Prognostic factors in polymyositis/dermatomyositis. A computer-assisted analysis of ninety-two cases

Myopathies in the elderly

Muscle disease symptoms and myopathies are not uncommon in the elderly. Inflammatory and noninflammatory myopathies lead to proximal extremity or axial weakness and are superimposed on the intrinsic changes that occur in muscle with aging (sarcopenia). This article surveys the more common myopathies in the elderly based on a review of the process of sarcopenia, and how these age-related changes in muscle structure and function affect the results of the standard assessments of muscle disease in the elderly.

Influence of age on characteristics of polymyositis and dermatomyositis in adults

In a retrospective study of 79 consecutive patients, we evaluated characteristics of polymyositis (PM) and dermatomyositis (DM) and compared clinical presentation, biochemical findings, histologic changes, evolution, complications, and mortality rate of elderly patients (aged > or = 65 yr) and younger patients (aged < or = 64 yr) at the onset of PM/DM. We found a high prevalence of PM/DM in elderly patients: 23 patients (29%) were aged 65 years or over. We also found that esophageal involvement (34.8% versus 16.1%, respectively) and bacterial pneumonia related to both ventilatory insufficiency and esophageal impairment (21.7% versus 5.4%, respectively) were more common in elderly patients compared with younger patients, resulting in increased morbidity and mortality rates. Moreover, malignancy frequency was higher in elderly patients compared with younger patients (47.8% versus 9.1%, respectively, p = 0.0001), particularly patients with DM (10/11). Fifty percent of malignancies were colon malignancies in elderly patients. Erythrocyte sedimentation rate, C-reactive protein, fibrinogen, and ferritin levels were also higher in the elderly patient group compared with the younger group, and the presence of serum hypoprotidemia, hypoalbuminemia, and anemia was more frequent. Finally, PM/DM complete remission was less frequent (13.6% versus 41.1%) and the mortality rate (47.8% versus 7.3%) was higher in elderly patients than in younger patients. The main causes of death in elderly patients were bacterial pneumonia, due to ventilatory insufficiency and esophageal impairment, and malignancies. Our findings therefore indicate that PM/DM-related esophageal and lung involvement should be systematically searched for in elderly patients. Esophageal manometry and pulmonary function tests should become an integral part of initial evaluation in elderly patients for early detection of impairment. Moreover, as we observed a marked overrepresentation of colon cancer in elderly patients with DM, we suggest that the search for malignancies in elderly patients with DM should include lower gastrointestinal tract investigations.

Dermatomyositis

Dermatomyositis is a rare inflammatory myopathy with characteristic skin manifestations and muscular weakness. The disease can be categorized as adult idiopathic, juvenile, or amyopathic dermatomyositis as well as that associated with a connective tissue disease or a malignancy. Immunologic factors are most likely involved in the pathogenesis of the disease; however, genetic and environmental issues may also play important roles. Treatment with immunosuppressive agents has proved successful in the majority of patients, although significant morbidity still occurs.

The lung in polymyositis

Polymyositis is associated with a variety of pulmonary manifestations that may complicate an established case, occur simultaneously with the muscle manifestations, or precede the muscle disease. Included are respiratory muscle involvement, aspiration syndromes, and a variety of interstitial lung reactions.

High incidence of malignancies in patients with dermatomyositis and polymyositis: an 11-year analysis

OBJECTIVES

Dermatomyositis and polymyositis (DM/PM) are associated with neoplasms. The aim of the present study is to compare our experience in Israel with other published data.

METHODS

Thirty-five adult patients with DM/PM, admitted to Sheba Medical Center during the 11-year interval between 1984 and 1994, were studied for the prevalence and features of malignant diseases. Patients with DM/PM alone and with DM/PM and malignancy were identified by using the hospital computer system. The manifestations of DM/PM and features of the malignant diseases were abstracted from the patients' charts. The presence or absence of malignancy and the type of cancer were verified in the National Cancer Registry.

RESULTS

There were 15 men and 20 women. The mean age at the onset of the disease was 53 +/- 18 years. A total of 15 had PM and 20 DM. Malignancies occurred in four patients with PM (27%) and in nine with DM (45%) a frequency 12.6 times higher than in the general population. In six patients, the malignancy and the DM/PM were diagnosed simultaneously; in four before and in three after the appearance of the DM/PM. Hematologic, gastrointestinal, breast, ovarian, and lung tumors, malignant melanoma, and metastatic carcinoma of unknown primary were found among our patients. Eight DM/PM patients with malignancy died during the study period of infection, pulmonary embolism, and tumor spread.

CONCLUSIONS

Our study found that DM/PM is associated with high rates of malignancy and mortality.

Distinctive features of idiopathic inflammatory myopathies in French Canadians

This is the first report on idiopathic inflammatory myopathies (IIM) in French Canadians. We reviewed retrospectively 30 French Canadian adults (20 women and 10 men) with IIM seen consecutively over 12 years. The median age at diagnosis was 45 years. The IIM were 8 (27%) primary polymyositis (PM), 9 (30%) primary dermatomyositis (DM), 5 (17%) IIM with neoplasia (lymphoma, breast, esophageal, colonic, and skin cancer) and 8 (27%) IIM with a connective tissue disease (4 with systemic sclerosis, 2 with mixed connective tissue disease, and 2 with rheumatoid arthritis). The most common presenting symptom was proximal muscle weakness (n = 10,33%). Of the remaining 20 patients, 6 (20%) had the onset of their weakness within 1 month of the presenting symptom. Only 3 (10%) patients did not have proximal muscle weakness. Twenty-six (87%) patients had weakness in the pelvic girdle, 25 (83%) in the shoulder girdle, and 7 (23%) in the neck muscles. Other common symptoms included dyspnea on exertion and dysphagia, each present in 13 (43%) patients. Gottron's papules and the heliotrope rash were the most common skin lesions documented in 11 (37%) and 10 (33%) patients, respectively. The serum creatine kinase (CK) level was between 171 and 1,000 U/L in 13 (43%) patients and between 1,001 and 6,000 U/L in 13 (43%) patients. Antinuclear antibodies (ANA) on HEp-2 cells were positive in 16 (53%) patients, of which 2 (13%) expressed autoantibodies to nuclear pore complexes. Autoantibody specificities were anti-La (n = 4, 13%), anti-U1RNP (n = 3, 10%), and anti-Ro (n = 2, 7%). None of the patients expressed anti-Jo-1, anti-topoisomerase I, or anticentromere antibodies. Twenty-eight (93%) patients received corticosteroid therapy, and 8 (27%) patients responded to prednisone alone. Thirteen (43%) patients were treated with methotrexate, and 9 (69%) responded. The mean follow-up was 62 months: 23 (77%) had their disease controlled, 3 (10%) patients were lost to follow-up, and 4 (13%) died (no death occurred because of IIM or its treatment). Therapy was discontinued because of remission in 5 (17%) patients. Cumulative survival rates at 2, 5, and 10 years were 89%, 89%, and 85%, respectively. The presence of autoantibodies to nuclear pore complexes and anti-La autoantibodies, the rare occurrence of anti-Jo-1 autoantibodies, the response to conventional therapies, and a high survival rate may distinguish IIM in French Canadians from that of other reported series.

[Association of polymyositis and rheumatoid arthritis. Apropos of a new case not related to drug ingestion]

Muscular manifestations are frequent during rheumatoid arthritis, mostly induced by drugs. In contrast with rheumatoid myositis whose existence has been debated, penicillamine induced polymyositis and dermatomyositis are well described. We report a case of rheumatoid arthritis associated with non-drug induced polymyositis.

Mortality in the rheumatic diseases

OBJECTIVE

To review mortality data in published studies of various rheumatic diseases.

METHODS

A MEDLINE search of the literature on the rheumatic diseases, including osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, systemic lupus erythematosus, scleroderma, polymyositis, and vasculitis.

RESULTS

Mortality rates higher than expected have been reported in most rheumatic conditions, considerably higher for inflammatory rheumatic diseases. The mortality rates in patients with systemic lupus erythematosus, scleroderma, polymyositis, and vasculitis are often comparable to mortality rates seen in patients with neoplastic or cardiovascular diseases, although the causes of death often are not identified as the rheumatic disease.

CONCLUSION

Mortality has been found to be predicted in most instances by more severe clinical status, and therefore death should not be considered as "unrelated" to the rheumatic disease. These observations may have important implications for clinical care and health policies regarding patients with rheumatic diseases.

Coronary artery disease in dermatomyositis. A case report

A sixty-two-year-old woman with chronic dermatomyositis (DM) receiving steroid monotherapy developed coronary artery stenosis. She had lung fibrosis and complained of dyspnea, but no ischemia was suggested by electrocardiogram. Ateriographic findings and clinical symptoms of coronary artery disease in DM have not been previously reported.

Inflammatory myopathies

New information regarding myositis specific autoantibodies, histopathologic analysis of muscle biopsy specimens, and immunogenetic features of the different serologic subsets of disease has greatly increased our understanding of the pathogenesis of the inflammatory myopathies. The clinical descriptions of inclusion body myositis and 'amyopathic dermatomyositis' (Euwer and Sontheimer, 1993) are examples of our expanded descriptive capabilities in the evaluation of patients with myopathy. Finally, newer techniques such as cytokine analysis and magnetic resonance imaging may help in the ongoing assessment of disease activity in patients with myositis. The combination of these recently described clinical and laboratory parameters are enough to force a reconsideration of the previously described classification and diagnostic criteria in the inflammatory myopathies.

Dermatomyositis with multiple skin ulcers showing vasculitis and membrano-cystic lesion

A 63-year-old woman with dermatomyositis (DM) developed multiple punched-out ulcers of the skin. She had not only a past history of gastric cancer 10 years prior to the onset of DM, but also a familial history of cancer. A skin biopsy from one of the ulcers revealed both vasculitis and membrano-cystic lesion in the same specimen. She died of interstitial pneumonitis one year after the onset of DM. Vasculitis and membrano-cystic lesion may be an important marker of a poor prognosis in DM.

Biopsy Proven Polymyositis in Victoria 1982–1987: Analysis of Prognostic Factors

Prognostic factors were analysed in 77 patients with idiopathic inflammatory myopathy identified over a 5 year period. Formal statistical tests did not differentiate useful prognostic indices and a polymyositis disability score was devised in an attempt to gain some prognostic information. Partial (47%) or full (31%) recovery were seen in most cases with no recovery of strength (9%) and death (11%) being less common outcomes. Onset before the age of 50 and duration of symptoms of less than 12 months prior to presentation were favourable prognostic features, and treatment with regimes other than steroid therapy alone a probable favourable indicator. Level of creatine kinase (CK) at presentation and histopathological separation of dermatomyositis or polymyositis failed to alter prognosis. Most patients who died did so within the initial 6 months of treatment. Four of five patients <50 years old with either a fatal outcome or no improvement were treated with steroids alone. Large multi-centre studies are required to provide reliable data about prognostic factors in idiopathic inflammatory myopathies and the methodology used in this study can only be regarded as providing pointers towards possible prognostic factors rather than being definitive.

Adult onset polymyositis/dermatomyositis: clinical and laboratory features and treatment response in 75 patients

OBJECTIVES

To determine possible similarities and differences in clinical and laboratory features and treatment response between patients in Singapore with polymyositis (PM) and dermatomyositis (DM) and reported series.

METHODS

Case records of adult patients (16 years old and above) referred to the 3 main electromyographic (EMG) laboratories in Singapore between 1 June 1986 and 31 May 1991 were reviewed if the referring diagnosis was myositis or myopathy for investigation. A computer search for adult patients with a diagnosis of PM/DM (ICD codes 710.3, 710.4, 517.8) who attended the main rheumatology and neurology centre during this period was also carried out. The criteria for PM/DM proposed by Bohan and Peter was adopted.

RESULTS

The incidence of PM/DM was 7.7 cases per million population per year. There were 35 PM and 40 DM cases with a median age at diagnosis of 50.7 years (SD: 16.7) and significantly more females in the PM group (p < 0.05). At presentation, 86.7% had proximal myopathy, 34.7% had arthralgia/arthritis and 18.7% had cutaneous vasculitis. The creatine kinase level was elevated in 89.3% of patients and positive EMG and muscle biopsy in 79.4% and 76.4% respectively. Systemic lupus erythematosus was the commonest associated connective tissue disease. The percentage of patients with malignancy was higher in DM compared with PM (p < 0.01) and they were significantly older (mean age 61.8 years) (p < 0.001). Patients who achieved remission were significantly younger (mean age 46.4 years, p < 0.05). The overall mortality rate was 26.7% with infection and malignancy as the main causes of death.

CONCLUSION

The results of the study suggest ethnicity does not influence the expression of PM/DM in view of the considerable similarities in frequency and clinical expression of disease in the population studied compared with series from other countries.

The heart in polymyositis: a prospective evaluation of 26 patients

Although cardiac abnormalities have been reported in patients with idiopathic polymyositis-dermatomyositis (PM), the nature and extent of these abnormalities have varied. The purpose of this study was to determine the prevalence and to obtain a better description of the spectrum of cardiac abnormalities in a cohort of patients with PM by use of a thorough noninvasive cardiac evaluation. Accordingly, we studied 26 patients with a history of PM and clinically inactive myositis (22 polymyositis, 4 dermatomyositis) between June 1984 and June 1991. Examination included history, physical examination, 12-lead electrocardiography, 24-h ambulatory electrocardiographic monitoring, chest radiography, transthoracic echocardiography, and radionuclide ventriculography. Of the patients studied, 77% were taking corticosteroid medications at a mean dose of 39 +/- 27 mg at the time of their evaluation. All 26 patients were identified as having two or more cardiac abnormalities. Cardiac symptoms and signs were common (62 and 81%, respectively), but were generally nonspecific. Electrocardiographic findings were most common (in 85% of cases), followed by findings on ambulatory monitoring (77%), echocardiography (42%), and radionuclide ventriculography (15%). The prevalence of mitral valve prolapse (8%) and hyperkinetic left ventricular contraction (12%) was significantly lower than previously reported. A secondary aim of this study was to determine associations between demographic variables including age, disease duration, cardiovascular symptoms, immunosuppressive therapy, autoantibody status, and creatinine phosphokinase level, and the presence of cardiac abnormalities. Of these patient variables, only increasing patient age was associated with an increased likelihood of cardiac abnormalities on noninvasive testing.(ABSTRACT TRUNCATED AT 250 WORDS)

Drug therapy of the idiopathic inflammatory myopathies: predictors of response to prednisone, azathioprine, and methotrexate and a comparison of their efficacy

PURPOSE

To identify factors associated with responses to treatment with prednisone, methotrexate, or azathioprine in patients with idiopathic inflammatory myopathy, and to compare the efficacy of these drugs.

PATIENTS AND METHODS

Data were collected on 113 adult patients meeting criteria for definite idiopathic inflammatory myopathy in this retrospective cohort study. Patients were categorized as responding completely, partially, or not at all to each therapeutic trial based upon clinical and laboratory criteria.

RESULTS

Clinical group, presence of certain myositis-specific autoantibodies, and time from disease onset to diagnosis influenced rates of complete clinical response to these therapeutic agents. Patients with inclusion body myositis responded comparatively poorly to prednisone and the other drugs: 43% had no clinical response to prednisone and none responded completely to any medication. Patients with autoantibodies to aminoacyl-tRNA synthetases or to signal recognition particle proteins were likely to respond partially, but not completely, to prednisone. No patient with a long delay to diagnosis (greater than 18 months) responded completely, compared with 34% of those with a short delay (less than 3 months). A patient's response to the first course of prednisone predicted subsequent responses to prednisone and to azathioprine better than response to methotrexate. Men responded to methotrexate better than women. Among certain subgroups of patients, responses to methotrexate were better than to either azathioprine or retreatment with prednisone.

CONCLUSION

Determining the clinical group, autoantibody status, and time from disease onset to diagnosis of patients with myositis provides useful information in predicting clinical responses to therapy, and these factors should be considered in designing future therapeutic trials. Methotrexate therapy may be superior to either azathioprine or further steroid treatment alone in certain patients who do not respond completely to an initial adequate course of prednisone.

Dermatomyositis and malignancy

During the past 12 years, many studies applying strict diagnostic criteria have been published that have attempted to settle the controversy about the reality of the association between dermatomyositis and malignancy. Although retrospective, recent studies have shown an increased incidence of malignancy among patients with dermatomyositis when compared with controls without myositis. In contrast, an increased frequency of malignancy in dermatomyositis as compared to polymyositis still has to be demonstrated. In most cases, malignant disease precedes or occurs concurrently with dermatomyositis and is discovered on the basis of clinical signs, symptoms, and routine screening laboratory tests. The types of neoplasms found in association with dermatomyositis parallel those observed in the general population. A possible link between dermatomyositis and an underlying malignancy remains largely hypothetical at a biologic level, although cellular immunity abnormalities may provide a direction for future investigations. Prospective epidemiologic studies using the case-control methods and cohort analysis remain necessary 1) to rigorously demonstrate the reality and to study the nature of the association between dermatomyositis and malignancy, and 2) to clarify the optimal screening strategies for malignant neoplasms in patients with dermatomyositis.

A clinical, serological, and histopathological study of myositis patients with and without anti-RNP antibodies

Twenty-nine patients with myositis, including 10 with polymyositis (PM), 6 with dermatomyositis (DM), and 13 with myositis associated with a connective tissue disease (CTD), were followed up for a mean observation time of 49 months. The 13 patients with CTD-associated myositis were further separated by the presence or absence of anti-RNP antibodies. The functional disability at diagnosis was pronounced without differences between the groups. The patients with anti-RNP antibodies did not differ from the other patients regarding initial muscle weakness, erythrocyte sedimentation rate, or creatinine phosphokinase values, but the histopathological muscle changes were generally milder. Rapid improvement of muscle strength on moderate doses of corticosteroids was seen in most patients. At the end of study, corticosteroid treatment had been withdrawn from 17 patients because of remission, including 6 of the 7 patients with anti-RNP antibodies. The presence of electromyographic changes compatible with myositis, pronounced muscle weakness before treatment, and a low erythrocyte sedimentation rate seemed to indicate a less favorable outcome unrelated to diagnostic subgroupings. However, the combination was rarely found among the anti-RNP-positive patients.

Malignancy and interstitial pneumonitis as fatal complications in dermatomyositis

By sending questionnaires to the major dermatological clinics in Japan, we examined the outcome and causes of death in 182 cases of dermatomyositis (DM) observed between 1983 and 1987. The mortality rate in adults was 26.7%. Associated malignancy occurred in 47 cases (25.8% of adults), and 16 of them died of neoplasms. In contrast to 43 carcinomas, only 1 patient died of lymphoma. Associated interstitial pneumonitis (IP) appeared in 31 cases. IP started simultaneously or within 6 months after the diagnosis of DM in the majority of these cases. Of the 13 fatal cases due to IP, 8 died of respiratory failure within two months of the onset of lung disease. In the malignancy group, periungual erythema was noted in a higher proportion. Raynaud's phenomenon was more frequently noted in the IP group. DM overlapped with other collagen diseases in 14 cases.

Asymmetrical weakness in polymyositis associated with neuropathic involvement

Peripheral nerve involvement is rare in polymyositis and dermatomyositis. We describe a patient in whom the clinical appearance was suggestive of a markedly asymmetrical presentation of polymyositis. Nerve conduction studies, however, were consistent with multiple neuropathies and suggest that neurological involvement may have been the basis of the asymmetrical weakness. Both the muscle weakness and the neurological abnormalities resolved with corticosteroid therapy. This case illustrates a previously undescribed neurological complication of polymyositis.

Correlation between tests of muscle involvement and clinical muscle weakness in polymyositis and dermatomyositis

A correlation study was performed on the degree of muscle weakness in 36 patients with dermatomyositis and 69 with polymyositis in relation to muscle biopsy findings, electromyography (EMG) abnormalities, and serum concentrations of creatine kinase (CK), aspartate aminotransferase (AST) and alanine aminotransferase (ALT) enzymes. Statistically significant correlations were found between muscle weakness and EMG results in patients with polymyositis, and between muscle weakness and serum CK and AST levels in dermatomyositis. As expected, correlations were found between the results of the three enzyme determinations in both groups of patients.

Adult-onset polymyositis-dermatomyositis: description of 25 patients with emphasis on treatment

A retrospective study of 25 patients with polymyositis-dermatomyositis (PM-DM) is analyzed with special attention to the effects of therapy and follow-up. All patients (100%) complained of muscle weakness and 68% of these demonstrated typical skin changes of DM. All patients, except 2, received corticosteroids at the onset of the disease, 23 were treated with azathioprine, 7 received cyclophosphamide, 4 methotrexate, and 1 had total body irradiation. Among the patients adequately treated with azathioprine, 75% had a good response, but 5 patients did not improve. Cyclophosphamide was used subsequently in 2, with a satisfactory response in 1. Another patient had a striking response to oral methotrexate, and total body irradiation helped to improve another patient. Although high dose corticosteroids were the preferred starting medication for the treatment of PM-DM, it is important to detect those patients who do not respond adequately and/or develop side effects. In these circumstances, the prompt use of immunosuppressive agents appears justified.

Dermatomyositis and malignancy

In summary, it can be stated that: 1. Dermatomyositis is probably associated with an increased incidence of malignancy. 2. Tumor types found seem to roughly approximate the frequencies of those found in the general population. 3. If present, the malignancy can precede, occur concurrently with, or follow the diagnosis of dermatomyositis. 4. Treatment of associated malignancy may or may not have an effect on myositic or cutaneous disease. 5. Dermatomyositis and associated malignancy may share a common pathogenesis resulting from abnormal immune function. 6. Search for malignancy should be carried out on the basis of abnormal findings on history and physical examination or screening laboratory.

Dermatomyositis as a systemic disease

Dermatomyositis is a classic example of a disease that has both cutaneous and systemic manifestations. The skin and muscle disease are described as well as the possible systemic manifestations including overlap syndromes, joint symptoms, pulmonary disease, and other internal organ involvement. The association with pregnancy is also discussed.

Polymyositis-dermatomyositis: a clinical review

Images

Constrictive pericarditis complicating dermatomyositis

Chronic constrictive pericarditis may complicate both rheumatoid arthritis and systemic lupus erythematosus. To our knowledge, however, this is the first time it has been described in a patient with dermatomyositis. This association should be kept in mind as constrictive pericarditis should be considered in the differential diagnosis of liver cirrhosis and Budd-Chiari syndrome in rheumatic diseases.

Adverse impact of interstitial pulmonary fibrosis on prognosis in polymyositis and dermatomyositis

Interstitial pulmonary fibrosis occurs in approximately 9% of patients with PM/DM, yet its effect on the course of PM/DM has been scarcely noted. In this report, two patients with PM/DM and IPF were presented to highlight the fact that pulmonary disease can overshadow the primary muscle disorder and progress despite therapy with corticosteroids and nonsteroidal immunosuppression. Our patients were added to previously reported cases and an overview of PM/DM and IPF was presented. Sixty-seven patients with the diagnosis of PM/DM and IPF, with a mean age of 60 +/- 18 years, were identified. Pulmonary complaints were present in 64 cases. Fever was present in 18, arthritis or arthralgias in 11, and Raynaud's phenomenon in 9. Forty percent died after followup of 31 +/- 32 months. This mortality was significantly higher (P less than .05) than that in 745 historical controls with PM/DM without IPF. Progressive IPF was the immediate cause of death in 58% of those who died. A subgroup of 29 patients who had histologic documentation of both myositis and IPF had a mortality of 62% after 22 +/- 25 months. In this latter group, six patients had RP; five of these died. Patients who were not treated with corticosteroids also appeared to fare worse but, given the small number of patients involved, definite conclusions cannot be drawn. We conclude that patients with PM/DM can be adversely affected by the presence of IPF and that this negative impact may be exaggerated by RP and perhaps by lack of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

[Dermatopolymyositis: evaluation of 63 patients]

Sixty-three patients with dermatopolymyositis were evaluated from the clinical, laboratory and therapeutical aspects during a period of 15 years: 39 are women and 24 men. The mean age was 36.8 +/- 15.6 years. No correlation was observed between clinical and isolated therapeutics employed; when corticosteroids and cytolytic drugs were used simultaneously, the clinical response was satisfactory. No special fact was seen that can predict the therapeutical response.

Dermatomyositis

Dermatomyositis and polymyositis are related disorders of unknown cause in which immunologic changes may be important. They sometimes overlap with other collagen vascular diseases, and not infrequently are associated with malignancy. The clinical features of the adult and juvenile forms of the disorder and the visceral manifestations of DM-PM are outlined, along with enzymatic, electromyographic, and histologic aids to diagnosis. While the cutaneous lesions often are resistant to treatment, systemic involvement may respond to corticosteroids or to immunosuppressive drugs. Treatment definitely alters the prognosis in cases not associated with malignancy.