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Katakura T, Shirai T, Sato H, Ishii T, Fujii H. Successful management of interstitial lung disease in dermatomyositis complicated by malignancy: a case-based review. Rheumatol Int 2023:10.1007/s00296-023-05442-y. [PMID: 37682289 DOI: 10.1007/s00296-023-05442-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 08/19/2023] [Indexed: 09/09/2023]
Abstract
Dermatomyositis (DM) is associated with interstitial lung disease (ILD) and malignancy. However, the coexistence of ILD and malignancy (DM-ILD-malignancy) is rare, and limited information exists regarding its management. Herein, we report the case of a 70-year-old man who developed DM with rapidly progressive ILD and advanced gastric cancer and provide a literature review of managing DM-ILD-malignancy. The patient presented with typical DM skin rashes and shortness of breath, which worsened within 1 month, without muscular symptoms. Additionally, the patient tested negative for myositis-specific autoantibodies (MSAs). Computed tomography revealed ILD and advanced gastric cancer, which was confirmed on endoscopic examination to be a poorly differentiated adenocarcinoma. Although the patient's ILD progressed rapidly, surgical treatment of the cancer was prioritized. Prednisolone (PSL) 0.5 mg/kg was initiated 3 days before surgery and increased to 1 mg/kg at 7 days postoperative. Remarkable improvement in the skin rash and ILD was observed, and the PSL dose was tapered without immunosuppressants. A literature review revealed that anti-melanoma differentiation-associated gene 5 and anti-aminoacyl transfer RNA synthetase antibodies are the predominant MSAs in DM-ILD-malignancy, and the optimal treatment should be determined based on several factors, including ILD patterns, and malignancy type and stage. In particular, lung cancer may be a risk factor for the acute exacerbation of ILD, and preceding immunosuppression would be useful. Furthermore, prioritizing surgery for gastric cancer is effective because of its paraneoplastic nature.
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Affiliation(s)
- Tokio Katakura
- Department of Rheumatology, Tohoku University Hospital Sendai, 1-1 Seiryo-Machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Tsuyoshi Shirai
- Department of Rheumatology, Tohoku University Hospital Sendai, 1-1 Seiryo-Machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.
| | - Hiroko Sato
- Department of Rheumatology, Tohoku University Hospital Sendai, 1-1 Seiryo-Machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Tomonori Ishii
- Department of Rheumatology, Tohoku University Hospital Sendai, 1-1 Seiryo-Machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Hiroshi Fujii
- Department of Rheumatology, Tohoku University Hospital Sendai, 1-1 Seiryo-Machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
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Marago I, Roberts M, Roncaroli F, DuPlessis D, Sewry C, Nagaraju S, Limbada F, Marini-Bettolo C, Hudson J, Banerjee S, Newton L, Bukhari M, Chinoy H, Lilleker JB. Limb girdle muscular dystrophy R12 (LGMD 2L, anoctaminopathy) mimicking idiopathic inflammatory myopathy: key points to prevent misdiagnosis. Rheumatology (Oxford) 2021; 61:1645-1650. [PMID: 34264321 DOI: 10.1093/rheumatology/keab553] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/21/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Diagnosing the idiopathic inflammatory myopathies (IIMs) can be challenging as several conditions, including genetic myopathies such as limb girdle muscular dystrophy type R12 (LGMD 2 l, anoctaminopathy), mimic the presentation. Here we describe learning points identified from review of four patients with LGMD 2 l who were initially incorrectly diagnosed with IIM. Our aim is to provide clinicians working in adult rheumatology services with a toolkit to help identify non-inflammatory presentations of myopathy. METHODS We performed retrospective review of medical notes, laboratory results, muscle imaging and histological findings of four patients with LGMD 2 l who were previously misdiagnosed with IIM. We focused on clinical presentation and progression, therapeutic agents used, and events leading to revision of the diagnosis. RESULTS Three males and one female patients with a mean age of 51 years at presentation were reviewed. In each case treatment with immunosuppressants, in one case for >15 years, was observed without a clear therapeutic response. All patients were negative for anti-nuclear antibodies and available myositis-associated/specific autoantibodies and associated connective tissue disease features were absent. Prominent fatty infiltration and selective muscle involvement on thigh muscle magnetic resonance imaging was a common. CONCLUSIONS Adult-onset genetic myopathies, particularly LGMD R12, can mimic IIM. Accurate diagnosis is crucial to avoid use of potentially harmful immunosuppressive therapies, allow appropriate genetic counselling, and facilitate involvement in research studies.
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Affiliation(s)
- Italo Marago
- Manchester Centre for Clinical Neuroscience, Salford Royal NHS Foundation Trust, Salford, UK
| | - Mark Roberts
- Manchester Centre for Clinical Neuroscience, Salford Royal NHS Foundation Trust, Salford, UK
| | - Federico Roncaroli
- Geoffrey Jefferson Brain Research Centre, Division of Neuroscience and Experimental Psychology, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Daniel DuPlessis
- Department of Cellular Pathology, Northern Care Alliance, Salford Royal NHS Foundation Trust, Salford, UK
| | - Caroline Sewry
- Department of Cellular Pathology, Northern Care Alliance, Salford Royal NHS Foundation Trust, Salford, UK
| | - Santhosh Nagaraju
- Department of Cellular Pathology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Faheema Limbada
- Department of Cellular Pathology, Northern Care Alliance, Salford Royal NHS Foundation Trust, Salford, UK
| | - Chiara Marini-Bettolo
- The John Walton Muscular Dystrophy Research Centre, Newcastle University and Newcastle Hospitals NHS Foundation Trust, Newcastle, UK
| | - Judith Hudson
- The John Walton Muscular Dystrophy Research Centre, Newcastle University and Newcastle Hospitals NHS Foundation Trust, Newcastle, UK
| | - Siwalik Banerjee
- Department of Rheumatology, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK
| | - Laura Newton
- Department of Rheumatology, Burnley General Teaching Hospital, East Lancashire Hospitals NHS Trust, Burnley, UK
| | - Marwan Bukhari
- Department of Rheumatology, University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, UK
| | - Hector Chinoy
- Centre for Musculoskeletal Research, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.,National Institute for Health Research Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, The University of Manchester, Manchester, UK.,Department of Rheumatology, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Salford, UK
| | - James B Lilleker
- Manchester Centre for Clinical Neuroscience, Salford Royal NHS Foundation Trust, Salford, UK.,National Institute for Health Research Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, The University of Manchester, Manchester, UK
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Abstract
INTRODUCTION The idiopathic inflammatory myopathies (IIM) dermatomyositis (DM) and polymyositis (PM) are chronic diseases affecting the striated muscles with variable involvement of other organs. Glucocorticoids are considered the cornerstone of treatment, but some patients require adjunctive immunosuppressive agents because of insufficient response to glucocorticoids, flares upon glucocorticoid tapering, or glucocorticoid-related adverse events. Areas covered: The aim of this article was to review (PubMed search until February 2018) the evidence on established and new therapies derived from randomized controlled trials (RCTs) on adult DM and PM. In addition, key data from open-label trials, case reports, and abstracts were included where data from RCT were lacking. Expert commentary: Numerous synthetic and biological immunosuppressive agents are currently available to treat the IIM, sometimes in combination. The choice of the specific medication in the individual patient depends upon the disease phenotype and patient's characteristics. Exercise improves muscle performance without causing disease flares and should be an integral part of the treatment of the IIM. Prompt diagnosis and treatment can lead to better outcome.
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Affiliation(s)
- Nicolò Pipitone
- a SC di Reumatologia, Dipartimento Medicina Interna e Specialità Mediche, Azienda Unità Sanitaria Locale di Reggio Emilia - Istituto di Ricerca e Cura a Carattere Scientifico , Reggio , Emilia-Romagna , Italy
| | - Carlo Salvarani
- a SC di Reumatologia, Dipartimento Medicina Interna e Specialità Mediche, Azienda Unità Sanitaria Locale di Reggio Emilia - Istituto di Ricerca e Cura a Carattere Scientifico , Reggio , Emilia-Romagna , Italy.,b Rheumatology Department , University of Modena and Reggio Emilia , Italy
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Brandão M, Marinho A. Idiopathic inflammatory myopathies: definition and management of refractory disease. Autoimmun Rev 2011; 10:720-4. [PMID: 21664497 DOI: 10.1016/j.autrev.2011.05.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Adult idiopathic inflammatory myopathies, commonly referred to as myositis, are a heterogeneous group of diseases with an autoimmune etiology. In this review, the authors are going to focus on myositis excluding inclusion body myositis. They will review the prognostic factors (for mortality and response to steroids), define refractory disease, introduce a new concept (presumed refractory disease), analyze definitions of active disease, damage and improvement criteria, and summarize therapeutic alternatives for refractory patients, based on different disease phenotypes.
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Affiliation(s)
- Mariana Brandão
- Centro Hospitalar do Porto, Hospital de Santo António, Department of Medicine, Unidade de Imunologia Clínica, Largo do Professor Abel Salazar, Porto, Portugal.
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