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Lu C, Xu C, Zhu X, Han Y. Plasma exchange for anti-MDA5 antibody-positive dermatomyositis-associated rapidly progressive interstitial lung disease: A case report and literature review. J Int Med Res 2023; 51:3000605231198742. [PMID: 37728627 PMCID: PMC10515533 DOI: 10.1177/03000605231198742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 08/16/2023] [Indexed: 09/21/2023] Open
Abstract
The prognosis of anti-MDA5-positive dermatomyositis (DM)-associated rapidly progressive interstitial lung disease (RPILD) is extremely poor and effective treatment options are limited. In addition, the risk of infection during immunosuppressive treatment is a major challenge. We report here, a case of RPILD in a 31-year-old man with anti-MDA5 antibody-positive DM. Despite treatment with methylprednisolone and human immunoglobulin, his lung condition worsened and his serum ferritin levels increased. Six cycles of plasma exchange (PE) adjuvant treatment significantly mitigated his symptoms and he was discharged from hospital two months later. We suggest that PE may be a promising therapeutic option for patients with anti-MDA5-positive DM-associated RPILD. However, randomized, controlled studies are required to confirm our findings.
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Affiliation(s)
- Ci Lu
- Department of Rheumatology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Cheng Xu
- Department of Rheumatology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Xiaoying Zhu
- Department of Rheumatology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Yongmei Han
- Department of Rheumatology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
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Ye WZ, Peng SS, Hu YH, Fang MP, Xiao Y. Anti-melanoma differentiation-associated gene 5 and anti-Ro52 antibody-dual positive dermatomyositis accompanied by rapidly lung disease: Three case reports. World J Clin Cases 2023; 11:5580-5588. [PMID: 37637698 PMCID: PMC10450387 DOI: 10.12998/wjcc.v11.i23.5580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/22/2023] [Accepted: 07/18/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND Clinically amyopathic deramatomyositis was manifested as the various cutaneous dermatomyositis (DM) manifestations without muscle weakness. Anti-melanoma differentiation-associated gene 5 (anti-MDA5) and anti-Ro52 antibody-dual positive clinically amyopathic DM patients are at a high risk of developing rapidly progressive interstitial lung disease, and they exhibit an immensely high half-year mortality. CASE SUMMARY We presented three patients with anti-MDA5 and anti-Ro52 antibody-dual positive DM patients and we reviewed the previous studies on the link between anti-MDA5 and anti-Ro52 antibody-dual positive DM. Although we aggressively treated these patients similarly, but they all exhibited different prognoses. We reviewed the importance of clinical cutaneous rashes as well as the pathogenesis and treatment in the dual positive anti-MDA5 and anti-Ro52 associated DM. CONCLUSION Patients with anti-MDA5 anti-Ro52 antibody-dual positive DM should be accurately diagnosed at an early stage and should be treated aggressively, thus, the patient's prognosis can be significantly modified.
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Affiliation(s)
- Wen-Zheng Ye
- Department of Dermatology, The Central Hospital of Xiaogan, Xiaogan Hospital Affiliated to Wuhan University of Science and Technology, Xiaogan 432000, Hubei Province, China
| | - Shan-Shan Peng
- Department of Respiratory and Critical Care Medicine, The Central Hospital of Xiaogan, Xiaogan Hospital Affiliated to Wuhan University of Science and Technology, Xiaogan 432000, Hubei Province, China
| | - You-Hong Hu
- Department of Dermatology, The Central Hospital of Xiaogan, Xiaogan Hospital Affiliated to Wuhan University of Science and Technology, Xiaogan 432000, Hubei Province, China
| | - Mu-Ping Fang
- Department of Dermatology, The Central Hospital of Xiaogan, Xiaogan Hospital Affiliated to Wuhan University of Science and Technology, Xiaogan 432000, Hubei Province, China
| | - Yu Xiao
- Department of Dermatology, The Central Hospital of Xiaogan, Xiaogan Hospital Affiliated to Wuhan University of Science and Technology, Xiaogan 432000, Hubei Province, China
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3
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Thompson TZ, Bobr A, Juskewitch JE, Winters JL. Therapeutic plasma exchange for steroid refractory idiopathic inflammatory myopathies with interstitial lung disease. J Clin Apher 2023; 38:481-490. [PMID: 36408807 DOI: 10.1002/jca.22034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 09/27/2022] [Accepted: 11/08/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Idiopathic inflammatory myopathies (IIMs) encompass many rheumatologic diseases characterized by inflammatory muscle disease, typically unified by proximal muscle weakness. A subset of patients with IIM present with interstitial lung disease (ILD) with identifiable antibodies such as in anti-synthetase syndrome (AS) with antibodies to aminoacyl-tRNA synthetases, and clinically amyopathic dermatomyositis (CADM) with anti-melanoma differentiation-associated protein 5 (MDA5). Recent case reports demonstrate response to therapeutic plasma exchange (TPE) or column filtration plasmapheresis in IIM with ILD resistant to medical management. We present our experience with eight patients with IIM with ILD undergoing TPE at a large US-based hospital system. PATIENT CHARACTERISTICS Eight patients with IIM with ILD were treated with TPE over the last 10 years. The therapy consisted of 5-7 one plasma volume exchanges every other day to daily. Seven of eight patients had identifiable antibodies. RESULTS Following completion of TPE, seven of eight demonstrated improvement in pulmonary function despite lack of improvement of pulmonary function with standard therapy. CONCLUSION In antibody-mediated, treatment refractory IIM with ILD, TPE may be a viable intervention. This is a disease for which the role of apheresis is evolving. CLINICAL TRIAL REGISTRATION Not application.
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Affiliation(s)
- Thomas Zachary Thompson
- Department of Laboratory Medicine and Pathology, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Aleh Bobr
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Justin Eddie Juskewitch
- Department of Laboratory Medicine and Pathology, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Jeffrey Lawrence Winters
- Department of Laboratory Medicine and Pathology, Mayo Clinic Minnesota, Rochester, Minnesota, USA
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Eggleston RH, Baqir M, Varghese C, Pennington KM, Bekele DI, Hartman TE, Ernste FC. Clinical Outcomes With and Without Plasma Exchange in the Treatment of Rapidly Progressive Interstitial Lung Disease Associated With Idiopathic Inflammatory Myopathy. J Clin Rheumatol 2023; 29:151-158. [PMID: 36729874 DOI: 10.1097/rhu.0000000000001923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND/OBJECTIVE A subset of patients with idiopathic inflammatory myopathy (IIM) develops highly fatal, rapidly progressive interstitial lung disease (RP-ILD). Treatment strategies consist of glucocorticoid and adjunctive immunosuppressive therapies. Plasma exchange (PE) is an alternative therapy, but its benefit is unclear. In this study, we aimed to determine whether PE benefited outcomes for patients with RP-ILD. METHODS In this medical records review study, we compared baseline characteristics and clinical outcomes for 2 groups of patients with IIM-related RP-ILD: those who received and did not receive PE. RESULTS Our cohort consisted of 15 patients, 9 of whom received PE. Baseline demographic characteristics and severity of lung, skin, and musculoskeletal disease between the 2 groups of patients were not significantly different. Five patients required mechanical ventilation (2, PE; 3, no PE). Plasma exchange was generally a third-line adjunctive treatment option. The PE group had a longer median (interquartile range) hospitalization (27.0 [23.0-36.0] days) than the non-PE group (12.0 [8.0-14.0] days) ( p = 0.02). There was a potential benefit in 30-day mortality improvement in those receiving PE (0% vs 33%, p = 0.14), with a statistically significant improvement in 2 important composite end points including 30-day mortality or need for lung transplant (0% vs 50%, p = 0.04) and 1-year mortality or need for lung transplant or hospital readmission for RP-ILD in those receiving PE (22% vs 83%, p = 0.04). CONCLUSIONS Plasma exchange may be an underutilized, safe salvage therapy for patients with IIM-related RP-ILD when other immunosuppressive therapies fail.
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Affiliation(s)
- Reid H Eggleston
- From the Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science
| | - Misbah Baqir
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester
| | | | - Kelly M Pennington
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester
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Wang L, Liu J, Peng L. High-Dose Tigecycline for the Treatment of Progressive Pneumonia Caused by Chlamydia psittaci: Case Series and Literature Review. Infect Drug Resist 2023; 16:115-124. [PMID: 36636374 PMCID: PMC9831003 DOI: 10.2147/idr.s393647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 12/23/2022] [Indexed: 01/07/2023] Open
Abstract
Purpose To summarize the clinical characteristics of progressive pneumonia caused by Chlamydia psittaci (C. psittaci) and to explore the effect of high-dose tigecycline on severe C psittaci. Patients and Methods We retrospectively analyzed the clinical characteristics, treatment, and outcomes of three progressive pneumonia patients caused by C. psittaci in our hospital in the past three years. Results All three patients showed high fever and progressive dyspnea, and all of them were finally diagnosed by bronchoalveolar lavage fluid (BALF) of metagenomic next-generation sequencing (mNGS). Case 1 rapidly developed into multilobar infiltration after raising a parrot with a normal appearance one week before. Respiratory failure occurred despite the use of moxifloxacin, requiring non-invasive ventilator-assisted ventilation. Case 2 developed discomfort one day after sightseeing in the forest park. Moxifloxacin was ineffective for her and she quickly developed respiratory failure, requiring invasive ventilator-assisted ventilation. Case 3 kept chickens and ducks at home. Respiratory failure and renal failure still occurred rapidly despite the use of doxycycline, requiring invasive ventilator-assisted ventilation and continuous renal replacement therapy (CRRT). After adjusting the antibiotic to high-dose tigecycline (100mg, I.V., q12h), all three patients were treated effectively and no side effects occurred. Conclusion C. psittaci pneumonia is one of the causes of progressive pneumonia. High-dose tigecycline is safe and effective for the treatment of severe C. psittaci.
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Affiliation(s)
- Lu Wang
- Department of Respiratory Medicine, The First Hospital of Jilin University, Changchun, Jilin Province, People’s Republic of China
| | - Jingwei Liu
- Department of Pediatric Intensive Care Unit, The First Hospital of Jilin University, Changchun, Jilin Province, People’s Republic of China
| | - Liping Peng
- Department of Respiratory Medicine, The First Hospital of Jilin University, Changchun, Jilin Province, People’s Republic of China,Correspondence: Liping Peng, Department of Respiratory Medicine, The First Hospital of Jilin University, Changchun, 130021, People’s Republic of China, Email
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Muacevic A, Adler JR, Anaji SC, Williams A. Dermatomyositis With Dual Positive Anti-melanoma Differentiation-Associated Gene 5 and Anti-Sjogren Syndrome-Related Antigen 52 kD Antibodies: A Case Report and Literature Review on Clinical Characteristics. Cureus 2023; 15:e34235. [PMID: 36852352 PMCID: PMC9962714 DOI: 10.7759/cureus.34235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2023] [Indexed: 01/27/2023] Open
Abstract
Anti-melanoma differentiation-associated gene 5 (MDA 5) is one of the subtypes of dermatomyositis associated with rapidly progressive lung disease. MDA 5 carries a high mortality risk due to respiratory failure. The exact pathophysiology is unclear, but it is linked to genetic predisposition and viral triggers with the associated innate response and cytokine production like interleukins IL-1,6,18, tumor necrosis factor-alpha, and interferons. It is usually treated with anti-cytokines, high-dose steroids, immunosuppressants, and plasma exchange. Due to the atypical presentation and rapidity of the disease course, the diagnosis is often delayed. We report a 39-year-old female presenting with rapidly progressive lung disease secondary to an aggressive form of dermatomyositis.
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Affiliation(s)
| | - John R Adler
- Internal Medicine, Baton Rouge General, Baton Rouge, USA
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Gono T, Masui K, Sato S, Kuwana M. Mortality Risk Stratification Using Cluster Analysis in Patients With Myositis-Associated Interstitial Lung Disease Receiving Initial Triple-Combination Therapy. Front Med (Lausanne) 2022; 9:883699. [PMID: 35615085 PMCID: PMC9124901 DOI: 10.3389/fmed.2022.883699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 04/19/2022] [Indexed: 12/04/2022] Open
Abstract
Objective To stratify patients with polymyositis/dermatomyositis-associated interstitial lung disease (ILD) who were initially treated with an intensive regimen consisting of high-dose corticosteroids, a calcineurin inhibitor, and intravenous cyclophosphamide (triple-combo therapy) into subgroups based on mortality outcomes by a cluster analysis using a large-scale multicenter retrospective cohort of Japanese patients with myositis-associated ILD (JAMI). Methods Two-step cluster analysis of preclustering and subsequent hierarchical clustering was conducted in 185 patients who received triple-combo therapy in an unbiased manner. Initial predictors for mortality previously reported in patients with myositis-associated ILD were used as variables and included age, sex, disease duration, classification of myositis, requirement of supplemental oxygen, anti-aminoacyl tRNA synthetase (ARS) antibody, anti-melanoma differentiation-associated gene 5 (MDA5) antibody, and serum levels of C-reactive protein (CRP) and Krebs von den Lungen-6 (KL-6). The cluster model was further applied to 283 patients who received conventional regimens consisting of corticosteroids with or without a single immunosuppressive agent (dual-combo therapy or monotherapy). Cumulative survival rates were compared using Kaplan-Meier analysis, and the log-rank test was used to test for significant differences between two groups. Results We developed a cluster model consisting of 6 clusters, which were categorized by age at onset, clinically amyopathic dermatomyositis, CRP, KL-6, requirement of supplemental oxygen, anti-ARS antibody, and anti-MDA5 antibody. This model was judged to be of good quality based on the silhouette measure of cohesion and separation of 0.6. These clusters were regrouped into three subsets based on low (<10%), moderate (10-50%), and high (>50%) mortality rates. The performance of the clustering was generally replicated in patients who received initial dual-combo therapy or monotherapy. Survival benefits of triple-combo therapy over dual-combo therapy or monotherapy were not observed in any of the clusters. Conclusion We successfully developed a cluster model that stratified patients with myositis-associated ILD who were treated with initial triple-combo therapy into subgroups with different prognoses, although this model failed to identify a patient subgroup that showed survival benefits from triple-combo therapy over dual-combo therapy or monotherapy.
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Affiliation(s)
- Takahisa Gono
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
- Scleroderma/Myositis Center of Excellence, Nippon Medical School Hospital, Tokyo, Japan
| | - Kenichi Masui
- Department of Anaesthesiology, Yokohama City University Hospital, Yokohama, Japan
| | - Shinji Sato
- Division of Rheumatology, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Japan
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
- Scleroderma/Myositis Center of Excellence, Nippon Medical School Hospital, Tokyo, Japan
- *Correspondence: Masataka Kuwana
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8
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Bai Z, Chen Y, Dong L. Experience of therapeutic plasma exchange in rheumatic diseases: Albumin may be a suitable substitute for plasma. Arch Rheumatol 2021; 36:398-408. [PMID: 34870172 PMCID: PMC8612486 DOI: 10.46497/archrheumatol.2021.8447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 11/07/2020] [Indexed: 11/16/2022] Open
Abstract
Objectives
In this study, we aimed to assess the value of therapeutic plasma exchange (TPE) in the treatment of rheumatic diseases and compare the safety of different replacement fluids used in TPE. Patients and methods
A total of 727 TPE procedures in 285 patients (57 males, 228 females; mean age: 39.7±15.4 years; range, 13 to 79 years) with rheumatic diseases between January 2011 and February 2019 were retrospectively analyzed. Data including demographic and clinical characteristics of the patients were recorded. Treatment response to TPE and adverse events were evaluated in all patients. Results
Indications for TPE included 13 different disorders, with the majority being systemic lupus erythematosus (up to 50%). The mean number of TPE sessions was 2.55±1.00 per patient and the mean exchange plasma volume was 2,270±256 mL per session. Combined plasma and albumin was the most frequently used replacement fluid (69.5%), followed by albumin and plasma in 20.5% and 10.0% of episodes, respectively. Up to 73.7% (210/285) patients achieved clinical improvement after TPE treatment. Adverse events occurred in 15.1% (110/727) of all the procedures, and allergic reaction (34.5%) was the most common event. The overall incidence rate of complication was similar among the three types of replacement fluids (p=0.214). Conclusion
Based on our study results, TPE is an invasive, but safe, useful and, sometimes, essential tool with an acceptable risk/benefit ratio for most rheumatic diseases. Albumin can be used as a feasible substitute for plasma in case of shortage of blood resources.
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Affiliation(s)
- Zhiqian Bai
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yu Chen
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lingli Dong
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Nombel A, Fabien N, Coutant F. Dermatomyositis With Anti-MDA5 Antibodies: Bioclinical Features, Pathogenesis and Emerging Therapies. Front Immunol 2021; 12:773352. [PMID: 34745149 PMCID: PMC8564476 DOI: 10.3389/fimmu.2021.773352] [Citation(s) in RCA: 91] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 10/07/2021] [Indexed: 12/24/2022] Open
Abstract
Anti-MDA5 dermatomyositis is a rare systemic autoimmune disease, historically described in Japanese patients with clinically amyopathic dermatomyositis and life-threatening rapidly progressive interstitial lung disease. Subsequently, the complete clinical spectrum of the disease was enriched by skin, articular and vascular manifestations. Depending on the predominance of these symptoms, three distinct clinical phenotypes with different prognosis are now defined. To date, the only known molecular component shared by the three entities are specific antibodies targeting MDA5, a cytosolic protein essential for antiviral host immune responses. Several biological tools have emerged to detect these antibodies, with drawbacks and limitations for each of them. However, the identification of this highly specific serological marker of the disease raises the question of its role in the pathogenesis. Although current knowledge on the pathogenic mechanisms that take place in the disease are still in their enfancy, several lines of evidence support a central role of interferon-mediated vasculopathy in the development of skin and lung lesions, as well as a possible pathogenic involvement of anti-MDA5 antibodies. Here, we review the clinical and biological evidences in favor of these hypothesis, and we discuss the contribution of emerging therapies that shed some light on the pathogenesis of the disease.
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Affiliation(s)
- Anaïs Nombel
- Immunology Department, Lyon-Sud Hospital, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Nicole Fabien
- Immunology Department, Lyon-Sud Hospital, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Frédéric Coutant
- Immunology Department, Lyon-Sud Hospital, Hospices Civils de Lyon, Pierre-Bénite, France.,Immunogenomics and Inflammation Research Team, University of Lyon, Edouard Herriot Hospital, Lyon, France
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Kondoh Y, Makino S, Ogura T, Suda T, Tomioka H, Amano H, Anraku M, Enomoto N, Fujii T, Fujisawa T, Gono T, Harigai M, Ichiyasu H, Inoue Y, Johkoh T, Kameda H, Kataoka K, Katsumata Y, Kawaguchi Y, Kawakami A, Kitamura H, Kitamura N, Koga T, Kurasawa K, Nakamura Y, Nakashima R, Nishioka Y, Nishiyama O, Okamoto M, Sakai F, Sakamoto S, Sato S, Shimizu T, Takayanagi N, Takei R, Takemura T, Takeuchi T, Toyoda Y, Yamada H, Yamakawa H, Yamano Y, Yamasaki Y, Kuwana M. 2020 guide for the diagnosis and treatment of interstitial lung disease associated with connective tissue disease. Respir Investig 2021; 59:709-740. [PMID: 34602377 DOI: 10.1016/j.resinv.2021.04.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 04/20/2021] [Accepted: 04/21/2021] [Indexed: 01/29/2023]
Abstract
The prognosis of patients with connective tissue disease (CTD) has improved significantly in recent years, but interstitial lung disease (ILD) associated with connective tissue disease (CTD-ILD) remains a refractory condition, which is a leading cause of mortality. Because it is an important prognostic factor, many observational and interventional studies have been conducted to date. However, CTD is a heterogeneous group of conditions, which makes the clinical course, treatment responses, and prognosis of CTD-ILD extremely diverse. To summarize the current understanding and unsolved questions, the Japanese Respiratory Society and the Japan College of Rheumatology collaborated to publish the world's first guide focusing on CTD-ILD, based on the evidence and expert consensus of pulmonologists and rheumatologists, along with radiologists, pathologists, and dermatologists. The task force members proposed a total of 27 items, including 7 for general topics, 9 for disease-specific topics, 3 for complications, 4 for pharmacologic treatments, and 4 for non-pharmacologic therapies, with teams of 2-4 authors and reviewers for each item to prepare a consensus statement based on a systematic literature review. Subsequently, public opinions were collected from members of both societies, and a critical review was conducted by external reviewers. Finally, the task force finalized the guide upon discussion and consensus generation. This guide is expected to contribute to the standardization of CTD-ILD medical care and is also useful as a tool for promoting future research by clarifying unresolved issues.
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Affiliation(s)
- Yasuhiro Kondoh
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan.
| | - Shigeki Makino
- Rheumatology Division, Osaka Medical College Mishima-Minami Hospital, Takatsuki, Osaka, Japan
| | - Takashi Ogura
- Division of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Kanagawa, Japan
| | - Takafumi Suda
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Hiromi Tomioka
- Department of Respiratory Medicine, Kobe City Medical Center West Hospital, Kobe, Hyogo, Japan
| | - Hirofumi Amano
- Department of Internal Medicine and Rheumatology, Juntendo University Graduate School of Medicine, Bunkyo, Tokyo, Japan
| | - Masaki Anraku
- Department of Thoracic Surgery, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, Itabashi, Tokyo, Japan
| | - Noriyuki Enomoto
- Health Administration Center, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Takao Fujii
- Department of Rheumatology and Clinical Immunology, Wakayama Medical University, Wakayama, Wakayama, Japan
| | - Tomoyuki Fujisawa
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Takahisa Gono
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Bunkyo, Tokyo, Japan
| | - Masayoshi Harigai
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Shinjuku, Tokyo, Japan
| | - Hidenori Ichiyasu
- Department of Respiratory Medicine, Faculty of Life Sciences, Kumamoto University, Kumamoto, Kumamoto, Japan
| | - Yoshikazu Inoue
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai, Osaka, Japan
| | - Takeshi Johkoh
- Department of Radiology, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Hideto Kameda
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Toho University, Meguro, Tokyo, Japan
| | - Kensuke Kataoka
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan
| | - Yasuhiro Katsumata
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Shinjuku, Tokyo, Japan
| | - Yasushi Kawaguchi
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Shinjuku, Tokyo, Japan
| | - Atsushi Kawakami
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Nagasaki, Japan
| | - Hideya Kitamura
- Division of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Kanagawa, Japan
| | - Noboru Kitamura
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Tomohiro Koga
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Nagasaki, Japan
| | - Kazuhiro Kurasawa
- Department of Rheumatology, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Yutaro Nakamura
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Ran Nakashima
- Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Sakyo, Kyoto, Japan
| | - Yasuhiko Nishioka
- Department of Respiratory Medicine and Rheumatology, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Tokushima, Japan
| | - Osamu Nishiyama
- Department of Respiratory Medicine and Allergology, Kindai University Faculty of Medicine, Osakasayama, Osaka, Japan
| | - Masaki Okamoto
- Department of Respirology, National Hospital Organization Kyushu Medical Center, Fukuoka, Fukuoka, Japan
| | - Fumikazu Sakai
- Department of Diagnostic Radiology, Saitama International Medical Center, Saitama Medical University, Hidaka, Saitama, Japan
| | - Susumu Sakamoto
- Department of Respiratory Medicine, Toho University Omori Medical Center, Tokyo, Japan
| | - Shinji Sato
- Division of Rheumatology, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Toshimasa Shimizu
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Nagasaki, Japan
| | - Noboru Takayanagi
- Department of Respiratory Medicine, Saitama Cardiovascular and Respiratory Center, Kumagaya, Saitama, Japan
| | - Reoto Takei
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan
| | - Tamiko Takemura
- Department of Pathology, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Kanagawa, Japan
| | - Tohru Takeuchi
- Department of Internal Medicine (IV), Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Yuko Toyoda
- Department of Respiratory Medicine, Japanese Red Cross Kochi Hospital, Kochi, Kochi, Japan
| | - Hidehiro Yamada
- Center for Rheumatic Diseases, Seirei Yokohama Hospital, Yokohama, Kanagawa, Japan
| | - Hideaki Yamakawa
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Saitama, Saitama, Japan
| | - Yasuhiko Yamano
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan
| | - Yoshioki Yamasaki
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Bunkyo, Tokyo, Japan
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Bunkyo, Tokyo, Japan
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11
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Selva-O'Callaghan A, Romero-Bueno F, Trallero-Araguás E, Gil-Vila A, Ruiz-Rodríguez JC, Sánchez-Pernaute O, Pinal-Fernández I. Pharmacologic Treatment of Anti-MDA5 Rapidly Progressive Interstitial Lung Disease. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2021; 7:319-333. [PMID: 34603940 PMCID: PMC8476986 DOI: 10.1007/s40674-021-00186-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2021] [Indexed: 11/15/2022]
Abstract
Purpose of the Review Idiopathic inflammatory myopathies are a heterogeneous group of autoimmune disorders. The presence of different autoantibodies allows clinicians to define distinct phenotypes. Antibodies against the melanoma differentiation-associated protein 5 gene, also called anti-MDA5 antibodies, are associated with a characteristic phenotype, the clinically amyopathic dermatomyositis with rapidly progressive interstitial lung disease. This review aims to analyze the different pharmacological options for the treatment of rapidly progressive interstitial lung disease in patients with anti-MDA5 antibodies. Recent Findings Evidence-based therapeutic recommendations suggest that the best initial approach to treat these patients is an early combination of immunosuppressive drugs including either glucocorticoids and calcineurin inhibitors or a triple therapy adding intravenous cyclophosphamide. Tofacitinib, a Janus kinase inhibitor, could be useful according to recent reports. High ferritin plasma levels, generalized worsening of pulmonary infiltrates, and ground-glass opacities should be considered predictive factors of a bad outcome. In this scenario, clinicians should consider rescue therapies such as therapeutic plasma exchange, polymyxin-B hemoperfusion, veno-venous extracorporeal membrane oxygenation, or even lung transplantation. Summary Combined immunosuppressive treatment should be considered the first-line therapy for patients with anti-MDA5 rapidly progressive interstitial lung disease. Aggressive rescue therapies may be useful in refractory patients.
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Affiliation(s)
- A Selva-O'Callaghan
- Systemic Autoimmune Diseases Unit, Medicine Department, Vall d'Hebron University Hospital, GEAS Group, Universitat Autónoma de Barcelona, 08012 Barcelona, Spain
| | - F Romero-Bueno
- Rheumatology Department, Fundación Jiménez Díaz University Hospital, Universidad Autónoma de Madrid, Madrid, Spain
| | - E Trallero-Araguás
- Rheumatology Department, Vall d'Hebron University Hospital, GEAS Group, Barcelona, Spain
| | - A Gil-Vila
- Systemic Autoimmune Diseases Unit, Medicine Department, Vall d'Hebron University Hospital, GEAS Group, Universitat Autónoma de Barcelona, 08012 Barcelona, Spain
| | - J C Ruiz-Rodríguez
- Intensive Care Department, Vall d'Hebron University Hospital, Shock, Organ Dysfunction, and Resuscitation Research Group, Vall D'Hebron Research Institute, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - O Sánchez-Pernaute
- Rheumatology Department, Fundación Jiménez Díaz University Hospital, Universidad Autónoma de Madrid, Madrid, Spain
| | - I Pinal-Fernández
- National Institutes of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, MD USA.,Johns Hopkins University School of Medicine, Baltimore, MD USA.,Faculty of Health Sciences and Faculty of Computer Science, Multimedia and Telecommunications, Universitat Oberta de Catalunya, Barcelona, Spain
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12
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Awaji K, Asano Y, Fukui Y, Oka T, Toyama T, Sato S. Rapidly progressive interstitial lung disease associated with dermatomyositis—Longitudinal course of anti‐MDA5 antibody titer in two cases. JOURNAL OF CUTANEOUS IMMUNOLOGY AND ALLERGY 2021. [DOI: 10.1002/cia2.12169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Kentaro Awaji
- Department of Dermatology University of Tokyo Graduate School of Medicine Tokyo Japan
| | - Yoshihide Asano
- Department of Dermatology University of Tokyo Graduate School of Medicine Tokyo Japan
| | - Yuki Fukui
- Department of Dermatology University of Tokyo Graduate School of Medicine Tokyo Japan
| | - Tomonori Oka
- Department of Dermatology University of Tokyo Graduate School of Medicine Tokyo Japan
| | - Tetsuo Toyama
- Department of Dermatology University of Tokyo Graduate School of Medicine Tokyo Japan
| | - Shinichi Sato
- Department of Dermatology University of Tokyo Graduate School of Medicine Tokyo Japan
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13
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Takahashi R, Yoshida T, Morimoto K, Kondo Y, Kikuchi J, Saito S, Ishigaki S, Kaneko Y, Takeuchi T, Itoh H, Oya M. Successful Treatment of Anti-MDA5 Antibody-Positive Dermatomyositis-Associated Rapidly Progressive-Interstitial Lung Disease by Plasma Exchange: Two Case Reports. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2021; 14:11795476211036322. [PMID: 34377045 PMCID: PMC8320549 DOI: 10.1177/11795476211036322] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 07/13/2021] [Indexed: 01/26/2023]
Abstract
Background Patients with anti-melanoma differentiation-associated gene 5 (MDA5) antibody-positive dermatomyositis (DM) are frequently accompanied by rapidly progressive-interstitial lung disease (RP-ILD). They are often refractory to intensive immunosuppressive therapy and have poor prognosis. Case presentation A 73-year-old woman presented with fever, cold symptoms, and skin eruption for a month. She also exhibited muscle weakness on upper extremities slightly. The titer of anti-MDA5 antibody was extremely high, and computed tomography showed ground glass opacity and reticular shadows in the lungs. She was diagnosed as anti-MDA5 antibody-positive classical DM-associated RP-ILD and treated with intensive immunosuppressive therapy. However, the titer of anti-MDA5 antibody did not decrease satisfactorily, and plasma exchange was alternatively initiated. The titer decreased remarkably, and she obtained disease remission. Similarly, a 63-year-old woman presented with stiffness of the neck and hands, fever and cough. She was also diagnosed as anti-MDA5 antibody-positive classical DM-associated RP-ILD, because she had skin eruptions, slight muscle weakness, an elevation in anti-MDA5 antibody, and RP-ILD. She was unresponsive to intensive immunosuppressive therapy, but plasma exchange successfully improved the titer of anti-MDA5 antibody, the symptoms, and the findings of computed tomography. Conclusions Although anti-MDA5 antibody-positive DM-associated RP-ILD has a high mortality rate, this report suggests the usefulness of plasma exchange to improve the prognosis.
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Affiliation(s)
- Rina Takahashi
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Tadashi Yoshida
- Apheresis and Dialysis Center, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
- Tadashi Yoshida, Apheresis and Dialysis Center, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan.
| | - Kohkichi Morimoto
- Apheresis and Dialysis Center, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Yasushi Kondo
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Jun Kikuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Shuntaro Saito
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Sho Ishigaki
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Hiroshi Itoh
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Mototsugu Oya
- Apheresis and Dialysis Center, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
- Department of Urology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
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14
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Fine A, Karp JK, Peedin AR. The role of therapeutic plasma exchange in clinically amyopathic dermatomyositis with MDA-5 antibody: A case report and review of the literature. J Clin Apher 2021; 35:483-487. [PMID: 33617011 DOI: 10.1002/jca.21815] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 02/12/2020] [Accepted: 06/16/2020] [Indexed: 12/22/2022]
Abstract
Clinically amyopathic dermatomyositis (CADM) is a rare, aggressive variant of dermatomyositis associated with interstitial lung disease (ILD) and refractoriness to immunosuppressants. Antibodies against melanoma differentiation-associated gene 5 (MDA-5) are often found in patients with CADM. We report a patient with advanced CADM with ILD and MDA-5 antibodies who failed to improve with immunosuppressants. We performed 2 TPE over 3 days, using 5% albumin as replacement fluid. Although five total TPE were planned, he was transferred for lung transplant evaluation after the second TPE; he died 16 days after transfer without receiving a transplant. A literature review identified four patients with CADM and MDA-5 antibodies treated with TPE; all experienced symptomatic improvement of their ILD. We attribute our patient's outcome to the advanced nature of his disease rather than a failure of TPE. Additional research may indicate a possible reclassification of CADM with MDA-5 antibodies in future ASFA guidelines.
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Affiliation(s)
- Alexander Fine
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Julie K Karp
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Alexis R Peedin
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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15
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Kaenmuang P, Navasakulpong A. Clinical characteristics of anti-MDA5 antibody-positive interstitial lung disease. Respirol Case Rep 2021; 9:e00701. [PMID: 33343905 PMCID: PMC7734424 DOI: 10.1002/rcr2.701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/16/2020] [Accepted: 11/23/2020] [Indexed: 11/29/2022] Open
Abstract
Clinically amyopathic dermatomyositis (CADM) with anti-melanoma differentiation-associated gene 5 antibody is associated with rapidly progressive interstitial lung disease (RP-ILD) which results in up to 50% mortality, especially within six months of diagnosis. However, limited data are available on this disease. This is the first case series of six patients in Thailand diagnosed with CADM with ILD. All patients presented with respiratory symptoms, such as progressive dyspnoea, dyspnoea on exertion, or cough. High-resolution computed tomography of the chest showed predominantly subpleural and peripheral consolidation in both lower lungs. Four patients had RP-ILD and three of the RP-ILD patients died within seven weeks of diagnosis. These cases illustrate the clinical characteristics, chest imaging, treatments, and clinical outcomes of the patients diagnosed with CADM and ILD.
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Affiliation(s)
- Punchalee Kaenmuang
- Division of Respiratory and Respiratory Critical Care Medicine, Department of Internal Medicine, Faculty of MedicinePrince of Songkhla UniversityHat YaiThailand
| | - Asma Navasakulpong
- Division of Respiratory and Respiratory Critical Care Medicine, Department of Internal Medicine, Faculty of MedicinePrince of Songkhla UniversityHat YaiThailand
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16
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Zhang QC, Liu MY, Chen ZX, Chen YT, Lin CS, Xu Q. Case Report: Treatment of Anti-MDA5-Positive Amyopathic Dermatomyositis Accompanied by a Rapidly Progressive Interstitial Lung Diseases With Methylprednisolone Pulse Therapy Combined With Cyclosporine A and Hydroxychloroquine. Front Med (Lausanne) 2020; 7:610554. [PMID: 33330573 PMCID: PMC7732655 DOI: 10.3389/fmed.2020.610554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 10/30/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: Patients with anti-melanoma differentiation-associated gene 5 (MDA5) antibody-positive amyopathic dermatomyositis (ADM) often develop rapidly progressive interstitial lung diseases (RP-ILD), with poor treatment success. Many studies have shown that this is the main cause of death in patients with anti-MDA5 antibody-positive ADM. Case Presentation: A 37-years-old woman developed a cough, shortness of breath, and a rash on both hands, which resembled Gottron's signs. Upon laboratory examination, the results were as follows: antinuclear antibody (ANA) positive; anti-Ro52 antibody positive; and anti-MDA5 antibody positive. Pulmonary high-resolution CT (HRCT) scan showed pulmonary interstitial inflammatory changes, and mediastinal and subcutaneous emphysema. She was finally diagnosed with anti-MDA5 antibody-positive ADM accompanied by RP-ILD. She was first given high-dose-steroid pulse therapy with methylprednisolone (500 mg per day for 3 days) followed by methylprednisolone (40 mg, daily), cyclosporine A (100 mg, twice per day), and hydroxychloroquine (200 mg, twice per day). Since her discharge from our hospital in March of 2018, she has maintained the methylprednisolone therapy (tapered to 10 mg daily), cyclosporine A (100 mg, twice per day), and hydroxychloroquine (200 mg, twice per day). Outcomes: Pulmonary HRCT scans taken on 4, 9, and 26 months after her discharge from our hospital showed that the interstitial pneumonitis had significantly improved and that mediastinal and subcutaneous emphysema had been gradually absorbed. The patient can now participate in regular work and activities of daily living. Conclusion: The treatment of methylprednisolone pulse therapy combined with cyclosporine A and hydroxychloroquine may be an option for the RP-ILD accompanied by anti-MDA-positive ADM. After the acute phase, this combination therapy strategy is helpful to the disease control of patients.
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Affiliation(s)
- Qia-Chun Zhang
- Guangzhou University of Chinese Medicine, Guangzhou, China.,Bao'an Traditional Chinese Medicine Hospital Affiliated to Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Min-Ying Liu
- Guangzhou University of Chinese Medicine, Guangzhou, China.,Department of Rheumatology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhi-Xin Chen
- The Chinese Medicine Department, South China Agricultural University Hospital, Guangzhou, China
| | | | - Chang-Song Lin
- Guangzhou University of Chinese Medicine, Guangzhou, China.,Department of Rheumatology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Qiang Xu
- Guangzhou University of Chinese Medicine, Guangzhou, China.,Department of Rheumatology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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17
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Jee AS, Sheehy R, Hopkins P, Corte TJ, Grainge C, Troy LK, Symons K, Spencer LM, Reynolds PN, Chapman S, de Boer S, Reddy T, Holland AE, Chambers DC, Glaspole IN, Jo HE, Bleasel JF, Wrobel JP, Dowman L, Parker MJS, Wilsher ML, Goh NSL, Moodley Y, Keir GJ. Diagnosis and management of connective tissue disease-associated interstitial lung disease in Australia and New Zealand: A position statement from the Thoracic Society of Australia and New Zealand. Respirology 2020; 26:23-51. [PMID: 33233015 PMCID: PMC7894187 DOI: 10.1111/resp.13977] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 09/26/2020] [Accepted: 10/22/2020] [Indexed: 12/12/2022]
Abstract
Pulmonary complications in CTD are common and can involve the interstitium, airways, pleura and pulmonary vasculature. ILD can occur in all CTD (CTD-ILD), and may vary from limited, non-progressive lung involvement, to fulminant, life-threatening disease. Given the potential for major adverse outcomes in CTD-ILD, accurate diagnosis, assessment and careful consideration of therapeutic intervention are a priority. Limited data are available to guide management decisions in CTD-ILD. Autoimmune-mediated pulmonary inflammation is considered a key pathobiological pathway in these disorders, and immunosuppressive therapy is generally regarded the cornerstone of treatment for severe and/or progressive CTD-ILD. However, the natural history of CTD-ILD in individual patients can be difficult to predict, and deciding who to treat, when and with what agent can be challenging. Establishing realistic therapeutic goals from both the patient and clinician perspective requires considerable expertise. The document aims to provide a framework for clinicians to aid in the assessment and management of ILD in the major CTD. A suggested approach to diagnosis and monitoring of CTD-ILD and, where available, evidence-based, disease-specific approaches to treatment have been provided.
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Affiliation(s)
- Adelle S Jee
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Central Clinical School, University of Sydney, Sydney, NSW, Australia.,NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia
| | - Robert Sheehy
- Department of Respiratory Medicine, Princess Alexandra Hospital, Brisbane, QLD, Australia.,School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Peter Hopkins
- NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia.,School of Medicine, University of Queensland, Brisbane, QLD, Australia.,Queensland Lung Transplant service, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Tamera J Corte
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Central Clinical School, University of Sydney, Sydney, NSW, Australia.,NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia
| | - Christopher Grainge
- NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia.,Department of Respiratory Medicine, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Lauren K Troy
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Central Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Karen Symons
- Department of Respiratory Medicine, Alfred Hospital, Melbourne, VIC, Australia
| | - Lissa M Spencer
- Department of Physiotherapy, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Paul N Reynolds
- NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia.,Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia.,Lung Research Laboratory, University of Adelaide, Adelaide, SA, Australia
| | - Sally Chapman
- Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Sally de Boer
- Respiratory Services, Auckland District Health Board, Auckland, New Zealand
| | - Taryn Reddy
- Department of Medical Imaging, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Anne E Holland
- NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia.,Department of Allergy, Immunology and Respiratory Medicine, Monash University, Melbourne, VIC, Australia.,Department of Physiotherapy, Alfred Health, Melbourne, VIC, Australia.,Institute for Breathing and Sleep, Melbourne, VIC, Australia
| | - Daniel C Chambers
- NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia.,School of Medicine, University of Queensland, Brisbane, QLD, Australia.,Queensland Lung Transplant service, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Ian N Glaspole
- NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia.,Department of Respiratory Medicine, Alfred Hospital, Melbourne, VIC, Australia.,Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Helen E Jo
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Central Clinical School, University of Sydney, Sydney, NSW, Australia.,NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia
| | - Jane F Bleasel
- Central Clinical School, University of Sydney, Sydney, NSW, Australia.,Department of Rheumatology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Jeremy P Wrobel
- Advanced Lung Disease Unit, Fiona Stanley Hospital, Perth, WA, Australia.,Department of Medicine, University of Notre Dame Australia, Fremantle, WA, Australia
| | - Leona Dowman
- NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia.,Department of Allergy, Immunology and Respiratory Medicine, Monash University, Melbourne, VIC, Australia.,Physiotherapy Department, Austin Health, Melbourne, VIC, Australia
| | - Matthew J S Parker
- Central Clinical School, University of Sydney, Sydney, NSW, Australia.,NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia.,Department of Rheumatology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Margaret L Wilsher
- NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia.,Respiratory Services, Auckland District Health Board, Auckland, New Zealand.,Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Nicole S L Goh
- Department of Respiratory Medicine, Alfred Hospital, Melbourne, VIC, Australia.,Institute for Breathing and Sleep, Melbourne, VIC, Australia.,Department of Respiratory Medicine, Austin Hospital, Melbourne, VIC, Australia.,Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
| | - Yuben Moodley
- NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia.,University of Western Australia, Institute for Respiratory Health, Perth, WA, Australia.,Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, WA, Australia
| | - Gregory J Keir
- Department of Respiratory Medicine, Princess Alexandra Hospital, Brisbane, QLD, Australia.,School of Medicine, University of Queensland, Brisbane, QLD, Australia
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18
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Hong LE, Proudman S, Limaye V. Interstitial pneumonia with autoimmune features in a patient with melanoma differentiation-associated gene 5 (MDA5) antibody. BMJ Case Rep 2020; 13:13/11/e234946. [DOI: 10.1136/bcr-2020-234946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Melanoma differentiation-associated gene 5 (MDA5) antibody, also known as anti-CADM140 antibody is recognised to be associated with rapidly progressive interstitial lung disease, which can be fatal within 3 months. It is also known to be associated with amyopathic dermatomyositis. We report a case of MDA5 antibody-associated interstitial pneumonia with autoimmune features, without cutaneous features of dermatomyositis, in a Sudanese patient with dual positive antibodies to Ro52. The patient notably had several features associated with poor prognosis, including age, high serum ferritin level, anti-Ro52 antibodies and progressive lung infiltrates during treatment.
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19
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Fisser C, Wiest C, Hamer OW, Müller T, Lubnow M, Pfeifer M, Lerzer C, Dvorak I. Die Diagnose liegt auf der Hand. Pneumologie 2020; 74:780-786. [DOI: 10.1055/a-1177-4209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
ZusammenfassungEine seltene Form der Dermatomyositis ist die klinische amyopathische Dermatomyositis (CADM). Charakterisiert ist sie durch das Fehlen einer bzw. durch eine nur sehr gering ausgeprägte Muskelbeteiligung. Dementsprechend sind die Kreatinkinase-Werte meist im Normalbereich. Typische Hautmanifestationen sind Gottron-Papeln und Mechanikerhände. Bei Nachweis eines MDa5 (Melanoma-differentiation-associated gene 5 intracellular pathogen sensor)-Antikörpers ist die CADM häufig mit einer rasch progredienten und schweren Verlaufsform einer interstitiellen Lungenerkrankung assoziiert. In der Lungenfunktion lässt sich eine Restriktion und eine Hypoxämie unterschiedlichen Ausmaßes nachweisen. Die HRCT-Bildgebung ist nicht spezifisch. Es lassen sich u. a. Milchglas, Retikulationen und Konsolidierungen beobachten. In der bronchioloalveolären Lavage zeigen sich gelegentlich vermehrt Lymphozyten. Histologisch ähnelt das Bild einer nicht-spezifischen interstitiellen Pneumonie oder einer organisierenden Pneumonie. Die Therapie richtet sich nach der Schwere der Ausprägung der klinischen Manifestation. Im Allgemeinen ist eine ausgeprägte immunsuppressive Therapie notwendig. Meist müssen verschiedene Immunsuppressiva kombiniert werden. Ein neuer Therapieansatz stellt die Verwendung des Januskinase-Inhibitors Tofacitinib dar. Zur Therapiekontrolle können der Ferritinspiegel und der MDa5-Antikörper-Titer verwendet werden. Es besteht eine hohe Mortalität von bis zu 84 %.
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Affiliation(s)
- C. Fisser
- Klinik und Poliklinik für Innere Medizin II, Universitätsklinik Regensburg, Regensburg
- Abteilung für Pneumologie, Fachklinik für Lungenerkrankungen Donaustauf, Donaustauf
| | - C. Wiest
- Klinik und Poliklinik für Innere Medizin II, Universitätsklinik Regensburg, Regensburg
| | - O. W. Hamer
- Institut für Röntgendiagnostik, Universitätsklinik Regensburg, Regensburg
- Abteilung für Radiologie, Fachklinik für Lungenerkrankungen Donaustauf, Donaustauf
| | - T. Müller
- Klinik und Poliklinik für Innere Medizin II, Universitätsklinik Regensburg, Regensburg
| | - M. Lubnow
- Klinik und Poliklinik für Innere Medizin II, Universitätsklinik Regensburg, Regensburg
| | - M. Pfeifer
- Klinik und Poliklinik für Innere Medizin II, Universitätsklinik Regensburg, Regensburg
- Abteilung für Pneumologie, Fachklinik für Lungenerkrankungen Donaustauf, Donaustauf
- Abteilung für Pneumologie, Krankenhaus der Barmherzigen Brüder Regensburg, Regensburg
| | - C. Lerzer
- Abteilung für Pneumologie, Fachklinik für Lungenerkrankungen Donaustauf, Donaustauf
| | - I. Dvorak
- Abteilung für Pneumologie, Fachklinik für Lungenerkrankungen Donaustauf, Donaustauf
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20
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Sasaki N, Ishii A, Kurabayashi T, Sugiyama M, Izumi Y, Nakagome Y, Hirano K, Sasaki S, Kondo Y, Nogi S, Nishikawa A, Hosono Y, Yamada C, Sato S. Early initiation of plasma exchange therapy for a patient with anti-MDA5 autoantibody-positive dermatomyositis developing rapidly progressive interstitial lung disease. Mod Rheumatol Case Rep 2020; 5:87-94. [PMID: 33048020 DOI: 10.1080/24725625.2020.1826641] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Dermatomyositis (DM) is a categorised as one of idiopathic inflammatory myopathy (IIM) indicated by symmetrical proximal muscle weakness as well as characteristic cutaneous manifestations typical of DM. Clinically amyopathic dermatomyositis (CADM), a subtype of DM, shows only the skin involvement without any clinical signs of myositis. This condition is often associated with fatal anti-MDA5 antibody-positive rapidly progressive interstitial lung disease (RP-ILD), especially in Eastern Asian populations. Here, we report a CADM patient with anti-MDA5 antibody-positive RP-ILD whom we successfully treated by early initiation of plasma exchange (PE) together with multiple immunosuppressive therapies. In this patient, initial treatment with high-dose prednisolone (PSL), tacrolimus and intermittent intravenous cyclophosphamide had resulted in no obvious improvement in the respiratory condition. Therefore, soon after the first evaluation, we initiated PE therapy in addition to these multiple immunosuppressive therapies. Although the patient had pneumomediastinum, cytomegalovirus and fungal infections over the clinical course, RP-ILD did gradually improved and the anti-MDA5 titre decreased down to within the normal range paralleled by improvement in the patient's respiratory condition.
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Affiliation(s)
- Noriko Sasaki
- Division of Rheumatology, Department of Internal Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Akira Ishii
- Division of Rheumatology, Department of Internal Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Takayoshi Kurabayashi
- Division of Rheumatology, Department of Internal Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Mai Sugiyama
- Division of Rheumatology, Department of Internal Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Yuto Izumi
- Division of Rheumatology, Department of Internal Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Yoko Nakagome
- Division of Rheumatology, Department of Internal Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Kazuki Hirano
- Division of Rheumatology, Department of Internal Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Sho Sasaki
- Division of Rheumatology, Department of Internal Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Yasushi Kondo
- Division of Rheumatology, Department of Internal Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Shinichi Nogi
- Division of Rheumatology, Department of Internal Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Ayumi Nishikawa
- Division of Rheumatology, Department of Internal Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Yuji Hosono
- Division of Rheumatology, Department of Internal Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Chiho Yamada
- Division of Rheumatology, Department of Internal Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Shinji Sato
- Division of Rheumatology, Department of Internal Medicine, Tokai University School of Medicine, Kanagawa, Japan
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21
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Stager K, Wise L. MDA-5 dermatomyositis complicated by interstitial lung disease and cutaneous ulcers: successful treatment with corticosteroids, mycophenolate mofetil and intravenous immunoglobulin. BMJ Case Rep 2020; 13:13/9/e236431. [DOI: 10.1136/bcr-2020-236431] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Antimelanoma differentiation-associated gene 5 (MDA-5) dermatomyositis is a subtype of dermatomyositis that is associated with rapidly progressive interstitial lung disease (RP-ILD), as well as with a variety of cutaneous manifestations. Patients with MDA-5 dermatomyositis tend to have a poor prognosis that is often attributed to the high rates of concurrent RP-ILD. Given the severity of disease, early diagnosis and aggressive management is pivotal. We present a case of a 40-year-old woman diagnosed with MDA-5 dermatomyositis who presented with weakness, painful cutaneous ulcerations and interstitial lung disease. She was treated with monthly intravenous Ig (IVIg), weight-based prednisone and mycophenolate mofetil (MMF). After approximately 2 years of treatment, her interstitial lung disease remains stable and she has had significant improvement in weakness and cutaneous ulcerations. Our case provides evidence for early and aggressive treatment of MDA-5 dermatomyositis with a combination of weight-based prednisone, MMF and IVIg.
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Abe Y, Kusaoi M, Tada K, Yamaji K, Tamura N. Successful treatment of anti-MDA5 antibody-positive refractory interstitial lung disease with plasma exchange therapy. Rheumatology (Oxford) 2020; 59:767-771. [PMID: 31504956 DOI: 10.1093/rheumatology/kez357] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 07/19/2019] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES We examined the effectiveness of plasma exchange (PE) therapy to reduce the mortality of rapidly progressive interstitial lung disease (RP-ILD) in patients positive for anti-melanoma differentiation-associated gene 5 (MDA5) antibodies. METHODS Among 142 patients newly diagnosed with PM/DM or clinically amyopathic DM from 2008 to 2019 at our hospital, 10 were diagnosed with refractory RP-ILD and were positive for anti-MDA5 antibodies. PE was used as an adjunct to standard therapy and consisted of fresh frozen plasma as replacement solution. The primary outcome was non-disease-specific mortality. RESULTS Anti-MDA5 antibodies were detected in 28 patients, of whom 21 were diagnosed with RP-ILD and 10 were refractory to intensive immunosuppressive therapy. Six patients received PE (PE group) and four did not (non-PE group). The 1-year survival rate of the PE group was higher than that of the non-PE group (100% and 25%, respectively, P = 0.033). Regarding adverse events associated with PE, two patients had anaphylactic shock, one had high fever due to fresh frozen plasma allergy and one had a catheter infection. All adverse events resolved with appropriate treatment. CONCLUSION We evaluated the association between 1-year survival rate and PE for refractory RP-ILD in patients positive for anti-MDA5 antibodies. Intensive immunosuppressive therapy improved the survival rate in RP-ILD patients with anti-MDA5 antibodies, but 20-30% of cases were still fatal. PE could be administered to patients with active infectious disease who were immunocompromised by intensive immunosuppressive therapy. PE may be considered in refractory RP-ILD patients positive for anti-MDA5 antibodies.
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Affiliation(s)
- Yoshiyuki Abe
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Makio Kusaoi
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Kurisu Tada
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Ken Yamaji
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Naoto Tamura
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
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23
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Yamagata A, Arita M, Tanaka A, Tokioka F, Yoshida T, Nishimura K, Ishida T. Therapeutic plasma exchange for clinically amyopathic dermatomyositis (CADM) associated with rapidly progressive interstitial pneumonia. J Clin Apher 2020; 35:435-443. [PMID: 32810902 DOI: 10.1002/jca.21824] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 07/01/2020] [Accepted: 07/20/2020] [Indexed: 01/20/2023]
Abstract
BACKGROUND Patients with clinically amyopathic dermatomyositis (CADM) with anti-melanoma differentiation-associated gene 5 antibody (anti-MDA5 Ab) frequently develop rapidly progressive interstitial pneumonia (RPIP), often with fatal outcomes. Therapeutic plasma exchange (TPE) has been reported as effective against CADM-RPIP refractory to conventional immunosuppressive therapy. However, the detailed mechanisms by which TPE improves disease activity of CADM-RPIP remain unclear. AIM To elucidate the clinical and demographic characteristics of patients with anti-MDA5 Ab-positive CADM-RPIP treated with TPE and to analyze changes in laboratory findings before, during, and after TPE. MATERIALS & METHODS Patients hospitalized for CADM-RPIP and treated with TPE in 2017 and 2018 were analyzed retrospectively. RESULTS Three patients were successfully treated with TPE, with good tolerance. Anti-MDA5 Ab titers decreased significantly over the course of TPE. CONCLUSION We emphasize that TPE could represent an effective treatment option for CADM-RPIP refractory to traditional therapy. Removal of anti-MDA5 Ab and other pathogenic factors may facilitate favorable outcomes.
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Affiliation(s)
- Akira Yamagata
- Department of Respiratory Medicine, Ohara Healthcare Foundation, Kurashiki Central Hospital, Okayama, Japan
| | - Machiko Arita
- Department of Respiratory Medicine, Ohara Healthcare Foundation, Kurashiki Central Hospital, Okayama, Japan
| | - Ayaka Tanaka
- Department of Respiratory Medicine, Ohara Healthcare Foundation, Kurashiki Central Hospital, Okayama, Japan
| | - Fumiaki Tokioka
- Department of Respiratory Medicine, Ohara Healthcare Foundation, Kurashiki Central Hospital, Okayama, Japan
| | - Tomohiro Yoshida
- Department of Endocrinology and Rheumatology, Ohara Healthcare Foundation, Kurashiki Central Hospital, Okayama, Japan
| | - Keisuke Nishimura
- Department of Endocrinology and Rheumatology, Ohara Healthcare Foundation, Kurashiki Central Hospital, Okayama, Japan
| | - Tadashi Ishida
- Department of Respiratory Medicine, Ohara Healthcare Foundation, Kurashiki Central Hospital, Okayama, Japan
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24
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Recommendations for the treatment of anti-melanoma differentiation-associated gene 5-positive dermatomyositis-associated rapidly progressive interstitial lung disease. Semin Arthritis Rheum 2020; 50:776-790. [PMID: 32534273 DOI: 10.1016/j.semarthrit.2020.03.007] [Citation(s) in RCA: 101] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 02/16/2020] [Accepted: 03/08/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVES The study aimed to develop evidence-based recommendations for the treatment of rapidly progressive interstitial lung disease (RPILD) associated with the anti-Melanoma Differentiation-Associated Gene 5-positive dermatomyositis (DM) syndrome. METHODS The task force comprised an expert panel of specialists in rheumatology, intensive care medicine, pulmonology, immunology, and internal medicine. The study was carried out in two phases: identifying key areas in the management of DM-RPILD syndrome and developing a set of recommendations based on a review of the available scientific evidence. Four specific questions focused on different treatment options were identified. Relevant publications in English, Spanish or French up to April 2018 were searched systematically for each topic using PubMed (MEDLINE), EMBASE, and Cochrane Library (Wiley Online). The experts used evidence obtained from these studies to develop recommendations. RESULTS A total of 134 studies met eligibility criteria and formed the evidentiary basis for the recommendations regarding immunosuppressive therapy and complementary treatments. Overall, there was general agreement on the initial use of combined immunosuppressive therapy. Combination of high-dose glucocorticoids and calcineurin antagonists with or without cyclophosphamide is the first choice. In the case of calcineurin antagonist contraindication or treatment failure, switching or adding other immunosuppressants may be individualized. Plasmapheresis, polymyxin B hemoperfusion and/or intravenous immunoglobulins may be used as rescue options. ECMO should be considered in life-threatening situations while waiting for a clinical response or as a bridge to lung transplant. CONCLUSIONS Thirteen recommendations regarding the treatment of the anti-MDA5 positive DM-RPILD were developed using research-based evidence and expert opinion.
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25
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Brown ZR, Thomas JS, Limaye V. A case of haemorrhagic myositis with concurrent anti-Ro52 and anti-NXP-2 antibodies treated with plasmapheresis. Rheumatology (Oxford) 2020; 59:682-684. [PMID: 31504945 DOI: 10.1093/rheumatology/kez365] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Zoe R Brown
- Medicine, Dentistry and Health Sciences Faculty, University of Melbourne, SA, Australia.,Rheumatology Department, St Vincent's Hospital, Melbourne, VC, SA, Australia
| | | | - Vidya Limaye
- Rheumatology Department, Royal Adelaide Hospital, SA, Australia.,Discipline of Medicine, University of Adelaide, Adelaide, SA, Australia
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26
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Kagawa H, Tsujino K, Yamamoto Y, Iwai A, Hara R, Matsuki T, Fukushima K, Oshitani Y, Yoshimura K, Miki M, Miki K, Kitada S, Mori M, Kida H. Acute lung injury after plasma exchange in a patient with anti-MDA5 antibody-positive, rapidly progressive, interstitial lung disease:A case report. Respir Med Case Rep 2020; 29:101016. [PMID: 32055439 PMCID: PMC7005565 DOI: 10.1016/j.rmcr.2020.101016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 01/31/2020] [Accepted: 01/31/2020] [Indexed: 12/11/2022] Open
Abstract
The presence of anti-melanoma differentiation-associated gene 5 antibody (anti-MDA5 Ab) is closely associated with rapidly progressive interstitial lung disease (RP-ILD) in patients with clinically amyopathic dermatomyositis. Despite intensive immunosuppressive therapies, some of these patients still have a poor prognosis with few treatment options. Although removal of pathogenic autoantibodies and cytokines by plasma exchange (PE) could be a treatment option, its safety and efficacy have never been determined. We report a patient with anti-MDA5 Ab-positive RP-ILD who was refractory to intensive therapies including steroids, cyclosporine, and intravenous cyclophosphamide, and then treated by PE to prevent the progression of RP-ILD. Shortly after the initiation of PE therapy, however, his respiratory condition suddenly deteriorated due to acute pulmonary edema and the patient died on the following day. Transfusion-related acute lung injury (TRALI) would be the most likely cause of the acute pulmonary edema because there was no sign of circulatory overload. To the best of our knowledge, this is the first report showing a critical adverse event associated with PE therapy for these patients. This case supports the idea that the presence of ILD could increase a risk for TRALI and therefore we should carefully evaluate the eligibility for PE therapy of anti-MDA5 Ab-positive RP-ILD patients given the risk of acute lung injury. Further studies collecting more clinical data are necessary to assess the efficacy, safety, and risk factors of PE therapy for these patients.
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Key Words
- ADAMTS, a disintegrin-like and metalloproteinase with thrombospondin type 1 motifs
- ALI, acute lung injury
- ANA, antinuclear antibody
- ANCA, antineutrophil cytoplasmic antibody
- ARS, anti-aminoacyl-tRNA sythetase
- Acute lung injury
- Anti-MDA5 antibody
- CADM, Clinically amyopathic dermatomyositis
- CK, creatine phosphokinase
- CRP, C-reactive protein
- Clinically amyopathic dermatomyositis
- EF, Ejection Fraction
- GGA, ground-glass attenuation
- IVCY, intravenous cyclophosphamide
- Interstitial pneumonia
- PE, plasma exchange
- Plasma exchange
- RP-ILD, rapidly progressive interstitial lung disease
- SP-D, surfactant protein D
- TRALI, Transfusion-related acute lung injury
- anti-MDA5 Ab, anti-melanoma differentiation-associated gene 5 antibody
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Affiliation(s)
| | - Kazuyuki Tsujino
- Department of Respiratory Medicine, National Hospital Organization Osaka Toneyama Medical Center, 5-1-1 Toneyama, Toyonaka, Osaka, 560-8552, Japan
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Tsuji H, Nakashima R, Hosono Y, Imura Y, Yagita M, Yoshifuji H, Hirata S, Nojima T, Sugiyama E, Hatta K, Taguchi Y, Katayama M, Tanizawa K, Handa T, Uozumi R, Akizuki S, Murakami K, Hashimoto M, Tanaka M, Ohmura K, Mimori T. Multicenter Prospective Study of the Efficacy and Safety of Combined Immunosuppressive Therapy With High-Dose Glucocorticoid, Tacrolimus, and Cyclophosphamide in Interstitial Lung Diseases Accompanied by Anti-Melanoma Differentiation-Associated Gene 5-Positive Dermatomyositis. Arthritis Rheumatol 2020; 72:488-498. [PMID: 31524333 DOI: 10.1002/art.41105] [Citation(s) in RCA: 163] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 09/10/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Interstitial lung disease (ILD) accompanied by anti-melanoma differentiation-associated gene 5 (anti-MDA-5)-positive dermatomyositis (DM) is often rapidly progressive and associated with poor prognosis. Because there is no established treatment, we undertook this study to prospectively evaluate the efficacy and safety of a combined immunosuppressive regimen for anti-MDA-5-positive DM patients with ILD. METHODS Adult Japanese patients with new-onset anti-MDA-5-positive DM with ILD (n = 29) were enrolled at multiple study centers from 2014 to 2017. They were treated with a regimen of high-dose glucocorticoids (GCs), tacrolimus, and intravenous cyclophosphamide (IV CYC). Plasmapheresis was used if a patient's condition worsened after the regimen started. The primary end point was 6-month survival, which was compared between this group of patients and a historical control group (n = 15) consisting of anti-MDA-5-positive DM patients with ILD who received step-up treatment (high-dose GC and stepwise addition of immunosuppressant). Secondary end points were 12-month survival rate, adverse events, and changes in laboratory data. RESULTS The combined immunosuppressive regimen group showed significantly higher 6-month survival rates than the step-up treatment group (89% versus 33%; P < 0.0001). Over a period of 52 weeks, improvements in anti-MDA-5 titers, serum ferritin levels, vital capacity, and chest high-resolution computed tomography scores were observed. The combined immunosuppressive regimen group received IV CYC nearly 20 days earlier with shorter intervals and tended to receive plasmapheresis more often than patients undergoing step-up treatment. Cytomegalovirus reactivation was frequently observed over 52 weeks. CONCLUSION A combined immunosuppressive regimen is effective for anti-MDA-5-positive DM patients with ILD. Plasmapheresis can be used for additional effect in intractable disease. Patients should be carefully monitored for opportunistic infections during treatment.
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Affiliation(s)
- Hideaki Tsuji
- Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ran Nakashima
- Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yuji Hosono
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
| | | | | | | | | | | | | | | | | | | | | | - Tomohiro Handa
- Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ryuji Uozumi
- Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shuji Akizuki
- Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | | | - Masao Tanaka
- Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | - Tsuneyo Mimori
- Kyoto University Graduate School of Medicine, Kyoto, Japan
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Ning Y, Yang G, Sun Y, Chen S, Liu Y, Shi G. Efficiency of Therapeutic Plasma-Exchange in Acute Interstitial Lung Disease, Associated With Polymyositis/Dermatomyositis Resistant to Glucocorticoids and Immunosuppressive Drugs: A Retrospective Study. Front Med (Lausanne) 2019; 6:239. [PMID: 31781564 PMCID: PMC6856642 DOI: 10.3389/fmed.2019.00239] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 10/14/2019] [Indexed: 01/23/2023] Open
Abstract
Interstitial lung disease (ILD) is a life-threating complication, commonly associated with polymyositis (PM), and dermatomyositis (DM). A subset of acute ILD associated with PM/DM patients are refractory to conventional treatment, and leads to a high rate of mortality. The efficacy of therapeutic plasma-exchange (TPE) as a PM/DM treatment to improve muscle involvement is controversial due to a lack of evidence. However, in recent reports, TPE has been effective in improving lung involvement. To evaluate the efficacy of this therapy, we retrospectively studied TPE treatment outcomes for in 18 acute PM/DM-ILD patients who were resistant to conventional therapies. Five patients were diagnosed with DM (27.8%), 11 with CADM (61.1%), and two with PM (11.1%). Among 18 patients, 11 (61.1%) achieved satisfactory improvement after four or more rounds of TPE, whereas seven died due to respiratory failure. We also analyzed risk factors to predict unresponsiveness to TPE in these patients. Notably, the prevalence of subcutaneous/mediastinal emphysema was significantly higher in the non-responsive group (6/7, 85.7%) than in the responsive group (2/11, 18.2%; P = 0.013); moreover, patients with this complication were mainly in the CADM subgroup (6/8, 75%). Subcutaneous/mediastinal emphysema and increased serum ferritin levels were shown to be poor prognostic factors, predictive of unresponsiveness to TPE, in PM/DM patients. No autoantibodies were found to be associated with TPE outcome, although we only investigated anti-Jo-1 and anti-Ro antibodies; the clinical significance of other myositis-specific autoantibodies, especially anti-melanoma differentiation-associated gene 5 (MDA5) antibody, is not known. Our results indicate that TPE might be an alternative treatment for acute PM/DM-ILD patients resistant to conventional therapies, except for those with subcutaneous/mediastinal emphysema and high serum ferritin levels.
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Affiliation(s)
- Yaogui Ning
- Department of Intensive Care Unit, The First Affiliated Hospital of Xiamen University, Xiamen, China.,Medical College, Xiamen University, Xiamen, China
| | - Guomei Yang
- Medical College, Xiamen University, Xiamen, China
| | - Yuechi Sun
- Department of Rheumatology and Clinical Immunology, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Shiju Chen
- Department of Rheumatology and Clinical Immunology, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Yuan Liu
- Department of Rheumatology and Clinical Immunology, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Guixiu Shi
- Department of Rheumatology and Clinical Immunology, The First Affiliated Hospital of Xiamen University, Xiamen, China
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de Souza FHC, de Araújo DB, Vilela VS, Simões RS, Bernardo WM, Frank TA, da Cunha BM, Shinjo SK. The Brazilian Society of Rheumatology recommendations on investigation and diagnosis of systemic autoimmune myopathies. Adv Rheumatol 2019; 59:42. [PMID: 31601261 DOI: 10.1186/s42358-019-0085-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 09/10/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This research is recommended by the Myopathy Committee of the Brazilian Society of Rheumatology for the investigation and diagnosis of systemic autoimmune myopathies. BODY: A systematic literature review was performed in the Embase, Medline (PubMed) and Cochrane databases, including studies published until October 2018. PRISMA was used for the review, and the articles were evaluated, based on the Oxford levels of evidence. Ten recommendations were developed addressing different aspects of systemic autoimmune myopathy investigation and diagnosis. CONCLUSIONS The European League Against Rheumatism/ American College of Rheumatology (EULAR/ACR) classification stands out for the diagnosis of systemic autoimmune myopathies. Muscular biopsy is essential, aided by muscular magnetic resonance images and electroneuromyography in complementary research. Analysis of the factors related to prognosis with the evaluation of extramuscular manifestations, and comorbidities and intense investigation regarding differential diagnoses are mandatory.
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Affiliation(s)
| | | | | | - Ricardo Santos Simões
- Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | | | - Thais Amanda Frank
- Programa Diretrizes da Associação Médica Brasileira (AMB), Brasília, Brazil
| | | | - Samuel Katsuyuki Shinjo
- Disciplina de Reumatologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Av. Dr. Arnaldo, 455, 3° andar, sala 3150, Sao Paulo, Cerqueira César, CEP: 01246-903, Brazil.
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30
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Blood purification in two patients with clinically amyopathic dermatomyositis associated with interstitial lung disease with anti-melanoma differentiation-associated gene-5 antibody (MDA-5). Respir Med Case Rep 2019; 28:100896. [PMID: 31360632 PMCID: PMC6637272 DOI: 10.1016/j.rmcr.2019.100896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 07/02/2019] [Accepted: 07/02/2019] [Indexed: 02/06/2023] Open
Abstract
Patients of clinically amyopathic dermatomyositis associated with rapidly progressive interstitial pneumonia (CADM-RFIP) with positive anti-MDA5 antibody usually presents rapid deterioration and traditional therapy such as cyclophosphamide combined with high-dose prednisone pulse therapy shows no clear benefit at whiles. However, blood purification combined with traditional therapy works according to the literature. We herein report two CADM-RFIP patients administered with DNA immunoadsorption combined with traditional therapy and then reviewed the literature of blood purification in CADM-RFIP patients at home and abroad to date. We emphasize blood purification such as DNA immunoadsorption could apply in the early stage of CADM-RFIP, which can decrease inflammation and allow us more time to control the condition better.
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31
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Treatment of Interstitial Lung Disease Associated With Myositis and the Anti-Synthetase Syndrome. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2018. [DOI: 10.1007/s40674-018-0111-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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