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Meer E, Ahmad M, Grob S, Winn BJ. Bilateral Facial Palsy: A Rare Presenting Symptom for Inclusion Body Myositis. Ophthalmic Plast Reconstr Surg 2024; 40:e107-e109. [PMID: 38319192 DOI: 10.1097/iop.0000000000002623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Inclusion body myositis is a common type of inflammatory myopathy among populations over the age of 50 years, classically presenting with weakness and atrophy of the forearms and quadriceps. While a third of patients may eventually present with mild facial weakness, findings of ptosis, facial palsy, or involvement of extraocular muscles are rarely, if ever, seen. The authors describe a unique case of inclusion body myositis in which a patient initially presented with bilateral severe facial palsy and exposure keratitis but minimal limb weakness. While midface weakness, unilateral lagophthalmos, and ptosis have been documented in one reported case, key presenting symptoms of bilateral facial palsy and symmetric paralytic lagophthalmos with corneal exposure have not been presented before. Therefore, this case serves as an important reminder to consider the inclusion body myositis in the differential diagnosis of bilateral facial palsy.
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Affiliation(s)
- Elana Meer
- Department of Ophthalmology, University of California, San Francisco, California, U.S.A
| | - Meleha Ahmad
- Department of Ophthalmology, University of California, San Francisco, California, U.S.A
- Division of Oculofacial Plastic and Orbital Surgery, Department of Ophthalmology, University of California, San Francisco, California, U.S.A
| | - Seanna Grob
- Department of Ophthalmology, University of California, San Francisco, California, U.S.A
- Division of Oculofacial Plastic and Orbital Surgery, Department of Ophthalmology, University of California, San Francisco, California, U.S.A
| | - Bryan J Winn
- Department of Ophthalmology, University of California, San Francisco, California, U.S.A
- Division of Oculofacial Plastic and Orbital Surgery, Department of Ophthalmology, University of California, San Francisco, California, U.S.A
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Fortanier E, Delmont E, Kouton L, Corazza G, Grapperon AM, Verschueren A, Attarian S, Salort-Campana E. Face to Face: deciphering facial involvement in inclusion body myositis. J Neurol 2024; 271:410-418. [PMID: 37740740 DOI: 10.1007/s00415-023-11986-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 08/31/2023] [Accepted: 09/01/2023] [Indexed: 09/25/2023]
Abstract
OBJECTIVE The objective of this study is to evaluate the frequency and characteristics of facial involvement in inclusion body myositis (IBM) patients and to compare it to the one previously described in facioscapulohumeral dystrophy (FSHD) patients. METHODS Thirty-two IBM patients were included and compared to 29 controls and 39 FSHD patients. All participants were recorded in a video as they performed a series of seven facial tasks. Five raters independently assessed facial weakness using both a qualitative evaluation and a semi-quantitative facial weakness score (FWS). RESULTS IBM patients had higher FWS than controls (7.89 ± 7.56 vs 1.06 ± 0.88, p < 0.001). Twenty IBM patients (63%) had a facial weakness with a FWS above the maximum value for controls. All facial tasks were significantly more impaired in IBM patients compared to controls (p < 0.001), task 2 evaluating orbiculari oculi muscle weakness being the most affected. IBM patients with facial weakness reported more swallowing troubles than IBM patients without facial weakness (p = 0.03). FSHD patients displayed higher FWS than IBM patients (12.16 ± 8.37 vs 7.89 ± 7.56, p = 0.01) with more pronounced facial asymmetry (p = 0.01). FWS inter-rater ICC was 0.775. CONCLUSION This study enabled us to estimate the frequency of facial impairment in IBM in more than half of patients, to detail its characteristics and to compare them with those of FSHD patients. The standardized, semi-quantitative FWS is an interesting diagnostic help in IBM as it appeared more sensitive than qualitative evaluation to detect mild facial weakness.
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Affiliation(s)
- Etienne Fortanier
- Referral Centre for Neuromuscular Diseases and ALS (Amyotrophic Lateral Sclerosis), Timone University Hospital, Marseille, France.
| | - Emilien Delmont
- Referral Centre for Neuromuscular Diseases and ALS (Amyotrophic Lateral Sclerosis), Timone University Hospital, Marseille, France
| | - Ludivine Kouton
- Referral Centre for Neuromuscular Diseases and ALS (Amyotrophic Lateral Sclerosis), Timone University Hospital, Marseille, France
| | - Giovanni Corazza
- Referral Centre for Neuromuscular Diseases and ALS (Amyotrophic Lateral Sclerosis), Timone University Hospital, Marseille, France
| | - Aude-Marie Grapperon
- Referral Centre for Neuromuscular Diseases and ALS (Amyotrophic Lateral Sclerosis), Timone University Hospital, Marseille, France
| | - Annie Verschueren
- Referral Centre for Neuromuscular Diseases and ALS (Amyotrophic Lateral Sclerosis), Timone University Hospital, Marseille, France
| | - Shahram Attarian
- Referral Centre for Neuromuscular Diseases and ALS (Amyotrophic Lateral Sclerosis), Timone University Hospital, Marseille, France
- Aix-Marseille University, Inserm, GMGF, Marseille, France
| | - Emmanuelle Salort-Campana
- Referral Centre for Neuromuscular Diseases and ALS (Amyotrophic Lateral Sclerosis), Timone University Hospital, Marseille, France
- Aix-Marseille University, Inserm, GMGF, Marseille, France
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Alamr M, Pinto MV, Naddaf E. Atypical presentations of inclusion body myositis: Clinical characteristics and long-term outcomes. Muscle Nerve 2022; 66:686-693. [PMID: 36052422 DOI: 10.1002/mus.27716] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 08/15/2022] [Accepted: 08/28/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTIONS/AIMS Inclusion body myositis (IBM) typically presents with progressive weakness preferentially involving finger flexors and quadriceps. Atypical presentations have been less commonly reported. Here, we aim to describe the clinical characteristics and long-term outcomes of IBM patients with atypical presentations. METHODS We retrospectively searched the Mayo Clinic medical records to identify IBM patients with atypical disease onset, seen between 2015 and 2020. RESULTS We identified 357 IBM patients, of whom 50 (14%) had an atypical presentation. Thirty-eight patients were diagnosed with IBM because they fulfilled one of the European Neuromuscular Center diagnostic categories at a later stage, 10 had all IBM histopathological features, and 2 were diagnosed on the basis of clinical and laboratory data. The most common presentation was dysphagia (50%), followed by asymptomatic hyperCKemia (24%; CK, creatine kinase), then foot drop (12%). 6% of patients presented with proximal arm weakness, 4% with axial weakness and 4% with facial diplegia. Median time from symptom onset to diagnosis was 9 y. Median age at diagnosis was 70.5 y. 16% of patients needed a walking aid. When tested, 86.5% of patients had impaired swallowing and 56% had elevated cytosolic nucleotidase-1A antibodies. Only 1/26 patients who received immunotherapy had minimal improvement. Upon follow-up, most patients had generalization of their weakness with a decline in their strength summated score of 0.082/mo. DISCUSSION A significant proportion of IBM patients may have an atypical presentation. Recognition of such heterogeneity could improve early diagnosis, prevent unnecessary immunotherapy, and provide insight for future diagnostic criteria development and clinical trials.
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Affiliation(s)
- Mazen Alamr
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Neurology, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Marcus V Pinto
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Elie Naddaf
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
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Naddaf E. Inclusion body myositis: Update on the diagnostic and therapeutic landscape. Front Neurol 2022; 13:1020113. [PMID: 36237625 PMCID: PMC9551222 DOI: 10.3389/fneur.2022.1020113] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 09/12/2022] [Indexed: 11/13/2022] Open
Abstract
Inclusion body myositis (IBM) is a progressive muscle disease affecting patients over the age of 40, with distinctive clinical and histopathological features. The typical clinical phenotype is characterized by prominent involvement of deep finger flexors and quadriceps muscles. Less common presentations include isolated dysphagia, asymptomatic hyper-CKemia, and axial or limb weakness beyond the typical pattern. IBM is associated with marked morbidity as majority of patients eventually become wheelchair dependent with limited use of their hands and marked dysphagia. Furthermore, IBM mildly affects longevity with aspiration pneumonia and respiratory complications being the most common cause of death. On muscle biopsy, IBM is characterized by a peculiar combination of endomysial inflammation, rimmed vacuoles, and protein aggregation. These histopathological features are reflective of the complexity of underlying disease mechanisms. No pharmacological treatment is yet available for IBM. Monitoring for swallowing and respiratory complications, exercise, and addressing mobility issues are the mainstay of management. Further research is needed to better understand disease pathogenesis and identify novel therapeutic targets.
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Triplett JD, Pinto MV, Hosfield EA, Milone M, Liewluck T. Myopathies featuring early or prominent dysphagia. Muscle Nerve 2020; 62:344-350. [PMID: 32510670 DOI: 10.1002/mus.26996] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 05/26/2020] [Accepted: 05/30/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Limited data exist regarding myopathies with early or prominent dysphagia. METHODS A retrospective study was performed (January 2003 to August 2019) to identify myopathy patients in whom dysphagia was the initial symptom or was disproportionately severe compared with limb weakness. RESULTS Thirty-two patients were identified. The median age at diagnosis was 65 y (range, 36-80 y). Inclusion body myositis (IBM) (n = 15), immune-mediated necrotizing myopathy (IMNM) (n = 5), and oculopharyngeal muscular dystrophy (n = 4), were the most common diagnoses. In 4 patients (3 IMNM and 1 nonspecific myositis) dysphagia evolved rapidly. At evaluation, 21 patients required diet alterations, 5 required feeding tubes, and 8 had aspiration pneumonia. Follow-up data were available for 20 patients (median, 24 mo). Eight patients received immunosuppressive therapies with improvement in 7, including 3 of 4 with rapidly progressive dysphagia. CONCLUSIONS IBM and IMNM accounted for approximately two-thirds of patients with early or prominent dysphagia at our institution. Rapidly progressive dysphagia may predict immunotherapy responsiveness.
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Affiliation(s)
- James D Triplett
- Division of Neuromuscular Medicine, Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | - Marcus V Pinto
- Division of Neuromuscular Medicine, Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | - Emily A Hosfield
- Division of Speech Pathology, Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | - Margherita Milone
- Division of Neuromuscular Medicine, Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | - Teerin Liewluck
- Division of Neuromuscular Medicine, Department of Neurology, Mayo Clinic, Rochester, Minnesota
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Cummins G, O'Donovan D, Molyneux A, Stacpoole S. Facial diplegia as the presenting symptom of inclusion body myositis. Muscle Nerve 2019; 60:E14-E16. [PMID: 31095754 DOI: 10.1002/mus.26514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 05/02/2019] [Accepted: 05/11/2019] [Indexed: 11/09/2022]
Affiliation(s)
- Gemma Cummins
- Department of Clinical Neuroscience, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Dominic O'Donovan
- Department of Clinical Neuroscience, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Adam Molyneux
- Department of Clinical Neurophysiology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Headington, Oxford, UK
| | - Sybil Stacpoole
- Department of Clinical Neuroscience, Peterborough Hospital, North West Anglia NHS Foundation Trust and Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
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Naddaf E, Barohn RJ, Dimachkie MM. Inclusion Body Myositis: Update on Pathogenesis and Treatment. Neurotherapeutics 2018; 15:995-1005. [PMID: 30136253 PMCID: PMC6277289 DOI: 10.1007/s13311-018-0658-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Inclusion body myositis is the most common acquired myopathy after the age of 50. It is characterized by progressive asymmetric weakness predominantly affecting the quadriceps and/or finger flexors. Loss of ambulation and dysphagia are major complications of the disease. Inclusion body myositis can be associated with cytosolic 5'-nucleotidase 1A antibodies. Muscle biopsy usually shows inflammatory cells surrounding and invading non-necrotic muscle fibers, rimmed vacuoles, congophilic inclusions, and protein aggregates. Disease pathogenesis remains poorly understood and consists of an interplay between inflammatory and degenerative pathways. Antigen-driven, clonally restricted, cytotoxic T cells represent a main feature of the inflammatory component, whereas abnormal protein homeostasis with protein misfolding, aggregation, and dysfunctional protein disposal is the hallmark of the degenerative component. Inclusion body myositis remains refractory to treatment. Better understanding of the disease pathogenesis led to the identification of novel therapeutic targets, addressing both the inflammatory and degenerative pathways.
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Affiliation(s)
- Elie Naddaf
- Neuromuscular Medicine Division, Department of Neurology, Mayo Clinic, Rochester, Minnesota, 55905, USA
| | - Richard J Barohn
- Neuromuscular Medicine Division, Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, 66103, USA
| | - Mazen M Dimachkie
- Neuromuscular Medicine Division, Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, 66103, USA.
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Milone M. Diagnosis and Management of Immune-Mediated Myopathies. Mayo Clin Proc 2017; 92:826-837. [PMID: 28473041 DOI: 10.1016/j.mayocp.2016.12.025] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Revised: 12/17/2016] [Accepted: 12/28/2016] [Indexed: 01/02/2023]
Abstract
Immune-mediated myopathies (IMMs) are a heterogeneous group of acquired muscle disorders characterized by muscle weakness, elevated creatine kinase levels, and myopathic electromyographic findings. Most IMMs feature the presence of inflammatory infiltrates in muscle. However, the inflammatory exudate may be absent. Indeed, necrotizing autoimmune myopathy (NAM), also called immune-mediated necrotizing myopathy, is characterized by a necrotizing pathologic process with no or minimal inflammation in muscle. The recent discovery of antibodies associated with specific subtypes of autoimmune myopathies has played a major role in characterizing these diseases. Although diagnostic criteria and classification of IMMs currently are under revision, on the basis of the clinical and muscle histopathologic findings, IMMs can be differentiated as NAM, inclusion body myositis (IBM), dermatomyositis, polymyositis, and nonspecific myositis. Because of recent developments in the field of NAM and IBM and the controversies around polymyositis, this review will focus on NAM, IBM, and dermatomyositis.
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Affiliation(s)
- Margherita Milone
- Neuromuscular Medicine Division, Department of Neurology, Mayo Clinic, Rochester, MN.
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Abstract
OBJECTIVE Inclusion body myositis (IBM) is the most common form of idiopathic inflammatory myopathy in adults older than 50 years. Few studies have focused on the functional, physical, and social limitations of this disease. This study identifies pertinent symptoms that impact the health and daily function of patients with IBM. METHODS We used semistructured interviews with 10 biopsy-confirmed adults with IBM to identify the psychological, physical, and functional limitations that have the greatest impact on the lives of patients with IBM. RESULTS Participants with IBM provided 644 direct quotes identifying issues that have the greatest effect on their lives. Two hundred nine individual symptoms and 17 symptomatic themes were identified by patients as having a significant impact on their lives. The symptomatic themes mentioned most frequently involved mobility and ambulation, emotional distress, and activity impairment. CONCLUSIONS Identifying critical issues to patients with IBM is potentially useful for clinicians whose aim is to provide optimal care to patients with IBM.
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Abstract
Inclusion body myositis (IBM) was first identified as a specific disorder about 40 years ago and is now recognized to be the most frequently presenting primary myopathy in middle age and beyond. Initial characterization was based on the observation of specific pathological features distinguishing it from polymyositis. It was soon appreciated that there were also distinguishing clinical features. The earliest diagnostic criteria were heavily biased towards pathological features, but over time revised criteria have given increasing importance to certain clinical features. Until the specific cause of IBM is determined, and the basic pathogenetic mechanisms are better understood, there can be no diagnostic gold-standard against which to compare the sensitivity and specificity of any proposed diagnostic criteria, but such criteria are essential to ensure that patients entering clinical, epidemiological, genetic, pathological or therapeutic studies represent a homogeneous population. It is likely that any currently accepted diagnostic criteria will, once a gold-standard is eventually established, be shown to have 'missed' patients with atypical features, but that has to be accepted to make certain that current studies are not contaminated by patients who do not have IBM. In other words, in everyday clinical practice there will be the occasional patient who an experienced myologist strongly suspects has IBM, but does not meet current criteria - the criteria lack sensitivity. But if the criteria are so broad as to include all such atypical cases, they would be likely to include patients who do not in fact have IBM - they would lack specificity. The sensitivity and specificity of existing criteria have been reviewed recently, in so far as it is possible to do so, and found to have high specificity but variable sensitivity.
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Affiliation(s)
- D Hilton-Jones
- Department of Neurology, John Radcliffe Hospital, Oxford, UK
| | - S Brady
- Department of Neurology, John Radcliffe Hospital, Oxford, UK
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Needham M, Mastaglia FL. Sporadic inclusion body myositis: A review of recent clinical advances and current approaches to diagnosis and treatment. Clin Neurophysiol 2015; 127:1764-73. [PMID: 26778717 DOI: 10.1016/j.clinph.2015.12.011] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 12/08/2015] [Accepted: 12/13/2015] [Indexed: 01/01/2023]
Abstract
Sporadic inclusion body myositis is the most frequent acquired myopathy of middle and later life and is distinguished from other inflammatory myopathies by its selective pattern of muscle involvement and slowly progressive course, and by the combination of inflammatory and degenerative muscle pathology and multi-protein deposits in muscle tissue. This review summarises the findings of recent studies that provide a more complete picture of the clinical phenotype and natural history of the disease and its global prevalence and genetic predisposition. Current diagnostic criteria, including the role of electrophysiological and muscle imaging studies and the recently identified anti-5'-nucleotidase (anti-cN1A) antibody in diagnosis are also discussed as well as current trends in the treatment of the disease.
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Affiliation(s)
- Merrilee Needham
- Institute for Immunology and Infectious Diseases, Murdoch University, Western Australia, Australia; Fiona Stanley Hospital, Murdoch, Western Australia, Australia; Notre Dame University, Fremantle, Western Australia, Australia.
| | - Frank L Mastaglia
- Institute for Immunology and Infectious Diseases, Murdoch University, Western Australia, Australia
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Ghosh PS, Milone M. Camptocormia as presenting manifestation of a spectrum of myopathic disorders. Muscle Nerve 2015; 52:1008-12. [DOI: 10.1002/mus.24689] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Revised: 03/29/2015] [Accepted: 04/13/2015] [Indexed: 12/13/2022]
Affiliation(s)
- Partha S. Ghosh
- Department of Neurology; Boston Children's Hospital; Boston Massachusetts USA
- Department of Neurology; Mayo Clinic; 200 First Street SW Rochester Minnesota 55905 USA
| | - Margherita Milone
- Department of Neurology; Mayo Clinic; 200 First Street SW Rochester Minnesota 55905 USA
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Abstract
The idiopathic inflammatory myopathies (IIMs) are a heterogeneous group of rare disorders that share many similarities. In addition to sporadic inclusion body myositis (IBM), these include dermatomyositis, polymyositis, and autoimmune necrotizing myopathy. IBM is the most common IIM after age 50 years. Muscle histopathology shows endomysial inflammatory exudates surrounding and invading nonnecrotic muscle fibers often accompanied by rimmed vacuoles and protein deposits. It is likely that IBM is has a prominent degenerative component. This article reviews the evolution of knowledge in IBM, with emphasis on recent developments in the field, and discusses ongoing clinical trials.
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