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Kamperman RG, Bogaards JA, Evers SW, Walter HAW, de Visser M, de Borgie C, Colen-de Koning JCA, Verhamme C, Maas M, Eftimov F, van Schaik IN, van der Kooi AJ, Raaphorst J. Treatment with add-on IVIg in Myositis Early In the diSease course May be sUperior to Steroids alone for reaching CLinical improvEment (TIME IS MUSCLE): study protocol of a phase-2 double-blind placebo-controlled randomised trial. BMJ Open 2023; 13:e067435. [PMID: 37429682 DOI: 10.1136/bmjopen-2022-067435] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/12/2023] Open
Abstract
INTRODUCTION For idiopathic inflammatory myopathies (IIM) ('myositis') standard initial treatment is high-dosed glucocorticoids, which results in relatively slow improvement of muscle strength. Early immunosuppression or modulation by intensive treatment ('hit-early, hit-hard') may induce faster reduction of disease activity and prevent chronic disability due to disease-induced structural muscle damage. Intravenous immunoglobulin (IVIg) in addition to standard glucocorticoid treatment may be promising in this regard as was shown in various studies: add-on IVIg improved symptoms and muscle strength in refractory myositis patients and monotherapy IVIg improved outcomes after 9 weeks, in about half of treatment-naive patients. HYPOTHESIS We hypothesise that early add-on IVIg leads to a greater clinical response after 12 weeks in patients with newly diagnosed myositis, in comparison to prednisone monotherapy. Second, we expect that early treatment with add-on IVIg leads to a faster time to improvement and sustained positive effects on multiple secondary outcomes. METHODS The Time Is Muscle trial is a phase-2 double-blind placebo-controlled randomised trial. Forty-eight patients with IIM will be treated with IVIg or placebo at baseline (within 1 week after diagnosis) and after 4 and 8 weeks, in addition to standard therapy with prednisone. The primary outcome is the Total Improvement Score (TIS) of the myositis response criteria at 12 weeks. At baseline, and after 4, 8, 12, 26 and 52 weeks, relevant secondary outcomes will be assessed, including time to moderate improvement (TIS≥40), mean daily prednisone dosage, physical activity, health-related quality of life, fatigue and MRI muscle imaging parameters. ETHICS AND DISSEMINATION Ethical approval was obtained from the medical ethics committee of the Academic Medical Centre, University of Amsterdam, the Netherlands (2020_180; including a first amendment approval at the 12 April 2023; A2020_180_0001). The results will be distributed through conference presentations and peer-reviewed publications. TRIAL REGISTRATION NUMBER EU Clinical trials register (2020-001710-37).
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Affiliation(s)
- Renske G Kamperman
- Department of Neurology and Clinical Neurophysiology, Amsterdam UMC Locatie AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Johannes A Bogaards
- Department of Epidemiology and Data Science, Amsterdam UMC - Locatie AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Sanne W Evers
- Department of Neurology and Clinical Neurophysiology, Amsterdam UMC Locatie AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Hannah A W Walter
- Department of Neurology and Clinical Neurophysiology, Amsterdam UMC Locatie AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marianne de Visser
- Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Corianne de Borgie
- Department of Epidemiology and Data Science, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Jantine C A Colen-de Koning
- Department of Clinical Pharmacy, Amsterdam UMC - Locatie AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Camiel Verhamme
- Department of Neurology and Clinical Neurophysiology, Amsterdam UMC Locatie AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Mario Maas
- Department of Radiology and Nuclear Medicine, Amsterdam UMC - Locatie AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Filip Eftimov
- Department of Neurology and Clinical Neurophysiology, Amsterdam UMC Locatie AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ivo N van Schaik
- Department of Neurology and Clinical Neurophysiology, Amsterdam UMC Locatie AMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Neurology, Sanquin Blood Supply Foundation, Amsterdam, The Netherlands
| | - Anneke J van der Kooi
- Department of Neurology and Clinical Neurophysiology, Amsterdam UMC Locatie AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Joost Raaphorst
- Department of Neurology and Clinical Neurophysiology, Amsterdam UMC Locatie AMC, University of Amsterdam, Amsterdam, The Netherlands
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Abstract
BACKGROUND AND OBJECTIVES Treatment of severe dermatological autoimmune diseases and toxic epidermal necrolysis (TEN) with high-dose intravenous immunoglobulin (IVIg) is a well-established procedure in dermatology. As treatment with IVIg is usually considered for rare clinical entities or severe cases, the use of immunoglobulin is not generally based on data from randomized controlled trials usually required for evidence-based medicine. Since the indications for the use of IVIg are rare, it is unlikely that such studies will be available in the foreseeable future. Because first-line use is limited by the high costs of IVIg, the first clinical guidelines on the use of IVIg in dermatological conditions were established in 2008 and renewed in 2011. METHODS The European guidelines presented here were prepared by a panel of experts nominated by the European Dermatology Forum (EDF) and European Academy of Dermatology and Venereology (EADV). The guidelines were developed to update the indications for treatment currently considered effective and to summarize the evidence for the use of IVIg in dermatological autoimmune diseases and TEN. RESULTS AND CONCLUSION The current guidelines represent consensual expert opinions and definitions on the use of IVIg reflecting current published evidence and are intended to serve as a decision-making tool for the use of IVIg in dermatological diseases.
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Enk A, Hadaschik E, Eming R, Fierlbeck G, French L, Girolomoni G, Hertl M, Jolles S, Karpati S, Steinbrink K, Stingl G, Volc‐Platzer B, Zillikens D. Europäische Leitlinien (S1) für die Anwendung von hochdosierten intravenösen Immunglobulinen in der Dermatologie. J Dtsch Dermatol Ges 2017; 15:227-238. [DOI: 10.1111/ddg.13013_g] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Alexander Enk
- HautklinikRuprecht‐Karls‐Universität Heidelberg Deutschland
| | - Eva Hadaschik
- HautklinikRuprecht‐Karls‐Universität Heidelberg Deutschland
| | - Rüdiger Eming
- Klinik für Dermatologie und AllergologiePhilipps‐Universität Marburg Deutschland
| | - Gerhard Fierlbeck
- Universitäts‐HautklinikEberhard‐Karls‐Universität Tübingen Deutschland
| | - Lars French
- Dermatologische KlinikUniversität Zürich Schweiz
| | | | - Michael Hertl
- Klinik für Dermatologie und AllergologiePhilipps‐Universität Marburg Deutschland
| | - Stephen Jolles
- Immundefizienz‐Zentrum für WalesUniversitätskrankenhaus Wales Cardiff GB
| | - Sarolta Karpati
- Abteilung für DermatologieSemmelweis‐Universität Budapest Ungarn
| | | | - Georg Stingl
- Universitätsklinik für DermatologieMedizinische Universität Wien Österreich
| | | | - Detlef Zillikens
- Klinik für DermatologieAllergologie und VenerologieUniversität zu Lübeck Deutschland
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4
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Enk A, Hadaschik E, Eming R, Fierlbeck G, French L, Girolomoni G, Hertl M, Jolles S, Karpati S, Steinbrink K, Stingl G, Volc-Platzer B, Zillikens D. European Guidelines (S1) on the use of high-dose intravenous immunoglobulin in dermatology. J Dtsch Dermatol Ges 2016; 15:228-241. [PMID: 28036140 DOI: 10.1111/ddg.13013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND OBJECTIVES Treatment of severe dermatological autoimmune diseases and toxic epidermal necrolysis (TEN) with high-dose intravenous immunoglobulin (IVIg) is a well-established procedure in dermatology. As treatment with IVIg is usually considered for rare clinical entities or severe cases, the use of immunoglobulin is not generally based on data from randomized controlled trials usually required for evidence-based medicine. Since the indications for the use of IVIg are rare, it is unlikely that such studies will be available in the foreseeable future. Because first-line use is limited by the high costs of IVIg, the first clinical guidelines on the use of IVIg in dermatological conditions were established in 2008 and renewed in 2011. METHODS The European guidelines presented here were prepared by a panel of experts nominated by the EDF and EADV. The guidelines were developed to update the indications for treatment currently considered effective and to summarize the evidence for the use of IVIg in dermatological autoimmune diseases and TEN. RESULTS AND CONCLUSION The current guidelines represent consensual expert opinions and definitions on the use of IVIg reflecting current published evidence and are intended to serve as a decision-making tool for the use of IVIg in dermatological diseases.
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Affiliation(s)
- Alexander Enk
- Department of Dermatology, Ruprecht-Karls-University Heidelberg, Germany
| | - Eva Hadaschik
- Department of Dermatology, Ruprecht-Karls-University Heidelberg, Germany
| | - Rüdiger Eming
- Department of Dermatology, Philipps-University Marburg, Germany
| | - Gerhard Fierlbeck
- Department of Dermatology, Eberhard-Karls-University Tübingen, Germany
| | - Lars French
- Department of Dermatology, University of Zurich, Switzerland
| | | | - Michael Hertl
- Department of Dermatology, Philipps-University Marburg, Germany
| | - Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Sarolta Karpati
- Department of Dermatology, Semmelweis University Budapest, Hungary
| | | | - Georg Stingl
- Department of Dermatology, Medical University of Vienna, Austria
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5
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Enk AH, Hadaschik EN, Eming R, Fierlbeck G, French LE, Girolomoni G, Hertl M, Jolles S, Karpati S, Steinbrink K, Stingl G, Volc-Platzer B, Zillikens D. European Guidelines (S1) on the use of high-dose intravenous immunoglobulin in dermatology. J Eur Acad Dermatol Venereol 2016; 30:1657-1669. [PMID: 27406069 DOI: 10.1111/jdv.13725] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 02/09/2016] [Indexed: 01/07/2023]
Abstract
BACKGROUND The treatment of severe dermatological autoimmune diseases and toxic epidermal necrolysis (TEN) with high-dose intravenous immunoglobulin (IVIg) is a well-established procedure in dermatology. As treatment with IVIg is usually considered for rare clinical entities or severe clinical cases, the use of immunoglobulin is not generally based on data from randomized controlled trials that are usually required for the practice of evidence-based medicine. Owing to the rarity of the indications for the use of IVIg, it is also unlikely that such studies will be available in the foreseeable future. Because the high costs of IVIg treatment also limit its first-line use, the first clinical guidelines on its use in dermatological conditions were established in 2008 and renewed in 2011. MATERIALS AND METHODS The European guidelines presented here were prepared by a panel of experts nominated by the EDF and the EADV. The guidelines were developed to update the indications for treatment currently considered as effective and to summarize the evidence base for the use of IVIg in dermatological autoimmune diseases and TEN. RESULTS AND CONCLUSION The current guidelines represent consensual expert opinions and definitions on the use of IVIg reflecting current published evidence and are intended to serve as a decision-making tool for the use of IVIg in dermatological diseases.
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Affiliation(s)
- A H Enk
- Department of Dermatology, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany.
| | - E N Hadaschik
- Department of Dermatology, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - R Eming
- Department of Dermatology, Philipps-University Marburg, Marburg, Germany
| | - G Fierlbeck
- Department of Dermatology, Eberhard-Karls-University Tübingen, Tübingen, Germany
| | - L E French
- Department of Dermatology, University of Zurich, Zurich, Switzerland
| | - G Girolomoni
- Department of Dermatology, University of Verona, Verona, Italy
| | - M Hertl
- Department of Dermatology, Philipps-University Marburg, Marburg, Germany
| | - S Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - S Karpati
- Department of Dermatology, Semmelweis University Budapest, Budapest, Hungary
| | - K Steinbrink
- Department of Dermatology, Johannes Gutenberg-University Mainz, Mainz, Germany
| | - G Stingl
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - B Volc-Platzer
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - D Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
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Lünemann JD, Quast I, Dalakas MC. Efficacy of Intravenous Immunoglobulin in Neurological Diseases. Neurotherapeutics 2016; 13:34-46. [PMID: 26400261 PMCID: PMC4720677 DOI: 10.1007/s13311-015-0391-5] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Owing to its anti-inflammatory efficacy in various autoimmune disease conditions, intravenous immunoglobulin (IVIG)-pooled IgG obtained from the plasma of several thousands individuals-has been used for nearly three decades and is proving to be efficient in a growing number of neurological diseases. IVIG therapy has been firmly established for the treatment of Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy, either as first-line therapy or adjunctive treatment. IVIG is also recommended as rescue therapy in patients with worsening myasthenia gravis and is beneficial as a second-line therapy for dermatomyositis and stiff-person syndrome. Subcutaneous rather than intravenous administration of IgG is gaining momentum because of its effectiveness in patients with primary immunodeficiency and the ease with which it can be administered independently from hospital-based infusions. The demand for IVIG therapy is growing, resulting in rising costs and supply shortages. Strategies to replace IVIG with recombinant products have been developed based on proposed mechanisms that confer the anti-inflammatory activity of IVIG, but their efficacy has not been tested in clinical trials. This review covers new developments in the immunobiology and clinical applications of IVIG in neurological diseases.
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Affiliation(s)
- Jan D Lünemann
- Institute of Experimental Immunology, Laboratory of Neuroinflammation, University of Zürich, Winterthurerstrasse 190, Zürich, Switzerland.
- Department of Neurology, University Hospital of Basel, Basel, Switzerland.
| | - Isaak Quast
- Institute of Experimental Immunology, Laboratory of Neuroinflammation, University of Zürich, Winterthurerstrasse 190, Zürich, Switzerland
| | - Marinos C Dalakas
- Neuroimmunology Unit, University of Athens Medical School, Athens, Greece
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
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Lünemann JD, Nimmerjahn F, Dalakas MC. Intravenous immunoglobulin in neurology—mode of action and clinical efficacy. Nat Rev Neurol 2015; 11:80-9. [DOI: 10.1038/nrneurol.2014.253] [Citation(s) in RCA: 191] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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8
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Sánchez-Ramón S, Valor L. [Therapy with intravenous gammaglobulins in systemic inflammatory autoimmune diseases: new indications?]. Med Clin (Barc) 2014; 143:130-3. [PMID: 24480286 DOI: 10.1016/j.medcli.2013.11.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Revised: 11/14/2013] [Accepted: 11/21/2013] [Indexed: 11/15/2022]
Affiliation(s)
| | - Lara Valor
- Servicio de Reumatología, Hospital General Universitario Gregorio Marañón, Madrid, España
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Novaretti MCZ, Dinardo CL. Clinical applications of immunoglobulin: update. Rev Bras Hematol Hemoter 2012; 33:221-30. [PMID: 23049300 PMCID: PMC3415732 DOI: 10.5581/1516-8484.20110058] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Accepted: 03/28/2011] [Indexed: 11/27/2022] Open
Abstract
Human immunoglobulin is the most used blood product in the clinical practice. Immunoglobulin applications have increased quickly since the elucidation of its immunomodulatory and antiinflammatory properties which turned this blood product into a precious tool in the treatment of numerous diseases that present with humoral immune deficiency or that cause immune system dysfunction. Currently, the approved indications for Ig are: primary immunodeficiencies, secondary immunodeficiencies (multiple myeloma or chronic lymphoid leukemia), Kawasaki syndrome, immune thrombocytopenic purpura, Guillain Barré syndrome, graft-versus-host disease following bone marrow transplantation and repeat infections in HIV children. On the other hand, there are numerous "off-label" indications of immunoglobulin, which represent 20-60% of all clinical applications of this drug. It is important to study all these indications and, above all, the scientific evidence for its use, in order to provide patients with a new therapeutic option without burdening the health system. This review results from a wide selection of papers identified in the Pubmed and Lilacs scientific electronic databases. A group of descriptors were used from human immunoglobulin to the names of each disease that immunoglobulin is clinically applied. Our main objective is to list the numerous indications of immunoglobulin, both authorized and "off-label" and to analyze these indications in the light of the most recent scientific evidence.
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Enk A, Fierlbeck G, French L, Hertl M, Messer G, Meurer M, Steinbrink K, Stingl G, Volc-Platzer B, Zillikens D. Use of high-dose immunoglobulins in dermatology. J Dtsch Dermatol Ges 2009; 7:806-812. [DOI: 10.1111/j.1610-0387.2009.07118.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
OBJECTIVE To understand belief in a specific scientific claim by studying the pattern of citations among papers stating it. DESIGN A complete citation network was constructed from all PubMed indexed English literature papers addressing the belief that beta amyloid, a protein accumulated in the brain in Alzheimer's disease, is produced by and injures skeletal muscle of patients with inclusion body myositis. Social network theory and graph theory were used to analyse this network. MAIN OUTCOME MEASURES Citation bias, amplification, and invention, and their effects on determining authority. RESULTS The network contained 242 papers and 675 citations addressing the belief, with 220,553 citation paths supporting it. Unfounded authority was established by citation bias against papers that refuted or weakened the belief; amplification, the marked expansion of the belief system by papers presenting no data addressing it; and forms of invention such as the conversion of hypothesis into fact through citation alone. Extension of this network into text within grants funded by the National Institutes of Health and obtained through the Freedom of Information Act showed the same phenomena present and sometimes used to justify requests for funding. CONCLUSION Citation is both an impartial scholarly method and a powerful form of social communication. Through distortions in its social use that include bias, amplification, and invention, citation can be used to generate information cascades resulting in unfounded authority of claims. Construction and analysis of a claim specific citation network may clarify the nature of a published belief system and expose distorted methods of social citation.
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Affiliation(s)
- Steven A Greenberg
- Children's Hospital Informatics Program and Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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Abstract
The intravenous administration of exogenous pooled human immunoglobulin (i.v. IG) was originally licensed as antibody replacement therapy in patients with primary immunodeficiencies and there are currently six FDA-approved uses for this agent. Despite a current lack of FDA approval, off-label treatment of a multitude of dermatologic disorders with i.v. IG has shown exciting potential for this unique treatment modality. The diseases successfully treated with i.v. IG include autoimmune bullous diseases, connective tissue diseases, vasculitides, toxic epidermal necrolysis, and infectious disorders (such as streptococcal toxic shock syndrome). Currently the biggest drawback in the consideration of i.v. IG therapy in dermatologic disorders is the lack of randomized controlled trials. Nevertheless, there is a significant body of evidence demonstrating the efficacy of i.v. IG in patients with dermatologic disorders that are resistant to treatment with standard agents. In summary, i.v. IG constitutes a valuable and potentially life-saving agent in managing patients with a variety of dermatologic disorders under the appropriate circumstances.
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Affiliation(s)
- Anthony P Fernandez
- Department of Dermatology and Cutaneous Surgery, Unversity of Miami Miller School of Medicine, Miami, Florida, USA
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Mii S, Niiyama S, Kusunoki M, Arai S, Katsuoka K. Cyclosporine A as treatment of esophageal involvement in dermatomyositis. Rheumatol Int 2006; 27:183-5. [PMID: 16900376 DOI: 10.1007/s00296-006-0168-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2006] [Accepted: 07/04/2006] [Indexed: 10/24/2022]
Abstract
We report a case of a 70-year-old man with dermatomyositis complicated by esophageal involvement resistant to corticosteroid therapy. It had serious and potentially life-threatening implications, resulting in impossible oral feeding. This condition was successfully resolved by administration of cyclosporine A.
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Affiliation(s)
- Sumiyuki Mii
- Department of Dermatology, Kitasato University, 1-15-1 Kitasato, Sagamihara, Kanagawa, 228-8555 Japan
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Lampe JB, Walter MC, Reichmann H. Neurodegeneration-associated proteins and inflammation in sporadic inclusion-body myositis. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2001; 487:219-28. [PMID: 11403162 DOI: 10.1007/978-1-4615-1249-3_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- J B Lampe
- Department of Neurology, Technical University of Dresden, Germany
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Patel SY, Kumararatne DS. From black magic to science: understanding the rationale for the use of intravenous immunoglobulin to treat inflammatory myopathies. Clin Exp Immunol 2001; 124:169-71. [PMID: 11422191 PMCID: PMC1906060 DOI: 10.1046/j.1365-2249.2001.01565.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
Autoimmune disorders can involve patients of any age and organs of any organ system. The central and peripheral nervous systems are frequently among the targets of these diseases. Immune dysfunction often presents in childhood or adolescence. Among the autoimmune disorders that present during childhood and adolescence, systemic lupus erythematosus, dermatomyositis, and Behcet's disease affect the nervous system with some degree of frequency. Furthermore, although juvenile rheumatoid arthritis only rarely affects the nervous system during childhood, it and its adult-onset counterpart may have profound long-term neurological consequences. Both symptomatic and pathophysiologically aimed therapies are important in the treatment of the nervous system sequelae of systemic autoimmune disorders.
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Affiliation(s)
- N F Schor
- Department of Pediatrics, University of Pittsburgh School of Medicine, PA, USA
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