Obstruction-related dysphagia in inclusion body myositis: Cricopharyngeal bar on videofluoroscopy indicates risk of aspiration

An Unusual Disease With a Common Presentation: Cricopharyngeal Dysfunction in Inclusion Body Myositis

Cricopharyngeal (CP) dysfunction is a frequent cause of dysphagia among patients with inclusion body myositis. Early identification and prompt treatment is necessary because aspiration pneumonia is a leading cause of mortality among these patients. We present a case of a 57-year-old woman with a history of inclusion body myositis who presented with progressive dysphagia and aspiration pneumonia found to have CP dysfunction treated with endoscopic CP myotomy. Postoperatively, patient's dysphagia improved with no further episodes of aspiration at 2-year follow-up.

255th ENMC workshop: Muscle imaging in idiopathic inflammatory myopathies. 15th January, 16th January and 22nd January 2021 - virtual meeting and hybrid meeting on 9th and 19th September 2022 in Hoofddorp, The Netherlands

The 255th ENMC workshop on Muscle Imaging in Idiopathic Inflammatory myopathies (IIM) aimed at defining recommendations concerning the applicability of muscle imaging in IIM. The workshop comprised of clinicians, researchers and people living with myositis. We aimed to achieve consensus on the following topics: a standardized protocol for the evaluation of muscle images in various types of IIMs; the exact parameters, anatomical localizations and magnetic resonance imaging (MRI) techniques; ultrasound as assessment tool in IIM; assessment methods; the pattern of muscle involvement in IIM subtypes; the application of MRI as biomarker in follow-up studies and clinical trials, and the place of MRI in the evaluation of swallowing difficulty and cardiac manifestations. The following recommendations were formulated: In patients with suspected IIM, muscle imaging is highly recommended to be part of the initial diagnostic workup and baseline assessment. MRI is the preferred imaging modality due to its sensitivity to both oedema and fat accumulation. Ultrasound may be used for suspected IBM. Repeat imaging should be considered if patients do not respond to treatment, if there is ongoing diagnostic uncertainty or there is clinical or laboratory evidence of disease relapse. Quantitative MRI is established as a sensitive biomarker in IBM and could be included as a primary or secondary outcome measure in early phase clinical trials, or as a secondary outcome measure in late phase clinical trials. Finally, a research agenda was drawn up.

Clinical characteristics of dysphagic inclusion body myositis

This study aimed to characterize dysphagic patients with inclusion body myositis (IBM) with cricopharyngeal bar (CPB) (n = 17; IBM-CPB(+)) by comparing their swallowing function and muscle magnetic resonance imaging data with IBM patients without CPB (n = 28; IBM-CPB(-)). IBM-CPB(+) patients were older at diagnosis and had more frequent obstruction-related dysphagia and stronger knee extension than IBM-CPB(-) patients. IBM-CPB(+) patients also had less intramuscular fatty infiltration than IBM-CPB(-) patients on T1-weighted magnetic resonance images of the rectus femoris (2.6% versus 10.3%, p < 0.05), vastus lateralis (27.8% versus 57.1%, p < 0.01), vastus intermedius (17.6% versus 43.5%, p < 0.01), vastus medialis (14.1% versus 39.1%, p < 0.01), deltoid (5.5% versus 18.7%, p < 0.05), biceps (6.6% versus 21.1%, p < 0.001), and triceps (12.9% versus 33.0%, p < 0.05). These findings suggest that IBM-CPB(+) patients were older, frequently exhibited obstruction-related dysphagia, had stronger knee extension, and had less fatty infiltration of the limb muscles compared to IBM-CPB(-) patients, and provide valuable information on the clinical subset of IBM-CBP(+) patients in order to expand the knowledge of the clinical heterogeneity in IBM.

Atypical presentations of inclusion body myositis: Clinical characteristics and long-term outcomes

INTRODUCTIONS/AIMS

Inclusion body myositis (IBM) typically presents with progressive weakness preferentially involving finger flexors and quadriceps. Atypical presentations have been less commonly reported. Here, we aim to describe the clinical characteristics and long-term outcomes of IBM patients with atypical presentations.

METHODS

We retrospectively searched the Mayo Clinic medical records to identify IBM patients with atypical disease onset, seen between 2015 and 2020.

RESULTS

We identified 357 IBM patients, of whom 50 (14%) had an atypical presentation. Thirty-eight patients were diagnosed with IBM because they fulfilled one of the European Neuromuscular Center diagnostic categories at a later stage, 10 had all IBM histopathological features, and 2 were diagnosed on the basis of clinical and laboratory data. The most common presentation was dysphagia (50%), followed by asymptomatic hyperCKemia (24%; CK, creatine kinase), then foot drop (12%). 6% of patients presented with proximal arm weakness, 4% with axial weakness and 4% with facial diplegia. Median time from symptom onset to diagnosis was 9 y. Median age at diagnosis was 70.5 y. 16% of patients needed a walking aid. When tested, 86.5% of patients had impaired swallowing and 56% had elevated cytosolic nucleotidase-1A antibodies. Only 1/26 patients who received immunotherapy had minimal improvement. Upon follow-up, most patients had generalization of their weakness with a decline in their strength summated score of 0.082/mo.

DISCUSSION

A significant proportion of IBM patients may have an atypical presentation. Recognition of such heterogeneity could improve early diagnosis, prevent unnecessary immunotherapy, and provide insight for future diagnostic criteria development and clinical trials.

Inclusion body myositis: Update on the diagnostic and therapeutic landscape

Inclusion body myositis (IBM) is a progressive muscle disease affecting patients over the age of 40, with distinctive clinical and histopathological features. The typical clinical phenotype is characterized by prominent involvement of deep finger flexors and quadriceps muscles. Less common presentations include isolated dysphagia, asymptomatic hyper-CKemia, and axial or limb weakness beyond the typical pattern. IBM is associated with marked morbidity as majority of patients eventually become wheelchair dependent with limited use of their hands and marked dysphagia. Furthermore, IBM mildly affects longevity with aspiration pneumonia and respiratory complications being the most common cause of death. On muscle biopsy, IBM is characterized by a peculiar combination of endomysial inflammation, rimmed vacuoles, and protein aggregation. These histopathological features are reflective of the complexity of underlying disease mechanisms. No pharmacological treatment is yet available for IBM. Monitoring for swallowing and respiratory complications, exercise, and addressing mobility issues are the mainstay of management. Further research is needed to better understand disease pathogenesis and identify novel therapeutic targets.

Botulinum toxin treatment improves dysphagia in patients with oculopharyngeal muscular dystrophy and sporadic inclusion body myositis

OBJECTIVE

Dysphagia can be troublesome in sporadic inclusion body myositis (sIBM) and oculopharyngeal muscular dystrophy (OPMD), but no established treatment exists. Cricopharyngeal muscle botulinum toxin injection has at case level been reported to be effective. We evaluated safety and efficacy of botulinum toxin injections in the cricopharyngeal muscle in patients with dysphagia due to sIBM or OPMD.

METHODS

Participants were included from our outpatient clinic. Cricopharyngeal constriction was confirmed by laryngoscopy. After EMG confirmation of needle placement in the cricopharyngeal muscle, botulinum toxin A was injected in awake patients. An individualized dose of 5-10 units of botulinum toxin A was applied initially and titrated up a maximum of 3 times. Outcome measures were change in dysphagia questionnaire, timed cold-water swallow test and subjective dysphagia status (worse, unchanged, improved). Due to the need for individualized dosing and a limited number of available patients, an uncontrolled, un-blinded design was used.

RESULTS

Thirteen patients, 3 with OPMD, received at least 1 injection. In the dysphagia questionnaire, all but 2 subjects, none with subjective worsening, improved (p < 0.001). Subjectively, seven felt an improvement, 4 no change and 2 a worsening. No overall change was seen the timed cold-water swallow test. No serious adverse events were observed.

CONCLUSION

Botulinum toxin injection of the cricopharyngeal muscle in patients with OPMD and sIBM had a beneficial effect on dysphagia in most of the treated patients. Two of 13 patients experienced a temporary worsening not reflected in dysphagia score. Limitations are the un-blinded and un-randomized design and subjective assessments methods.

PROSPECTIVE TRIAL REGISTRATION

EudraCT-number: 2014-002210-23.

Autoimmune Neurogenic Dysphagia

Autoimmune neurogenic dysphagia refers to manifestation of dysphagia due to autoimmune diseases affecting muscle, neuromuscular junction, nerves, roots, brainstem, or cortex. Dysphagia is either part of the evolving clinical symptomatology of an underlying neurological autoimmunity or occurs as a sole manifestation, acutely or insidiously. This opinion article reviews the autoimmune neurological causes of dysphagia, highlights clinical clues and laboratory testing that facilitate early diagnosis, especially when dysphagia is the presenting symptom, and outlines the most effective immunotherapeutic approaches. Dysphagia is common in inflammatory myopathies, most prominently in inclusion body myositis, and is frequent in myasthenia gravis, occurring early in bulbar-onset disease or during the course of progressive, generalized disease. Acute-onset dysphagia is often seen in Guillain–Barre syndrome variants and slowly progressive dysphagia in paraneoplastic neuropathies highlighted by the presence of specific autoantibodies. The most common causes of CNS autoimmune dysphagia are demyelinating and inflammatory lesions in the brainstem, occurring in patients with multiple sclerosis and neuromyelitis optica spectrum disorders. Less common, but often overlooked, is dysphagia in stiff-person syndrome especially in conjunction with cerebellar ataxia and high anti-GAD autoantibodies, and in gastrointestinal dysmotility syndromes associated with autoantibodies against the ganglionic acetyl-choline receptor. In the setting of many neurological autoimmunities, acute-onset or progressive dysphagia is a potentially treatable condition, requiring increased awareness for prompt diagnosis and early immunotherapy initiation.

Dysphagia in adult myopathies

Dysphagia (impaired swallowing) is not a rare problem in various neuromuscular disorders, both in the pediatric and the adult patient population. On many occasions such patients are first presented to other medical specialists or health professionals. Disorders of deglutition are probably underrecognized in patients with a neuromuscular disease as a result of patient's and doctor's delay. This review will focus on dysphagia in adults suffering from a myopathy. Dysphagia in myopathies usually affects the oropharyngeal phases which rely mostly on voluntary muscle activity of the mouth, pharynx and upper esophageal sphincter. Dysphagia is known to contribute to a reduction of quality of life and may also lead to increased morbidity and mortality. The review includes an overview on symptomatology and tools of assessments, and elaborates on dysphagia in specific hereditary and acquired myopathies.

Cricopharyngeal bar and dermatomyositis: A cause of rapidly progressive dysphagia

BACKGROUND

Idiopathic inflammatory myopathies (IIM) are immune-mediated conditions that affect striated muscle, and are frequently associated with dysphagia. Dysphagia in these cases can be due to weakness of the muscles involved in swallowing or the presence of restrictive pharyngeal defects, such as cricopharyngeal bars. Treatment of dysphagia in IIM revolves around immunosuppressive therapies, and procedures to disrupt cricopharyngeus muscle when immunosuppressive therapies are unsuccessful.

CASE REPORT

A 73-year-old female presented with rapidly progressive proximal muscle weakness and dysphagia to the point she could not swallow liquids or solids. She had a rash over the extensor surfaces of the limbs, and periorbital-edema. Her creatine kinase was elevated, and skin biopsy showed an interface inflammatory reaction; however, myositis line assay revealed no autoantibodies, and a muscle biopsy was unremarkable. She was diagnosed with dermatomyositis with life-threatening dysphagia, and was admitted to our institution and treated with corticosteroids, methotrexate and intravenous immunoglobulin. A videofluoroscopic swallowing study revealed a large esophageal protrusion at the level of C5-C6, which was thought to be consistent with a cricopharyngeal bar, with large boluses unable to pass, leading to aspiration. After 10 weeks of treatment, the cricopharyngeal bar remained present, but swallowing had improved to the point that she was successfully swallowing all consistencies.

CONCLUSION

Dysphagia associated with IIM can be multifactorial, and can be due to the involvement of the muscles of swallowing in the inflammatory process, or due to restrictive pharyngeal defects, and determination of the cause of dysphagia can assist with management.

Cricopharyngeal bar on videofluoroscopy: high specificity for inclusion body myositis

OBJECTIVE

To determine the prevalence and characteristics of the cricopharyngeal bar (CPB), defined as marked protrusion with lacking relaxation and stricture of the upper esophageal sphincter on videofluoroscopy, in patients with inclusion body myositis (IBM).

METHODS

We conducted a case-control study of comprehensive series of adult healthy individuals and consecutive patients with neuropsychiatric disorders aged over 45 (52 versus 2486). A standard videofluoroscopy was performed.

RESULTS

Overall, 47 individuals with CPB were identified. Of the individuals with CPB, 36% were IBM followed by neurodegenerative disorders, muscular disorders, neuromuscular disorders, and others (32%, 21%, 2.1%, and 8.5%, respectively), indicating the heterogeneity of the etiologies. Against muscular disorders, the sensitivity and specificity of the CPB for IBM were 33% (= 17/52; 95% confidence interval [CI], 20-45%) and 96% (= 264/274; 95% CI, 94-99%), respectively. IBM with CPB showed a higher frequency of obstruction-related dysphagia (88% versus 22%, p < 0.001) and severe CPB (76% versus 23%, p < 0.001) than the control with one. The ratio of the upper esophageal distance at the maximum distension at the level of C6 to that of C4 was lower in IBM with CPB than in the controls with one (0.50 versus 0.77, p < 0.001), which suggests the insufficient opening of the upper esophageal sphincter.

CONCLUSION

A CPB could be indicative of IBM. The upper esophagus in IBM with CPB became narrow, like a bottleneck. We provide new perspectives of dysphagia diagnosis by videofluoroscopy, especially for IBM-associated dysphagia, to expand the knowledge on the CPB.

Impact and Management of Dysphagia in Inflammatory Myopathies

PURPOSE OF REVIEW

Dysphagia is a common symptom in inflammatory myopathies. This review provides an overview on the epidemiology, clinical impact, and management of dysphagia in myositis. Relevant diagnostic tools and treatment strategies are discussed.

RECENT FINDINGS

Dysphagia can occur in any inflammatory myopathy, particularly in inclusion body myositis (IBM). It can lead to malnutrition or aspiration with subsequent pneumonia or even death. Dysphagia can be explored and monitored by patient-reported outcome scales for swallowing. New diagnostic tools such as real-time MRI and oro-pharyngo-esophageal scintigraphy have been studied for assessing dysphagia. Botulinum toxin injection can alleviate dysphagia in IBM. High-dose glucocorticosteroids are considered a first-line treatment for dysphagia in all other myositis subforms. Evaluation of dysphagia in myositis requires thorough clinical workup and appropriate instrumental procedures. Treatment options are available for dysphagia, but controlled trials and consensus on best patient care are required for this important symptom.