1
|
Umemoto D, Kanzawa Y, Nakamura T, Nishino I, Mizuki S, Ohnishi J, Nakajima T, Ishimaru N, Kinami S. Immune-mediated Necrotizing Myopathy in a Patient with Microscopic Polyangiitis. Intern Med 2024; 63:1485-1490. [PMID: 37813608 DOI: 10.2169/internalmedicine.2583-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/11/2023] Open
Abstract
We herein report a case of immune-mediated necrotizing myopathy (IMNM) in a patient with microscopic polyangiitis (MPA). A 77-year-old Japanese woman presented with a 2-day history of proximal muscle weakness and myalgia, with elevated serum creatinine kinase (CK) levels. Findings of a muscle biopsy were compatible with IMNM; however, anti-signal recognition particle (SRP) and anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR) antibodies were negative. She also had peripheral neuropathy with elevated serum myeloperoxidase anti-neutrophil cytoplasmic antibody titers, leading to a diagnosis of MPA. IMNM can be a pathological result of MPA muscle involvement.
Collapse
Affiliation(s)
- Daichi Umemoto
- Department of General Internal Medicine, Akashi Medical Center, Japan
| | - Yohei Kanzawa
- Department of General Internal Medicine, Akashi Medical Center, Japan
| | | | - Ichizo Nishino
- Department of Neuromuscular Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Japan
| | - Shimpei Mizuki
- Department of General Internal Medicine, Akashi Medical Center, Japan
| | - Jun Ohnishi
- Department of General Internal Medicine, Akashi Medical Center, Japan
| | - Takahiro Nakajima
- Department of General Internal Medicine, Akashi Medical Center, Japan
| | - Naoto Ishimaru
- Department of General Internal Medicine, Akashi Medical Center, Japan
| | - Saori Kinami
- Department of General Internal Medicine, Akashi Medical Center, Japan
| |
Collapse
|
2
|
Julien S, Challier I, Malleter M, Jouen F, Drouot L, Boyer O. Immune-Mediated Necrotizing Myopathy (IMNM): A Story of Antibodies. Antibodies (Basel) 2024; 13:12. [PMID: 38390873 PMCID: PMC10885118 DOI: 10.3390/antib13010012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 01/10/2024] [Accepted: 02/02/2024] [Indexed: 02/24/2024] Open
Abstract
Immune-mediated necrotizing myopathy (IMNM) is a rare and severe disease that corresponds to a specific entity of idiopathic inflammatory myopathy. Patients with IMNM suffer from proximal muscle weakness, and present high levels of creatine kinase and necrotic myofibers. Anti-Signal Recognition Particle (SRP) and anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase autoantibodies (HMGCR) have recently been identified in two thirds of patients with IMNM and are used as a hallmark of the disease. In this review, we provide a detailed description of these antibodies and the tests used to detect them in the serum of patients. Based on in vitro studies and mouse models of IMNM, we discuss the role of autoantibodies in the pathogenesis of the disease. Finally, in the light of the latest knowledge, we conclude with a review of recent therapeutic approaches in IMNM.
Collapse
Affiliation(s)
- Sarah Julien
- INSERM U1234, PAn'THER FOCIS Center of Excellence, Université de Rouen, F-76000 Rouen, France
| | - Inès Challier
- Department of Pharmacy, CHU Rouen, F-76000 Rouen, France
| | - Marine Malleter
- INSERM U1234, PAn'THER FOCIS Center of Excellence, Université de Rouen, F-76000 Rouen, France
| | - Fabienne Jouen
- INSERM U1234, PAn'THER FOCIS Center of Excellence, Université de Rouen, F-76000 Rouen, France
- Department of Immunology and Biotherapy, CHU Rouen, F-76000 Rouen, France
| | - Laurent Drouot
- INSERM U1234, PAn'THER FOCIS Center of Excellence, Université de Rouen, F-76000 Rouen, France
| | - Olivier Boyer
- INSERM U1234, PAn'THER FOCIS Center of Excellence, Université de Rouen, F-76000 Rouen, France
- Department of Immunology and Biotherapy, CHU Rouen, F-76000 Rouen, France
| |
Collapse
|
3
|
Sakai K, Takahashi M, Ito Y, Yamada S, Ito T, Higuchi Y, Kameda S. Thrombotic microangiopathy in a patient with anti-signal recognition particle antibody-positive immune-mediated necrotizing myopathy. Int J Rheum Dis 2024; 27:e14942. [PMID: 37828793 DOI: 10.1111/1756-185x.14942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/20/2023] [Accepted: 10/04/2023] [Indexed: 10/14/2023]
Abstract
We describe the case of a 61-year-old woman with anti-signal recognition particle (SRP) antibody-positive immune-mediated necrotizing myopathy (IMNM) who exhibited biopsy-confirmed thrombotic microangiopathy (TMA). The patient developed proximal-dominant muscle weakness and was diagnosed with anti-SRP antibody-positive IMNM based on muscle biopsy results and serological examination. A high-dose corticosteroid prescription was initiated, followed by intravenous methylprednisolone and intravenous immunoglobulin therapy (IVIg). The patient showed IVIg-induced hemolytic anemia with preserved ADAMTS13 activity. Transient oral tacrolimus administration was initiated. Approximately 8 weeks after admission, the serum creatinine levels gradually increased. Renal histological examination revealed TMA, including ischemic changes in the renal tubules, stenosis, and occlusion of the interlobular arteries with fibrinoid necrosis of the afferent arteriolar walls. The arteriolar walls demonstrated an accumulation of C1q and C3c. Myofiber damage in patients with IMNM accounts for the activation of the classical pathway of the complement cascade in the sarcolemma due to antibody deposition. Additionally, a membrane attack complex is observed on capillaries in the muscle tissues of patients with anti-SRP antibody-positive IMNM. Although drug-induced pathomechanisms, such as IVIg and tacrolimus, can trigger the development of TMA, we suggest that the presence of serum anti-SRP antibodies would be implicated in complement-associated kidney vascular damage.
Collapse
Affiliation(s)
- Kenji Sakai
- Department of Neurology, Joetsu General Hospital, Joetsu, Japan
| | - Megumi Takahashi
- Department of Nephrology, Joetsu General Hospital, Joetsu, Japan
| | - Yumi Ito
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Shota Yamada
- Department of Neurology, Joetsu General Hospital, Joetsu, Japan
| | - Toru Ito
- Department of Nephrology, Joetsu General Hospital, Joetsu, Japan
| | - Yo Higuchi
- Department of Neurology, Joetsu General Hospital, Joetsu, Japan
| | - Shigemi Kameda
- Department of Nephrology, Joetsu General Hospital, Joetsu, Japan
| |
Collapse
|
4
|
Belkhribchia MR, Lobrinus JA, Semlil L, Chauveau N, Ajrinija A, Egervari K, Ennhaili ZE. Rheumatoid Arthritis Associated With Anti-Signal Recognition Particle Immune-Mediated Necrotizing Myopathy: A Case Report. J Investig Med High Impact Case Rep 2024; 12:23247096241231646. [PMID: 38353222 PMCID: PMC10868492 DOI: 10.1177/23247096241231646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 01/11/2024] [Accepted: 01/23/2024] [Indexed: 02/16/2024] Open
Abstract
Immune-mediated necrotizing myopathy (IMNM) is a rare subtype of idiopathic inflammatory myopathy that is characterized by severe subacute proximal weakness, myofiber necrosis, and significantly elevated serum creatine kinase. Anti-signal recognition particle (SRP) and anti-3-hydroxy-3-methylglutaryl-coenzyme-A reductase autoantibodies have been found in about two-thirds of patients with IMNM. This myopathy is usually idiopathic and there is a scarce literature concerning its association with connective tissue diseases. Herein, we report an unusual case of a young woman who presented with both rheumatoid arthritis and severe anti-SRP IMNM. Thankfully to a therapeutic protocol combining rituximab and cyclophosphamide, an important improvement was achieved, and notably no serious side effect was observed.
Collapse
|
5
|
Liu H, Deng L, Guo Y, Liu H, Chen B, Zhang J, Ran J, Yin G, Xie Q. Comprehensive transcriptomic analysis and machine learning reveal unique gene expression profiles in patients with immune-mediated necrotizing myopathy. J Gene Med 2024; 26:e3598. [PMID: 37743820 DOI: 10.1002/jgm.3598] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 07/22/2023] [Accepted: 09/07/2023] [Indexed: 09/26/2023] Open
Abstract
BACKGROUND Immune-mediated necrotizing myopathy (IMNM) is an autoimmune myopathy characterized by severe proximal weakness and muscle fiber necrosis, yet its pathogenesis remains unclear. So far, there are few bioinformatics studies on underlying pathogenic genes and infiltrating immune cell profiles of IMNM. Therefore, we aimed to characterize differentially expressed genes (DEGs) and infiltrating cells in IMNM muscle biopsy specimens, which may be useful for elucidating the pathogenesis of IMNM. METHODS Three datasets (GSE39454, GSE48280 and GSE128470) of gene expression profiling related to IMNM were obtained from the Gene Expression Omnibus database. Data were normalized, and DEG analysis was performed using the limma package. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analyses of DEGs were performed using clusterProfiler. The CIBERSORT algorithm was performed to identify infiltrating cells. Machine learning algorithm and gene set enrichment analysis (GSEA) were performed to find distinctive gene signatures and the underlying signaling pathways of IMNM. RESULTS DEG analysis identified upregulated and downregulated in IMNM muscle compared to the gene expression levels of other groups. GO and KEGG analysis showed that the pathogenesis of IMNM was notable for the under-representation of pathways that were important in dermatomyositis and inclusion body myositis. Three immune cells (M2 macrophages, resting dendritic cells and resting natural killer cells) with differential infiltration and five key genes (NDUFAF7, POLR2J, CD99, ARF5 and SKAP2) in patients with IMNM were identified through the CIBERSORT and machine learning algorithm. The GSEA results revealed that the key genes were remarkably enriched in diverse immunological and muscle metabolism-related pathways. CONCLUSIONS We comprehensively explored immunological landscape of IMNM, which is indicative for the research of IMNM pathogenesis.
Collapse
Affiliation(s)
- Hongjiang Liu
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Lin Deng
- National Key Laboratory of Fundamental Science on Synthetic Vision, Sichuan University, Chengdu, China
| | - Yixue Guo
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Huan Liu
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Bo Chen
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Jiaqian Zhang
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Jingjing Ran
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Geng Yin
- Health Management Center, General Practice Medical Center, West China Hospital, Sichuan University, Chengdu, China
| | - Qibing Xie
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| |
Collapse
|
6
|
Ichikawa T, Furukawa R, Shimojima Y, Hoshino Y, Kishida D, Sekijima Y. Immune-mediated necrotizing myopathy with concomitant development of Kikuchi-Fujimoto disease. Int J Rheum Dis 2024; 27:e14894. [PMID: 37653623 DOI: 10.1111/1756-185x.14894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 08/08/2023] [Accepted: 08/18/2023] [Indexed: 09/02/2023]
Abstract
Immune-mediated necrotizing myopathy (IMNM) is a distinct type of idiopathic inflammatory myositis, pathologically characterized by myofiber necrosis and degeneration in the absence of lymphocyte infiltration. Herein, we present a case of IMNM with concomitant development of Kikuchi-Fujimoto disease (KFD), characterized by histiocytic necrotizing lymphadenitis, in a 36-year-old woman who had a treatment history for rheumatoid arthritis (RA). Treatment with oral prednisolone and tacrolimus as immunosuppressants resulted in the remission of the skeletomuscular involvement and lymphadenopathy. To the best of our knowledge, this is the first report of IMNM and KFD developing concomitantly during the clinical course of RA.
Collapse
Affiliation(s)
- Takanori Ichikawa
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Ryo Furukawa
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Yasuhiro Shimojima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Yumi Hoshino
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Dai Kishida
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| |
Collapse
|
7
|
Chen S, Yang J, He D, Fu J, Lai X, Zhao B, Chen X, Shang H. Anti-SRP immune-mediated necrotizing myopathy responsive to ofatumumab: a case report. Front Immunol 2023; 14:1301109. [PMID: 38169756 PMCID: PMC10758405 DOI: 10.3389/fimmu.2023.1301109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 12/05/2023] [Indexed: 01/05/2024] Open
Abstract
Background Immune-mediated necrotizing myopathies (IMNM) is a rare disease that was first described in 2004. Due to the lack of large case series, there are no formal treatment recommendations for IMNM. Methods We presented a case of a 47-year-old woman who experienced progressive limb weakness, starting from the lower limbs and gradually affecting the upper limbs. She also reported experiencing dyspnea after engaging in daily activities. When she was admitted to the hospital, her upper limbs were almost unable to move and she could not stand even with support. Her Creatine kinase (CK) level significantly increased (> 3500 u/l). Electromyography showed myogenic damage, anti-Signal recognition particle (anti-SRP) and anti-Ro52 antibodies were highly positive. Pathological biopsy of the right biceps muscle showed necrotizing myopathy in the skeletal muscle. She was ultimately diagnosed with anti-SRP IMNN, and was given monotherapy with methylprednisolone and combination therapy with immunoglobulin, but her symptoms continued to worsen. The patient refused to bear the possible further liver dysfunction and blood system damage caused by Cyclophosphamide and Rituximab, and she chose to try to use Ofatumumab (OFA). Results After receiving three doses of OFA treatment without any adverse reactions, she reported that her muscle strength had basically recovered and she was able to walk independently. The B cells in the circulatory system have been depleted, and blood markers such as liver function have consistently remained within normal range. During the follow up, her activity tolerance continued to improve. Discussion We have presented a severe case of SRP-IMNM in which the patient showed poor response to conventional immunotherapy. However, rapid symptom relief was achieved with early sequential use of OFA treatment. This provides a new option for the treatment of SRP-IMNM, and more large-scale studies will be needed in the future to verify our results.
Collapse
Affiliation(s)
- Sihui Chen
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jing Yang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Du He
- Department of Pathology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jiajia Fu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xiaohui Lai
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Bi Zhao
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xueping Chen
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Huifang Shang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| |
Collapse
|
8
|
Tsuzuki Wada T, Yokota K, Inayoshi F, Sakai S, Okumura N, Matsuda M, Osawa I, Araki Y, Funakubo Asanuma Y, Akiyama Y, Mimura T. New-onset Immune-mediated Necrotizing Myopathy and Trigeminal Neuropathy after SARS-CoV-2 mRNA Vaccination in a Patient with Rheumatoid Arthritis and Sjögren's Syndrome. Intern Med 2023; 62:3699-3706. [PMID: 37839879 PMCID: PMC10781545 DOI: 10.2169/internalmedicine.2551-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 08/30/2023] [Indexed: 10/17/2023] Open
Abstract
We present the case of a 42-year-old woman with rheumatoid arthritis and Sjögren's syndrome treated with adalimumab who developed immune-mediated necrotizing myopathy (IMNM) and trigeminal neuropathy after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) mRNA vaccination. Trigeminal neuralgia and elevated serum creatine kinase levels emerged 12 days post-vaccination, followed by myalgia in the femoral muscles. IMNM was histologically diagnosed. The pathogenesis may involve molecular mimicry between the SARS-CoV-2 spike glycoprotein and autologous tissues triggered by vaccination. This case emphasizes the association between SARS-CoV-2 vaccination, tumor necrosis factor inhibitor, IMNM, and trigeminal neuropathy, as well as the importance of monitoring immune-mediated adverse events following SARS-CoV-2 vaccination in patients with autoimmune disease.
Collapse
Affiliation(s)
- Takuma Tsuzuki Wada
- Department of Rheumatology and Applied Immunology, Faculty of Medicine, Saitama Medical University, Japan
| | - Kazuhiro Yokota
- Department of Rheumatology and Applied Immunology, Faculty of Medicine, Saitama Medical University, Japan
| | - Fumito Inayoshi
- Department of Rheumatology and Applied Immunology, Faculty of Medicine, Saitama Medical University, Japan
| | - Sakon Sakai
- Department of Rheumatology and Applied Immunology, Faculty of Medicine, Saitama Medical University, Japan
| | - Nobuhito Okumura
- Department of Rheumatology and Applied Immunology, Faculty of Medicine, Saitama Medical University, Japan
| | - Mayumi Matsuda
- Department of Rheumatology and Applied Immunology, Faculty of Medicine, Saitama Medical University, Japan
| | - Iichiro Osawa
- Department of Radiology, Saitama Medical University Hospital, Japan
| | - Yasuto Araki
- Department of Rheumatology and Applied Immunology, Faculty of Medicine, Saitama Medical University, Japan
| | - Yu Funakubo Asanuma
- Department of Rheumatology and Applied Immunology, Faculty of Medicine, Saitama Medical University, Japan
| | - Yuji Akiyama
- Department of Rheumatology and Applied Immunology, Faculty of Medicine, Saitama Medical University, Japan
| | - Toshihide Mimura
- Department of Rheumatology and Applied Immunology, Faculty of Medicine, Saitama Medical University, Japan
| |
Collapse
|
9
|
Yang M, Ge H, Ji S, Li Y, Xu L, Bi Z, Bu B. TWEAK and Fn14 are overexpressed in immune-mediated necrotizing myopathy: implications for muscle damage and repair. Rheumatology (Oxford) 2023; 62:3732-3741. [PMID: 36916753 DOI: 10.1093/rheumatology/kead108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/12/2023] [Accepted: 02/27/2023] [Indexed: 03/15/2023] Open
Abstract
OBJECTIVES TNF-like weak inducer of apoptosis (TWEAK) and its sole receptor fibroblast growth factor-inducible 14 (Fn14) are involved in various inflammatory conditions. This study was performed to investigate the potential role of TWEAK/Fn14 in immune-mediated necrotizing myopathy (IMNM). METHODS Muscle biopsies from patients with IMNM (n = 37) and controls (n = 11) were collected. Human muscle cells were treated with TWEAK in vitro. Muscle biopsies and cultured muscle cells were analysed by immunostaining and quantitative PCR. Serum levels of TWEAK and Fn14 were detected by ELISA. RESULTS TWEAK and Fn14 were overexpressed in IMNM muscle biopsies. The percentage of Fn14-positive myofibers correlated with disease severity, myonecrosis, regeneration and inflammation infiltrates. Fn14-positive myofibers tended to be surrounded or invaded by CD68+ macrophages. TWEAK treatment had a harmful effect on cultured muscle cells by inducing the production of multiple chemokines and pro-inflammatory cytokines. Serum Fn14 levels were increased in patients with IMNM and correlated with muscle weakness. CONCLUSIONS TWEAK/Fn14 signalling was activated in IMNM, most likely aggravating muscle damage via amplifying inflammatory response and macrophages chemotaxis. Fn14 seems to be a biomarker for assessing disease severity in IMNM. In addition, Fn14 may also contribute to muscle injury repair.
Collapse
Affiliation(s)
- Mengge Yang
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Huizhen Ge
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Suqiong Ji
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yue Li
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Li Xu
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Zhuajin Bi
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Bitao Bu
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| |
Collapse
|
10
|
Mulvany-Robbins B, Schmitt LM, Johnston WS, Beecher G. Double trouble: Kennedy Disease and Immune-Mediated Necrotizing Myopathy in a Cree Male. Can J Neurol Sci 2023:1-3. [PMID: 37877257 DOI: 10.1017/cjn.2023.303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Affiliation(s)
| | - Laura M Schmitt
- Section of Neuropathology Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, AB, Canada
| | - Wendy S Johnston
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Grayson Beecher
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| |
Collapse
|
11
|
Wei P, Zhong H, Xie Q, Li J, Luo S, Guan X, Liang Z, Yue D. Machine learning-based radiomics to differentiate immune-mediated necrotizing myopathy from limb-girdle muscular dystrophy R2 using MRI. Front Neurol 2023; 14:1251025. [PMID: 37936913 PMCID: PMC10627227 DOI: 10.3389/fneur.2023.1251025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 10/09/2023] [Indexed: 11/09/2023] Open
Abstract
Objectives This study aimed to assess the feasibility of a machine learning-based radiomics tools to discriminate between Limb-girdle muscular dystrophy R2 (LGMDR2) and immune-mediated necrotizing myopathy (IMNM) using lower-limb muscle magnetic resonance imaging (MRI) examination. Methods After institutional review board approval, 30 patients with genetically proven LGMDR2 (12 females; age, 34.0 ± 11.3) and 45 patients with IMNM (28 females; age, 49.2 ± 16.6) who underwent lower-limb MRI examination including T1-weighted and interactive decomposition water and fat with echos asymmetric and least-squares estimation (IDEAL) sequences between July 2014 and August 2022 were included. Radiomics features of muscles were obtained, and four machine learning algorithms were conducted to select the optimal radiomics classifier for differential diagnosis. This selected algorithm was performed to construct the T1-weighted (TM), water-only (WM), or the combined model (CM) for calf-only, thigh-only, or the calf and thigh MR images, respectively. And their diagnostic performance was studied using area under the curve (AUC) and compared to the semi-quantitative model constructed by the modified Mercuri scale of calf and thigh muscles scored by two radiologists specialized in musculoskeletal imaging. Results The logistic regression (LR) model was the optimal radiomics model. The performance of the WM and CM for thigh-only images (AUC 0.893, 0.913) was better than those for calf-only images (AUC 0.846, 0.880) except the TM. For "calf + thigh" images, the TM, WM, and CM models always performed best (AUC 0.953, 0.907, 0.953) with excellent accuracy (92.0, 84.0, 88.0%). The AUCs of the Mercuri model of the calf, thigh, and "calf + thigh" images were 0.847, 0.900, and 0.953 with accuracy (84.0, 84.0, 88.0%). Conclusion Machine learning-based radiomics models can differentiate LGMDR2 from IMNM, performing better than visual assessment. The model built by combining calf and thigh images presents excellent diagnostic efficiency.
Collapse
Affiliation(s)
- Ping Wei
- Department of Radiology, Jing’an District Center Hospital of Shanghai, Fudan University, Shanghai, China
| | - Huahua Zhong
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Qian Xie
- Department of Radiology, Jing’an District Center Hospital of Shanghai, Fudan University, Shanghai, China
| | - Jin Li
- Department of Radiology, Jing’an District Center Hospital of Shanghai, Fudan University, Shanghai, China
| | - Sushan Luo
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xueni Guan
- Department of Radiology, Jing’an District Center Hospital of Shanghai, Fudan University, Shanghai, China
| | - Zonghui Liang
- Department of Radiology, Jing’an District Center Hospital of Shanghai, Fudan University, Shanghai, China
| | - Dongyue Yue
- Department of Neurology, Jing’an District Center Hospital of Shanghai, Fudan University, Shanghai, China
| |
Collapse
|
12
|
De Paepe B, Bracke KR, De Bleecker JL. Retrospective Study Shows That Serum Levels of Chemokine CXCL10 and Cytokine GDF15 Support a Diagnosis of Sporadic Inclusion Body Myositis and Immune-Mediated Necrotizing Myopathy. Brain Sci 2023; 13:1369. [PMID: 37891738 PMCID: PMC10605230 DOI: 10.3390/brainsci13101369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 10/29/2023] Open
Abstract
The implementation of novel blood-based biomarkers is desired to reduce the diagnostic delay and burden for myositis patients. In this retrospective study, the potential of C-X-C motif chemokine ligand 10 (CXCL10) and growth differentiation factor 15 (GDF15) was explored in an established patient cohort diagnosed with immune-mediated necrotizing myopathy (IMNM; n = 21), sporadic inclusion body myositis (IBM; n = 18), overlap myositis (OM; n = 3), dermatomyositis (DM; n = 2), and anti-synthetase syndrome (ASS; n = 1), comparing these results with healthy controls (n = 10) and patients with a hereditary neuromuscular disorder (n = 14). CXCL10 and GDF15 were quantified in sera with enzyme-linked immunosorbent assays and immunolocalized in skeletal muscle tissue. In myositis patients, serum CXCL10 levels were significantly increased 9.6-fold compared to healthy controls and 4.2-fold compared to disease controls. Mean levels of CXCL10 were 929 ± 658 pg/mL of serum in IBM and 425 ± 324 pg/mL of serum in IMNM. With the threshold set to 180 pg/mL of CXCL10, myositis patients could be differentiated from healthy and disease controls with a sensitivity of 0.80 and a specificity of 0.71. Incorporating a threshold of 300 pg/mL for GDF15 reduced false negatives to two IMNM patients only. Subsets of muscle-infiltrating immune cells expressed CXCL10, and serum levels correlated with muscle inflammation grade. We propose adding circulating CXCL10 and GDF15 to the blood-based diagnostic toolkit for myositis as a valuable patient-friendly approach.
Collapse
Affiliation(s)
- Boel De Paepe
- Department of Neurology, Ghent University Hospital, B-9000 Ghent, Belgium;
- Neuromuscular Reference Center, Ghent University Hospital, B-9000 Ghent, Belgium
| | - Ken R. Bracke
- Department of Respiratory Medicine, Ghent University Hospital, B-9000 Ghent, Belgium;
| | - Jan L. De Bleecker
- Department of Neurology, Ghent University Hospital, B-9000 Ghent, Belgium;
- Neuromuscular Reference Center, Ghent University Hospital, B-9000 Ghent, Belgium
| |
Collapse
|
13
|
Liang X, Li Y, Cheng L, Wu Y, Wu T, Wen J, Huang D, Liao Z, Tan C, Luo Y, Liu Y. Gut microbiota dysbiosis characterized by abnormal elevation of Lactobacillus in patients with immune-mediated necrotizing myopathy. Front Cell Infect Microbiol 2023; 13:1243512. [PMID: 37692165 PMCID: PMC10486907 DOI: 10.3389/fcimb.2023.1243512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 08/07/2023] [Indexed: 09/12/2023] Open
Abstract
Aim The gut microbiota plays an important role in human health. In this study, we aimed to investigate whether and how gut microbiota communities are altered in patients with immune-mediated necrotizing myopathy (IMNM) and provide new ideas to further explore the pathogenesis of IMNM or screen for its clinical therapeutic targets in the future. Methods The gut microbiota collected from 19 IMNM patients and 23 healthy controls (HCs) were examined by using 16S rRNA gene sequencing. Alpha and beta-diversity analyses were applied to examine the bacterial diversity and community structure. Welch's t test was performed to identify the significantly abundant taxa of bacteria between the two groups. Spearman correlation analysis was performed to analyze the correlation between gut microbiota and clinical indicators. A receiver operator characteristic (ROC) curve was used to reflect the sensitivity and specificity of microbial biomarker prediction of IMNM disease. P < 0.05 was considered statistically significant. Results Nineteen IMNM patients and 23 HCs were included in the analysis. Among IMNM patients, 94.74% (18/19) of them used glucocorticoids, while 57.89% (11/19) of them used disease-modifying antirheumatic drugs (DMARDs), and the disease was accessed by MITAX (18.26 ± 8.62) and MYOACT (20.68 ± 8.65) scores. Participants in the groups were matched for gender and age. The diversity of the gut microbiota of IMNM patients differed and decreased compared to that of HCs (Chao1, Shannon, and Simpson indexes: p < 0.05). In IMNM patients, the relative abundances of Bacteroides, Roseburia, and Coprococcus were decreased, while that of Lactobacillus and Streptococcus were relatively increased. Furthermore, in IMNM patients, Lactobacillus was positively correlated with the levels of anti-signal recognition particle (SRP) antibodies, anti-Ro52 antibodies, and erythrocyte sedimentation rate (ESR), while Streptococcus was positively correlated with anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR) antibodies and C-reactive protein (CRP). Roseburia was negatively correlated with myoglobin (MYO), cardiac troponin T (cTnT), ESR, CRP, and the occurrence of interstitial lung disease (ILD). Bacteroides was negatively correlated with ESR and CRP, and Coprococcus was negatively correlated with ESR. Finally, the prediction model was built using the top five differential genera, which was verified using a ROC curve (area under the curve (AUC): 87%, 95% confidence interval: 73%-100%). Conclusion We observed a characteristic compositional change in the gut microbiota with an abnormal elevation of Lactobacillus in IMNM patients, which was accompanied by changes in clinical indicators. This suggests that gut microbiota dysbiosis occurs in IMNM patients and is correlated with systemic autoimmune features.
Collapse
Affiliation(s)
- Xiuping Liang
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
- Rare Diseases Center, West China Hospital, Sichuan University, Chengdu, China
- Institute of Immunology and Inflammation, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Chengdu, China
| | - Yanhong Li
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
- Rare Diseases Center, West China Hospital, Sichuan University, Chengdu, China
- Institute of Immunology and Inflammation, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Chengdu, China
| | - Lu Cheng
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
- Rare Diseases Center, West China Hospital, Sichuan University, Chengdu, China
- Institute of Immunology and Inflammation, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Chengdu, China
| | - Yinlan Wu
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
- Rare Diseases Center, West China Hospital, Sichuan University, Chengdu, China
- Institute of Immunology and Inflammation, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Chengdu, China
| | - Tong Wu
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
- Rare Diseases Center, West China Hospital, Sichuan University, Chengdu, China
- Institute of Immunology and Inflammation, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Chengdu, China
| | - Ji Wen
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
- Rare Diseases Center, West China Hospital, Sichuan University, Chengdu, China
- Institute of Immunology and Inflammation, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Chengdu, China
| | - Deying Huang
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
- Rare Diseases Center, West China Hospital, Sichuan University, Chengdu, China
- Institute of Immunology and Inflammation, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Chengdu, China
| | - Zehui Liao
- Department of Rheumatolopy and Immunolopy, Meishan People’s Hospital, Meishan, Sichuan, China
| | - Chunyu Tan
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
- Rare Diseases Center, West China Hospital, Sichuan University, Chengdu, China
- Institute of Immunology and Inflammation, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Chengdu, China
| | - Yubin Luo
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
- Rare Diseases Center, West China Hospital, Sichuan University, Chengdu, China
- Institute of Immunology and Inflammation, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Chengdu, China
| | - Yi Liu
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
- Rare Diseases Center, West China Hospital, Sichuan University, Chengdu, China
- Institute of Immunology and Inflammation, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Chengdu, China
| |
Collapse
|
14
|
Khan OA, Wilches RM, Mehrabi JN, Tanji K, Konka S. Evidence of Cardiac Involvement in a Patient With Necrotizing Autoimmune Myopathy (NAM). Cureus 2023; 15:e44106. [PMID: 37750137 PMCID: PMC10518158 DOI: 10.7759/cureus.44106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2023] [Indexed: 09/27/2023] Open
Abstract
Necrotizing autoimmune myopathy (NAM) is a rare inflammatory myopathy primarily affecting skeletal muscles. Cardiac involvement has been reported in immune-mediated necrotizing myopathy (IMNM), but its extent remains poorly understood. We present a unique case of a 68-year-old male with anti-signal recognition particle (SRP) antibody-positive NAM initially presenting with elevated troponin levels. Our case demonstrates cardiac involvement as the presenting feature of NAM, which is a unique feature of inflammatory myopathy.
Collapse
Affiliation(s)
- Omair A Khan
- Internal Medicine, Maimonides Medical Center, New York, USA
| | - Rita M Wilches
- Internal Medicine, Maimonides Medical Center, New York, USA
| | | | | | - Sarita Konka
- Rheumatology, Maimonides Medical Center, New York, USA
| |
Collapse
|
15
|
Ge Y, Yang H, Jiang W, Tian X, Lu X, Wang G. Clinical characteristics of myositis patients with isolated anti-U1 ribonucleoprotein antibody resemble immune-mediated necrotizing myopathy. Ther Adv Musculoskelet Dis 2023; 15:1759720X231181336. [PMID: 37465567 PMCID: PMC10350785 DOI: 10.1177/1759720x231181336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 05/24/2023] [Indexed: 07/20/2023] Open
Abstract
Background Anti-U1 ribonucleoprotein (U1RNP) antibodies were associated with connective tissue diseases (CTDs), but the clinical characteristics of this antibody in Chinese myositis patients have not been studied. Objective We aim to analyze the clinical features of myositis patients who test positive for anti-U1RNP antibodies and delineate a subgroup of myositis. Design This is a retrospective cohort study. Methods We reviewed the clinical data of myositis patients with anti-U1RNP antibodies and compared them to those with anti-signal recognition particle (SRP) and hydroxy-3-methylglutaryl-CoA reductase (HMGCR) antibody-associated immune-mediated necrotizing myopathy (IMNM). Results A total of 30 adult cases were identified; median age was 47.5 years and 24 (80%) were females, and 12 patients did not coexist with myositis-specific antibodies (MSAs) (isolated anti-U1RNP). The serum creatine kinase (CK) was significantly higher in patients with isolated anti-U1RNP (2182.5 U/L versus 289 U/L, p = 0.01), and the number of patients with CK > 2000 U/L was higher compared to that in anti-U1RNP antibody patients coexisting with MSAs (66.7% versus 16.7%, p = 0.009). The prevalence of IMNM in patients' muscle pathology with isolated anti-U1RNP was significantly higher (75%, p = 0.003). Skin rashes were less common in isolated anti-U1RNP group (p < 0.05). Of the 25 individuals with available pulmonary high-resolution CT (HRCT), 14 (56%) were diagnosed with interstitial lung disease (ILD). The incidence of muscular weakness, dysphagia, or levels of CK was not different between the isolated anti-U1RNP antibody individuals and the anti-HMGCR or SRP-IMNM groups (p > 0.05). But the frequency of Raynaud's phenomenon, arthritis, and membrane attack complex (MAC) deposits in myositis patients with isolated anti-U1RNP antibodies were higher than in anti-HMGCR and SRP-IMNM (all p < 0.005). There was no difference between anti-U1RNP patients with and without Ro-52 (p > 0.05). Isolated anti-U1RNP individuals showed marked improvements in muscle strength, and the remission rate in 1 and 2 years was significantly higher than that in anti-HMGCR and SRP-IMNM (p < 0.05). Conclusions The clinical and pathological features of myositis patients with isolated anti-U1RNP antibodies were similar to IMNM. Arthritis and ILD are the most common extramuscular clinical features. Most respond well to treatment and have a good prognosis.
Collapse
Affiliation(s)
- Yongpeng Ge
- Department of Rheumatology, The Key Laboratory of Myositis, China-Japan Friendship Hospital, Beijing, China
| | - Hongxia Yang
- Department of Rheumatology, The Key Laboratory of Myositis, China-Japan Friendship Hospital, Beijing, China
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Wei Jiang
- Department of Rheumatology, The Key Laboratory of Myositis, China-Japan Friendship Hospital, Beijing, China
| | - Xiaolan Tian
- Department of Rheumatology, The Key Laboratory of Myositis, China-Japan Friendship Hospital, Beijing, China
| | - Xin Lu
- Department of Rheumatology, The Key Laboratory of Myositis, China-Japan Friendship Hospital, Beijing, China
| | - Guochun Wang
- Department of Rheumatology, The Key Laboratory of Myositis, China-Japan Friendship Hospital, Yinghua East Road, Chaoyang District, Beijing 100029, China
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| |
Collapse
|
16
|
Xu L, Yang MG, Hu L, Gao H, Ji S. Anti-signal recognition particle positive necrotizing myopathy-sjogren’s syndrome overlap syndrome: a descriptive study on clinical and myopathology features. BMC Musculoskelet Disord 2023; 24:219. [PMID: 36959614 PMCID: PMC10035234 DOI: 10.1186/s12891-023-06354-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 03/21/2023] [Indexed: 03/25/2023] Open
Abstract
Background and objective The aim of this study was to elucidate the clinical and myopathological characteristics of patients with anti-signal recognition particle (SRP) positive immune-mediated necrotizing myopathy (IMNM) overlap Sjogren’s syndrome (SS). Materials and methods We retrospectively analyzed the data of anti-SRP positive IMNM patients admitted in the Neurology Department of Tongji Hospital between January 2011 to December 2020. Patients were divided into two groups: anti-SRP IMNM overlap SS group and anti-SRP IMNM control group. The clinical features, laboratory results, histological features, treatment, and prognosis were compared between the two groups. Results A total of 30 patients with anti-SRP IMNM were included, including six anti-SRP IMNM overlap SS patients (two males, four females), with a median age of 39 years, and 24 anti-SRP IMNM patients (ten males, fourteen females), with a median age of 46 years. The anti-SRP IMNM overlap SS group had a lower prevalence of muscle atrophy (0 vs 50%, p = 0.019), and a higher prevalence of extramuscular manifestations, including cardiac abnormalities and ILD (Interstitial lung disease). CD4 + and CD68 + inflammatory infiltrations were significantly increased in anti-SRP IMNM overlap SS patients, with an increased presence of CD4 + cells in both necrotic(p = 0.023) and endomysial areas (p = 0.013), and more CD68 + cells (p = 0.016) infiltrated the endomysial area. Deposition of membrane attack complex (MAC) on sarcolemma (p = 0.013) was more commonly seen in the anti-SRP IMNM overlap SS group. Conclusion Our data revealed that anti-SRP IMNM-SS overlap patients may present with milder muscular manifestation, but worse extramuscular manifestations compared to anti-SRP IMNM patients without SS. CD4 + and CD68 + inflammatory infiltrations and MAC deposition were remarkably increased in anti-SRP IMNM-SS overlap patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-023-06354-5.
Collapse
Affiliation(s)
- Li Xu
- grid.412793.a0000 0004 1799 5032Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Jiefang Street 1095#, Wuhan, 430000 China
| | - Meng-ge Yang
- grid.412793.a0000 0004 1799 5032Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Jiefang Street 1095#, Wuhan, 430000 China
| | - Liya Hu
- grid.412793.a0000 0004 1799 5032Department of Geriatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei China
| | - Huajie Gao
- grid.412793.a0000 0004 1799 5032Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Jiefang Street 1095#, Wuhan, 430000 China
| | - Suqiong Ji
- grid.412793.a0000 0004 1799 5032Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Jiefang Street 1095#, Wuhan, 430000 China
| |
Collapse
|
17
|
Zerlotin R, Fornaro M, Errede M, Pignataro P, Suriano C, Ruggieri M, Colucci S, Iannone F, Grano M, Colaianni G. Elevated Expression of ADAM10 in Skeletal Muscle of Patients with Idiopathic Inflammatory Myopathies Could Be Responsible for FNDC5/Irisin Unbalance. Int J Mol Sci 2023; 24. [PMID: 36768791 DOI: 10.3390/ijms24032469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/20/2023] [Accepted: 01/26/2023] [Indexed: 01/31/2023] Open
Abstract
Dermatomyositis (DM) and immune-mediated necrotizing myopathy (IMNM) are two rare diseases belonging to the group of idiopathic inflammatory myopathies (IIM). Muscle involvement in DM is characterized by perifascicular atrophy and poor myofiber necrosis, while IMNM is characterized by myofiber necrosis with scarce inflammatory infiltrates. Muscle biopsies and laboratory tests are helpful in diagnosis, but currently, few biomarkers of disease activity and progression are available. In this context, we conducted a cohort study of forty-one DM and IMNM patients, aged 40-70 years. In comparison with control subjects, in the muscle biopsies of these patients, there was a lower expression of FNDC5, the precursor of irisin, a myokine playing a key role in musculoskeletal metabolism. Expectedly, the muscle cross-sectional areas of these patients were reduced, while, surprisingly, serum irisin levels were higher than in CTRL, as were mRNA levels of ADAM10, a metalloproteinase recently shown to be the cleavage agent for FNDC5. We hypothesize that elevated expression of ADAM10 in the skeletal muscle of DM and IMNM patients might be responsible for the discrepancy between irisin levels and FNDC5 expression. Future studies will be needed to understand the mechanisms underlying exacerbated FNDC5 cleavage and muscle irisin resistance in these inflammatory myopathies.
Collapse
|
18
|
Muacevic A, Adler JR, Silver A. Statin-Induced Anti-3-Hydroxy-3-Methylglutaryl-Coenzyme A Reductase (Anti-HMGCR) Myopathy. Cureus 2023; 15:e34121. [PMID: 36843759 PMCID: PMC9947569 DOI: 10.7759/cureus.34121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2023] [Indexed: 01/26/2023] Open
Abstract
Statins are known to pharmacologically target 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR). Several subtypes of anti-HMGCR autoimmune myopathies have been reported as a result of statin use. Although these types vary widely, a severe and rare form of statin-induced myopathy is immune-mediated necrotizing myopathy (IMNM), resulting in severe muscle injury that does not respond to statin cessation and is associated with poor outcomes. Diagnosis is confirmed through biopsy confirming the necrosis of biopsy fibers, in addition to elevated anti-HMGCR serum levels. Management lacks proper guidelines, however, immunosuppressive therapy has been proposed as a possible intervention. The aim of this report is to increase providers' knowledge of the presentation and possible treatment of statin-induced immune-mediated necrotizing myopathy.
Collapse
|
19
|
Wang CH, Liang WC. Pediatric immune-mediated necrotizing myopathy. Front Neurol 2023; 14:1123380. [PMID: 37021281 PMCID: PMC10067916 DOI: 10.3389/fneur.2023.1123380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 03/03/2023] [Indexed: 04/07/2023] Open
Abstract
Immune-mediated necrotizing myopathy (IMNM) is a type of inflammatory myopathy. Most patients with IMNM produce anti-3-hydroxy-3-methylglutaryl coenzyme A reductase or anti-signal-recognition particle autoantibodies. IMNM is much rarer in children than in adults. We conducted this mini review focusing on pediatric IMNM to present current evidence regarding its epidemiology, clinical characteristics, diagnosis, and treatment. Our findings indicate that pediatric IMNM often causes severe muscle weakness and is refractory to corticosteroids alone. Furthermore, delayed diagnosis is common because of the clinicopathological similarity between IMNM and inherited myopathy. Raising awareness regarding pediatric IMNM may facilitate early diagnosis and effective treatment.
Collapse
Affiliation(s)
- Chen-Hua Wang
- Department of Pediatrics, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wen-Chen Liang
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Pediatrics, School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- *Correspondence: Wen-Chen Liang,
| |
Collapse
|
20
|
Salazar DM, Damani DN, Kositangool P, Ortiz MJ, Lavezo J, Dihowm F. Leflunomide-Induced Immune-Mediated Necrotizing Myopathy in a Patient With Rheumatoid Arthritis: A Case Report. J Investig Med High Impact Case Rep 2023; 11:23247096221150636. [PMID: 36661254 PMCID: PMC9871974 DOI: 10.1177/23247096221150636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Immune-mediated necrotizing myopathy (IMNM) is a subtype of inflammatory myopathy that is characterized by proximal muscle weakness, markedly elevated serum creatine kinase, myopathic electromyographic findings, and muscle biopsies revealing necrosis or regeneration with sparse inflammatory infiltrate. IMNM tends to be idiopathic but has been associated with certain medications. This supports the possibility for other pharmacotherapies to induce IMNM-particularly leflunomide. Leflunomide is used in the treatment for rheumatoid arthritis and has been shown to induce autoimmune diseases-including autoimmune hepatitis and polymyositis. After an extensive review of history and workup of muscle weakness, we conclude that leflunomide induced an IMNM in our patient. As this is the first case of leflunomide-induced IMNM, it is important for clinicians to suspect an inflammatory myopathy in the setting of myositis while on leflunomide.
Collapse
Affiliation(s)
| | | | | | | | | | - Fatma Dihowm
- Texas Tech University Health Sciences Center El Paso, USA
| |
Collapse
|
21
|
Ohnuki Y, Suzuki S, Uruha A, Oyama M, Suzuki S, Kulski JK, Nishino I, Shiina T. Association of immune-mediated necrotizing myopathy with HLA polymorphisms. HLA 2022; 101:449-457. [PMID: 36565042 DOI: 10.1111/tan.14950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 11/08/2022] [Accepted: 12/19/2022] [Indexed: 12/25/2022]
Abstract
Immune-mediated necrotizing myopathy (IMNM) is a type of autoimmune myositis typically characterized clinically by proximal muscle weakness with elevated creatine kinase levels, pathologically by myofiber necrosis and regeneration with paucity of lymphocytic cell infiltration, and serologically by the presence of either of two myositis-specific autoantibodies, anti-SRP, and anti-HMGCR antibodies. However, the HLA loci and alleles associated with IMNM are still not fully understood at least partly because IMNM was a relatively recently established condition. In this study, we genotyped the six HLA loci (HLA-A, -B, -C, -DRB1, -DQB1 and -DPB1) in 250 patients (237 patients over age 18 years and 13 juvenile patients) diagnosed with IMNM based on clinicopathological features and autoantibody information and performed a case control study with Japanese healthy subjects. In the adult patients, specific HLA alleles associated with IMNM were identified at all HLA loci, with DRB1*08:03 showing the strongest association (OR = 2.5; p = 0.00000017). Furthermore, subgroup analysis with various clinical information showed that C*03:04 (OR = 3.7; p = 0.00012) was a higher risk allele for collagen disease in adult patients, and B*13:01 (OR = 23.2; p = 0.021) and C*03:04 (OR = 5.8; p = 0.0074) were higher risk for juvenile patients with anti-HMGCR antibody-positive IMNM. These findings will help to better understand the HLA genetic background and features of IMNM in designing future studies.
Collapse
Affiliation(s)
- Yuko Ohnuki
- Department of Medical Ethics, Tokai University School of Medicine, Kanagawa, Japan.,Department of Clinical Genetics, Tokai University Hospital, Kanagawa, Japan
| | - Shigeaki Suzuki
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Akinori Uruha
- Department of Neuromuscular Research, National Institute of Neuroscience, and Department of Genome Medicine Development, Medical Genome Center, National Center of Neurology and Psychiatry, Tokyo, Japan.,Department of Neurology, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Munenori Oyama
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Shingo Suzuki
- Department of Molecular Life Science, Tokai University School of Medicine, Kanagawa, Japan
| | - Jerzy K Kulski
- Department of Molecular Life Science, Tokai University School of Medicine, Kanagawa, Japan
| | - Ichizo Nishino
- Department of Neuromuscular Research, National Institute of Neuroscience, and Department of Genome Medicine Development, Medical Genome Center, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Takashi Shiina
- Department of Molecular Life Science, Tokai University School of Medicine, Kanagawa, Japan
| |
Collapse
|
22
|
Tanemoto M, Oda R, Toyama Y, Shizukawa H, Yokokawa K, Saito T, Suzuki S, Matsumura A, Hisahara S. Anti-signal Recognition Particle Antibody-positive Immune-mediated Myopathy after mRNA-1273 SARS-CoV-2 Vaccination. Intern Med 2022; 61:3605-3609. [PMID: 36104199 PMCID: PMC9790798 DOI: 10.2169/internalmedicine.0404-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
A 26-year-old Japanese woman developed a fever, myalgia and gait disturbance one day after receiving the second dose of the mRNA-1273 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine. A neurological examination revealed symmetrical weakness and myalgia in proximal lower limbs, and a blood examination showed prominent elevation of creatinine kinase. Magnetic resonance imaging (MRI) revealed a high signal intensity in the thigh muscles on short-tau inversion recovery images, and antibody testing revealed positive findings for anti-signal recognition particle (SRP) antibody. Thus, anti-SRP antibody-positive immune-mediated myopathy was diagnosed. We initiated immunotherapy, and she was ultimately able to walk stably.
Collapse
Affiliation(s)
- Masanobu Tanemoto
- Department of Neurology, Sapporo Medical University School of Medicine, Japan
| | - Ryosuke Oda
- Department of Neurology, Sapporo Kosei General Hospital, Japan
| | - Yuichiro Toyama
- Department of Neurology, Sapporo Kosei General Hospital, Japan
| | | | - Kazuki Yokokawa
- Department of Neurology, Sapporo Medical University School of Medicine, Japan
| | - Taro Saito
- Department of Neurology, Sapporo Medical University School of Medicine, Japan
| | - Syuuichirou Suzuki
- Department of Neurology, Sapporo Medical University School of Medicine, Japan
| | - Akihiro Matsumura
- Department of Neurology, Sapporo Medical University School of Medicine, Japan
| | - Shin Hisahara
- Department of Neurology, Sapporo Medical University School of Medicine, Japan
| |
Collapse
|
23
|
Yang MG, Zhang Q, Wang H, Ma X, Ji S, Li Y, Xu L, Bi Z, Bu B. The accumulation of muscle RING finger-1 in regenerating myofibers: Implications for muscle repair in immune-mediated necrotizing myopathy. Front Neurol 2022; 13:1032738. [PMID: 36504647 PMCID: PMC9730696 DOI: 10.3389/fneur.2022.1032738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 11/07/2022] [Indexed: 11/26/2022] Open
Abstract
Background Muscle RING finger-1 (MuRF-1) plays a key role in the degradation of skeletal muscle proteins. We hypothesize the involvement of MuRF-1 in immune-mediated necrotizing myopathy (IMNM). Methods Muscle biopsies from patients with IMNM (n = 37) were analyzed and compared to biopsies from patients with dermatomyositis (DM, n = 13), dysferlinopathy (n = 9) and controls (n = 7) using immunostaining. Results MuRF-1 staining could be observed in IMNM, DM and dysferlinopathy biopsies, whereas the percentage of MuRF-1 positive myofibers was significantly higher in IMNM than in dysferlinopathy (p = 0.0448), and positively correlated with muscle weakness and disease activity in IMNM and DM. Surprisingly, MuRF-1 staining predominantly presented in regenerating fibers but not in atrophic fibers. Moreover, MuRF-1-positive fibers tended to be distributed around necrotic myofibers and myofibers with sarcolemma membrane attack complex deposition. Abundant MuRF-1 expression in IMNM and DM was associated with rapid activation of myogenesis after muscle injury, whereas relatively low expression of MuRF-1 in dysferlinopathy may be attributed to damaged muscle regeneration. Conclusions MuRF-1 accumulated in regenerating myofibers, which may contribute to muscle injury repair in IMNM and DM. MuRF-1 staining may help clinicians differentiate IMNM and dysferlinopathy.
Collapse
Affiliation(s)
- Meng-Ge Yang
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qing Zhang
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hong Wang
- Genetic Diagnostic Centre, Department of Internal Medicine, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xue Ma
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Suqiong Ji
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yue Li
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Li Xu
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhuajin Bi
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bitao Bu
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China,*Correspondence: Bitao Bu
| |
Collapse
|
24
|
Yang M, Ji S, Xu L, Zhang Q, Li Y, Gao H, Bu B. The Clinicopathological Distinction between Immune-Mediated Necrotizing Myopathy and Limb-Girdle Muscular Dystrophy R2: Key Points to Prevent Misdiagnosis. J Clin Med 2022; 11. [PMID: 36362794 DOI: 10.3390/jcm11216566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 10/30/2022] [Accepted: 11/03/2022] [Indexed: 11/09/2022] Open
Abstract
Background: Limb−girdle muscular dystrophy R2 (LGMD R2) is most frequently misdiagnosed as immune-mediated necrotizing myopathy (IMNM). This study aimed to compare the clinicopathological data of IMNM and LGMD R2 to find distinguishing features. Methods: We retrospectively reassessed the medical data of patients with IMNM (n = 41) and LGMD R2 (n = 8) treated at Tongji Hospital from January 2017 to December 2021. Results: In our cohort, patients with LGMD R2 had a longer interval of onset to first visit, mild muscle weakness with late upper limb involvement, less myalgia, no cervical muscle weakness or dysphagia, no extramuscular organs affected except cardiac involvement, and lack of various autoantibodies, such as antinuclear antibodies. These features were completely reversed in IMNM. Moreover, thigh MRIs showed that muscle edema prominently affecting the adductor magnus was a characteristic of IMNM, while extensive fatty replacement was more common in LGMD R2 (p = 0.0086). Necrotic myofibers presented in both entities (p = 0.1693), while features such as ring/whorled and splitting myofibers were more often found in LGMD R2 (p = 0.0112 and p < 0.0001, respectively). Conversely, sarcoplasmic p62 expression was more pronounced in IMNM (p < 0.05). There were 4 of 8 (50%) patients with LGMD R2 initially considered as seronegative IMNM, and therefore unnecessarily treated with immunosuppressive drugs. Insufficient recognition of the early clinical, imaging, and histopathological features of LGMD R2 is the main reason for misdiagnosis. Conclusions: These findings may help clinicians differentiate seronegative IMNM and LGMD R2, reducing early misdiagnosis and mismanagement. Particularly, prominent adductor magnus edema on MRI and abundant p62 staining seem to be good markers for IMNM, while the presence of splitting myofibers is a crucial clue to early hereditary myopathy, including LGMD R2.
Collapse
|
25
|
Munekane A, Ohsawa Y, Okubo M, Nagai T, Nishimura H, Nishino I, Sunada Y. Becker Muscular Dystrophy Accompanied by Anti-HMGCR Antibody-positive Immune-mediated Necrotizing Myopathy. Intern Med 2022; 62:1345-1349. [PMID: 36130887 DOI: 10.2169/internalmedicine.0202-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Becker muscular dystrophy (BMD) is an X-linked neuromuscular disease characterized by progressive muscle weakness that currently has no cure. Immune-mediated necrotizing myopathy (IMNM) is a type of autoimmune inflammatory myopathy characterized by proximal muscle weakness that is treated with immunosuppressive therapy. We herein report a patient diagnosed with BMD complicated with IMNM by a pathological analysis. Notably, the patient had an elevated serum anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase antibody level. Oral glucocorticoid and methotrexate treatment partially improved the muscle weakness with decreased levels of serum creatine kinase. An accurate diagnosis is important for therapeutic decisions in these complicated cases.
Collapse
Affiliation(s)
| | - Yutaka Ohsawa
- Department of Neurology, Kawasaki Medical School, Japan
| | - Mariko Okubo
- Department of Neuromuscular Research, National Institute of Neuroscience (NCNP), Japan
| | - Taiji Nagai
- Department of Neurology, Kawasaki Medical School, Japan
| | | | - Ichizo Nishino
- Department of Neuromuscular Research, National Institute of Neuroscience (NCNP), Japan
| | | |
Collapse
|
26
|
Tan CY, Toh TH, Toh YF, Wong KT, Shahrizaila N, Goh KJ. A temporal association between COVID-19 vaccination and immune-mediated necrotizing myopathy. Muscle Nerve 2022; 65:E24-E26. [PMID: 35307849 DOI: 10.1002/mus.27531] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 03/14/2022] [Accepted: 03/16/2022] [Indexed: 12/20/2022]
Affiliation(s)
- Cheng-Yin Tan
- Division of Neurology, Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Tsun-Haw Toh
- Division of Neurology, Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Yen-Fa Toh
- Department of Pathology, University of Malaya, Kuala Lumpur, Malaysia
| | - Kum-Thong Wong
- Department of Pathology, University of Malaya, Kuala Lumpur, Malaysia
| | - Nortina Shahrizaila
- Division of Neurology, Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Khean-Jin Goh
- Division of Neurology, Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| |
Collapse
|
27
|
Suzuki I, Nakao R, Unai Y, Miyazaki Y. [A case of anti-SRP antibody-positive immune-mediated necrotizing myopathy triggered by human parvovirus B19 infection]. Rinsho Shinkeigaku 2022; 62:363-368. [PMID: 35474284 DOI: 10.5692/clinicalneurol.cn-001684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
We have reported a case of a 44-year-old woman with anti-signal recognition particle (SRP) antibody-positive immune-mediated necrotizing myopathy triggered by human parvovirus B19 (PVB19) infection. She was admitted to the hospital because of lower leg edema and muscle weakness after erythema infectiosum. Magnetic resonance imaging of the lower extremities revealed high signals in the proximal muscles and subcutaneous edema on STIR. Muscle biopsy showed myofiber regenerative changes and variation in fiber size. A myositis-specific autoantibody profile indicated a positive result for anti-SRP antibodies. We diagnosed the patient with immune-mediated necrotizing myopathy (IMNM). Muscle strength and subcutaneous edema improved gradually in 3 months following immunotherapy. This is the first case report of an IMNM associated with PVB19 infection.
Collapse
Affiliation(s)
- Iku Suzuki
- Department of Neurology, Hyogo Prefectural Awaji Medical Center
| | - Ryohei Nakao
- Department of Neurology, Hyogo Prefectural Awaji Medical Center
| | - Yuki Unai
- Department of Neurology, Hyogo Prefectural Awaji Medical Center
| | | |
Collapse
|
28
|
Silva AMS, Campos ED, Zanoteli E. Inflammatory myopathies: an update for neurologists. Arq Neuropsiquiatr 2022; 80:238-248. [PMID: 35976321 PMCID: PMC9491410 DOI: 10.1590/0004-282x-anp-2022-s131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 04/29/2022] [Indexed: 06/15/2023]
Abstract
Idiopathic inflammatory myopathies (IIM) are a heterogenous group of treatable myopathies. Patients present mainly to the rheumatologist and neurologists, complaining of acute or subacute onset of proximal weakness. Extramuscular manifestations may occur, including involvement of the lungs, skin, and joints. Classically, the diagnosis used to be made based on the creatine kinase level increase, abnormalities in electroneuromyography and presence of inflammatory infiltrates in the muscle biopsy. Recently, the importance of autoantibodies has increased, and now they may be identified in more than half of IIM patients. The continuous clinicoseropathological improvement in IIM knowledge has changed the way we see these patients and how we classify them. In the past, only polymyositis, dermatomyositis and inclusion body myopathy were described. Currently, immune-mediated necrotizing myopathy, overlap myositis and antisynthetase syndrome have been considered the most common forms of IIM in clinical practice, increasing the spectrum of classification. Patients previously considered to have polymyositis, in fact have these other forms of seropositive IIM. In this article, we reviewed the new concepts of classification, a practical way to make the diagnosis and how to plan the treatment of patients suffering from IIM.
Collapse
Affiliation(s)
| | - Eliene Dutra Campos
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| | - Edmar Zanoteli
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| |
Collapse
|
29
|
Hunziker L, Dracklé J. [Subacute Flaccid Tetraparesis]. Praxis (Bern 1994) 2022; 111:354-357. [PMID: 35473326 DOI: 10.1024/1661-8157/a003828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Subacute Flaccid Tetraparesis Abstract. The patient presented herself with a subacute flaccid tetraparesis. After clinical examination, laboratory analysis, EMG, MRI and muscle biopsy we diagnosed a statin-associated immune-mediated necrotizing myopathy. Neurorehabilitation and prednisolone therapy as well as immunomodulatory therapy with azathioprine did not result in remission. After two cycles of Privigen®, the patient was almost symptom-free and no longer restricted in everyday life; the CK fell to 400U/l.
Collapse
Affiliation(s)
- Lisa Hunziker
- Klinik für Innere Medizin, Kantonsspital Winterthur, Winterthur Schweiz
| | - Jan Dracklé
- Klinik für Innere Medizin, Kantonsspital Winterthur, Winterthur Schweiz
| |
Collapse
|
30
|
Khan N, Kazmi Z. A Rare Case of Anti-HMGCR and Anti-SRP-Positive Immune-Mediated Necrotizing Myopathy. Qatar Med J 2022; 2022:6. [PMID: 35261909 PMCID: PMC8863816 DOI: 10.5339/qmj.2022.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 11/09/2021] [Indexed: 11/16/2022] Open
Abstract
Immune-mediated necrotizing myopathy (IMNM) or necrotizing autoimmune myopathy includes a set of distinct disorders associated with marked myasthenia, myofiber necrosis, and high creatine kinase levels. Anti-3-hydroxy-3-methylglutaryl coenzyme A reductase (anti-HMGCR) and anti-signal recognition particle (anti-SRP) are the two main autoantibodies associated with IMNM. Anti-HMGCR is usually associated with statin use. However, it may also be discovered in children without previous statin exposure, suggesting the existence of a complex genetic–environmental relationship in disease pathogenesis. Anti-SRP IMNM tends to present with more severe disease distinguished by pronounced myasthenia, worse neurologic outcomes, and treatment refractoriness. Its pathogenesis is also unknown; however, preliminary data suggest an antibody–complement-mediated mechanism of muscle cell lysis. Herein, we present the case of a 63-year-old man diagnosed with anti-HMGCR- and anti-SRP-positive IMNM that was treated with multiple immunosuppressants resulting in clinical improvement.
Collapse
Affiliation(s)
- Nariman Khan
- UT Health San Antonio, Joe R. and Terry Lozano Long School of Medicine, Department of Internal Medicine, Texas, USA E-mail:
| | - Zehra Kazmi
- UT Health San Antonio, Joe R. and Terry Lozano Long School of Medicine, Department of Medicine, Division of Rheumatology, Texas, USA
| |
Collapse
|
31
|
Ye L, Zuo Y, Chen F, Peng Q, Lu X, Wang G, Shu X. miR-18a-3p and Its Target Protein HuR May Regulate Myogenic Differentiation in Immune-Mediated Necrotizing Myopathy. Front Immunol 2022; 12:780237. [PMID: 35069550 PMCID: PMC8766969 DOI: 10.3389/fimmu.2021.780237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 12/13/2021] [Indexed: 11/18/2022] Open
Abstract
Immune-mediated necrotizing myopathy (IMNM) is characterized by manifestation of myonecrosis and regeneration of muscle fibers; however, the underlying pathogenesis remains unclear. This study aimed to investigate the role and mechanism of miR-18a-3p and its target RNA-binding protein HuR in IMNM. HuR and miR-18a-3p levels were detected in the skeletal muscles of 18 patients with IMNM using quantitative reverse-transcription real-time polymerase chain reaction (qRT-PCR) and western blotting analysis. Human myoblasts were transfected with small interfering RNA targeting HuR and miR-18a-3p mimic or inhibitor. Myogenic differentiation markers, myogenin and myosin heavy chain, were analyzed by qRT-PCR, western blotting analysis, and immunofluorescence staining. The results showed that miR-18a-3p was upregulated (p=0.0002), whereas HuR was downregulated (p=0.002) in the skeletal muscles of patients with IMNM. The expression of miR-18a-3p in patients with IMNM was negatively correlated with those of HuR (r = -0.512, p = 0.029). We also found that disease activity was positively correlated with HuR expression (r = 0.576, p = 0.012) but muscle activity was negatively correlated with miR-18a-3p expression (r = -0.550, p = 0.017). Besides, bioinformatics analysis and dual-luciferase reporter assays suggested that miR-18a-3p could directly target HuR. Cellular experiments showed that overexpression of miR-18a-3p inhibited myogenic differentiation by targeting HuR, whereas inhibition of miR-18a-3p led to opposite results. Therefore, miR-18a-3p and its target protein HuR may be responsible for modulating the myogenic process in IMNM and can thus be therapeutic targets for the same.
Collapse
Affiliation(s)
- Lifang Ye
- Department of Rheumatology, Key Laboratory of Myositis, China-Japan Friendship Hospital, Beijing, China.,Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yu Zuo
- Department of Rheumatology, Key Laboratory of Myositis, China-Japan Friendship Hospital, Beijing, China
| | - Fang Chen
- Department of Rheumatology, Key Laboratory of Myositis, China-Japan Friendship Hospital, Beijing, China
| | - Qinglin Peng
- Department of Rheumatology, Key Laboratory of Myositis, China-Japan Friendship Hospital, Beijing, China
| | - Xin Lu
- Department of Rheumatology, Key Laboratory of Myositis, China-Japan Friendship Hospital, Beijing, China
| | - Guochun Wang
- Department of Rheumatology, Key Laboratory of Myositis, China-Japan Friendship Hospital, Beijing, China.,Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaoming Shu
- Department of Rheumatology, Key Laboratory of Myositis, China-Japan Friendship Hospital, Beijing, China
| |
Collapse
|
32
|
Shelly S, Mielke MM, Paul P, Milone M, Tracy JA, Mills JR, Klein CJ, Ernste FC, Mandrekar J, Liewluck T. Incidence and Prevalence of Immune-mediated Necrotizing Myopathy in Adults in Olmsted County, Minnesota. Muscle Nerve 2022; 65:541-546. [PMID: 35064938 PMCID: PMC9035036 DOI: 10.1002/mus.27504] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 01/12/2022] [Accepted: 01/15/2022] [Indexed: 11/08/2022]
Abstract
INTRODUCTION/AIMS Immune-mediated necrotizing myopathy (IMNM) is considered a rare subtype of the immune-mediated myopathies, but its incidence and prevalence are unknown. This study aimed to determine the incidence and prevalence of IMNM in the adults in Olmsted County, Minnesota. METHODS We identified adult patients with IMNM defined by the 2016 European Neuromuscular Centre diagnostic criteria among Olmsted County, Minnesota, residents over a 20-year period RESULTS: Seven patients fulfilled the inclusion criteria. Six patients were tested for IMNM antibodies: 4 were anti 3-Hydroxy-3-Methylglutaryl-CoA Reductase (HMGCR)-positive, 1 was anti-signal recognition particle (SRP)-positive and 1 was seronegative. The incidence of IMNM during 2010-2019 was 8.3 per million person-years. The prevalence of IMNM in 2010 was 1.85 per 100,000 people ≥50 years. Median age at symptom onset was 64 years (range: 52-86) and median time from symptom onset to diagnosis was 3 months (range <1-156). Statin use among anti-HMGCR IMNM patients, but not the entire IMNM cohort, was higher than in controls (P=0.024). Two IMNM patients developed cancers. The incidence of malignancy in IMNM was not higher than that of the general population. Treatment outcome was favorable in all patients except for 1 with delayed treatment and one with insufficient therapy. Among 3 deceased patients, 1 died from cancer while 2 died from IMNM-related cardiorespiratory complications. DISCUSSION IMNM is a rare disease. Its prevalence is one tenth that of inclusion body myositis in Olmsted County, Minnesota. IMNM patients in our cohort were not at higher risk for developing cancer.
Collapse
Affiliation(s)
- Shahar Shelly
- Department of Neurology, Mayo Clinic, Rochester, MN.,Department of Neurology, Chaim Sheba Medical Center, Tel HaShomer, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Michelle M Mielke
- Department of Neurology, Mayo Clinic, Rochester, MN.,Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | - Pritikanta Paul
- Department of Neurology, Mayo Clinic, Rochester, MN.,Department of Neurology and Rehabilitation, University of Illinois at Chicago, Chicago, IL
| | | | | | - John R Mills
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | - Floranne C Ernste
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Jay Mandrekar
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | | |
Collapse
|
33
|
Abstract
INTRODUCTION The autoimmune disorders of the skeletal muscle tissue termed myositis are a rare yet diverse group of diseases with distinct clinical and pathological features and with different prognoses and treatment responses. Subtyping of patients is necessary for appropriate disease management, and requires specialized expertise and elaborate diagnostic testing of clinico-pathological disease features. AREAS COVERED Current clinical practice and diagnostic criteria for subtyping patients are searched on medical online platforms including PubMed and Web of Science. Recent publications on growth differentiation factor-15 (GDF-15) and muscle disorders are summarized and analyzed, and comparisons are made of data published in studies describing disease cohorts as well as individual patients. Influence of age and physical activity on GFD-15 levels and potential as a diagnostic criterion are discussed. This review contains supportive evidence of the elevated levels of GDF-15 in the blood of myositis patients, a feature which distinguishes these autoimmune muscle disorders from muscular dystrophy with secondary inflammation. EXPERT OPINION GDF-15 represents a novel and promising serological biomarker for diagnosing myositis, yet more studies are needed to assay its sensitivity and specificity. Increased diagnostic power is expected by combining GDF-15 levels with other blood-derived biomarkers.
Collapse
Affiliation(s)
- Boel De Paepe
- Neuromuscular Reference Center, Ghent University Hospital, Ghent, Belgium
| |
Collapse
|
34
|
Cui BB, Tian YR, Ma XY, Yin G, Xie Q. Belimumab for Immune-Mediated Necrotizing Myopathy Associated With Anti-SRP Antibodies: A Case Report and Retrospective Review of Patients Treated With Anti-B-Cell Therapy in a Single Center and Literature. Front Immunol 2021; 12:777502. [PMID: 34925350 PMCID: PMC8675000 DOI: 10.3389/fimmu.2021.777502] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 11/08/2021] [Indexed: 02/05/2023] Open
Abstract
Background Immune-mediated necrotizing myopathy (IMNM) is characterized by markedly elevated creatinine kinase and histologically scattered necrotic muscle fibers and generally associated with autoantibodies against signal recognition particle (SRP) or 3-hydroxy-3-methylglutaryl-coA-reductase (HMGCR). Poor clinical response to conventional therapies and relapses commonly occur in severe cases. Anti-B-cell therapies have been used in refractory/relapsing cases. Methods The characteristics of a patient with IMNM associated with anti-SRP antibodies including physical examination, laboratory tests, and disease activity assessment were evaluated. Conventional therapy, belimumab treatment schedule, and follow-up data were recorded. Medical records of IMNM patients treated in our department from September 2014 to June 2021 were reviewed to evaluate the efficacy and safety of anti-B-cell therapy for anti-SRP IMNM. A literature review of patients with anti-SRP IMNM treated with anti-B-cell therapies was performed. Results We describe a case of a 47-year-old woman with IMNM associated with anti-SRP antibodies who relapsed twice after conventional therapy but showed good response and tolerance to belimumab at 28 weeks follow-up. In this review, three patients from our department were treated with rituximab. Two of the three patients rapidly improved after treatment. Twenty patients and five retrospective studies were included in the literature review. All patients were administered rituximab as an anti-B-cell drug. Conclusion Despite a lack of rigorous clinical trials, considerable experience demonstrated that anti-B-cell therapy might be effective for patients with IMNM associated with anti-SRP antibodies. Belimumab in association with steroids might be an encouraging option for refractory/relapsing cases.
Collapse
Affiliation(s)
- Bei-Bei Cui
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Yun-Ru Tian
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Xin-Yue Ma
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Geng Yin
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Qibing Xie
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| |
Collapse
|
35
|
Fujii S, Horiuchi K, Oshima Y, Eguchi K, Nagai A, Iwata I, Matsushima M, Yabe I. Inflammatory Myopathy Associated with Anti-mitochondrial Antibody Presenting Only with Respiratory Failure. Intern Med 2021; 60:3801-3804. [PMID: 34092736 PMCID: PMC8710372 DOI: 10.2169/internalmedicine.7448-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
A 56-year-old woman presenting with type II respiratory failure was transferred to our hospital. She did not exhibit muscle weakness or elevated serum myogenic enzymes, but needle electromyography revealed myogenic changes in the limb muscles, and her blood tests were positive for anti-mitochondrial antibodies (AMA). Muscle histopathological findings included immune-mediated necrotizing myopathy, so she was diagnosed with inflammatory myopathy associated with AMA. After treatment with corticosteroids and noninvasive positive pressure ventilation, her symptoms improved. If a diagnosis of type II respiratory failure is difficult, inflammatory myopathy associated with AMA should be considered as a differential diagnosis.
Collapse
Affiliation(s)
- Shintaro Fujii
- Department of Neurology, Hakodate Municipal Hospital, Japan
| | | | - Yuki Oshima
- Department of Neurology, Hakodate Municipal Hospital, Japan
| | - Katsuki Eguchi
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Japan
| | - Azusa Nagai
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Japan
| | - Ikuko Iwata
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Japan
| | - Masaaki Matsushima
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Japan
| | - Ichiro Yabe
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Japan
| |
Collapse
|
36
|
Park S, Jang DH, Kim JM, Yoon N. Prominent Asymmetric Muscle Weakness and Atrophy in Seronegative Immune-Mediated Necrotizing Myopathy. Diagnostics (Basel) 2021; 11:2064. [PMID: 34829411 DOI: 10.3390/diagnostics11112064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/18/2021] [Accepted: 11/04/2021] [Indexed: 11/17/2022] Open
Abstract
Immune-mediated necrotizing myopathy, a new subgroup of inflammatory myopathies, usually begins with subacute onset of symmetrical proximal muscle weakness. A 35-year-old male presented with severe asymmetric iliopsoas atrophy and low back pain with a previous history of left lower extremity weakness. Although his first left lower extremity weakness occurred 12 years ago, he did not receive a clear diagnosis. Magnetic resonance imaging of both thigh muscles showed muscle edema and contrast enhancement in patch patterns, and the left buttock and thigh muscles were more atrophied compared to the right side. Serum creatine kinase levels were elevated, and serologic testings were all negative. Genetic testing using a targeted gene-sequencing panel for neuromuscular disease including myopathy identified no pathogenic variants. Muscle biopsy on the right vastus lateralis showed scattered myofiber necrosis with phagocytosis and an absence of prominent inflammatory cells, consistent with seronegative necrotizing myopathy. Thus, unusual asymmetric muscle weakness and atrophy can be a manifestation of inflammatory myopathy.
Collapse
|
37
|
Nicolau S, Milone M, Tracy JA, Mills JR, Triplett JD, Liewluck T. Immune-mediated necrotizing myopathy: Unusual presentations of a treatable disease. Muscle Nerve 2021; 64:734-739. [PMID: 34617293 DOI: 10.1002/mus.27435] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 09/28/2021] [Accepted: 10/03/2021] [Indexed: 01/21/2023]
Abstract
INTRODUCTION/AIMS Immune-mediated necrotizing myopathy (IMNM) is an immune-mediated myopathy typically presenting with progressive subacute weakness and characteristic, but nonspecific, myopathological findings. Atypical cases however can mimic other inherited or acquired myopathies, depriving patients of treatment. We describe a cohort of such patients. METHODS We retrospectively identified IMNM patients who either previously carried a diagnosis of an inherited myopathy established on clinicopathological grounds or whose muscle biopsies displayed atypical features suggestive of a different myopathy. RESULTS Among 131 IMNM patients, seven previously unreported patients (5%) met one of the above criteria. Three patients were diagnosed with limb-girdle muscular dystrophy on the basis of a chronic progressive course of weakness and family history of myopathy or cardiomyopathy. The other four patients displayed atypical histological features (two prominent mitochondrial abnormalities, one myofibrillar pathology, and one granulomatous inflammation). Immunostaining of biopsies from 12 additional IMNM patients did not identify myofibrillar pathology. The patient with granulomatous inflammation was known to have pulmonary sarcoidosis. Genetic testing for inherited myopathies was unrevealing. Antibodies against 3-hydroxy-3-methylglutaryl-CoA reductase or signal recognition particle were identified in 5 and 1 patients, respectively. Four patients presented with slowly progressive weakness over 3-13 y, while weakness was subacute over ≤6 mo in three patients. All patients responded to immunomodulatory therapy. DISCUSSION Atypical clinical and histological features can occur in IMNM patients, causing delays in diagnosis and treatment. Clinicians should, therefore, consider IMNM in the differential diagnosis of unexplained proximal myopathies in spite of atypical clinical and myopathological findings.
Collapse
Affiliation(s)
- Stefan Nicolau
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - John R Mills
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Teerin Liewluck
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
38
|
Tamura T, Miyajima K, Watanabe K, Ito K, Kin F, Okazaki A, Takashima Y, Watanabe T, Kawaguchi Y, Wakabayashi Y, Miyajima H, Maekawa Y. An Autopsy Case of Antibody-negative Immune-mediated Necrotizing Myopathy with Severe Cardiac Involvement. Intern Med 2021; 60:3113-3119. [PMID: 33840691 PMCID: PMC8545633 DOI: 10.2169/internalmedicine.6355-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 41-year-old man was admitted with a chief complaint of dyspnea. Echocardiography showed diffuse severe hypokinesis in the left ventricle. Although his heart failure improved, high creatine kinase levels persisted. A muscle biopsy of the biceps brachii showed necrotic and regenerating fibers along with positive findings for major histocompatibility complex class I and membrane attack complex. He was diagnosed with antibody-negative immune-mediated necrotizing myopathy (IMNM). Steroid therapy was started, but he died due to ventricular fibrillation. Autopsy findings revealed CD68-positive macrophages in the myocardium and quadriceps. To our knowledge, this is the first case of antibody-negative IMNM with cardiac involvement.
Collapse
Affiliation(s)
- Takumi Tamura
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Japan
| | - Keisuke Miyajima
- Department of Cardiology, Seirei Mikatahara General Hospital, Japan
| | - Kazuki Watanabe
- Division of Neurology, Internal Medicine I, Hamamatsu University School of Medicine, Japan
| | - Kazuki Ito
- Department of Cardiology, Seirei Mikatahara General Hospital, Japan
| | - Fumihiko Kin
- Department of Cardiology, Seirei Mikatahara General Hospital, Japan
| | - Ayako Okazaki
- Department of Cardiology, Seirei Mikatahara General Hospital, Japan
| | - Yasuyo Takashima
- Department of Cardiology, Seirei Mikatahara General Hospital, Japan
| | | | | | | | - Hiroaki Miyajima
- Division of Neurology, Internal Medicine I, Hamamatsu University School of Medicine, Japan
| | - Yuichiro Maekawa
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Japan
| |
Collapse
|
39
|
Loarce-Martos J, Lilleker JB, Parker M, McHugh N, Chinoy H. Polymyositis: is there anything left? A retrospective diagnostic review from a tertiary myositis centre. Rheumatology (Oxford) 2021; 60:3398-3403. [PMID: 33367878 DOI: 10.1093/rheumatology/keaa801] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 11/03/2020] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE The current classification criteria for idiopathic inflammatory myopathy (IIM) retain PM as a major disease subgroup. However, evolution in the understanding of IIM has suggested that many of these patients could be better described as having an alternative diagnosis. In the present study, we apply the latest understanding of IIM subtyping to retrospectively review PM diagnoses in a large cohort of IIM patients. METHODS Within a previously reported cohort of 255 patients from a UK tertiary myositis clinic, 37 patients classified as PM according to both the EULAR/ACR IIM criteria and expert opinion were identified. Clinical data and complementary tests were reviewed, and consensus decisions regarding final classification were reached in each case. RESULTS Nine (9/37, 24.3%) patients remained classified as PM, 3.5% (9/255) of the original cohort; these PM patients were seronegative for myositis antibodies, responsive to immunosuppression, and in 4/7 (57.1%) patients where muscle biopsy was performed had HLA-1 upregulation and endomysial inflammatory infiltrates. Immune-mediated necrotizing myopathy (5/37, 13.5%) and connective tissue disease overlap myositis (7/37, 19%) were the main alternative diagnoses. The remaining patients were diagnosed as: unspecified myopathy (6/37, 16%), dermatomyositis (2/37, 5%), cancer-associated myopathy (3/37, 8.1%), and non-inflammatory myopathy (1/37, 3%, myofibrillar myopathy). Four patients (4/37, 10%) had insufficient data available to confidently reclassify. CONCLUSION Our study confirms that PM can now be considered a rare IIM subgroup. A thorough examination, complete myositis autoantibody panel, and careful interpretation of the biopsy results is recommended to confirm the correct IIM sub-type.
Collapse
Affiliation(s)
- Jesus Loarce-Martos
- Rheumatology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - James B Lilleker
- Centre for Musculoskeletal Research, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Manchester Centre for Clinical Neuroscience, Salford Royal NHS Foundation Trust, Salford, UK
| | - Matthew Parker
- Department of Rheumatology, RPA Institute of Rheumatology and Orthopaedics, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Neil McHugh
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
- Royal National Hospital for Rheumatic Disease, Bath, UK
| | - Hector Chinoy
- National Institute for Health Research Manchester Musculoskeletal Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Department of Rheumatology, Salford Royal NHS Foundation Trust, Salford, UK
| |
Collapse
|
40
|
Ma X, Xu L, Ji S, Li Y, Bu B. The Clinicopathological Distinction Between Seropositive and Seronegative Immune-Mediated Necrotizing Myopathy in China. Front Neurol 2021; 12:670784. [PMID: 34290662 PMCID: PMC8287052 DOI: 10.3389/fneur.2021.670784] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 05/31/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives: The present study aimed to compare the clinicopathological features of patients with seronegative immune-mediated necrotizing myopathy (IMNM) and those positive for anti-signal recognition particle (SRP) or anti-3-hydroxy-3-methylglutarylcoenzyme-a reductase (HMGCR) antibodies. Methods: We retrospectively analyzed the data of patients with IMNM treated in the Neurology Department of Tongji Hospital from January 1, 2013, to December 31, 2019. Results: Among the 117 patients with IMNM, 30.8% (36/117) were positive for anti-SRP antibodies, 6.0% (7/117) were positive for anti-HMGCR antibodies, and 13.7% (16/117) were seronegative. Myalgia at presentation (62.5 vs. 23.3%, p = 0.0114) was more commonly observed in patients with seronegative IMNM than in those with seropositive IMNM. Subclinical cardiac involvement was more frequently detected in seronegative IMNM than in seropositive IMNM (6/13 vs. 5/33, p = 0.0509, echocardiogram; 7/7 vs. 12/24, p = 0.0261, cardiac MRI). Deposition of membrane attack complex (MAC) on the sarcolemma of myofibers in biopsied muscle was less commonly observed in patients with seronegative IMNM than in patients with seropositive IMNM (16.7 vs. 68.2%, p = 0.0104). The rate of marked improvement following immunotherapy tended to be higher in patients with seronegative IMNM than in those with seropositive IMNM (87.5 vs. 61%, p = 0.0641). Conclusions: Patients with seronegative IMNM more frequently present with myalgia at onset, exhibit more subclinical cardiac involvement and uncommon MAC deposition on myofibers, and experience better outcomes than those with seropositive IMNM.
Collapse
Affiliation(s)
| | | | | | | | - Bitao Bu
- Department of Neurology, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
41
|
Schmuter G, Paniagua-Morales JA. Novel Presentation of Aphasia and Tremor in Immune-Mediated Necrotizing Myopathy. Cureus 2021; 13:e16159. [PMID: 34367769 PMCID: PMC8330158 DOI: 10.7759/cureus.16159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2021] [Indexed: 11/25/2022] Open
Abstract
The authors present a unique case of immune-mediated necrotizing myopathy in a 60-year-old female who presented with aphasia, tremor, and progressive muscular weakness. To the best of our knowledge, the presentation of aphasia and tremor has not been previously reported in immune-mediated necrotizing myopathy. This rare presentation may mimic a variety of other central nervous system and myopathic disorders. Delays in prompt diagnosis and treatment of immune-mediated necrotizing myopathy can be detrimental to the physical and mental well-being of the patient and additionally leads to inefficient use of healthcare resources. Therefore, it is beneficial for clinicians to be aware of this symptomatic presentation in order to include immune-mediated necrotizing myopathy as a key differential diagnosis. Awareness of aphasia and tremor as potential symptoms of immune-mediated necrotizing myopathy will improve the quality of patient care.
Collapse
Affiliation(s)
- Gabriella Schmuter
- Department of Internal Medicine, St. Barnabas Hospital Health System, Bronx, USA
| | | |
Collapse
|
42
|
Paul M, Paul P, Dey D, Moazzem SW, Shamrin F. A Case of Statin-Associated Immune-Mediated Necrotizing Myopathy, Successfully Treated With Intravenous Immunoglobulin. Cureus 2021; 13:e16001. [PMID: 34336492 PMCID: PMC8318619 DOI: 10.7759/cureus.16001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2021] [Indexed: 11/05/2022] Open
Abstract
Statins have become the commonest lipid-lowering agent worldwide and have significantly reduced morbidity and mortality associated with cardiovascular diseases. Overall, statins are very well tolerated. However, in clinical practice, a wide variety of skeletal myopathic effects have been observed, ranging from asymptomatic patients with high creatine phosphokinase (CPK) to fatal cases of acute rhabdomyolysis. Recent reports suggest that statins are associated with immune-mediated necrotizing myopathy (IMNM), a unique autoimmune myopathy. Unlike other drug reactions, this can occur months to years after initiation of statin. It is a distinctive autoimmune myopathy where symptoms persist or even progress after statin discontinuation and requires immunosuppressive therapy. The presence of anti-hydroxy-methyl-glutaryl coenzyme-A reductase (HMGCR) antibody in serum strengthens the diagnosis of statin-associated necrotizing myopathy. Here we present a case of statin-associated IMNM in a 43-year-old Caucasian female who had statin-induced progressive deterioration of proximal muscle weakness with poor response to high-dose steroids and required further immunosuppressive therapy.
Collapse
Affiliation(s)
- Mishouri Paul
- Medicine, Interfaith Medical Center, New York City, USA
| | - Prodip Paul
- Internal Medicine, Geisinger Community Medical Center, Scranton, USA
| | - Dipon Dey
- Epidemiology and Public Health, ZWH Medical Care PC, Queens, USA
| | | | | |
Collapse
|
43
|
Abstract
Immunosuppression is the cornerstone therapy for anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase (anti-HMGCR) myopathy. Typical immunosuppressants such as corticosteroids, methotrexate, and azathioprine have been used in conjunction with removal of the offending agent, yet the use of rituximab is more limited in this type of myopathy. Reported here is a case of a patient who responded well to rituximab (RTX) after the standard immunosuppressants had failed. This case illustrates the importance of further studies to evaluate the role of RTX in anti-HMGCR myopathy.
Collapse
Affiliation(s)
- Sonia Gupta
- Department of Internal Medicine, Creighton University, Omaha, Nebraska, USA
- Address correspondence to:Sonia Gupta, Department of Internal Medicine, Creighton University, 7710 Mercy Road #3000, Omaha, Nebraska 68124, USA. E-mail:
| | - Amandeep Rakhra
- Department of Rheumatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Vinay Thallapally
- Department of Internal Medicine, Creighton University, Omaha, Nebraska, USA
| | - Joseph Nahas
- Department of Internal Medicine, Creighton University, Omaha, Nebraska, USA
| |
Collapse
|
44
|
Takahashi F, Sawada J, Minoshima A, Sakamoto N, Ono T, Akasaka K, Takei H, Nishino I, Hasebe N. Antimitochondrial Antibody-associated Myopathy with Slowly Progressive Cardiac Dysfunction. Intern Med 2021; 60:1035-1041. [PMID: 33116011 PMCID: PMC8079923 DOI: 10.2169/internalmedicine.5600-20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
A 45-year-old woman was referred to our hospital for the evaluation of proximal muscle weakness and serum creatine kinase elevation [corrected]. She had atrial fibrillation and left ventricular asynergy. She was diagnosed with myopathy, accompanied by cardiomyopathy of unknown etiology. She was treated with prednisolone. After long-term follow-up and a detailed examination, the patient was diagnosed with antimitochondrial antibody (AMA)-associated myopathy with cardiac involvement. Although the patient received medical treatment, including beta-blockers and prednisolone, her cardiac function deteriorated progressively. Physicians should consider AMA-associated myopathy when diagnosing myopathies of unknown etiology. The presence of cardiac involvement should be proactively investigated in AMA-associated myopathy.
Collapse
Affiliation(s)
| | - Jun Sawada
- Department of the Internal Medicine, Cardiovascular, Respiratory and Neurology Division, Asahikawa Medical University, Japan
| | - Akiho Minoshima
- Department of the Internal Medicine, Cardiovascular, Respiratory and Neurology Division, Asahikawa Medical University, Japan
| | - Naka Sakamoto
- Department of the Internal Medicine, Cardiovascular, Respiratory and Neurology Division, Asahikawa Medical University, Japan
| | - Toshiyuki Ono
- Department of the Internal Medicine, Cardiovascular, Respiratory and Neurology Division, Asahikawa Medical University, Japan
| | - Kazumi Akasaka
- Department of Laboratory Medicine, Asahikawa Medical University, Japan
| | - Hidehiro Takei
- Department of Diagnostic Pathology, Asahikawa Medical University Hospital, Japan
| | - Ichizo Nishino
- Department of the Neuromuscular Research, National Institute of Neuroscience, Japan
| | - Naoyuki Hasebe
- Department of the Internal Medicine, Cardiovascular, Respiratory and Neurology Division, Asahikawa Medical University, Japan
| |
Collapse
|
45
|
Li S, Li W, Jiang W, He L, Peng Q, Wang G, Lu X. The Efficacy of Tocilizumab in the Treatment of Patients with Refractory Immune-Mediated Necrotizing Myopathies: An Open-Label Pilot Study. Front Pharmacol 2021; 12:635654. [PMID: 33815117 PMCID: PMC8010666 DOI: 10.3389/fphar.2021.635654] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 01/26/2021] [Indexed: 12/03/2022] Open
Abstract
Objective: To evaluate the efficacy of tocilizumab (TCZ) in adult patients with refractory immune-mediated necrotizing myopathies (IMNMs) and investigate possible predictive biomarkers of the response to treatment with TCZ. Methods: Patients with refractory IMNM were enrolled in this open-label pilot observational study and received intravenous TCZ treatment. The clinical response was assessed after 6 months of TCZ treatment according to the 2016 American College of Rheumatology–European League Against Rheumatism (ACR–EULAR) response criteria for adult dermatomyositis and polymyositis. Muscle biopsies were performed to investigate muscle fiber regeneration by immunohistochemical staining of CD56. Serum levels of interleukin (IL)-6 were measured using a multiplex bead-based flow fluorescent immunoassay. The levels of muscle IL-6 mRNA were detected by real-time polymerase chain reaction. Results: A total of 11 patients with refractory IMNM were enrolled in the study, including 3 anti-3-hydroxy-3-methylglutaryl-CoA reductase- and 8 anti-signal recognition particle-positive patients. Seven (63.6%) of these patients achieved clinically significant responses according to the 2016 ACR–EULAR myositis response criteria. Responders had higher baseline serum IL-6 and muscle IL-6 mRNA levels and percentage of CD56-positive muscle fibers than non-responders. Baseline serum IL-6 levels and the percentage of CD56-positive muscle fibers were positively correlated with total improvement score after 6 months of TCZ treatment. Furthermore, muscle fiber necrosis and muscle fiber size variation decreased in repeated muscle biopsies in five responders. Conclusion: Patients with refractory IMNM may respond to TCZ. Baseline serum IL-6 and muscle IL-6 mRNA levels and the percentage of CD56-positive muscle fibers may predict the response to TCZ treatment in these patients.
Collapse
Affiliation(s)
- Sizhao Li
- Department of Rheumatology, China-Japan Friendship Hospital, Beijing, China
| | - Wenli Li
- Department of Rheumatology, China-Japan Friendship Hospital, Beijing, China
| | - Wei Jiang
- Department of Rheumatology, China-Japan Friendship Hospital, Beijing, China
| | - Linrong He
- Department of Rheumatology, China-Japan Friendship Hospital, Beijing, China
| | - Qinglin Peng
- Department of Rheumatology, China-Japan Friendship Hospital, Beijing, China
| | - Guochun Wang
- Department of Rheumatology, China-Japan Friendship Hospital, Beijing, China
| | - Xin Lu
- Department of Rheumatology, China-Japan Friendship Hospital, Beijing, China
| |
Collapse
|
46
|
Xiong A, Yang G, Song Z, Xiong C, Liu D, Shuai Y, He L, Zhang L, Guo Z, Shuai S. Rituximab in the treatment of immune-mediated necrotizing myopathy: a review of case reports and case series. Ther Adv Neurol Disord 2021; 14:1756286421998918. [PMID: 33786066 PMCID: PMC7958167 DOI: 10.1177/1756286421998918] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 02/02/2021] [Indexed: 12/20/2022] Open
Abstract
Immune-mediated necrotizing myopathy (IMNM) is a group of immune-related myopathies characterized by progressive proximal muscle weakness, extremely high serum creatine kinase (CK) levels, and necrotic muscle fibers with a relative lack of inflammation. Treatment of IMNM is challenging, with most cases refractory to high-dose steroids in combination with multiple immunotherapies. The role of rituximab (RTX) for IMNM has been explored in isolated case reports and small series. The aim of this article was to perform a literature review of patients with IMNM treated with RTX and to evaluate RTX efficacy and safety. A total of 34 patients with IMNM were reviewed: 52.9% (18/34) with anti-signal recognition particle (SRP) antibodies and 47.1% (16/34) with anti-3-hydroxy-3-methylglutaryl-CoA reductase (HMGCR) antibodies. Patient age at onset varied from 11 years to 81 years (mean 41 years). The majority of patients presented as a severe proximal muscle weakness and the peak level of CK varied from 3900 IU/L to 56,000 IU/L (mean 18,440 IU/L). Prior to RTX administration, all patients were treated with high-dose steroids and most were treated with multiple immunotherapies. The reason for initiating RTX was that 64.7% (22/34) of patients showed no improvement after previous treatments, and 35.3% (12/34) of patients relapsed when attempting to wean steroids or other immunosuppressive agents. With regard to RTX efficacy, 61.8% (21/34) of patients presented a response to RTX. Our data may support the use of RTX as an effective treatment strategy against IMNM resistant to steroids and multiple immunotherapies. Meanwhile, RTX as a first-line therapy could be a choice in IMNM, particularly in African Americans with anti-SRP antibody-positive subsets. ANA, antinuclear antibody; CK, creatine kinase; HMGCR, 3-hydroxy-3-methylglutaryl-CoA reductase; IMNM, immune-mediated necrotizing myopathy; MAC, membrane attack complex; MHC-I, major histocompatibility complex-I; RTX, rituximab; SRP, signal recognition particle.
Collapse
Affiliation(s)
- Anji Xiong
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, No.97, Renmin Nan Lu, Nanchong, Sichuan, China
| | - Guancui Yang
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, No.97,Renmin Nan Lu, Nanchong, Sichuan, China
| | - Zhuoyao Song
- Department of Rheumatology and Immunology, Nanchong Central Hospital, Nanchong, Sichuan, China
| | - Chen Xiong
- Department of Rheumatology and Immunology, Nanchong Central Hospital, Nanchong, Sichuan, China
| | - Deng Liu
- Department of Rheumatology and Immunology, Nanchong Central Hospital, Nanchong, Sichuan, China
| | - Yu Shuai
- Department of Rheumatology and Immunology, Nanchong Central Hospital, Nanchong, Sichuan, China
| | - Linqian He
- Department of Rheumatology and Immunology, Nanchong Central Hospital, Nanchong, Sichuan, China
| | - Liangwen Zhang
- Department of Rheumatology and Immunology, Nanchong Central Hospital, Nanchong, Sichuan, China
| | - Zepeng Guo
- Department of Rheumatology and Immunology, Nanchong Central Hospital, Nanchong, Sichuan, China
| | - Shiquan Shuai
- Department of Rheumatology and Immunology, Nanchong Central Hospital, Nanchong, Sichuan, China
| |
Collapse
|
47
|
Abstract
We describe a 68-year-old man who presented with progressive weakness in proximal muscles of all four limbs and was found to have autoantibody-negative necrotizing autoimmune myopathy (NAM). His myopathy was refractory to corticosteroids and methotrexate, but subsequently demonstrated successful response to intravenous immunoglobulin (IVIG). The patient also received rituximab, but the timing of his recovery favored IVIG as the more important factor in terms of efficacy. Treatment guidelines for seronegative necrotizing myopathies are lacking. This case suggests a potential efficacious treatment option for the seronegative subset of NAM.
Collapse
Affiliation(s)
- Rebecca Liu
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Andrew Z Fenves
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Samantha N Champion
- Department of Neuropathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jonathan Dau
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
48
|
Lim D, Landon-Cardinal O, Ellezam B, Belisle A, Genois A, Sirois J, Bourré-Tessier J. Statin-associated anti-HMGCR immune-mediated necrotizing myopathy with dermatomyositis-like features: A case report. SAGE Open Med Case Rep 2020; 8:2050313X20984120. [PMID: 33447390 PMCID: PMC7780312 DOI: 10.1177/2050313x20984120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR) immune-mediated necrotizing myopathy is a subtype of idiopathic inflammatory myopathy which may be associated with statin exposure. It presents with severe proximal muscle weakness, high creatine kinase levels and muscle fiber necrosis. Treatment with intravenous immunoglobulins and immunosuppressants is often necessary. This entity is not commonly known among dermatologists as there are usually no extramuscular manifestations. We report a rare case of statin-associated anti-HMGCR immune-mediated necrotizing myopathy with dermatomyositis-like cutaneous features. The possibility of anti-HMGCR immune-mediated necrotizing myopathy should be considered in patients with cutaneous dermatomyositis-like features associated with severe proximal muscle weakness, highly elevated creatine kinase levels and possible statin exposure. This indicates the importance of muscle biopsy and specific autoantibody testing for accurate diagnosis, as well as significant therapeutic implications.
Collapse
Affiliation(s)
- Darosa Lim
- Division of Dermatology, Department of Medicine, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - Océane Landon-Cardinal
- Division of Rheumatology, Department of Medicine, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - Benjamin Ellezam
- Department of Pathology, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada
| | - Annie Belisle
- Department of Pathology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - Annie Genois
- Division of Dermatology, Hôpital Pierre-Le Gardeur, Terrebonne, QC, Canada
| | - Jennifer Sirois
- Department of Anatomopathology, Hôpital Pierre-Le Gardeur, Terrebonne, QC, Canada
| | - Josiane Bourré-Tessier
- Division of Rheumatology, Department of Medicine, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| |
Collapse
|
49
|
Triplett JD, Shelly S, Livne G, Milone M, Kassardjian CD, Liewluck T, Kelly C, Naddaf E, Laughlin RS, Lamb CJ, Rubin D, Dimberg EL, Dubey D, Mills JR, Mandrekar J, Klein CJ. Diagnostic modelling and therapeutic monitoring of immune-mediated necrotizing myopathy: role of electrical myotonia. Brain Commun 2020; 2:fcaa191. [PMID: 33364599 PMCID: PMC7749792 DOI: 10.1093/braincomms/fcaa191] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 09/19/2020] [Accepted: 09/28/2020] [Indexed: 12/11/2022] Open
Abstract
Delayed diagnosis of immune-mediated necrotizing myopathy leads to increased morbidity. Patients with the chronic course without 3-hydroxy-3-methylglutaryl-coenzyme-A reductase-IgG or signal recognition particle-IgG are often challenging to diagnose. Immunotherapy response can also be difficult to assess. We created a statistical model to assist immune-mediated necrotizing myopathy diagnosis. Electrical myotonia versus fibrillations were reviewed as biomarkers for immunotherapy treatment response. Identified were 119 immune-mediated necrotizing myopathy cases and 938 other myopathy patients. Inclusion criteria included all having electrophysiological evaluations, muscle biopsies showing inflammatory/necrotizing myopathies, comprehensively recorded neurological examinations, and creatine kinase values. Electrical myotonia was recorded in 56% (67/119) of retrospective and 67% (20/30) of our validation immune-mediated necrotizing myopathy cohorts, and significantly (P < 0.001) favoured immune-mediated necrotizing myopathy over other myopathies: sporadic inclusion body myositis (odds ratio = 4.78); dermatomyositis (odds ratio = 10.61); non-specific inflammatory myopathies (odds ratio = 8.46); limb-girdle muscular dystrophies (odds ratio = 5.34) or mitochondrial myopathies (odds ratio = 14.17). Electrical myotonia occurred in immune-mediated necrotizing myopathy seropositive (3-hydroxy-3-methylglutaryl-coenzyme-A reductase-IgG 70%, 37/53; signal recognition particle-IgG 29%, 5/17) and seronegative (51%, 25/49). Multivariate regression analysis of 20 variables identified 8 (including electrical myotonia) in combination accurately predicted immune-mediated necrotizing myopathy (97.1% area-under-curve). The model was validated in a separate cohort of 30 immune-mediated necrotizing myopathy cases. Delayed diagnosis of cases with electrical myotonia occurred in 24% (16/67, mean 8 months; range 0–194). Half (8/19) had a chronic course and were seronegative, with high model prediction (>86%) at the first visit. Inherited myopathies were commonly first suspected in them. Follow-up evaluation in patients with electrical myotonia on immunotherapy was available in 19 (median 21 months, range 2–124) which reduced from 36% (58/162) of muscles to 7% (8/121; P < 0.001). Reduced myotonia correlated with immunotherapy response in 64% (9/14) as well as with median creatine kinase reduction of 1779 U/l (range 401–9238, P < 0.001). Modelling clinical features with electrical myotonia is especially helpful in immune-mediated necrotizing myopathy diagnostic suspicion among chronic indolent and seronegative cases. Electrical myotonia favours immune-mediated necrotizing myopathy diagnosis and can serve as an adjuvant immunotherapy biomarker.
Collapse
Affiliation(s)
| | - Shahar Shelly
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Charles D Kassardjian
- Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, Canada
| | | | - Cecilia Kelly
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Elie Naddaf
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Devon Rubin
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Divanshu Dubey
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - John R Mills
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Jay Mandrekar
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | |
Collapse
|
50
|
Shelly S, Triplett JD, Pinto MV, Milone M, Diehn FE, Zekeridou A, Liewluck T. Immune checkpoint inhibitor-associated myopathy: a clinicoseropathologically distinct myopathy. Brain Commun 2020; 2:fcaa181. [PMID: 33305263 PMCID: PMC7713997 DOI: 10.1093/braincomms/fcaa181] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/16/2020] [Accepted: 09/22/2020] [Indexed: 01/21/2023] Open
Abstract
Immune checkpoint inhibitors have revolutionized the landscape of cancer treatment. Alongside their many advantages, they elicit immune-related adverse events, including myopathy, which potentially result in substantial morbidity if not recognized and treated promptly. Current knowledge of immune checkpoint inhibitor-associated myopathy is limited. We conducted a 5-year retrospective study of patients with immune checkpoint inhibitor-associated myopathy. Clinical features, survival and ancillary test findings were analysed and compared with those of immune-mediated necrotizing myopathy patients without immune checkpoint inhibitor exposure seen during the same time period. We identified 24 patients with immune checkpoint inhibitor-associated myopathy (median age 69 years; range 28-86) and 38 patients with immune-mediated necrotizing myopathy. Ocular involvement occurred in 9/24 patients with immune checkpoint inhibitor exposure, without electrodiagnostic evidence of neuromuscular transmission defect, and in none of the immune-mediated necrotizing myopathy patients (P < 0.001). Myocarditis occurred in eight immune checkpoint inhibitor-associated myopathy patients and in none of the immune-mediated necrotizing myopathy patients (P < 0.001). Median creatine kinase was 686 IU/l in the immune checkpoint inhibitor cohort (seven with normal creatine kinase) compared to 6456 IU/l in immune-mediated necrotizing myopathy cohort (P < 0.001). Lymphopenia was observed in 18 and 7 patients with and without immune checkpoint inhibitor exposure, respectively (P < 0.001). Myopathological findings were similar between patients with and without immune checkpoint inhibitor exposure, consisting of necrotic fibres with no or subtle inflammation. Necrotic fibres however arranged in clusters in 10/11 immune checkpoint inhibitor-associated myopathy patients but in none of the immune checkpoint inhibitor-naïve patients (P < 0.001). Despite the lower creatine kinase levels in immune checkpoint inhibitor-exposed patients, the number of necrotic fibres was similar in both groups. Immune checkpoint inhibitor-associated myopathy patients had a higher frequency of mitochondrial abnormalities and less number of regenerating fibres than immune-mediated necrotizing myopathy patients (P < 0.001). Anti-hydroxy-3-methylglutaryl-CoA reductase or signal recognition particle antibodies were absent in patients with immune checkpoint inhibitor exposure but positive in two-thirds of immune checkpoint inhibitor-naïve patients. Most patients with immune checkpoint inhibitor-associated myopathy responded favourably to immunomodulatory treatments, but four died from myopathy-related complications and one from myocarditis. Intubated patients had significantly shorter survival compared to non-intubated patients (median survival of 22 days; P = 0.004). In summary, immune checkpoint inhibitor-associated myopathy is a distinct, treatable immune-mediated myopathy with common ocular involvement, frequent lymphopenia and necrotizing histopathology, which contrary to immune-mediated necrotizing myopathy, is featured by clusters of necrotic fibres and not accompanied by anti-hydroxy-3-methylglutaryl-CoA reductase or signal recognition particle antibodies. Normal or mildly elevated creatine kinase level does not exclude the diagnosis.
Collapse
Affiliation(s)
- Shahar Shelly
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Marcus V Pinto
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Felix E Diehn
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Anastasia Zekeridou
- Department of Neurology, Mayo Clinic, Rochester, MN, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | | |
Collapse
|