonary valve&#59; 2&#47;3 jugular distension without inspiratory collapse&#59; mouth opening limitation&#59; facial telangiectasias&#59; generalized skin thickening with a Rodnan skin score of 27&#47;51&#59; and mild Raynaud&#39;s phenomenon&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The laboratory findings were&#58; antinuclear antibodies&#44; 1&#47;1280&#44; with a fine speckled pattern&#59; negative tests for Scl-70&#44; anti-centromere&#44; anti-RO&#44; anti-LA and anti-ribonucleoprotein &#40;RNP&#41; antibodies&#59; and brain natriuretic peptide&#44; 2495<span class="elsevierStyleHsp" style=""></span>pg&#47;mL&#46; Transthoracic echocardiography revealed global hypokinesia with severely depressed systolic function &#40;SF&#41;&#59; left ventricular &#40;LV&#41; ejection fraction&#44; 25&#37;&#59; dilated right cardiac chambers&#44; with depressed right ventricular &#40;RV&#41; SF&#59; severe tricuspid regurgitation&#59; LV with restricted mitral flow&#46; Chest computed tomography showed no evidence of lung parenchyma involvement&#46; Capillaroscopy revealed a pattern of active DSS&#46; Cardiac MRI demonstrated dilation and severe deterioration of LV SF&#44; dilation of left atrium&#44; gadolinium enhancement with a diffuse subendocardial pattern consistent with fibrosis secondary to scleroderma&#44; with extensive myocardial involvement&#59; dilation and severe deterioration of RV SF&#59; mild pericardial effusion&#59; and T2-weighted images without edema&#46; Neither skin biopsy nor other imaging studies &#40;single-photon emission computed tomography &#91;SPECT&#93;&#41; were performed&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patient was being treated with azathioprine at 150<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#44; meprednisone at 20<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#44; nebivolol at 5<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#44; losartan at 50<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#44; spironolactone at 50<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#44; furosemide at 40<span class="elsevierStyleHsp" style=""></span>mg&#47;day and omeprazole at 20<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">As the patient failed to respond to this regimen&#44; heart transplantation was performed&#46; At discharge&#44; her immunosuppressive therapy consisted of tacrolimus 3<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#44; mycophenolate mofetil 2<span class="elsevierStyleHsp" style=""></span>g&#47;day&#44; meprednisone 20<span class="elsevierStyleHsp" style=""></span>mg&#47;day and leukovorin 15<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Post-transplantation TTE showed preserved RV and LV function&#44; and an ejection fraction of 55&#37;&#46; A biopsy revealed marked replacement fibrosis in large areas of myocardium and endocardium&#44; and in portions with transmural involvement&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Fifteen days after transplantation&#44; the patient experienced cardiopulmonary arrest and failed to respond to resuscitation maneuvers&#46; The outcome was attributed to humoral immunity-mediated rejection&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">Early selective cardiac involvement in patients with scleroderma is an uncommon occurrence&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Goetz and Berne coined the term systemic sclerosis in 1945&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">8</span></a> Earlier&#44; Heine &#40;1926&#41;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">9</span></a> and Weiss and Warren &#40;1943&#41;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">10</span></a> had described cardiac involvement in this disease&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">In 1943&#44; Weiss&#44; Stead and Warren reported 9 cases of patients with cutaneous involvement associated with heart disease&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">11</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">A study published in 1976 by Bulkley et al&#46; of Johns Hopkins Hospital included 52 cases of autopsies in which they found &#8220;contraction band necrosis and replacement of the myocardial tissue by patchy fibrosis&#44; with no associated coronary artery disease or pulmonary hypertension&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">6</span></a> A number of reviews indicate an incidence of cardiac manifestations in 15&#37;&#8211;35&#37; of the patients with SS&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">12</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Domsic et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a> demonstrated that severe cardiac involvement was significantly more common in patients with rapid skin progression&#46; The latter was associated with severe heart disease in 3&#37; of the patients&#44; versus 1&#37; of those with slow progression&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Magnetic resonance imaging was found to have greater sensitivity and specificity for the study of cardiac involvement than TTE&#46; Moreover&#44; MRI is an accurate and reliable technique for the diagnosis of cardiac involvement in SS and for the accurate analysis its mechanisms&#44; including inflammatory&#44; microvascular and fibrotic components&#46; As it is noninvasive&#44; quantitative and highly sensitive&#44; MRI appears to be the method of choice for the determination of the natural history of untreated patients&#44; or for the accurate monitoring of the effects of treatment&#46; Compared with TTE&#44; MRI seems to provide additional information regarding the visualization of myocardial infarction and fibrosis&#44; there being linear late gadolinium enhancement with a subendocardial pattern&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">5</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The course of our patient was indolent&#44; but was also atypical of that associated with the underlying disease&#44; with selective cardiac involvement that was resistant to medical treatment&#44; and cardiac transplantation was ultimately required&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Cardiac transplantation is currently considered to be the treatment of choice in end-stage heart failure refractory to medical treatment&#46; Graft rejection is one of the most feared complications&#46; Three types of rejection have been recognized&#58; hyperacute&#44; acute &#40;cellular and humoral&#41; and chronic&#46; Our patient had acute humoral rejection&#44; which can develop days or weeks after transplantation&#46; One of its features is the possibility of rejection episodes with hemodynamic compromise and no evidence of cellular infiltration in the biopsy&#46; Humoral rejection is mediated by antibodies&#8211;more than by cells&#8211;directed against donor human leukocyte antigens &#40;HLA&#41; or endothelial antigens&#46; It affects 7&#37; of transplant recipients and occurs more frequently in women&#46; It is associated with severe left ventricular dysfunction &#40;47&#37; of the cases&#41; and a higher incidence of chronic rejection&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">14&#8211;16</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In an extensive review of the literature&#44; we found only 2 similar cases&#46; One occurred in a 14-year-old girl who had a diagnosis of DSS&#44; with cutaneous and selective cardiac involvement&#44; but that affected no other organs&#46; Like our patient&#44; she tested positive for antinuclear antibodies in the absence of any other antibodies&#44; TTE revealed global hypokinesia and an endomyocardial biopsy disclosed fibrosis&#46; Likewise&#44; despite medical treatment&#44; her course was indolent and she ultimately required heart transplantation&#46; Despite the administration of immunosuppressive therapy&#44; she died 27 months later due to humoral rejection&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">17</span></a> The other case we found was that of a 36-year-old man with a 3-year history of DSS&#44; but only cardiac and cutaneous involvement&#46; The findings on TTE&#44; MRI and cardiac biopsy were similar to those observed in our patient&#46; Despite optimal medical treatment&#44; his heart failure progressed rapidly&#44; requiring emergency transplantation&#46; The article mentions that the patient was alive more than 1 year after the intervention&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">18</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">We report this case because of the low prevalence of this mode of presentation of DSS&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0110" class="elsevierStylePara elsevierViewall">Although the case report we present here had a fatal outcome due to graft rejection&#44; the literature includes the report of a successful outcome 1 year after the patient underwent transplantation&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical Disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Protection of human and animal subjects</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of Interest</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Systemic sclerosis &#40;SS&#41; in a multifactorial and systemic&#44; chronic&#44; autoimmune disease that affects the connective tissue&#46; We present this clinical case given the low prevalence of diffuse SS with early and progressive cardiac compromise in a young patient&#44; and treatment with cardiac transplantation&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La esclerosis sist&#233;mica &#40;ES&#41; en una enfermedad autoinmune&#44; cr&#243;nica&#44; multifactorial y sist&#233;mica que afecta al tejido conectivo&#46; Presentamos este caso cl&#237;nico dado la baja prevalencia de ES difusa con compromiso card&#237;aco temprano y progresivo en una paciente joven&#44; y tratamiento con trasplante card&#237;aco&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Bennasar G&#44; Carlevaris L&#44; Secco A&#44; Romanini F&#44; Mamani M&#46; Trasplante card&#237;aco en una paciente joven con diagn&#243;stico de esclerosis sist&#233;mica difusa&#46; Reumatol Clin&#46; 2016&#59;12&#58;285&#8211;287&#46;</p>"
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Case Report
Cardiac Transplant in Young Female Patient Diagnosed With Diffuse Systemic Sclerosis
Trasplante cardíaco en una paciente joven con diagnóstico de esclerosis sistémica difusa
Guillermo Bennasar
Corresponding author
guillo15@hotmail.com

Corresponding author.
, Leandro Carlevaris, Anastasia Secco, Felix Romanini, Marta Mamani
Servicio de Reumatología, Hospital Bernardino Rivadavia, Buenos Aires, Argentina
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Systemic sclerosis &#40;SS&#41; is a multisystem autoimmune disease characterized by inflammation and excessive extracellular matrix deposition in skin and internal organs&#46; The clinical course can range from that of a benign condition&#44; with only cutaneous and peripheral vascular involvement to that of a rapidly progressive disease&#44; affecting 1 or more internal organs&#46; It is classified as localized &#40;involving only the skin&#41; or systemic&#46; In turn&#44; the systemic variant is subclassified as limited and diffuse&#44; depending on the expanse of skin affected&#46; The diffuse form is characterized by the rapid development of symmetrical skin thickening in the proximal and distal regions of the extremities&#44; and in face and trunk&#46; This subgroup is positive for anti-topoisomerase 1 antibody &#40;Scl 70&#41; and is at higher risk of internal organ involvement in the initial phases of the disease&#46; The limited form is defined by the development of symmetrical skin thickening confined to the distal regions of the extremities and the face&#46; The patients test positive for the anti-centromere antibody and the prognosis is better except in those with pulmonary hypertension and biliary cirrhosis&#46; The incidence of cardiac involvement is similar in the two forms of presentation&#44; but is more severe in diffuse SS &#40;DSS&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a> It can be a primary cause of &#8211; or secondary to &#8211; pulmonary hypertension&#44; pulmonary interstitial disease and kidney disease&#44; and can affect myocardium&#44; the conduction system&#44; pericardium and the valve apparatus&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Transthoracic echocardiography &#40;TTE&#41; should be a routine evaluation&#44; in combination with electrocardiography and chest X-ray&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">4</span></a> Gadolinium-enhanced nuclear magnetic resonance imaging &#40;MRI&#41; characteristically shows &#8220;late linear and subendocardial enhancement&#8221; corresponding to the pattern of myocardial fibrosis&#46; The T2-weighted images evaluate the presence of myocardial edema&#44; characteristic of &#8220;scleroderma myocarditis&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">5</span></a> Cardiac biopsy is pathognomonic and reveals &#8220;contraction band necrosis and replacement of the myocardial tissue by patchy fibrosis&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Among the treatments administered&#44; calcium antagonists&#44; angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers were found to improve myocardial perfusion&#46; Immunosuppression is proposed as an option in myocarditis&#46; In the case of congestive heart failure &#40;CHF&#41; refractory to drug therapy&#44; heart transplantation should be considered&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">We present the case of a young woman with a diagnosis of DSS&#44; with early progressive cardiac involvement&#46; The importance of this case lies in the form of presentation and its refractoriness to medical treatment&#44; making heart transplantation necessary&#46; We decided to perform a literature review and report this association&#44; taking into account the limited number of references to this condition&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case Report</span><p id="par0025" class="elsevierStylePara elsevierViewall">A 19-year-old woman was referred to our service to be evaluated for DSS&#46; Her medical history included CHF complicated by acute pulmonary edema&#44; for which she had required several hospital stays over the preceding 5 months&#46; Three years earlier&#44; her condition had begun with rapidly progressing&#44; generalized skin thickening&#44; microstomia and Raynaud&#39;s phenomenon&#44; myalgia&#44; muscle weakness&#44; xerostomia&#44; xerophthalmia and dyspnea&#44; which became progressively more marked&#46; There was no evidence of pulmonary&#44; respiratory or renal involvement&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The physical examination revealed arterial blood pressure of 100&#47;70<span class="elsevierStyleHsp" style=""></span>mmHg&#59; heart rate&#44; 80<span class="elsevierStyleHsp" style=""></span>beats&#47;min&#59; respiratory rate&#44; 16<span class="elsevierStyleHsp" style=""></span>breaths&#47;min&#59; body temperature&#44; 36<span class="elsevierStyleHsp" style=""></span>&#176;C&#59; body weight&#44; 63<span class="elsevierStyleHsp" style=""></span>kg&#59; prominent second heart sound localized to pulmonary valve&#59; 2&#47;3 jugular distension without inspiratory collapse&#59; mouth opening limitation&#59; facial telangiectasias&#59; generalized skin thickening with a Rodnan skin score of 27&#47;51&#59; and mild Raynaud&#39;s phenomenon&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The laboratory findings were&#58; antinuclear antibodies&#44; 1&#47;1280&#44; with a fine speckled pattern&#59; negative tests for Scl-70&#44; anti-centromere&#44; anti-RO&#44; anti-LA and anti-ribonucleoprotein &#40;RNP&#41; antibodies&#59; and brain natriuretic peptide&#44; 2495<span class="elsevierStyleHsp" style=""></span>pg&#47;mL&#46; Transthoracic echocardiography revealed global hypokinesia with severely depressed systolic function &#40;SF&#41;&#59; left ventricular &#40;LV&#41; ejection fraction&#44; 25&#37;&#59; dilated right cardiac chambers&#44; with depressed right ventricular &#40;RV&#41; SF&#59; severe tricuspid regurgitation&#59; LV with restricted mitral flow&#46; Chest computed tomography showed no evidence of lung parenchyma involvement&#46; Capillaroscopy revealed a pattern of active DSS&#46; Cardiac MRI demonstrated dilation and severe deterioration of LV SF&#44; dilation of left atrium&#44; gadolinium enhancement with a diffuse subendocardial pattern consistent with fibrosis secondary to scleroderma&#44; with extensive myocardial involvement&#59; dilation and severe deterioration of RV SF&#59; mild pericardial effusion&#59; and T2-weighted images without edema&#46; Neither skin biopsy nor other imaging studies &#40;single-photon emission computed tomography &#91;SPECT&#93;&#41; were performed&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patient was being treated with azathioprine at 150<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#44; meprednisone at 20<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#44; nebivolol at 5<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#44; losartan at 50<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#44; spironolactone at 50<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#44; furosemide at 40<span class="elsevierStyleHsp" style=""></span>mg&#47;day and omeprazole at 20<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">As the patient failed to respond to this regimen&#44; heart transplantation was performed&#46; At discharge&#44; her immunosuppressive therapy consisted of tacrolimus 3<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#44; mycophenolate mofetil 2<span class="elsevierStyleHsp" style=""></span>g&#47;day&#44; meprednisone 20<span class="elsevierStyleHsp" style=""></span>mg&#47;day and leukovorin 15<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Post-transplantation TTE showed preserved RV and LV function&#44; and an ejection fraction of 55&#37;&#46; A biopsy revealed marked replacement fibrosis in large areas of myocardium and endocardium&#44; and in portions with transmural involvement&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Fifteen days after transplantation&#44; the patient experienced cardiopulmonary arrest and failed to respond to resuscitation maneuvers&#46; The outcome was attributed to humoral immunity-mediated rejection&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">Early selective cardiac involvement in patients with scleroderma is an uncommon occurrence&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Goetz and Berne coined the term systemic sclerosis in 1945&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">8</span></a> Earlier&#44; Heine &#40;1926&#41;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">9</span></a> and Weiss and Warren &#40;1943&#41;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">10</span></a> had described cardiac involvement in this disease&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">In 1943&#44; Weiss&#44; Stead and Warren reported 9 cases of patients with cutaneous involvement associated with heart disease&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">11</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">A study published in 1976 by Bulkley et al&#46; of Johns Hopkins Hospital included 52 cases of autopsies in which they found &#8220;contraction band necrosis and replacement of the myocardial tissue by patchy fibrosis&#44; with no associated coronary artery disease or pulmonary hypertension&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">6</span></a> A number of reviews indicate an incidence of cardiac manifestations in 15&#37;&#8211;35&#37; of the patients with SS&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">12</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Domsic et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a> demonstrated that severe cardiac involvement was significantly more common in patients with rapid skin progression&#46; The latter was associated with severe heart disease in 3&#37; of the patients&#44; versus 1&#37; of those with slow progression&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Magnetic resonance imaging was found to have greater sensitivity and specificity for the study of cardiac involvement than TTE&#46; Moreover&#44; MRI is an accurate and reliable technique for the diagnosis of cardiac involvement in SS and for the accurate analysis its mechanisms&#44; including inflammatory&#44; microvascular and fibrotic components&#46; As it is noninvasive&#44; quantitative and highly sensitive&#44; MRI appears to be the method of choice for the determination of the natural history of untreated patients&#44; or for the accurate monitoring of the effects of treatment&#46; Compared with TTE&#44; MRI seems to provide additional information regarding the visualization of myocardial infarction and fibrosis&#44; there being linear late gadolinium enhancement with a subendocardial pattern&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">5</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The course of our patient was indolent&#44; but was also atypical of that associated with the underlying disease&#44; with selective cardiac involvement that was resistant to medical treatment&#44; and cardiac transplantation was ultimately required&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Cardiac transplantation is currently considered to be the treatment of choice in end-stage heart failure refractory to medical treatment&#46; Graft rejection is one of the most feared complications&#46; Three types of rejection have been recognized&#58; hyperacute&#44; acute &#40;cellular and humoral&#41; and chronic&#46; Our patient had acute humoral rejection&#44; which can develop days or weeks after transplantation&#46; One of its features is the possibility of rejection episodes with hemodynamic compromise and no evidence of cellular infiltration in the biopsy&#46; Humoral rejection is mediated by antibodies&#8211;more than by cells&#8211;directed against donor human leukocyte antigens &#40;HLA&#41; or endothelial antigens&#46; It affects 7&#37; of transplant recipients and occurs more frequently in women&#46; It is associated with severe left ventricular dysfunction &#40;47&#37; of the cases&#41; and a higher incidence of chronic rejection&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">14&#8211;16</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In an extensive review of the literature&#44; we found only 2 similar cases&#46; One occurred in a 14-year-old girl who had a diagnosis of DSS&#44; with cutaneous and selective cardiac involvement&#44; but that affected no other organs&#46; Like our patient&#44; she tested positive for antinuclear antibodies in the absence of any other antibodies&#44; TTE revealed global hypokinesia and an endomyocardial biopsy disclosed fibrosis&#46; Likewise&#44; despite medical treatment&#44; her course was indolent and she ultimately required heart transplantation&#46; Despite the administration of immunosuppressive therapy&#44; she died 27 months later due to humoral rejection&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">17</span></a> The other case we found was that of a 36-year-old man with a 3-year history of DSS&#44; but only cardiac and cutaneous involvement&#46; The findings on TTE&#44; MRI and cardiac biopsy were similar to those observed in our patient&#46; Despite optimal medical treatment&#44; his heart failure progressed rapidly&#44; requiring emergency transplantation&#46; The article mentions that the patient was alive more than 1 year after the intervention&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">18</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">We report this case because of the low prevalence of this mode of presentation of DSS&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0110" class="elsevierStylePara elsevierViewall">Although the case report we present here had a fatal outcome due to graft rejection&#44; the literature includes the report of a successful outcome 1 year after the patient underwent transplantation&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical Disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Protection of human and animal subjects</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of Interest</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Systemic sclerosis &#40;SS&#41; in a multifactorial and systemic&#44; chronic&#44; autoimmune disease that affects the connective tissue&#46; We present this clinical case given the low prevalence of diffuse SS with early and progressive cardiac compromise in a young patient&#44; and treatment with cardiac transplantation&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La esclerosis sist&#233;mica &#40;ES&#41; en una enfermedad autoinmune&#44; cr&#243;nica&#44; multifactorial y sist&#233;mica que afecta al tejido conectivo&#46; Presentamos este caso cl&#237;nico dado la baja prevalencia de ES difusa con compromiso card&#237;aco temprano y progresivo en una paciente joven&#44; y tratamiento con trasplante card&#237;aco&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Bennasar G&#44; Carlevaris L&#44; Secco A&#44; Romanini F&#44; Mamani M&#46; Trasplante card&#237;aco en una paciente joven con diagn&#243;stico de esclerosis sist&#233;mica difusa&#46; Reumatol Clin&#46; 2016&#59;12&#58;285&#8211;287&#46;</p>"
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ISSN: 21735743
Original language: English
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Idiomas
Reumatología Clínica (English Edition)
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¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?