Mixed connective tissue disease (MCTD) is a systemic autoimmune disease that shares characteristics with at least two other systemic autoimmune diseases, including systemic sclerosis (Ssc), systemic lupus erythematosus (SLE), polymyositis/dermatomyositis (PM/DM), and rheumatoid arthritis. The idea behind the "mixed" disease is that this specific autoantibody is also present in other autoimmune diseases such as systemic lupus erythematosus, polymyositis, scleroderma, etc. MCTD was characterized as an individual disease in 1972 by Sharp et al., and the term was introduced by Leroy in 1980. Some experts consider MCTD to be the same as undifferentiated connective tissue disease, but other experts specifically reject this idea because undifferentiated connective tissue disease is not necessarily associated with serum antibodies directed against the U1-RNP. Furthermore, MCTD is associated with a more clearly defined set of signs and symptoms.
Signs and symptoms The early clinical features of MCTD are nonspecific and may include fatigue, low-grade fever, myalgias, Raynaud phenomenon, swelling of the fingers or hands, arthralgia, esophageal reflux or dysmotility, acrosclerosis (also known as sclerodactyly), mild myositis, and various forms of pulmonary involvement. MCTD can affect nearly any organ system.
Skin involvement Skin involvement is common in most people with MCTD and is frequently a presenting characteristic. The most prevalent skin change is Raynaud's phenomenon, which usually appears early in the course of the disease. Swollen digits are a common sign, and on occasion, the complete hand swells. Acrosclerosis, also known as sclerodactyly, can develop with or without proximal scleroderma and is usually a later symptom of the condition. Rashes are found in 50–60% of patients. Common symptoms include photosensitivity and malar rashes, similar to those seen with SLE. Discoid lesions are also occasionally seen. Some patients with MCTD may have scleroderma-like symptoms such as squared telangiectasia on the hands and face, periungual telangiectasia, sclerodactyly, and calcinosis cutis. Like systemic sclerosis, aberrant nailfold capillaroscopy with enormous capillaries, atypical forms, and low capillary density is a common hallmark of MCTD, and this can accumulate over time.
Joint involvement Approximately 60% of MCTD patients develop visible arthritis, frequently with rheumatoid arthritis (RA) deformities such as boutonniere deformities and swan neck alterations. Other features include tiny marginal erosions and destructive arthritis, such as arthritis mutilans.
Pulmonary involvement The lungs are commonly affected in MCTD, with around 75% of patients having lung involvement. The most prevalent pulmonary complications of MCTD are interstitial lung disease (ILD) and pulmonary hypertension; however, a wide spectrum of other pulmonary problems have been recorded, including pleural effusions, pleuritic discomfort, alveolar hemorrhage, and thromboembolic illness. Early indications of pulmonary involvement include dyspnea, dry cough, and pleuritic chest pain.
Muscle involvement Diagnosing MCTD involves identification of inflammatory myopathy that is histologically and clinically identical to polymyositis (PM). The majority of persons with MCTD do not experience clinical weakness. People with MCTD typically have mild myositis, with normal muscle enzymes and electromyographic results. Some people may be completely asymptomatic. Myositis can be severe and difficult to differentiate from conventional dermatomyositis. Myalgia is a prevalent complaint among patients with MCTD.
Cardiac involvement About 30% of MCTD patients have symptomatic heart disease, whereas up to 40% have subclinical cardiac illness. The most common ECG abnormalities are hemiblock, bundle branch block, and atrioventricular block. Pericarditis is the most common clinical indication of cardiac involvement, affecting up to 40% of patients.
Kidney involvement Renal involvement is a key complication of MCTD. Some studies show that it affects around 25% of people and is generally asymptomatic. The most prevalent finding is membranous nephropathy; however, nephrotic range proteinuria may also occur. Tubulointerstitial nephritis, mesangioproliferative glomerulonephritis, and hypertensive episodes resembling scleroderma renal crisis have also been observed.
Gastrointestinal involvement Gastrointestinal involvement is prevalent and overlaps with systemic sclerosis. Esophageal dysfunction is the most common gastrointestinal manifestation. The condition is initially asymptomatic, with difficulty swallowing (dysphagia) being the most prevalent symptom.
Nervous system involvement The original clinical criteria of MCTD stressed the absence of central nervous system (CNS) involvement. For instance, people with MCTD do not suffer serious problems such as cerebritis, psychosis, or seizures. However, roughly 25% of individuals have some form of CNS illness. The most common central nervous system manifestation is trigeminal (fifth cranial) nerve neuropathy, which may be a patient’s first symptom. Headaches are prevalent and are typically vascular in origin. Headaches can also be due to aseptic meningitis. Sensorineural hearing loss is frequently overlooked; however, it is estimated to occur in 50% of MCTD patients.
Hematologic involvement Hematologic abnormalities are prevalent in MCTD. Mild lymphadenopathy affects 25–50% of patients, and it is frequently an early symptom of the disease. This usually subsides over time; however, it may reappear during flares. Between 50% and 75% of people with MCTD will experience anemia, lymphopenia, or leukopenia. Anemia of chronic disease is the most common type of anemia seen in MCTD. Thrombocytopenia can develop in MCTD but is less common than leukopenia or anemia.
Systemic involvement Malaise and low-grade fever may develop with MCTD. The condition can cause elevated body temperatures without a clear cause. Sicca symptoms are frequent in MCTD, affecting 25-50% of individuals.
Causes Genetic and environmental factors both influence susceptibility to MCTD. The condition is associated with aberrant immunological regulation and immune-effector pathways.
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