1
|
Suh J, Amato AA. Management of immune-mediated necrotizing myopathy. Muscle Nerve 2024; 70:166-172. [PMID: 38801022 DOI: 10.1002/mus.28114] [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: 01/25/2024] [Revised: 04/14/2024] [Accepted: 04/23/2024] [Indexed: 05/29/2024]
Abstract
The immune-mediated necrotizing myopathies (IMNM) are autoimmune myositides clinically characterized by proximal predominant weakness and elevated creatine kinase (CK). They may be associated with autoantibodies (anti-HMGCR, anti-SRP), triggered by statin use (e.g., anti-HMGCR myopathy), associated with cancer, or may be idiopathic. Immunotherapy is required to improve strength and decrease the CK level, but no therapies are currently approved by the U.S. Food and Drug Administration for the treatment of IMNM. The optimal treatment strategy for IMNM is currently unknown and wide practice variation exists in the management of this condition. However, observational studies and expert opinion suggest that certain therapies may be more effective for the different serological subtypes of IMNM. HMGCR IMNM often responds favorably to intravenous immunoglobulin (IVIG) even as monotherapy. Signal recognition peptide and seronegative IMNM typically require combination immunotherapy, most often consisting of an oral immunosuppressant, corticosteroids, and IVIG or rituximab. Patients often remain on immunotherapy for years and relapse is common during tapering of immunotherapy. Further studies are needed to guide the optimal management of these patients.
Collapse
Affiliation(s)
- Joome Suh
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anthony A Amato
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
2
|
Koumas C, Michelassi F. Immune-Mediated Necrotizing Myopathies: Current Landscape. Curr Neurol Neurosci Rep 2024; 24:141-150. [PMID: 38589696 DOI: 10.1007/s11910-024-01337-y] [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] [Accepted: 03/11/2024] [Indexed: 04/10/2024]
Abstract
PURPOSE OF REVIEW Immune-mediated necrotizing myopathy (IMNM), characterized by acute or subacute onset, severe weakness, and elevated creatine kinase levels, poses diagnostic and therapeutic challenges. This article provides a succinct overview of IMNM, including clinical features, diagnostic strategies, and treatment approaches. RECENT FINDINGS Recent insights highlight the different clinical presentations and therapeutic options of IMNM stratified by autoantibody positivity and type. Additionally, recent findings call into question the reported link between statin use and IMNM. This review synthesizes current knowledge on IMNM, emphasizing its distinct clinical features and challenging management. The evolving understanding of IMNM underscores the need for a comprehensive diagnostic approach that utilizes a growing range of modalities. Early and aggressive immunomodulatory therapy remains pivotal. Ongoing research aims to refine diagnostic tools and therapeutic interventions for this challenging muscle disorder, underscoring the importance of advancing our understanding to enhance patient outcomes.
Collapse
Affiliation(s)
- Christoforos Koumas
- Department of Neurology, Columbia University Medical Center, New York, NY, USA.
| | | |
Collapse
|
3
|
Mali M, Pirilä L, Perander L, Gardberg M, Jokela M. Identical twins with statin-associated anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase autoantibody-positive autoimmune myopathy. Scand J Rheumatol 2024; 53:81-82. [PMID: 38090763 DOI: 10.1080/03009742.2023.2289729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 11/28/2023] [Indexed: 12/29/2023]
Affiliation(s)
- M Mali
- Centre for Rheumatology and Clinical Immunology, Turku University Hospital, Turku, Finland
- University of Turku, Turku, Finland
| | - L Pirilä
- Centre for Rheumatology and Clinical Immunology, Turku University Hospital, Turku, Finland
- University of Turku, Turku, Finland
| | - L Perander
- Centre for Rheumatology and Clinical Immunology, Turku University Hospital, Turku, Finland
- University of Turku, Turku, Finland
- Åland's Health Care, Mariehamn, Finland
| | - M Gardberg
- TYKS Laboratories, Department of Pathology, Turku University Hospital, Turku, Finland
- Institute of Biomedicine, University of Turku, Turku, Finland
| | - M Jokela
- Neurocenter, Turku University Hospital, Turku, Finland
- Department of Neurology, University of Turku, Turku, Finland
- Neuromuscular Center, Tampere University Hospital, Tampere, Finland
| |
Collapse
|
4
|
Khoo T, Chinoy H. Anti-HMGCR immune-mediated necrotising myopathy: Addressing the remaining issues. Autoimmun Rev 2023; 22:103468. [PMID: 37884200 DOI: 10.1016/j.autrev.2023.103468] [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: 10/02/2023] [Accepted: 10/23/2023] [Indexed: 10/28/2023]
Abstract
The discovery of autoantibodies directed against the 3-hydroxy-3-methylglutaryl-CoA reductase (HMGCR) enzyme has defined a sub-set of immune-mediated necrotising myopathy (IMNM) which is strongly associated with exposure to statin medications. Although understanding of anti-HMGCR IMNM has grown considerably with the reporting of multiple cohorts in North America, Europe, Asia and Oceania, there remain many unanswered questions. The true incidence of anti-HMGCR IMNM is not known and heterogeneity of phenotype and treatment response within this autoantibody sub-group is being increasingly recognised. Statin-naïve adults and juvenile patients with anti-HMGCR potentially share characteristics distinct from statin-exposed patients, alluding to unique pathogenesis. Conflicting data exists on whether malignancies are associated with anti-HMGCR and further clarification is required to determine the degree of cancer screening required. Treatment approaches to anti-HMGCR IMNM are heterogeneous but generally highlight the efficacy of intravenous immunoglobulin. Even with multimodal immunosuppression, patients with anti-HMGCR remain prone to relapse, with younger patients generally manifesting more refractory disease. In this Review, we aim to summarise the current literature on anti-HMGCR and discuss the remaining issues.
Collapse
Affiliation(s)
- Thomas Khoo
- Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; School of Medicine, Faculty of Health and Medical Sciences, The University of Adelaide, South Australia, Australia; Department of Rheumatology, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Salford, United Kingdom.
| | - Hector Chinoy
- Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Department of Rheumatology, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Salford, United Kingdom
| |
Collapse
|
5
|
Khoo T, Lilleker JB, Thong BYH, Leclair V, Lamb JA, Chinoy H. Epidemiology of the idiopathic inflammatory myopathies. Nat Rev Rheumatol 2023; 19:695-712. [PMID: 37803078 DOI: 10.1038/s41584-023-01033-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2023] [Indexed: 10/08/2023]
Abstract
The idiopathic inflammatory myopathies (IIMs) are a heterogeneous group of systemic autoimmune diseases that affect the skeletal muscles and can also involve the skin, joints, lungs and heart. The epidemiology of IIM is obscured by changing classification criteria and the inherent shortcomings of case identification using healthcare record diagnostic coding. The incidence of IIM is estimated to range from 0.2 to 2 per 100,000 person-years, with prevalence from 2 to 25 per 100,000 people. Although the effects of age and gender on incidence are known, there is only sparse understanding of ethnic differences, particularly in indigenous populations. The incidence of IIM has reportedly increased in the twenty-first century, but whether this is a genuine increase is not yet known. Understanding of the genetic risk factors for different IIM subtypes has advanced considerably. Infections, medications, malignancy and geography are also commonly identified risk factors. Potentially, the COVID-19 pandemic has altered IIM incidence, although evidence of this occurrence is limited to case reports and small case series. Consideration of the current understanding of the epidemiology of IIM can highlight important areas of interest for future research into these rare diseases.
Collapse
Affiliation(s)
- Thomas Khoo
- Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- School of Medicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Rheumatology, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Salford, UK
| | - James B Lilleker
- Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Manchester Centre for Clinical Neuroscience, Manchester Academic Health Science Centre, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Bernard Yu-Hor Thong
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Valérie Leclair
- Department of Medicine, Division of Rheumatology, McGill University, Montreal, Canada
| | - Janine A Lamb
- Epidemiology and Public Health Group, School of Health Sciences, The University of Manchester, Manchester, UK
| | - Hector Chinoy
- Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.
- Department of Rheumatology, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Salford, UK.
| |
Collapse
|
6
|
Abstract
PURPOSE OF REVIEW The global spread of severe acute respiratory syndrome coronavirus 2 resulted in many cases of acute and postacute muscular symptoms. In this review, we try to decipher the potential underlying pathomechanisms and summarize the potential links between viral infection and muscle affection. RECENT FINDINGS Disregarding single case studies that do not allow safe conclusions due to the high number of infections, histopathological evidence of myositis has only been reported in deceased individuals with severe COVID-19. Postacute myalgia and weakness seem to occur in a subset of patients up to one year after initial infection, reminiscent of postinfectious syndromes (PIS) described in prior epidemics and pandemics of the past. SUMMARY COVID-19 associated myopathy likely comprises different entities with heterogeneous pathomechanisms. Individual factors such as disease severity and duration, age, sex, constitutional susceptibilities, and preexisting conditions are important to consider when formulating a diagnosis. Persisting symptoms show overlapping features with PIS or postintensive care syndrome. In lack of strong evidence for a direct infection of myocytes, inflammatory myopathies associated with COVID-19 are presumably immune-mediated. Differential diagnosis of rheumatological and nonmuscular neurological origin coinciding with the infection need to be considered, due to the extremely high numbers of newly occurring infections the last 2 years.
Collapse
Affiliation(s)
- Tom Aschman
- Department of Neuropathology, Charité - Universitätsmedizin, Berlin, Germany
| | | |
Collapse
|
7
|
What Is in the Myopathy Literature? J Clin Neuromuscul Dis 2022; 24:38-48. [PMID: 36005472 DOI: 10.1097/cnd.0000000000000428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT We cover intensive care unit-acquired neuromuscular disorders associated with coronavirus disease 2019. Outcomes may be worse than expected in these patients, and there is some evidence that coronavirus disease 2019 causes myopathy directly. Corticosteroid regimens in Duchenne muscular dystrophy are addressed including outcomes in pulmonary and cardiac function. A recent article notes a continued diagnostic delay in Duchenne muscular dystrophy. An interesting report of a Canary Islands cohort of patients with oculopharyngeal muscular dystrophy is discussed. Features and clinical pearls related to a series of patients with limb-girdle muscle dystrophy R12 (anoctaminopathy) and a misdiagnosis of idiopathic inflammatory myopathy are provided. The last section on autoimmune myopathy includes articles on clinical and pathologic features associated with myositis-specific antibodies and dermatomyositis, the epidemiology of immune-mediated necrotizing myopathies (IMNMs) in Olmsted County, Minnesota, and features of a German cohort of hydroxy-3-methylglutaryl coenzyme A reductase-associated IMNM. A recent article proposes the benefit of early intravenous immunoglobulin use for adults with IMNM. We also highlight a report of 2 unusual cases of antisignal recognition particle myopathy presenting with asymmetric distal weakness.
Collapse
|
8
|
Nicolau S, Milone M, Liewluck T. Reply to: Atypical presentations of immune-mediated necrotizing myopathy: Clues and caveats. Muscle Nerve 2022; 65:E30-E31. [PMID: 35373841 DOI: 10.1002/mus.27549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 02/23/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Stefan Nicolau
- Department of Neurology, Mayo Clinic, Rochester, Minnesota.,Center for Gene Therapy, Abigail Wexner Research institute, Nationwide Children's Hospital, Columbus, Ohio
| | | | | |
Collapse
|
9
|
Yeo CH, Yaakub A, Wang MCL, Shim SA, Chong PL, Khalil MAM, Telisinghe PU, Lim KC, Tan J, Chong VH. Refractory Statin-Induced Immune-Mediated Necrotizing Myositis: Challenges and Perils in Its Management. Cureus 2022; 14:e24778. [PMID: 35676976 PMCID: PMC9167579 DOI: 10.7759/cureus.24778] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2022] [Indexed: 12/22/2022] Open
Abstract
Statin or 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR) inhibitor is widely used and plays a vital role in the management of cardiovascular and cerebrovascular diseases. Statin is generally safe and its side effects are mostly mild and self-limiting. Immune-mediated necrotizing myositis (IMNM) is a rare and serious side effect characterized by the presence of anti-HMGCR inhibitor and myositis. Long-term immunosuppressive therapy is often required to manage it, and in refractory cases, the treatment can be very challenging. We report the case of a 55-year-old female with underlying diabetes mellitus and hyperlipidemia who developed refractory statin-induced IMNM despite being administered prednisolone, methotrexate, azathioprine, and immunoglobulin. After the introduction of rituximab, steroids were able to be tapered down to the lowest maintenance dose. Unfortunately, the patient subsequently succumbed to severe coronary artery disease (CAD) likely caused by the long-term steroid therapy, highlighting the difficulty and complications associated with the treatment of IMNM, especially in patients with cardiovascular risk factors.
Collapse
Affiliation(s)
- Chong Hsien Yeo
- Department of Medicine, Raja Isteri Pengiran Anak Saleha Hospital, Bandar Seri Begawan, BRN
| | - Aziman Yaakub
- Department of Medicine, Raja Isteri Pengiran Anak Saleha Hospital, Bandar Seri Begawan, BRN
| | | | - Sylvester Andrew Shim
- Department of Medicine, Raja Isteri Pengiran Anak Saleha Hospital, Bandar Seri Begawan, BRN
| | - Pui L Chong
- Department of Medicine, Raja Isteri Pengiran Anak Saleha Hospital, Bandar Seri Begawan, BRN
| | | | - Pemasiri U Telisinghe
- Department of Pathology, Raja Isteri Pengiran Anak Saleha Hospital, Bandar Seri Begawan, BRN
| | - Kian C Lim
- Department of Radiology, Raja Isteri Pengiran Anak Saleha Hospital, Bandar Seri Begawan, BRN
| | - Jackson Tan
- Department of Renal Medicine, Raja Isteri Pengiran Anak Saleha Hospital, Bandar Seri Begawan, BRN
| | - Vui H Chong
- Department of Medicine, Raja Isteri Pengiran Anak Saleha Hospital, Bandar Seri Begawan, BRN.,Department of Medicine, Pengiran Muda Mahkota Pengiran Muda Haji Al-Muhtadee Billah Hospital, Tutong, BRN
| |
Collapse
|