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Ernste FC, Reed AM. Idiopathic inflammatory myopathies: current trends in pathogenesis, clinical features, and up-to-date treatment recommendations. Mayo Clin Proc 2013; 88:83-105. [PMID: 23274022 DOI: 10.1016/j.mayocp.2012.10.017] [Citation(s) in RCA: 112] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Revised: 10/30/2012] [Accepted: 10/31/2012] [Indexed: 01/13/2023]
Abstract
Recently, there have been important advances in the understanding of the pathophysiologic features, assessment, and management of patients with a newly diagnosed idiopathic inflammatory myopathy (IIM). Myositis-specific autoantibodies have been identified to define patient subgroups and offer prognostic implications. Similarly, proinflammatory cytokines, such as interleukin 6 and type 1 interferon-dependent genes, may serve as potential biomarkers of disease activity in adult and juvenile patients with dermatomyositis (DM). Moreover, magnetic resonance imaging has become an important modality for the assessment of muscle inflammation in adult IIM and juvenile DM. Immune-mediated necrotizing myopathies also are being recognized as a subset of IIM triggered by medications such as statins. However, confusion exists regarding effective management strategies for patients with IIM because of the lack of large-scale, randomized, controlled studies. This review focuses primarily on our current management and treatment algorithms for IIM including the care of pediatric patients with juvenile DM. For this review, we conducted a search of PubMed and MEDLINE for articles published from January 1, 1970, to December 1, 2011, using the following search terms: idiopathic inflammatory myopathies, dermatomyositis, polymyositis, juvenile dermatomyositis, sporadic inclusion body myositis, inclusion body myositis, inflammatory myositis, myositis, myopathies, pathogenesis, therapy, and treatment. Studies published in English were selected for inclusion in our review as well as additional articles identified from bibliographies.
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Katsuyuki Shinjo S, Carlos de Souza FH, Bertacini de Moraes JC. Dermatomiosite e polimiosite: da imunopatologia à imunoterapia (imunobiológicos). REVISTA BRASILEIRA DE REUMATOLOGIA 2013. [DOI: 10.1590/s0482-50042013000100010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Skuk D, Tremblay JP. Necrosis, sarcolemmal damage and apoptotic events in myofibers rejected by CD8+ lymphocytes: Observations in nonhuman primates. Neuromuscul Disord 2012; 22:997-1005. [PMID: 22749896 DOI: 10.1016/j.nmd.2012.05.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2011] [Revised: 03/29/2012] [Accepted: 05/14/2012] [Indexed: 11/16/2022]
Abstract
To detect the mechanisms of death in allogeneic myofibers rejected by the immune system, myoblasts were allotransplanted in muscles of macaques immunosuppressed with tacrolimus. Immunosuppression was stopped 1month later to induce a massive rejection of allogeneic myofibers. Grafted sites were biopsied at 2-week intervals and analyzed by histology. The loss of allogeneic myofibers was rapid and concomitant with an intense infiltration of CD8+ lymphocytes. Several necrotic myofibers were observed in the lymphocyte accumulations by intracellular complement immunodetection. Dystrophin and spectrin immunodetection showed sarcolemmal damage in myofibers surrounded and invaded by CD8+ lymphocytes. Active caspase-3 was immunodetected in some myofibers surrounded by CD8+ lymphocytes. This is the first evidence that the collapse of myofibers attacked by T lymphocytes occurs by necrosis possibly due to damage of the sarcolemma. Caspase 3 is activated at least in some myofibers, but there was no evidence of a complete classical process of apoptosis.
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Affiliation(s)
- Daniel Skuk
- Neurosciences Division - Human Genetics, CHUQ Research Center - CHUL, Quebec, QC, Canada.
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Yamashita H, Matsuki Y, Shimizu A, Mochizuki M, Takahashi Y, Kano T, Mimori A. Hemophagocytic lymphohistiocytosis complicated by central nervous system lesions in a patient with dermatomyositis: a case presentation and literature review. Mod Rheumatol 2012; 23:386-92. [PMID: 22576792 DOI: 10.1007/s10165-012-0661-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Accepted: 04/20/2012] [Indexed: 10/28/2022]
Abstract
We report a case of dermatomyositis (DM) and hemophagocytic lymphohistiocytosis (HLH) complicated by central nervous system (CNS) lesions and review eight literature cases of DM and HLH. A 17-year-old woman, admitted to our hospital because of severe muscle weakness and high fever, was diagnosed with DM based on elevated serum levels of muscle enzymes and a typical skin rash. Pancytopenia, high serum ferritin and soluble interleukin (IL)-2 receptor, and hepatosplenomegaly were also noted. Bone-marrow examination was negative for hemophagocytosis. Steroid therapy combined with immunoglobulin i.v. was ineffective against the DM, pancytopenia, hepatic dysfunction, and hyperferritinemia. On the 27th hospital day, seizures and acute respiratory failure occurred. In the course of improving muscle enzyme levels after starting adjunctive treatment with cyclosporine, the patient suffered disturbed consciousness, dyskinesia, and tremor. Brain magnetic resonance imaging (MRI) revealed T2 hyperintense lesions in the pons. Additional cyclophosphamide pulse therapy successfully decreased serum ferritin. Unfortunately, the diffuse alveolar damage (DAD) confirmed by biopsy progressed and the patient died. Autopsy findings revealed DAD throughout both lungs, HLH liver lesions, and a hemorrhagic necrotic lesion of the pons in the brain. Even when pathological examination yields no findings of hemophagocytosis, it is important to comprehensively and rapidly diagnose HLH based on the clinical picture. Because DM complicated by HLH may be associated with abnormal production of cytokines and systemic autoimmune responses, it may be necessary to immediately administer additional immunosuppressive therapy. We describe and discuss the extraordinary, severe form of DM in our patient, along with cases in the literature.
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Affiliation(s)
- Hiroyuki Yamashita
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan.
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Acute Rejection of Myofibers in Nonhuman Primates: Key Histopathologic Features. J Neuropathol Exp Neurol 2012; 71:398-412. [DOI: 10.1097/nen.0b013e31825243ae] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Abstract
OBJECTIVES To describe the course of change in muscle strength sporadic inclusion body myositis (IBM) patients. MATERIAL AND METHODS We have studied a cohort of 66 IBM pateints using a hand-held dynamometer. RESULTS Follow-up during a mean of 61.1 months showed a deterioration of on average -0.79% per month. The 'natural course' without immunosuppressive treatment (IS), analyzed in 43 patients (mean 46.4 months) was mean -1.03% per month. Loss of muscle power was most rapid in knee extension -1.12% (P < 0.001 when compared with elbow flexion, elbow extension and hip flexion). There was a tendency towards a more rapid decline in males than females and over the first 5 years after onset, while the level of serum creatine kinase (CK), age, or region affected at onset did not predict the prognosis. The mean change during periods with any IS treatment was -0.76% per month which was significantly lower compared to the total of untreated periods -1.03% (P < 0.05). Patients (n = 13) treated with mykofenolatmofetil showed a better prognosis of -0.67% per month (P < 0.05). In this group elbow flexion and extension and hip flexion showed a positive response, while knee extension was seemingly unaffected. CONCLUSIONS There is a mean of 1% loss in power per month in the untreated IBM patient - the rate of loss was greater in the quadriceps muscle and in untreated compared with IS-treated patients.
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Affiliation(s)
- C Lindberg
- Clinical Neuroscience and Physiology, Section of Neurology, Sahlgrenska Neuromuscular Center, Sahlgrenska University Hospital, Gothenburg, Sweden.
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57
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Eriksson M, Lindberg C. Hand Function in 45 Patients with Sporadic Inclusion Body Myositis. Occup Ther Int 2012; 19:108-16. [DOI: 10.1002/oti.1325] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Revised: 01/29/2012] [Accepted: 01/30/2012] [Indexed: 11/12/2022] Open
Affiliation(s)
- Marianne Eriksson
- Department of Occupational Therapy; Sahlgrenska University Hospital, University of Gothenburg; Sweden
| | - Christopher Lindberg
- Neuromuscular Center; Sahlgrenska University Hospital, University of Gothenburg; Sweden
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58
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Value of muscle enzyme measurement in evaluating different neuromuscular diseases. Clin Chim Acta 2012; 413:520-4. [DOI: 10.1016/j.cca.2011.11.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2011] [Revised: 11/18/2011] [Accepted: 11/18/2011] [Indexed: 11/17/2022]
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Lee MK, Kim BS, Jung SH, Lee GH, Kim JO, Rim DH, Lee YH, Kim WJ, Bang SY, Lee HS. A Case of Klinefelter's Syndrome Accompanying with Polymyositis. JOURNAL OF RHEUMATIC DISEASES 2012. [DOI: 10.4078/jrd.2012.19.3.152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Min Kyu Lee
- Division of Rheumatology, Department of Internal Medicine, Hanyang University College of Medicine, Guri Hospital, Guri, Korea
| | - Byung Sik Kim
- Division of Rheumatology, Department of Internal Medicine, Hanyang University College of Medicine, Guri Hospital, Guri, Korea
| | - Suk Hyun Jung
- Division of Rheumatology, Department of Internal Medicine, Hanyang University College of Medicine, Guri Hospital, Guri, Korea
| | - Gun Hwa Lee
- Division of Rheumatology, Department of Internal Medicine, Hanyang University College of Medicine, Guri Hospital, Guri, Korea
| | - Jin Ok Kim
- Division of Rheumatology, Department of Internal Medicine, Hanyang University College of Medicine, Guri Hospital, Guri, Korea
| | - Dong Hwi Rim
- Division of Rheumatology, Department of Internal Medicine, Hanyang University College of Medicine, Guri Hospital, Guri, Korea
| | - Yu Hwa Lee
- Division of Rheumatology, Department of Internal Medicine, Hanyang University College of Medicine, Guri Hospital, Guri, Korea
| | - Woong Jun Kim
- Division of Rheumatology, Department of Internal Medicine, Hanyang University College of Medicine, Guri Hospital, Guri, Korea
| | - So-Young Bang
- Division of Rheumatology, Department of Internal Medicine, Hanyang University College of Medicine, Guri Hospital, Guri, Korea
| | - Hye-Soon Lee
- Division of Rheumatology, Department of Internal Medicine, Hanyang University College of Medicine, Guri Hospital, Guri, Korea
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Abstract
Inflammatory myopathies are chronic, immune-mediated diseases characterized with progressive proximal muscle weakness. They encompass a variety of syndromes with protean manifestations. The aims of therapy are to increase muscle strength, prevent the development of contractures, and to manage the systemic manifestations of the disease. This is a complex treatment which requires routine and wide knowledge. The most important task is to recognize the disease and guide the patient to immunologic center. Although the first line of therapy continues to include corticosteroids, there are a multitude of agents available for treating patients with myositis. There are several different immunosuppressive agents which may be applied alone or in combination with each other, as well as an increasing number of novel and exciting biologic agents targeting molecules participating in the pathogenesis of inflammatory myopathy. Physiotherapy and rehabilitation in the remission period may significantly improve the functional outcome of patients with these disorders. Orv. Hetil., 2011, 152, 1552–1559.
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Affiliation(s)
- Katalin Dankó
- Debreceni Egyetem, Orvos- és Egészségtudományi Centrum, Belgyógyászati Intézet III. Belgyógyászati Klinika, Klinikai Immunológia Tanszék Debrecen Móricz Zs. krt. 22. 4032
| | - Melinda Vincze
- Debreceni Egyetem, Orvos- és Egészségtudományi Centrum, Belgyógyászati Intézet III. Belgyógyászati Klinika, Klinikai Immunológia Tanszék Debrecen Móricz Zs. krt. 22. 4032
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Joshi N, Nautiyal A, Davies PG. Successful use of rituximab in recalcitrant skin predominant dermatomyositis. J Clin Rheumatol 2011; 17:111-2. [PMID: 21364354 DOI: 10.1097/rhu.0b013e31821072b7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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62
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Zong M, Lundberg IE. Pathogenesis, classification and treatment of inflammatory myopathies. Nat Rev Rheumatol 2011; 7:297-306. [DOI: 10.1038/nrrheum.2011.39] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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63
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Dalakas MC. Pathophysiology of inflammatory and autoimmune myopathies. Presse Med 2011; 40:e237-47. [PMID: 21411269 DOI: 10.1016/j.lpm.2011.01.005] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2010] [Accepted: 01/04/2011] [Indexed: 11/27/2022] Open
Abstract
The main subtypes of inflammatory myopathies include dermatomyositis (DM), polymyositis (PM), necrotizing autoimmune myositis (NAM) and sporadic inclusion-body myositis (sIBM). The review provides an update on the main clinical characteristics unique to each subset, including fundamental aspects on muscle pathology helpful to assure accurate diagnosis, underlying immunopathomechanisms and therapeutic strategies. DM is a complement-mediated microangiopathy leading to destruction of capillaries, distal hypoperfusion and inflammatory cell stress on the perifascicular regions. NAM is an increasingly recognized subacute myopathy triggered by statins, viral infections, cancer or autoimmunity with macrophages as the final effector cells mediating fiber injury. PM and IBM are characterized by cytotoxic CD8-positive T cells which clonally expand in situ and invade MHC-I-expressing muscle fibers. In IBM, in addition to autoimmunity, there is vacuolization and intrafiber accumulation of degenerative and stressor molecules. Pro-inflammatory mediators, such as gamma interferon and interleukin IL1-β, seem to enhance the accumulation of stressor and amyloid-related misfolded proteins. Current therapies using various immunosuppressive and immunomodulating drugs are discussed for PM, DM and NAM, and the principles for effective treatment strategies in IBM are outlined.
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Affiliation(s)
- Marinos C Dalakas
- National University of Athens Medical School, Department of Pathophysiology, 11527 Athens, Greece.
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65
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66
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Paciello O, Wojcik S, Gradoni L, Oliva G, Trapani F, Iovane V, Politano L, Papparella S. Syrian hamster infected with Leishmania infantum: a new experimental model for inflammatory myopathies. Muscle Nerve 2010; 41:355-61. [PMID: 19813199 DOI: 10.1002/mus.21502] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Idiopathic inflammatory myopathies (IIMs) are inflammatory disorders of unknown origin. On the basis of clinical, histopathological, and immunological features, they can be differentiated into three major and distinct subsets: dermatomyositis; polymyositis; and inclusion-body myositis. Although a few animal models for IIM are currently available, they lack several characteristic aspects of IIMs. The aim of our study was to examine skeletal muscle involvement in an experimental animal model of visceral leishmaniasis, a disseminated infection caused by the protozoan parasite Leishmania infantum, and to compare features of associated inflammation with those of human IIM. Syrian hamsters infected intraperitoneally with amastigotes of L. infantum were killed at 3 or 4 months post-infection, and the skeletal muscles were studied. Focal inflammation was predominantly observed in the endomysium and, to a lesser extent, in perivascular areas. Degenerating muscle fibers were also found, as well as myonecrosis. Immunofluorescence with confocal laser scanning microscopy was used to characterize the phenotype of inflammatory infiltrates and the distribution of MHC class I and II in muscle biopsies. The infiltrating inflammatory cells consisted mainly of T cells, and CD8(+) T cells were found in non-necrotic muscle fibers that expressed MHC class I on the sarcolemma. In addition to T cells, several macrophages were present. The model we are proposing closely resembles polymyositis and may be useful in studying certain aspects of this disease such as the role of T cells in muscle inflammation and myocytotoxicity, while also providing novel therapeutic targets.
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Affiliation(s)
- Orlando Paciello
- Department of Pathology and Animal Health, University of Naples Federico II, Via Delpino 1, 80137 Naples, Italy.
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67
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Dalakas MC. Immunotherapy of myositis: issues, concerns and future prospects. Nat Rev Rheumatol 2010; 6:129-37. [DOI: 10.1038/nrrheum.2010.2] [Citation(s) in RCA: 133] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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69
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Evans NP, Misyak SA, Robertson JL, Bassaganya-Riera J, Grange RW. Immune-mediated mechanisms potentially regulate the disease time-course of duchenne muscular dystrophy and provide targets for therapeutic intervention. PM R 2009; 1:755-68. [PMID: 19695529 DOI: 10.1016/j.pmrj.2009.04.010] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2009] [Revised: 04/23/2009] [Accepted: 04/28/2009] [Indexed: 11/19/2022]
Abstract
Duchenne muscular dystrophy is a lethal muscle-wasting disease that affects boys. Mutations in the dystrophin gene result in the absence of the dystrophin glycoprotein complex (DGC) from muscle plasma membranes. In healthy muscle fibers, the DGC forms a link between the extracellular matrix and the cytoskeleton to protect against contraction-induced membrane lesions and to regulate cell signaling. The absence of the DGC results in aberrant regulation of inflammatory signaling cascades. Inflammation is a key pathological characteristic of dystrophic muscle lesion formation. However, the role and regulation of this process in the disease time-course has not been sufficiently examined. The transcription factor nuclear factor-kappaB has been shown to contribute to the disease process and is likely involved with increased inflammatory gene expression, including cytokines and chemokines, found in dystrophic muscle. These aberrant signaling processes may regulate the early time-course of inflammatory events that contribute to the onset of disease. This review critically evaluates the possibility that dystrophic muscle lesions in both patients with Duchenne muscular dystrophy and mdx mice are the result of immune-mediated mechanisms that are regulated by inflammatory signaling and also highlights new therapeutic directions.
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Affiliation(s)
- Nicholas P Evans
- Department of Human Nutrition, Foods and Exercise, Virginia Polytechnic Institute and State University, Blacksburg, VA 24061-0002, USA.
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70
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Choi JH, Park YE, Kim SI, Kim JI, Lee CH, Park KH, Kim DS. Differential immunohistological features of inflammatory myopathies and dysferlinopathy. J Korean Med Sci 2009; 24:1015-23. [PMID: 19949654 PMCID: PMC2775846 DOI: 10.3346/jkms.2009.24.6.1015] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2008] [Accepted: 12/05/2008] [Indexed: 11/20/2022] Open
Abstract
This study was performed in order to characterize the types of the infiltrating cells, and the expression profiles of major histocompatibility complex (MHC) class I and membrane attack complex (MAC) in patients with inflammatory myopathies and dysferlinopathy. Immunohistochemical stains were performed using monoclonal antibodies against several inflammatory cell types, MHC class I, and MAC in muscles from inflammatory myopathies and dysferlinopathy. There was significant difference in the types of infiltrating cells between polymyositis (PM), dermatomyositis (DM), and dysferlinopathy, including significantly high CD4+/CD8+ T cell ratio and B/T cell ratio in DM. In dysferlinopathy, CD4+ T cells were the most abundant and the proportions of infiltrating cell types were similar to those of DM. MHC class I was expressed in muscle fibers of PM and DM regardless of the presence of inflammatory infiltrates. MAC was expressed in necrotic fibers and vessels of PM and DM. One patient with early stage DM had a MAC deposits on endomysial capillaries. In dysferlinopathy, MAC deposit was also observed on the sarcolemma of nonnecrotic fibers. The analysis of inflammatory cells, MHC class I expressions and MAC deposits may help to differentiate dysferlinopathy from idiopathic inflammatory myopathy.
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Affiliation(s)
- Jae-Hwan Choi
- Department of Neurology, Pusan National University School of Medicine, Yangsan, Korea
| | - Yeong-Eun Park
- Department of Neurology, Pusan National University School of Medicine, Yangsan, Korea
| | - Sung-Il Kim
- Department of Rheumatology, Pusan National University School of Medicine, Yangsan, Korea
- Medical Research Institute, Pusan National University School of Medicine, Yangsan, Korea
| | - Jeong-Il Kim
- Department of Orthopedic Surgery, Pusan National University School of Medicine, Yangsan, Korea
- Medical Research Institute, Pusan National University School of Medicine, Yangsan, Korea
| | - Chang-Hoon Lee
- Department of Pathology, Pusan National University School of Medicine, Yangsan, Korea
- Medical Research Institute, Pusan National University School of Medicine, Yangsan, Korea
| | - Kyu-Hyun Park
- Department of Neurology, Pusan National University School of Medicine, Yangsan, Korea
- Medical Research Institute, Pusan National University School of Medicine, Yangsan, Korea
| | - Dae-Seong Kim
- Department of Neurology, Pusan National University School of Medicine, Yangsan, Korea
- Medical Research Institute, Pusan National University School of Medicine, Yangsan, Korea
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Abstract
The idiopathic inflammatory myopathies (IIM) are systemic autoimmune diseases that have predominant mononuclear inflammatory cell infiltrates in the skeletal muscle. The cells that are typically involved in the pathogenesis of disease are B-lymphocytes, T-lymphocytes, macrophages, dendritic cells, and natural killer cells. However, in addition to these immune cells, cells of nonimmunologic origin, such as myocytes, may be directly involved in the immune response. The local milieu also consists of distinct cytokine and chemokine profiles considered related to type 1 interferon stimulation. Tumor necrosis factor and interleukin 1 are also prominent, proinflammatory cytokines involved in the evolution of IIM. Although the pathologic processes involved in IIM have yet to be fully elucidated, we understand the inflammatory milieu is a model of dynamic flux made of diverse cytokine and chemokine expressions leading to alterations in muscle fiber structure and function.
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Affiliation(s)
- Ann M Reed
- Division of Rheumatology, Departments of Pediatrics and Medicine, Mayo Clinic, Rochester, MN 55905, USA.
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O’Hanlon TP, Miller FW. Genetic risk and protective factors for the idiopathic inflammatory myopathies. Curr Rheumatol Rep 2009; 11:287-94. [DOI: 10.1007/s11926-009-0040-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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73
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Dysregulated intracellular signaling and inflammatory gene expression during initial disease onset in Duchenne muscular dystrophy. Am J Phys Med Rehabil 2009; 88:502-22. [PMID: 19454857 DOI: 10.1097/phm.0b013e3181a5a24f] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Duchenne muscular dystrophy is a debilitating genetic disorder characterized by severe muscle wasting and early death in affected boys. The primary cause of this disease is mutations in the dystrophin gene that result in the absence of the protein dystrophin and the associated dystrophin-glycoprotein complex in the plasma membrane of muscle fibers. In normal muscle, this complex forms a link between the extracellular matrix and the cytoskeleton that is thought to protect muscle fibers from contraction-induced membrane lesions and to regulate cell signaling cascades. Although the primary defect is known, the mechanisms that initiate disease onset have not been characterized. Data collected during early maturation suggest that inflammatory and immune responses are key contributors to disease pathogenesis and may be initiated by aberrant signaling in dystrophic muscle. However, detailed time course studies of the inflammatory and immune processes are incomplete and need to be characterized further to understand the disease progression. The purposes of this review are to examine the possibility that initial disease onset in dystrophin-deficient muscle results from aberrant inflammatory signaling pathways and to highlight the potential clinical relevance of targeting these pathways to treat Duchenne muscular dystrophy.
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Bronner IM, Hoogendijk JE, de Visser M, van de Vlekkert J, Badrising UA, Wintzen AR, Uitdehaag BMJ, Blokland-Fromme M, Leusen JHW, van der Pol WL. Association of the leukocyte immunoglobulin G (Fcγ) receptor IIIa-158V/F polymorphism with inflammatory myopathies in Dutch patients. ACTA ACUST UNITED AC 2009; 73:586-9. [DOI: 10.1111/j.1399-0039.2009.01236.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
PURPOSE OF REVIEW To review progress in areas pertinent to the development of better therapies for the idiopathic inflammatory myopathies. RECENT FINDINGS New classification criteria for the idiopathic inflammatory myopathies have been proposed in an effort to define disease subsets with more uniform prognoses and responses to therapy. Diseases that may mimic the idiopathic inflammatory myopathies can be differentiated more accurately with molecular testing and biochemical and immunohistochemical analysis of muscle tissue. Advances in our understanding of the pathogenesis of the idiopathic inflammatory myopathies have served to identify potential new therapeutic targets. International collaborative study groups have reached consensus on outcome measures and on the optimal design of clinical trials in the idiopathic inflammatory myopathies. Tumor necrosis factor-alpha antagonists, rituximab, and the calcineurin inhibitors are being used to treat the idiopathic inflammatory myopathies, but their efficacy has not yet been tested in randomized clinical trials. SUMMARY Future advances in the development of therapies for the idiopathic inflammatory myopathies have been enabled by recent progress in myositis classification, differential diagnosis, basic science, and clinical trial design. Preliminary studies suggest that calcineurin inhibitors, tumor necrosis factor antagonists, and rituximab may be effective treatments.
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Affiliation(s)
- Alan N Baer
- Division of Allergy, Immunology, and Rheumatology, Department of Medicine, University at Buffalo, SUNY, Erie County Medical Center, Buffalo, New York 14215, USA.
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Serratrice J, Figarella-Branger D, Schleinitz N, Pellissier JF, Serratrice G. Miopatie infiammatorie. Neurologia 2008. [DOI: 10.1016/s1634-7072(08)70522-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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79
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Ishii W, Matsuda M, Shimojima Y, Itoh S, Sumida T, Ikeda SI. Flow cytometric analysis of lymphocyte subpopulations and TH1/TH2 balance in patients with polymyositis and dermatomyositis. Intern Med 2008; 47:1593-9. [PMID: 18797118 DOI: 10.2169/internalmedicine.47.0967] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Polymyositis (PM) and dermatomyositis (DM) are idiopathic inflammatory myopathies; autoimmune mechanisms are thought to play an important role in their pathogenesis. We investigated the immunocytochemical characteristics and Th1/Th2 balance of peripheral blood lymphocytes in PM and DM using flow cytometry. PATIENTS AND METHODS Eight patients with PM and 13 with DM were enrolled in this study. Of these, 8 patients with DM were examined before and after clinical remission. No patients were receiving any treatment for PM or DM at enrollment. Ten healthy subjects were used as controls. RESULTS Patients with PM showed significant increases in CD3+CD4+HLA-DR+ (p<0.01) and CD19+CD23+ cells (p<0.05), and significant decreases in CD3+CD4+ (p<0.005) and CD4+CD45RO+ cells (p<0.05) compared with controls. Patients with DM showed significant increases in CD19+ (p<0.05) and CD19+CD23+ cells (p<0.05), and significant decreases in CD4+CD45RO+ cells (p<0.005) and the CD4+CD45RO+/CD4+CD45RA+ ratio (p<0.005) compared with controls. CD4+interferon (IFN)-gamma+ cells and the intracellular IFN-gamma/interleukin (IL)-4 ratio in CD4+ cells were significantly lower in patients with DM than in those with PM (p<0.05) or controls (p<0.0005 and p<0.001, respectively). The intracellular IFN-gamma/IL-4 ratio in CD4+ cells was significantly increased in DM after clinical remission compared with before (p<0.05). CONCLUSION Both B and helper T cells are activated in peripheral blood of active PM. Th2 cells predominate in peripheral blood of active DM, and the intracellular IFN-gamma/IL-4 ratio in CD4+ cells may be useful as a clinical marker indicating disease activity.
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Affiliation(s)
- Wataru Ishii
- Department of Internal Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, and Department of Transfusion, Shinshu University Hospital, Matsumoto
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80
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Farini A, Meregalli M, Belicchi M, Battistelli M, Parolini D, D'Antona G, Gavina M, Ottoboni L, Constantin G, Bottinelli R, Torrente Y. T and B lymphocyte depletion has a marked effect on the fibrosis of dystrophic skeletal muscles in the scid/mdx mouse. J Pathol 2007; 213:229-38. [PMID: 17668421 DOI: 10.1002/path.2213] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abnormal connective tissue proliferation following muscle degeneration is a major pathological feature of Duchenne muscular dystrophy (DMD), a genetic myopathy due to lack of the sarcolemmal dystrophin protein. Since this fibrotic proliferation is likely to be a major obstacle to the efficacy of future therapies, research is needed to understand and prevent the fibrotic process in order to develop an effective treatment. Murine muscular dystrophy (mdx) is genetically homologous to DMD, and histopatological alterations are comparable to those of the muscles of patients with DMD. To investigate the development of fibrosis, we bred the mdx mouse with the scid immunodepressed mouse and analysed fibrosis histologically; we used ELISA analysis to determine TGF-beta1 expression. Significant reduction of fibrosis and TGF-beta1 expression was found in the muscles of the scid/mdx mice. However, we observed similar centrally located nuclei, necrosis, muscle degeneration and muscle force compared to the mdx animals. These data demonstrate a correlation between the absence of B and T lymphocytes and loss of fibrosis accompanied by reduction of TGF-beta1, suggesting the importance of modulation of the immune system in DMD.
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MESH Headings
- Animals
- B-Lymphocytes/immunology
- Cell Adhesion Molecules/metabolism
- Crosses, Genetic
- Enzyme-Linked Immunosorbent Assay/methods
- Fibrosis/immunology
- Male
- Mice
- Mice, Inbred mdx
- Mice, SCID
- Muscle Fibers, Skeletal/metabolism
- Muscle Fibers, Skeletal/pathology
- Muscle, Skeletal/metabolism
- Muscle, Skeletal/pathology
- Muscle, Skeletal/physiopathology
- Muscular Dystrophy, Animal/immunology
- Muscular Dystrophy, Animal/metabolism
- Muscular Dystrophy, Animal/pathology
- Muscular Dystrophy, Animal/physiopathology
- Muscular Dystrophy, Duchenne/immunology
- Muscular Dystrophy, Duchenne/metabolism
- Muscular Dystrophy, Duchenne/pathology
- Muscular Dystrophy, Duchenne/physiopathology
- Pedigree
- T-Lymphocytes/immunology
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Affiliation(s)
- A Farini
- Fondazione IRCCS Ospedale Maggiore Policlinico of Milan, Department of Neurological Sciences, Dino Ferrari Center, University of Milan, Italy
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81
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Suelves M, Vidal B, Serrano AL, Tjwa M, Roma J, López-Alemany R, Luttun A, de Lagrán MM, Díaz-Ramos A, Díaz MA, Jardí M, Roig M, Dierssen M, Dewerchin M, Carmeliet P, Muñoz-Cánoves P. uPA deficiency exacerbates muscular dystrophy in MDX mice. J Cell Biol 2007; 178:1039-51. [PMID: 17785520 PMCID: PMC2064626 DOI: 10.1083/jcb.200705127] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2007] [Accepted: 08/10/2007] [Indexed: 11/25/2022] Open
Abstract
Duchenne muscular dystrophy (DMD) is a fatal and incurable muscle degenerative disorder. We identify a function of the protease urokinase plasminogen activator (uPA) in mdx mice, a mouse model of DMD. The expression of uPA is induced in mdx dystrophic muscle, and the genetic loss of uPA in mdx mice exacerbated muscle dystrophy and reduced muscular function. Bone marrow (BM) transplantation experiments revealed a critical function for BM-derived uPA in mdx muscle repair via three mechanisms: (1) by promoting the infiltration of BM-derived inflammatory cells; (2) by preventing the excessive deposition of fibrin; and (3) by promoting myoblast migration. Interestingly, genetic loss of the uPA receptor in mdx mice did not exacerbate muscular dystrophy in mdx mice, suggesting that uPA exerts its effects independently of its receptor. These findings underscore the importance of uPA in muscular dystrophy.
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Affiliation(s)
- Mònica Suelves
- Program on Differentiation and Cancer, Center for Genomic Regulation, E-08003, Barcelona, Spain
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82
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Zhao Y, Fedczyna TO, McVicker V, Caliendo J, Li H, Pachman LM. Apoptosis in the skeletal muscle of untreated children with juvenile dermatomyositis: impact of duration of untreated disease. Clin Immunol 2007; 125:165-72. [PMID: 17704000 PMCID: PMC2219965 DOI: 10.1016/j.clim.2007.06.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2007] [Revised: 06/22/2007] [Accepted: 06/25/2007] [Indexed: 10/22/2022]
Abstract
Juvenile dermatomyositis (JDM) is the most common myopathy in children with characteristic skin rash and muscle weakness, in which longer duration of untreated disease was associated with less muscle weakness. The duration of untreated inflammation may alter the apoptotic pathways involved in skeletal muscle damage. Diagnostic muscle biopsies from 14 untreated patients were stained for apoptosis markers. TUNEL-positive nuclei and caspase 3 were detected within the laminin layer, indicating apoptosis of skeletal muscle nuclei. Untreated JDM disease duration greater than 2 months ("long"), was associated with higher Fas-positive cell counts in the perivascular region compared with the "short" disease duration group, 2 months or less. Within the "long" duration group, higher Fas-positive cell counts were positively associated with increased TUNEL-positive nuclei and caspase 3. We conclude that the duration of untreated disease (chronic inflammation) influences the mode of continuing cell damage and death in children with JDM.
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Affiliation(s)
- Yongdong Zhao
- Molecular and Cellular Pathobiology Program, Children's Memorial Research Center, USA
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83
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Lundberg IE, Alexanderson H. Technology Insight: tools for research, diagnosis and clinical assessment of treatment in idiopathic inflammatory myopathies. ACTA ACUST UNITED AC 2007; 3:282-90. [PMID: 17471247 DOI: 10.1038/ncprheum0479] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2006] [Accepted: 02/19/2007] [Indexed: 01/15/2023]
Abstract
Idiopathic inflammatory myopathies, known collectively as myositis, are chronic diseases that cause disability, mainly from muscle weakness, despite the use of immunosuppressive therapies. An improved outcome requires increased knowledge of the key molecular pathways that cause symptoms in muscles and other organs. Technological advances offer promise for improving our understanding of disease mechanisms, and some tools will be helpful in diagnosis and the assessment of therapeutic success. The application of new tools depends on their validation in longitudinal studies using clinical outcome measures combined with assessments of molecular events in affected organs. Clinical outcome measures and definitions of improvement have been developed and validated through the International Myositis Assessment and Clinical Studies collaboration. Some imaging techniques, such as MRI and magnetic resonance spectroscopy of muscles, and high-resolution CT of lungs, can assess changes in local inflammatory activity, among many other aspects of pathology. Changes in protein and gene expression patterns in repeated biopsies from affected organs (muscle, skin and lungs) provide molecular information and allow increasingly precise disease classifications and therapeutic evaluation, but are to date only research tools. This Review focuses on advances in diagnostic and outcome tools and their roles in clinical practice and clinical research in patients with polymyositis and dermatomyositis.
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Affiliation(s)
- Ingrid E Lundberg
- Rheumatology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.
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84
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Benveniste O, Dubourg O, Herson S. [New classifications and pathophysiology of the inflammatory myopathies]. Rev Med Interne 2007; 28:603-12. [PMID: 17462794 DOI: 10.1016/j.revmed.2007.03.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2006] [Revised: 03/03/2007] [Accepted: 03/09/2007] [Indexed: 11/19/2022]
Abstract
SCOPE Review on new classifications of myositis linked with their different pathophysiology. CURRENT SITUATION AND SALIENT POINTS The classification of myositis refined recently, taking into account clinical (such as isolated muscle involvement or not, association with cancer...), immunological (presence or absence of auto-antibodies) and pathological criteria. This new classification has the ability to separate different clinical and physiopathological entities, having actually different prognosis factors. The most common inflammatory myopathies include dermatomyositis (DM), polymyositis (PM), inclusion body myositis (IBM), but also, overlap myositis (defined, among others, by the presence of auto-antibodies), and myositis associated to cancers. These myopathies may be also distinguished by their histological features which also reflect their different underlying pathogeneses. The mechanism of DM is complement-mediated microangiopathy, the inflammatory infiltrate being secondary to ischaemic damage. In PM the muscle fibres are damaged by cytotoxic CD8 T lymphocytes. IBM may be a degenerative disease with accumulation of a variety of proteins within the fibres. The inflammatory infiltrate, which is similar to that seen in PM, may be secondary to accumulated proteins. PERSPECTIVES These diseases with different pathogeny and prognosis should be treated by specific approaches. That is the reason why we initiated specific clinical trials for respectively inclusion body myositis and overlap myositis.
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Affiliation(s)
- O Benveniste
- Service de médecine interne 1, laboratoire de neuropathologie, faculté de médecine Pierre-et-Marie-Curie, Assistance publique-Hôpitaux de Paris, groupe hôpitalier Pitié-Salpêtrière, 75651 Paris cedex 13, France.
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85
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Abstract
Dermatomyositis is an idiopathic inflammatory myopathy with characteristic cutaneous manifestations and proximal muscle weakness. Patients with this condition frequently require treatment for muscular, systemic, and cutaneous involvement; however, the cutaneous symptoms often cause significant morbidity and frustration to patients. The skin lesions of dermatomyositis often persist or recur after treatment of myositis, and there are subsets of patients who have significant cutaneous disease with little or no muscle involvement. Only anecdotal evidence is available for cutaneous treatment, and the approach to therapy is guided by disease severity and refractoriness. First-line therapy for localized disease begins with topical agents such as antipruritics and/or corticosteroids, while widespread disease often requires initial systemic therapy. Antimalarials are generally used for significant skin disease, followed by other anti-inflammatory agents, systemic corticosteroids, corticosteroid-sparing immunosuppressants and, recently, biologics and intravenous immunoglobulin. While there is a recognized absence of randomized prospective clinical trials examining the optimal monotherapy and combination treatment for the cutaneous manifestations of dermatomyositis, we have tried to provide a review of the literature and a systematic approach to dealing with these often refractory and debilitating symptoms.
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Affiliation(s)
- Rhonda D Quain
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
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86
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Dinh HV, McCormack C, Hall S, Prince HM. Rituximab for the treatment of the skin manifestations of dermatomyositis: A report of 3 cases. J Am Acad Dermatol 2007; 56:148-53. [PMID: 17097377 DOI: 10.1016/j.jaad.2006.05.068] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2005] [Revised: 05/23/2006] [Accepted: 05/31/2006] [Indexed: 11/26/2022]
Abstract
Three patients suffering from classic dermatomyositis (juvenile and adult-onset) with prominent recalcitrant skin manifestations are described. All patients demonstrated good control of muscle symptoms on immunosuppressive medications, but their cutaneous disease persisted despite treatment with at least 4 different systemic treatments and topical agents. They were given rituximab, a monoclonal anti-CD20 antibody, achieving a response with minimal side effects. We document our experience with this medication for the cutaneous lesions of dermatomyositis.
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Affiliation(s)
- Hope V Dinh
- Department of Dermatology, St Vincent's Hospital, Melbourne, Australia
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87
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Stone KB, Oddis CV, Fertig N, Katsumata Y, Lucas M, Vogt M, Domsic R, Ascherman DP. Anti–Jo-1 antibody levels correlate with disease activity in idiopathic inflammatory myopathy. ACTA ACUST UNITED AC 2007; 56:3125-31. [PMID: 17763431 DOI: 10.1002/art.22865] [Citation(s) in RCA: 152] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Previous case series have examined the relationship between anti-Jo-1 antibody levels and myositis disease activity, demonstrating equivocal results. Using enzyme-linked immunosorbent assays (ELISAs) and novel measures of myositis disease activity, the current study was undertaken to systematically reexamine the association between anti-Jo-1 antibody levels and various disease manifestations of myositis. METHODS Serum anti-Jo-1 antibody levels were quantified using 2 independent ELISA methods, while disease activity was retrospectively graded using the Myositis Disease Activity Assessment Tool, which measures disease activity in 7 different organ systems via the Myositis Disease Activity Assessment Visual Analog Scale (VAS) and the Myositis Intention-to-Treat Index (MITAX) components. Spearman's rank correlation coefficients and mixed linear regression analysis were used to identify associations between anti-Jo-1 antibody levels and organ-specific disease activity in cross-sectional and longitudinal analyses, respectively. RESULTS Cross-sectional assessment of 81 patients with anti-Jo-1 antibody revealed a modest correlation between the anti-Jo-1 antibody level and the serum creatine kinase (CK) level, as well as muscle and joint disease activity. Correlation coefficients were similar for CK levels (r(s) = 0.38, P = 0.002), myositis VAS (r(s) = 0.36, P = 0.002), and arthritis VAS (r(s) = 0.40, P = 0.001). In multiple regression analyses of 11 patients with serial samples, anti-Jo-1 antibody levels correlated significantly with CK levels (R(2) = 0.65, P = 0.0002), myositis VAS (R(2) = 0.53, P = 0.0008), arthritis VAS (R(2) = 0.53, P = 0.006), pulmonary VAS (R(2) = 0.69, P = 0.005), global VAS (R(2) = 0.63, P = 0.002), and global MITAX (R(2) = 0.64, P = 0.0003). CONCLUSION In this large series of patients with idiopathic inflammatory myopathy, anti-Jo-1 antibody levels correlated modestly with muscle and joint disease, an association confirmed by a custom ELISA using recombinant human Jo-1. More striking associations emerged in a smaller longitudinal subset of patients that link anti-Jo-1 antibody levels to muscle, joint, lung, and global disease activity.
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Affiliation(s)
- Kerry B Stone
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15261, USA
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88
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Dalakas MC. B cells in the pathophysiology of autoimmune neurological disorders: A credible therapeutic target. Pharmacol Ther 2006; 112:57-70. [PMID: 16644016 DOI: 10.1016/j.pharmthera.2006.03.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2006] [Accepted: 03/13/2006] [Indexed: 12/14/2022]
Abstract
There is evidence that B cells are involved in the pathophysiology of many neurological diseases, either in a causative or contributory role, via production of autoantibodies, cytokine secretion, or by acting as antigen-presenting cells leading to T cell activation. Clonal expansion of B cells either in situ or intrathecally and circulating autoantibodies are critical elements in multiple sclerosis (MS), Devic's disease, paraneoplastic central nervous system disorders, stiff-person syndrome, myasthenia gravis, autoimmune demyelinating neuropathies and dermatomyositis. The pathogenic role of B cells and autoantibodies in central and peripheral nervous system disorders, as reviewed here, provides a rationale for investigating whether depletion of B cells with new agents can improve clinical symptomatology and, potentially, restore immune function. Preliminary results from several clinical studies and case reports suggest that B cell depletion may become a viable alternative approach to the treatment of autoimmune neurological disorders.
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Affiliation(s)
- Marinos C Dalakas
- Neuromuscular Diseases Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20892-1382, USA.
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89
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Andreetta F, Bernasconi P, Baggi F, Ferro P, Oliva L, Arnoldi E, Cornelio F, Mantegazza R, Confalonieri P. Immunomodulation of TGF-beta 1 in mdx mouse inhibits connective tissue proliferation in diaphragm but increases inflammatory response: implications for antifibrotic therapy. J Neuroimmunol 2006; 175:77-86. [PMID: 16647144 DOI: 10.1016/j.jneuroim.2006.03.005] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2005] [Revised: 02/14/2006] [Accepted: 03/06/2006] [Indexed: 11/16/2022]
Abstract
Irreversible connective tissue proliferation in muscle is a pathological hallmark of Duchenne muscular dystrophy (DMD), a genetic degenerative muscle disease due to lack of the sarcolemmal protein dystrophin. Focal release of transforming growth factor-beta1 (TGF-beta1) is involved in fibrosis development. Murine muscular dystrophy (mdx) is genetically homologous to DMD and histopathological alterations comparable to those in DMD muscles occur in diaphragm of older mdx mice. To investigate the early development of fibrosis and TGF-beta1 involvement, we assessed diaphragms in 6-36-week-old mdx and C57/BL6 (control) mice for fibrosis, and used real-time PCR and ELISA to determine TGF-beta1 expression. Significantly greater fibrosis and TGF-beta1 expression were found in mdx from the 6th week. Mice treated with neutralizing antibody against TGF-beta1 had lower levels of TGF-beta1 protein, reduced fibrosis, unchanged muscles fiber degeneration/regeneration, but increased inflammatory cells (CD4+lymphocytes). These data demonstrate early and progressive fibrosis in mdx diaphragm accompanied by TGF-beta1 upregulation. Reduction of TGF-beta1 appears promising as a therapeutic approach to muscle fibrosis, but further studies are required to evaluate long term effects of TGF-beta1 immunomodulation on the immune system.
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Affiliation(s)
- Francesca Andreetta
- Department of Neuroimmunology and Neuromuscular Diseases, National Neurological Institute Carlo Besta, via Celoria 11, 20133 Milan, Italy
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90
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Abstract
PURPOSE OF REVIEW Recent work has continued to clarify the role of major histocompatibility complex class I in the pathogenesis of autoimmune myositis. In the past year, several new observations have been made in this area. This review describes these findings and discusses their relevance to the pathogenesis of autoimmune myositis. RECENT FINDINGS Recent studies have confirmed earlier observations of the up-regulation of major histocompatibility complex class I antigens in myositis. In particular, a recent study has strengthened the conclusion that major histocompatibility complex class I expression is highly specific to inflammatory myopathies and may be of diagnostic value. Two new studies have indicated that endoplasmic reticulum stress response pathway (the endoplasmic reticulum overload [NF-kB] and unfolded protein response [GRP78]) are highly activated in patients with myositis. One study using transgenic mice has further indicated that abnormal accumulation of major histocompatibility complex class I in the endoplasmic reticulum of muscle may be responsible for the initiation of this endoplasmic reticulum stress response. Furthermore, studies of normal muscle cells have shown that endoplasmic reticulum stress also plays an important role in skeletal muscle development. Investigations of autoantigen expression in myositis biopsies have revealed that regenerating muscle cells express high levels of autoantigens and major histocompatibility complex class I, indicating that these cells are the targets of cytotoxic T-cell attack and may participate in the initiation of a myositis-specific autoimmune response. SUMMARY Defining the role of major histocompatibility complex class I in autoimmune myositis may be useful not only for diagnosis of this group of diseases but also for therapeutic opportunities for these difficult disorders.
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Affiliation(s)
- Kanneboyina Nagaraju
- Division of Rheumatology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland 21224, USA.
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91
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Takahashi A, Takeda I, Kanno T, Nakahara T, Odajima H, Kasukawa R. CD8-positive T cell-induced liver damage was found in a patient with polymyositis. Intern Med 2006; 45:1059-63. [PMID: 17043378 DOI: 10.2169/internalmedicine.45.1710] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We describe a case of polymyositis (PM) with liver injury that occurred in a patient with rheumatoid arthritis (RA). A 74-year-old woman who had a 12-year history of RA was admitted to our hospital because of muscle weakness and liver dysfunction. CD8-positive T cell infiltration was found in the interstitium of both the liver and muscle. In addition to the administration of a large amount of prednisolone (PSL), high-dose intravenous immunoglobulin (IVIG) successfully improved myositis and hepatitis. Our case indicates the pathogenic potential of CD8-positive T cells in PM-associated liver injury.
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92
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Abstract
Most neuromuscular disorders display only non-specific myopathological features in routine histological preparations. However, a number of proteins, including sarcolemmal, sarcomeric, and nuclear proteins as well as enzymes with defects responsible for neuromuscular disorders, have been identified during the past two decades, allowing a more specific and firm diagnosis of muscle diseases. Identification of protein defects relies predominantly on immunohistochemical preparations and on Western blot analysis. While immunohistochemistry is very useful in identifying abnormal expression of primary protein abnormalities in recessive conditions, it is less helpful in detecting primary defects in dominantly inherited disorders. Abnormal immunohistochemical expression patterns can be confirmed by Western blot analysis which may also be informative in dominant disorders, although its role has yet to be established. Besides identification of specific protein defects, immunohistochemistry is also helpful in the differentiation of inflammatory myopathies by subtyping cellular infiltrates and demonstrating up-regulation of subtle immunological parameters such as cell adhesion molecules. The role of immunohistochemistry in denervating disorders, however, remains controversial in the absence of a reliable marker of muscle fibre denervation. Nevertheless, as well as the diagnostic value of immunocytochemical analysis it may also widen understanding of muscle fibre pathology as well as help in the development of therapeutic strategies.
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Affiliation(s)
- D S Tews
- Edinger-Institute of the Johann-Wolfgang Goethe-University, Frankfurt, Germany.
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93
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Aleksza M, Szegedi A, Antal-Szalmás P, Irinyi B, Gergely L, Ponyi A, Hunyadi J, Sipka S, Zeher M, Szegedi G, Dankó K. Altered cytokine expression of peripheral blood lymphocytes in polymyositis and dermatomyositis. Ann Rheum Dis 2005; 64:1485-9. [PMID: 15829578 PMCID: PMC1755238 DOI: 10.1136/ard.2003.017715] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To investigate the intracellular and soluble cytokine levels and T cell subsets in peripheral blood of patients with active and inactive polymyositis and dermatomyositis. METHODS The frequencies of T and B lymphocytes, T helper (Th), and T cytotoxic (Tc) cells and of interferon gamma (IFNgamma), interleukin (IL)4, and IL10 expression of CD4+ or CD8+ cells were determined by flow cytometry. The concentrations of soluble cytokines were measured with commercial enzyme linked immunosorbent assays. RESULTS In active dermatomyositis there was a decreased percentage of T (CD3+) lymphocytes and Tc (CD8+) lymphocytes, decreased IFNgamma expression of CD4+ and CD8+ cells, but an increase in B and IL4 producing CD4+ lymphocyte frequencies. These prominent changes disappeared in the inactive stage of the disease. In polymyositis no significant change in these lymphocyte subsets or in intracellular cytokine expression could be detected in either the active or the inactive form. The frequency of IL4+/IFNgamma+ Th cells was calculated and a significantly increased Th2/Th1 frequency was found in active dermatomyositis, and a decreased frequency in inactive dermatomyositis, compared with the control population. CONCLUSIONS There appears to be a difference between polymyositis and dermatomyositis in the level of peripheral blood lymphocytes and their intracellular cytokine content. These findings provide further evidence for a difference in the pathogenesis of polymyositis and dermatomyositis.
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Affiliation(s)
- M Aleksza
- Third Department of Internal Medicine, University of Debrecen, Medical and Health Centre, Debrecen, Hungary.
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94
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Gendek EG, Kedziora J, Gendek-Kubiak H. Can tissue transglutaminase be a marker of idiopathic inflammatory myopathies? Immunol Lett 2005; 97:245-9. [PMID: 15752564 DOI: 10.1016/j.imlet.2004.11.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2004] [Revised: 10/27/2004] [Accepted: 11/08/2004] [Indexed: 11/18/2022]
Abstract
In the normal striated muscle, tissue transglutaminase (TG2) content is vestigial. However, this protein's presence has been reported to occur in myoblasts and myotubes during the fetal period. Its increased expression has been also found in the muscle tissue in the course of sporadic inclusion body myositis, as well as in polymyositis (PM) and dermatomyositis (DM), which are considered to be diseases of immunological origin. Based on in vitro studies, a substantial TG2 role in the infiltration of some T cell subsets into inflamed tissues has been suggested lately. In this study, the immunohistochemical reactions in the guinea pig experimental myositis specimens and in the ones from PM/DM patients were compared. The guinea pig tissue specimens were taken from muscles affected by experimental myositis induced by intramuscular injections of: 1/sera from 30 neoplasm patients with no metastases; 2/sera from 10 healthy people; 3/sera from 2 DM patients; 4/neuropeptides (SP, NPY or VIP) and from 5/the muscles affected by the reversed passive Arthus reaction (RPAR). The immunostaining for TG2 revealed substantial presence of this protein in single, damaged muscle fibers and a weak reaction in regenerating fibers appearing in PM/DM patients' specimens. From among experimental myositis specimens, a very intensive reaction appeared only in the damaged and regenerating muscle fibers present in the slides from guinea pig muscles injected with DM patients' sera. Such results suggest some presence of a specific factor(s) (the one(s) responsible for TG2 expression in the damaged muscle fibers) in DM patients' sera. The results suggest that transglutaminase can be a marker of inflammatory myopathies. A probable correlation between TG2 expression in muscles and organismal immunological factors, including the complement activation status, requires additional studies.
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Affiliation(s)
- Ewa G Gendek
- Department of Chemistry and Clinical Biochemistry, Medical University of Lodz, Pl. Hallera 1, 90-647 Lodz, Poland.
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95
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Civatte M, Bartoli C, Schleinitz N, Chetaille B, Pellissier JF, Figarella-Branger D. Expression of the beta chemokines CCL3, CCL4, CCL5 and their receptors in idiopathic inflammatory myopathies. Neuropathol Appl Neurobiol 2005; 31:70-9. [PMID: 15634233 DOI: 10.1111/j.1365-2990.2004.00591.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The idiopathic inflammatory myopathies (IIM) are a group of autoimmune diseases characterized by chronic lymphocytic and macrophagic infiltration in muscle. Because the mechanism for recruitment of these cells probably involves chemokines, we focused on the study of the expression pattern of some beta chemokines and receptors because it may provide a basis for selective immunotherapy. The expression of CCL3 (MIP-1alpha), CCL4 (MIP-1beta), CCL5 (RANTES) and their main receptors (CCR1 and CCR5) was studied by semi-quantitative reverse transcriptase polymerase chain reaction (RT-PCR) and immunohistochemistry in a series of 16 IIM and five controls (four normal muscles and one tonsil). Except for CCL5, strong expression was observed by RT-PCR with all molecules in all IIM subtypes in comparison to control muscle. Immunohistochemistry revealed diffuse CCL4 expression in all vessels in dermatomyositis. In both polymyositis and sporadic inclusion body myositis (s-IBM) it was restricted to vessels in the vicinity of inflammatory exudates. CCL5 expression was low, restricted to a few inflammatory cells in all IIM; CCR1 expression was mainly restricted to macrophages and s-IBM endothelial cells, whereas CCR5 was localized in inflammatory cells invading non-necrotic muscle fibres. Expressions of both receptors were also recorded in few muscle fibres. In conclusion, the upregulation of beta chemokines and receptors in IIM and their differential expression by various cells may contribute to chronic inflammation and to the peculiar distribution of inflammatory exudates in these diseases.
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Affiliation(s)
- M Civatte
- Laboratoire de Biopathologie Nerveuse et Musculaire (EA 3281), Faculté de Médecine Timone, Université de la Méditerranée, Institut de Physiopathologie Humaine de Marseille (I.P.H.M), FR125 Marseille
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96
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Abstract
OBJECTIVE To test the hypothesis that B cells play a role in the pathophysiology of dermatomyositis (DM) by examining the effect of B cell depletion in patients with symptomatic DM. Patients were treated with rituximab, a CD20+ B cell-depleting monoclonal antibody. METHODS This was an open-label uncontrolled pilot trial in 7 adult patients with DM, 6 of whom had longstanding illness that was responding inadequately to a number of currently available immunosuppressive agents. All patients received 4 intravenous infusions of rituximab given at weekly intervals. Patients were followed up for up to 1 year without further treatment with rituximab. One patient was lost to followup. The principal efficacy outcome was muscle strength, measured by quantitative dynomometry. RESULTS All 6 evaluable patients exhibited major clinical improvement, with muscle strength increasing over baseline by 36-113%. Maximal improvements in muscle strength occurred as early as 12 weeks after the initial infusion of rituximab. CD20+ B cells were effectively depleted in all patients by 12 weeks. Four patients experienced a return of symptoms that coincided with the return of B cells before the 52-week end point. Two patients maintained their increased muscle strength at 52 weeks, and 1 of these patients maintained this strength even after the return of B cells. Other symptoms of DM, including rash, alopecia, and reduced forced vital capacity, improved markedly in patients with these symptoms. Rituximab was well tolerated, with no treatment-related severe or serious adverse events during the observation period of this study. CONCLUSION This small open-label study of DM patients treated with rituximab provided sufficiently encouraging results to justify a more formal evaluation of the value of B cell depletion therapy in the treatment of DM.
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Affiliation(s)
- Todd D Levine
- Phoenix Neurological Associates, Phoenix, Arizona 85006, USA.
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97
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Vianna MAAG, Borges CTL, Borba EF, Caleiro MTC, Bonfá E, Marie SKN. Myositis in mixed connective tissue disease: a unique syndrome characterized by immunohistopathologic elements of both polymyositis and dermatomyositis. ARQUIVOS DE NEURO-PSIQUIATRIA 2004; 62:923-34. [PMID: 15608947 DOI: 10.1590/s0004-282x2004000600001] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE: To characterize the inflammatory cells, the expression pattern of adhesion molecules (ICAM-1 and VCAM-1), membrane attack complex (C5b-9), and major histocompatibility complex (MHC) antigens in muscle biopsy of mixed connective tissue disease (MCTD). METHOD: We studied 14 patients with MCTD, and compared to 8 polimyositis (PM) patients, 5 dermatomyositis (DM) and 4 dystrophies. Inflammatory cells were examined for CD4+, CD8+, memory and naïve T cells, natural killer cells, and macrophages. Expression of MHC-I and -II, ICAM-1, VCAM-1 and C5b -9 were characterized on muscle fibers and vessels. RESULTS: Morphological analysis displayed a pattern of PM. Immunohistochemical study revealed a decreased number of capillaries, predominance of CD4+ and B cells in perivascular regions and predominance of CD8+ and CD45RO+ in endomysial regions. The expression of MHC-I on vessels and on degenerated muscle fibers, MHC-II expression on vessels and perifascicular muscle fibers, and the expression of ICAM-1 / VCAM-1 on endothelial cells indicated both vascular and cellular-immune mediated processes causing the muscular lesion. CONCLUSION:Our findings revealed a mixed mechanism in MCTD, both vascular involvement as DM, and cell-mediated like PM.
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Affiliation(s)
- Maria Angela A G Vianna
- Division of Rheumatology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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98
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Nirmalananthan N, Holton JL, Hanna MG. Is it really myositis? A consideration of the differential diagnosis. Curr Opin Rheumatol 2004; 16:684-91. [PMID: 15577605 DOI: 10.1097/01.bor.0000143441.27065.bc] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW The idiopathic inflammatory myopathies are an important and treatable group of disorders. However, the potential toxicity associated with the immune therapeutic regimens used to treat these disorders may be significant; therefore, accurate diagnosis before such treatment is essential. The differential diagnosis is potentially large. Accurate diagnosis usually depends on a combination of careful clinical assessment in conjunction with detailed laboratory investigations. Muscle biopsy remains essential in achieving an accurate diagnosis that will then guide treatment. This review describes the diagnostic approach used. RECENT FINDINGS There has been debate over the requirements for an accurate diagnosis of inflammatory myopathy (i.e., polymyositis and dermatomyositis). It is increasingly recognized that there can be clinical and muscle histopathologic overlap between the features of inflammatory myopathies and those of other muscle disorders, in particular, the genetic muscular dystrophies. Pathologic findings of inflammation and major histocompatibility complex upregulation, although typical of inflammatory myopathies, have been shown to occur in some muscular dystrophies, complicating the diagnostic process. Inclusion body myositis is much less responsive to immunotherapy and is now recognized as the most common acquired muscle disease in those older than 50 years of age. It is likely that genetic muscular dystrophies and inclusion body myositis account for some cases of apparently "treatment-resistant" myositis. SUMMARY A thorough clinical assessment, including a detailed family history, complemented by electromyography and creatine kinase measurements, should be undertaken in any patient with presumed idiopathic inflammatory myopathy. In addition, a muscle biopsy remains essential in all cases. A precise tissue diagnosis confirming features of an active inflammatory process should be achieved before immunosuppressive treatment is commenced. An increasing array of immunocytochemical and histioenzymatic stains now allows a full analysis and will help to confirm or exclude virtually all the differential diagnostic possibilities considered in this review. Electron microscopy may also be valuable in selected cases. Close collaboration between clinicians and muscle pathologists is essential in allowing the most accurate interpretation of myopathologic findings in the clinical context.
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Affiliation(s)
- Niranjanan Nirmalananthan
- Neurogenetics Group, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK
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99
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Benveniste O, Squier W, Boyer O, Hilton-Jones D, Herson S. Physiopathologie des myopathies inflammatoires primitives. Presse Med 2004; 33:1444-50. [PMID: 15611679 DOI: 10.1016/s0755-4982(04)98952-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
COMMON ELEMENTS: Primary inflammatory myopathies consist of dermatomyositis (DM), polymyositis (PM) and inclusion body myositis (IBM). They have certain characteristics in common: progressive muscle weakness and mononuclear inflammatory infiltrates in the muscle. DIFFERENT MECHANISMS: They may be distinguished by their histological features which also reflect their different underlying pathogeneses. The mechanism of DM would be complement-mediated microangiopathy, the inflammatory infiltrate of which would be secondary to ischemic phenomena, whereas in PM the muscle fibres are damaged by cytotoxic CD8 T lymphocytes. The factors triggering-off these two forms of myositis remain unknown. IBM may be a degenerative disease with accumulation of a variety of proteins within the fibres. The inflammatory infiltrate, which is similar to that seen in PM, may be a reaction to accumulated proteins.
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Affiliation(s)
- Olivier Benveniste
- Service de médecine interne 1, Groupe hospitalier Pitié-Salpêtrière, 47-83 boulevard de l'Hôpital, 75651 Paris Cedex 13, France.
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100
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Benveniste O, Herson S, Salomon B, Dimitri D, Trébeden-Nègre H, Jean L, Bon-Durand V, Antonelli D, Klatzmann D, Boyer O. Long-term persistence of clonally expanded T cells in patients with polymyositis. Ann Neurol 2004; 56:867-72. [PMID: 15514965 DOI: 10.1002/ana.20293] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Polymyositis is a CD8(+) T-cell-mediated disease. T-cell clonal expansions are observed at disease onset, but little is known about their persistence over time. Qualitative and quantitative spectratyping demonstrated that PM relapse features dramatically perturbed blood T-cell repertoires but is not associated with the emergence of new T-cell clones. It is striking that patients in remission also maintained all their T-cell repertoire abnormalities. The clonally expanded T-cells displayed a memory phenotype, expressed intracellular perforin, and dramatically responded to IL-2, showing a potential to be reactivated upon appropriate conditions. These results indicate that persistent T-cell clonal expansion is an important feature of polymyositis.
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