Current management of polymyositis and dermatomyositis

A case of postpartum dermatomyositis with onset at three months: expanding the clinical spectrum

Introduction and importance

Dermatomyositis (DM) is an autoimmune disorder affecting all age groups, with a higher prevalence in women. Diagnosis typically occurs around age 40. Manifestation can be acute or chronic. Diagnosis relies on clinical, laboratory, electromyography, and histopathological tests. Limited information exists regarding DM's occurrence during pregnancy and its connection to pregnancy.

Case presentation

A 31-year-old, 3-month postpartum female presented with features of proximal muscle weakness and generalized erythematous itchy rash. The weakness was associated with muscle tenderness. Laboratory evaluation and skin biopsy revealed features consistent with dermatomyositis. Pulmonary pathology and occult tumors were investigated. Symptoms gradually improved on steroids and azathioprine.

Clinical discussion

The relationship between dermatomyositis and pregnancy remains poorly understood, with only a few documented cases highlighting the impact of pregnancy on the development and progression of the disease. From the available literature, it is evident that postpartum dermatomyositis is uncommon yet significant, necessitating careful attention during pregnancy to enhance outcomes for both the mother and the unborn child.

Conclusion

Our experience highlights a rare case of postpartum dermatomyositis, with symptoms emerging 3 months after childbirth, differing from documented cases. More research is needed to understand pregnancy's role in dermatomyositis development and improve treatment for pregnant women with autoimmune skin diseases.

Dermatomyositis onset in the puerperium period

Dermatomyositis is rare during the reproductive period, but when it does occur, most cases have been reported from the viewpoint of the obstetric management of high-risk pregnancy. In return, there is little information concerning the contribution of pregnancy to the development and course of dermatomyositis. We describe a patient with dermatomyositis that presented after the delivery of a healthy infant. This case, with support from a literature review, suggests that pregnancy could be a trigger or contributor for the development of dermatomyositis.

Postpartum-onset dermatomyositis: case report and literature review

Abstract Dermatomyositis (DM) is rare during the reproductive period, but when it does occur most reports have noted that it has an adverse effect on fetal outcome. Conversely, there is little information concerning the contribution of pregnancy to the development and course of DM. We describe here a patient with DM that developed after delivery of an infant and summarize previously documented cases of postpartum-onset DM. This case suggests that pregnancy could be a trigger for the development of DM.

Idiopathic inflammatory myopathy: treatment options

Idiopathic inflammatory myopathy (IIM) comprises a group of rare disorders in which there is an immune-mediated attack on skeletal muscle, the consequence of which is muscle damage and weakness in the patient. As in other inflammatory diseases, the general approach to therapy is use of immunosuppressive agents. Many options exist for IIM treatment, but therapeutic approaches are based mostly on empirical evidence and small studies, many of which are uncontrolled. Recently, new agents have been designed to target specific components of the immune response, and they offer hope for more effective or safer IIM therapy.

Inflammatory muscle disease: therapeutic aspects

The present treatment of the inflammatory myopathies remains unsatisfactory in several areas, perhaps due in part to our incomplete knowledge of their aetiology. These conditions have been grouped together for practical purposes and because of a similar approach to treatment. However, recent data regarding pathological findings, serological patterns and different outcomes, suggest that some of these myopathies may be distinct, and perhaps approaches to treatment should be tailored according to these findings. This chapter will attempt to update our current management, offer an analysis of recent data regarding newer treatment modalities and highlight areas lacking solid data that need to be further addressed. Although corticosteroids are still considered to be the mainstay of treatment, the earlier use of immunosuppressive therapy will be discussed, as will the use of autoantibody profiles for tailoring treatment. Newer modalities for the monitoring of therapeutic response and their current place in clinical practice will be analysed. The management of refractory cases will be addressed as will the current management of calcinosis, a problem more frequently encountered in children.

Acute onset of dermatomyositis presenting in pregnancy with rhabdomyolysis and fetal loss

We report a case of acute onset of dermatomyositis with rhabdomyolysis and myoglobinuria, which presented in the 14th week of pregnancy and resulted in spontaneous abortion of the fetus. The diagnostic work up for an underlying disease was negative and the histologic examination confirmed the diagnosis of dermatomyositis, which subsequently improved with corticosteroids.

Dermatomyositis

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

The lung in polymyositis

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

Methotrexate use in miscellaneous inflammatory diseases

Methotrexate has proven to be a safe, effective, long-term therapy for rheumatoid arthritis. Its property as a corticosteroid-sparing drug in rheumatoid arthritis has been recognized and its potential has been explored in other inflammatory and autoimmune diseases. This article describes and analyzes the use of methotrexate for a wide variety of diseases, some of which are not the usual province of rheumatologists, to provide some guidance concerning its role for treatment. Methotrexate therapy seems promising for systemic lupus erythematosus, inflammatory myopathy, inflammatory eye disease, inflammatory bowel disease, and some manifestations of sarcoidosis. Its role in other diseases is not as well defined.

Review: corticosteroid usage: observations at a community hospital

Corticosteroids have revolutionized the medical treatment of many diseases. However, their value is limited by substantial potential adverse effects. Therefore, the authors reviewed their clinical use at their community medical center by comparing physician decisions about therapeutic management with the indications published in the current medical literature. They retrospectively reviewed 100 consecutive charts of patients from 1993 to 1994 who received corticosteroid therapy during their hospital stay. They found that 36 patients received appropriate corticosteroid intervention, 49 received partially appropriate corticosteroid intervention, and 15 received inappropriate corticosteroid intervention when compared with current medical literature recommendations for patients with the corresponding diagnoses. Ninety-five percent of patients given "partially appropriate" corticosteroid therapy and 73% given "inappropriate" corticosteroid therapy experienced medication-related side effects compared with 19% of patients given appropriate corticosteroid therapy intervention (P < 0.05). No patient records addressed the possibility of steroid-related osteoporosis. There were no significant differences in the clinical course of the three groups of patients treated with corticosteroids. On the basis of these data, the majority of hospitalized patients given corticosteroids did not receive them entirely in accordance with literature recommendations; these patients experienced increased medication toxicity and did not receive prophylaxis for osteoporosis. These limited observations suggest opportunities to improve patient care.

Dermatomyositis presenting in pregnancy

We report the onset of dermatomyositis in a woman pregnant 38-weeks who subsequently delivered a healthy infant. The disease improved rapidly following delivery. The association of dermatomyositis with pregnancy is unusual, and fetal outcome may be adversely affected.

Laboratory evaluation of the inflammatory myopathies

The laboratory plays an important role in the diagnosis, evaluation, and classification of the heterogeneous group of diseases known as the IIM, which are characterized by chronic muscle inflammation. Serial measurements of the levels of muscle-derived enzymes in serum are the traditional laboratory studies used to follow the clinical course of patients with IIM, although other laboratory tests can also be useful in assessing myositis disease activity. Several markers of immune system activation, including cytokines and lymphocyte markers, show promise as possibly more sensitive measures of myositis disease activity. Discovery of a unique group of MSAs over the past decade has provided an immunologic basis for defining relatively homogeneous subsets of patients who share similar clinical features, disease courses, and responses to therapy. Future investigations of novel immunologic activation markers, as well as the cloning and expression of target autoantigens of the MSAs, should allow better diagnostic assays, enhanced prognosis, and a better understanding of the pathogenesis of these disorders.

Chlorambucil. An effective corticosteroid-sparing agent for patients with recalcitrant dermatomyositis

OBJECTIVE

To investigate the effectiveness of oral chlorambucil treatment in patients with dermatomyositis (DM) that is recalcitrant to treatment with prednisone and/or immunosuppressive agents.

METHODS

Five patients with recalcitrant DM were treated with oral chlorambucil, 4 mg/day, after discontinuation of the other immunosuppressive agent (azathioprine or methotrexate). Three patients were treated with a combination of prednisone and chlorambucil, and 2 with chlorambucil alone.

RESULTS

Beneficial effects were noted within 4-6 weeks in all 5 patients, and corticosteroids were eventually discontinued in 4. Currently, only 1 patient is still receiving therapy; the other 4 have stopped chlorambucil after 13-30 months of treatment, and their disease remains in remission. Minimal chlorambucil toxicity was noted, consisting of leukopenia in 2 patients.

CONCLUSION

Our findings suggest that chlorambucil is an effective, corticosteroid-sparing agent for the control of DM.

Severe acute form of adult dermatomyositis treated with cyclosporine

The classical treatment of severe forms of dermatomyositis includes high doses of steroids and/or cytotoxic agents. Acute forms are frequently life threatening. Because cyclosporine is a fast-acting immunosuppressive drug, it appears to be a good candidate for the treatment of refractory forms of acute dermatomyositis. We report a dramatic improvement of a severe, acute, steroid-resistant adult form after cyclosporine administration. A rapid clinical and biochemical improvement is reported, and the reversibility of immunologic abnormalities is emphasized.