Prognosis and mortality of polymyositis and dermatomyositis patients

The efficacy and safety of tacrolimus in patients with dermatomyositis/polymyositis: A meta-analysis and systematic review

OBJECTIVE

To evaluate the efficacy and safety of tacrolimus for dermatomyositis (DM) and polymyositis (PM) treatment.

METHODS

We searched the Embase, PubMed, the Cochrane Central Register of Controlled Trials, and China National Knowledge Infrastructure were used as searching tools from inception up to October 2022. Two authors independently selected studies. The available studies were comprehensively reviewed and investigated.

RESULTS

A total of 9 studies, including 350 patients, were analysed. Pooled results showed a higher overall survival rate in tacrolimus therapy group. Creatine kinase (CK) levels and forced vital capacity (FVC) showed significant improvement after tacrolimus therapy. The incidence of adverse events including infection and renal dysfunction showed no significant differences between the tacrolimus therapy group and conventional therapy group.

CONCLUSION

The results of this meta-analysis indicated that GC therapy in combination with tacrolimus therapy could help improving overall survival rate, pulmonary function and had similar safety outcomes compared to conventional therapy in DM and PM patients.

A Narrative Review of Acthar Gel for the Treatment of Myositis

Idiopathic inflammatory myopathies (IIMs) are autoimmune disorders characterized by symmetric proximal muscle weakness and chronic inflammation, with an increased risk of morbidity and mortality. The current standard of care includes traditional immunosuppressive pharmacotherapies; however, some patients cannot tolerate or do not adequately respond to these therapies, highlighting the need for alternative treatments for refractory disease. Acthar^® Gel (repository corticotropin injection) is a naturally sourced mixture of adrenocorticotropic hormone analogs and other pituitary peptides that has been approved by the US Food and Drug Administration since 1952 for use in patients with two subgroups of IIMs, dermatomyositis (DM) and polymyositis (PM). However, it has not been routinely used in the treatment of IIMs. While Acthar may induce steroidogenesis, it also has a steroid-independent mechanism of action by exerting immunomodulatory effects through the activation of melanocortin receptors on immune cells, such as macrophages, B cells, and T cells. Recent clinical trials, retrospective analyses, and case reports add to the growing evidence suggesting that Acthar may be effective in patients with DM and PM. Here we review the current evidence supporting the safety and efficacy of Acthar for the treatment of refractory DM and PM.

Anti-signal recognition particle positive necrotizing myopathy-sjogren’s syndrome overlap syndrome: a descriptive study on clinical and myopathology features

Background and objective

The aim of this study was to elucidate the clinical and myopathological characteristics of patients with anti-signal recognition particle (SRP) positive immune-mediated necrotizing myopathy (IMNM) overlap Sjogren’s syndrome (SS).

Materials and methods

We retrospectively analyzed the data of anti-SRP positive IMNM patients admitted in the Neurology Department of Tongji Hospital between January 2011 to December 2020. Patients were divided into two groups: anti-SRP IMNM overlap SS group and anti-SRP IMNM control group. The clinical features, laboratory results, histological features, treatment, and prognosis were compared between the two groups.

Results

A total of 30 patients with anti-SRP IMNM were included, including six anti-SRP IMNM overlap SS patients (two males, four females), with a median age of 39 years, and 24 anti-SRP IMNM patients (ten males, fourteen females), with a median age of 46 years. The anti-SRP IMNM overlap SS group had a lower prevalence of muscle atrophy (0 vs 50%, p = 0.019), and a higher prevalence of extramuscular manifestations, including cardiac abnormalities and ILD (Interstitial lung disease). CD4 + and CD68 + inflammatory infiltrations were significantly increased in anti-SRP IMNM overlap SS patients, with an increased presence of CD4 + cells in both necrotic(p = 0.023) and endomysial areas (p = 0.013), and more CD68 + cells (p = 0.016) infiltrated the endomysial area. Deposition of membrane attack complex (MAC) on sarcolemma (p = 0.013) was more commonly seen in the anti-SRP IMNM overlap SS group.

Conclusion

Our data revealed that anti-SRP IMNM-SS overlap patients may present with milder muscular manifestation, but worse extramuscular manifestations compared to anti-SRP IMNM patients without SS. CD4 + and CD68 + inflammatory infiltrations and MAC deposition were remarkably increased in anti-SRP IMNM-SS overlap patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-023-06354-5.

Incidence, Prevalence, and Mortality of Dermatomyositis: A Population-Based Cohort Study

OBJECTIVE

We aimed to determine the population-based incidence, prevalence, and mortality of dermatomyositis (DM) using European Alliance of Associations for Rheumatology (EULAR)/American College of Rheumatology (ACR) criteria.

METHODS

This population-based cohort study included incident DM from January 1, 1995 to December 31, 2019. We manually reviewed all individuals with at least 1 code for DM or polymyositis to determine if they met EULAR/ACR criteria, subspecialty physician diagnosis, and/or Bohan and Peter criteria. We age- and sex-adjusted incidence and prevalence estimates to the US non-Hispanic White year 2000 population and estimated prevalence on January 1, 2015. Standardized mortality ratios (SMRs) with 95% confidence intervals (95% CIs) compared observed to expected mortality adjusting for age, sex, and year.

RESULTS

We identified 40 cases of verified DM, with 29 cases incident in Olmsted County from 1995 to 2019. The mean age was 57 years, 26 (90%) were female, and 12 (41%) had clinically amyopathic DM (CADM). The median follow-up time was 8.2 years. The overall adjusted incidence of DM was 1.1 (95% CI 0.7-1.5) per 100,000 person-years, and prevalence was 13 (95% CI 6-19) per 100,000. The SMR was significantly elevated among the myopathic DM cases (3.1 [95% CI 1.1-6.8]) but not CADM cases (1.1 [95% CI 0.2-3.3]). The positive predictive value of ≥2 DM codes was only 40 of 82 (49%).

CONCLUSION

This population-based study found that DM incidence and prevalence were higher than previously reported. Mortality was significantly elevated for myopathic DM but not for CADM.

Evolution of Seronegative Inflammatory Myositis to Dermatomyositis With Characteristic Cutaneous Features: A Case Report

Dermatomyositis (DM) is a rare inflammatory myopathy with an incidence of 9.63 per 1 000 000 people and typically presents with skin rash and muscle weakness. We report a case of DM that presented with proximal muscle weakness, normal creatine phosphokinase (CPK), negative myositis antibody panel, and non-specific histopathological findings on muscle biopsy, without initial skin involvement. A 67-year-old male presented with subacute bilateral proximal lower-extremity weakness and weight loss of 20 pounds over 3 months. Laboratory investigation was significant for elevated erythrocyte sedimentation rate, C-reactive protein, CPK, and aldolase, with negative myositis-specific antibodies. Femur magnetic resonance imaging revealed subcutaneous, fascial, and muscle edema throughout quadriceps and gluteal muscles. Muscle biopsy showed myofiber atrophy with perivascular and endomysial T-lymphocytes and histiocytes, as well as scattered necrotic myofibers. He was diagnosed with inflammatory myositis and started on prednisone and monthly IVIG infusions. At 2-month follow-up, he reported new rashes on the extensor surfaces of the hands consistent with Gottron's papules, mechanic's hands, and livedo reticularis of feet and arms. Cases of DM that present with myopathy and later develop skin changes are rare. Our patient had several months of progressive proximal muscle weakness, and skin changes occurred after he was started on treatment. Laboratory findings include elevated CPK, aldolase, and myositis-specific auto-antibodies. Muscle biopsy helps in diagnosis; however, findings may be nonspecific-as was the case in our patient. Corticosteroids are first-line treatment. Long-term follow-up studies are necessary to better understand the incidence of late-onset development of typical skin findings.

Dermatomyositis Associated with Lung Cancer: A Brief Review of the Current Literature and Retrospective Single Institution Experience

Dermatomyositis is a rare inflammatory myopathy that is often related to lung cancer. In this retrospective observational study, we analyzed data from patients diagnosed with lung cancer at Soroka University Medical Center between January 2017 and July 2021. A total of 689 patients with lung cancer were included in this study, 97 of whom had small cell lung cancer and 592 had non-small cell lung cancer. We identified a single patient (60-year-old female) who presented with signs and symptoms of dermatomyositis, which was later confirmed to be associated with lung cancer as a paraneoplastic syndrome. Both our study and a recent review of the literature illustrate the temporal link between dermatomyositis and lung cancer, as well as reinforce the need for heightened cancer screenings in DM patients.

Cancer and immune-mediated necrotizing myopathy: a longitudinal referral case-controlled outcomes evaluation

OBJECTIVES

To investigate immune-mediated necrotizing myopathy (IMNM) association with cancer and its clinical implications.

METHODS

IMNM cases were identified 1 January 2000 to 31 December 2020 matching sex and age controls (4:1).

RESULTS

A total of 152 patients with IMNM were identified and among serologically tested, 60% (83/140) were HMGCR-IgG+, 14% (20/140) were SRP-IgG+ and 26% (37/140) were seronegative. Cancer rates were not significantly different between serological subgroups; 18.1% (15/83) HMGCR-IgG+, 25% (5/20) SRP-IgG+ and 30% (11/37) seronegative (P = 0.34). Cancer screening was performed within 12 months from IMNM diagnosis in 88% (134/152) (whole-body CT plus FDG-PET CT in 53, CT alone in 72 and FDG-PET alone in 9). FDG-PET/CT was positive in 73% (25/34) of cancers. Increasing age was the only risk associated with cancer (P = 0.02). The odds of developing cancer at ±3 or ±5 years from IMNM diagnosis was not higher than controls (OR = 0.49; CI: 0.325-0.76). Lifetime IMNM diagnosis of cancer was less compared with controls (OR = 0.5 CI: 0.33-0.78, P = 0.002). Most patients responded to treatment (137/147, P < 0.001). Death and treatment response did not significantly differ between cancer [23% (8/34); 88% (29/33)] and non-cancer patients [19% (23/118); 92% (108/118)]. In total, 13% (20/152) of patients died during follow-up compared with 14% (41/290) of medicine and 16% (46/290) of neurology controls (P = 0.8). Seropositives had greater life expectancy than seronegatives (P = 0.01).

CONCLUSIONS

Greater cancer risk is not observed in IMNM vs controls. Cancer screening in IMNM should be individualized based on age-personal and family history, including consideration of FDG-PET/CT. Immune-treatment response did not differ with cancer.

Progressive interstitial lung disease in hypomyopathic dermatomyositis in the COVID-19 pandemic: A case report

BACKGROUND

Clinically amyopathic dermatomyositis (CADM) is characterized by typical skin lesions with no (amyopathic) or subclinical (hypomyopathic) evidence of muscle involvement. Patients with CADM may also develop rapidly progressive interstitial lung disease (ILD), and have a poor prognosis. However, the diagnosis of rapidly progressive ILD faces a challenge during the severe acute respiratory syndrome coronavirus 2 pandemic. Severe acute respiratory syndrome and ground-glass attenuation on a chest computed tomography scan are the presenting features in both conditions.

CASE PRESENTATION

A 45-year-old woman with amyopathic dermatomyositis had acute onset of fever and dyspnea in February 2020. She had abnormal lung findings on CT scan. Polymerase chain reaction testing for SARS-CoV-2 was not available at that time. Chest CT revealed non-specific manifestations that could be either the signs of ILD or SARS-CoV-2 infection. Antiviral therapy was initiated with oseltamivir. Three days later, she had erythema on face, palm, and back. The ratio of lactate dehydrogenase (LDH) isoenzyme 3 to total LDH was elevated. The ratio of LDH isoenzyme 1 to total LDH was declined. Therefore, she was transferred to the rheumatology ward for further treatment. However, she died from respiratory failure 2 weeks later.

CONCLUSIONS

We speculate that the altered LDH isoenzyme pattern may be an early biomarker for co-occurrence of CADM and ILD.

Effective therapy of polymyositis in mice via selective inhibition of the immunoproteasome

Polymyositis (PM) is a chronic autoimmune inflammatory myopathy resulting in muscle weakness. The limited approved therapies and their poor efficacy contribute to its comorbidity. We investigated the therapeutic use of ONX 0914 and KZR-616, selective inhibitors of the immunoproteasome, in C protein-induced myositis (CIM), a mouse model of PM that closely resembles the human disease. Diseased mice (day 13 post-immunization) were treated with 10 mg/kg ONX 0914 or KZR-616 or vehicle on alternate days until day 28. Endpoints included muscle strength assessed by a grip strength meter, serum creatine kinase activity, histology, and immunohistochemistry analysis. Treatment with ONX 0914 or KZR-616 prevented the loss of grip strength in mice after CIM induction, while vehicle-treated animals displayed progressive muscle weakness. Immunoproteasome inhibition lowered PM-associated leukocyte infiltration of the muscle and prevented increased serum creatine kinase levels. LMP7-deficient mice were resistant to CIM induction as they depicted no alteration in the grip strength, creatine kinase (CK) levels, nor showed muscular alterations. In conclusion, selective inhibition of the immunoproteasome displays therapeutic efficacy in a pre-clinical mouse model of PM with suppression of muscle inflammation and preservation of muscle strength. Positive results from this study support the rationale for using KZR-616 in clinical studies. This article is protected by copyright. All rights reserved.

Clinical Features of Anti-Synthetase Syndrome Associated with Prognosis in Patients with Dermatomyositis and Polymyositis

We evaluated whether the clinical features of anti-synthetase syndrome (ASA)—myositis, fever, arthritis, mechanic’s hand, Raynaud’s phenomenon and interstitial lung disease—are relevant to prognosis in patients with dermatomyositis/polymyositis (DM/PM). A retrospective analysis was performed to identify patients diagnosed with DM/PM according to Bohan and Peter criteria. Clinical information, laboratory data and the presence of ASA clinical features at disease diagnosis were searched, and the outcomes of all-cause mortality, intensive care unit admission and disease remission at 1 year were assessed. Among the 86 patients included, fever (36.0%) and interstitial lung disease (26.7%) were the most common ASA clinical features. During the follow-up, 12 patients experienced death, and 7 of the 12 deaths (58.3%) occurred within 3 months of DM/PM diagnosis. Mortality was more frequently observed in those presenting with fever than in those without (25.8% versus 7.3%, p = 0.024). Multivariable Cox proportional analysis revealed that male sex (hazard ratio [HR] 5.53, 95% confidence interval [CI] 1.65, 18.49, p < 0.01) and fever (HR 4.20, 95% CI 1.26, 14.01, p = 0.02) independently predicted mortality. The clinical impact of fever was consistent in both sexes. Fever could be a warning signal heralding the poor outcome of mortality in patients with DM/PM, especially in early disease phases.

Reasons for Hospitalization and In-Hospital Mortality in Adults With Dermatomyositis and Polymyositis

OBJECTIVE

Dermatomyositis (DM) and polymyositis (PM) are systemic autoimmune diseases that have been associated with high in-hospital mortality (IHM). The aim of this study was to use the National Inpatient Sample (NIS), a large US population database, to determine the reasons for hospitalization and IHM in patients with DM and PM.

METHODS

We conducted a medical records review of adult DM/PM hospitalizations in 2016 and 2017 in acute care hospitals across the United States using the NIS. The reasons for IHM and reasons for hospitalization were divided into 19 broad categories based on their principal International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10) diagnosis.

RESULTS

A total of 27,140 hospitalizations carried either a principal or secondary ICD-10 code for DM or PM. The main reasons for hospitalization were rheumatologic (22%, n = 6085), cardiovascular (15%, n = 3945), infectious (13%, n = 3515), respiratory (12%, n = 3170), and gastrointestinal, (8%, n = 2150). A total of 3.5% of all patients experienced IHM. Infectious (34%, n = 325), respiratory (23%, n = 215), and cardiovascular (15%, n = 140) diagnoses were the most common reasons for IHM. Sepsis ICD-10 A41.9 was the most frequent specific principal diagnosis for both hospitalizations and IHM.

CONCLUSIONS

Our analysis demonstrated that in the NIS the most common reasons for hospitalization in patients with DM/PM were rheumatologic diagnoses. However, IHM in these patients was most frequently from infectious diagnoses, highlighting the need for increased attention to infectious complications in these patients.

Premature coronary artery disease in patients with immune-mediated inflammatory disease: a population-based study

Background

The associations between premature atherosclerosis and immune-mediated inflammatory diseases (IMIDs) are not fully investigated. To determine whether IMIDs are associated with premature atherosclerosis, we examined the risk of incident coronary artery disease (CAD) in men less than 45 years old and women less than 50 years old with various forms of IMIDs compared with general population.

Methods

A population-based cohort was established and included patients with IMID, who were followed until the development of CAD, withdrawal from the insurance system, death, or 31 December 2016, whichever point came first. Patients with IMID included rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), primary Sjogren’s syndrome (SjS), idiopathic inflammatory myositis, systemic sclerosis (SSc), Behcet’s disease (BD), and systemic vasculitis (SV). The comparison group was 1 000 000 beneficiaries sampled at random from the whole population as matched control participants. The Kaplan-Meier method was used to compare the cumulative incidences of CAD in patients with and without IMID.

Results

Among 58 862 patients with IMID, 2139 (3.6%) developed CAD and 346 (1.3%) developed premature CAD. Relative to the comparison cohorts, the adjusted HRs for premature CAD were 1.43 (95% CI 1.09 to 1.86) for primary SjS, 2.85 (95% CI 2.63 to 3.43) for SLE, 3.18 (95% CI 1.99 to 5.09) for SSc and 2.27 (95% CI 1.01 to 5.07) for SV.

Conclusions

Primary Sjogren’s syndrome, SLE, SSc and SV are associated with an increased risk of premature CAD. Our findings will support essential efforts to improve awareness of IMID impacting young adults.

Clinical manifestations, outcomes, and antibody profile of Brazilian adult patients with dermatomyositis: a single-center longitudinal study

BACKGROUND

Currently, only a few retrospective cohort or cross-sectional studies have described the general characteristics of Brazilian patients with classical dermatomyositis (DM). In contrast, we aimed to longitudinally assess a large sample of these patients, and several myositis autoantibodies.

METHODS

This single-center longitudinal study included 91 Brazilian adults with defined DM (EULAR/ACR 2017) who underwent follow-up appointments in our tertiary center from 2012 to 2021. Myositis autoantibody analysis was performed using a commercial kit.

RESULTS

The mean age of the patients was 47.3 ± 15.4 years, with a predominance of female (67.0%) and White (81.3%) patients. As an initial treatment, 76.9% of the patients received methylprednisolone pulse therapy, 59.3% received intravenous immunoglobulin, and 54.9% received both drugs. The median follow-up duration was 44 months (interquartile 17-67) months. There were 92 severe episodes of infection, and neoplasms were identified in 20 patients (22.0%). Hypertension was identified in 46.2% of patients, whereas diabetes mellitus and myocardial infarction occurred in 19.8% and 4.4%, respectively. Nine patients died during the follow-up. At the last visit, one-third of the patients had disease activity, half had a complete clinical response, and one-fifth were in disease remission. In a univariate logistic regression, anti-aminoacyl-tRNA synthetase antibodies (n = 13) were associated with interstitial lung disease, "mechanic's hands", and anti-Ro-52, and had an inverse association with "V"-neck and "shawl" signs. Anti-MDA-5 (n = 10) were associated with male gender, digital ulcers, vasculitis, arthritis, anti-Ro-52, and active disease. Anti-Ro-52 (n = 26) were associated with "mechanics' hands", arthritis, interstitial lung disease, anti-tRNA synthetases, and anti-MDA-5. No association was found for anti-Mi-2 (n = 10).

CONCLUSIONS

This study shows the general profile of a significant sample of Brazilian patients with DM as well as the association of some antibodies with clinical and laboratory manifestations of this myositis.

Survival of Patients With Idiopathic Inflammatory Myopathies in Slovenia

Background: Idiopathic inflammatory myopathies (IIMs) are rare systemic diseases associated with significant morbidity and mortality. The aim of our study was to estimate for the first time the survival of IIM patients in Slovenia.

Methods: We included IIM patients diagnosed between January 2005 and December 2020 and followed at two secondary/tertiary rheumatology centers in the country. To study survival/mortality the censor date of April 14 2021 was set. Kaplan–Meier analysis and standardized mortality ratio (SMR) were plotted using data of age and sex matched Slovenian population as a reference. Cox proportional hazards regression analysis was used to study prognostic factors for IIM mortality.

Results: During the 16-year observation period, we identified 217 new IIM patients. During follow up 65 (30.0%) patients died. In the first year following IIM diagnosis the SMR was nearly 7-fold higher compared to the matched general population [SMR 6.88 (95%CI 4.41–10.24)] and remained higher also during the following 4 years. However, when excluding IIM patients with cancer, the survival outcome was, except in the first year after IIM diagnosis [SMR 5.55 (95%CI 3.10–9.15)], comparable to matched general population. In addition to cancer [HR 3.71 (95% CI 2.18–6.04)], cardiac involvement [HR 2.18 (95% CI 1.07–4.45)], fever [HR 2.13 (95% CI 1.13–4.03)], and older age [HR 1.07 (95% CI 1.04–1.09)] were extracted as prognostic factors associated with death.

Conclusion: The survival of patients with IIM patients was substantially worse compared to matched general population. Cancer was the leading cause of death in our cohort.

Long-term effects of early pulse methylprednisolone and intravenous immunoglobulin in patients with dermatomyositis and polymyositis

OBJECTIVE

To evaluate the long-term effects of pulse intravenous methylprednisolone (IVMP) or intravenous immunoglobulin (IVIG) administered during the first year of diagnosis in dermatomyositis (DM) and polymyositis (PM) patients.

METHODS

This is a retrospective single-center cohort study of patients with DM/PM followed for up to 4 years from 2001 to 2017. We used Cox regression models to estimate hazard ratios (HRs) and assess the effects of early pulse IVMP or IVIG on 3 outcomes: complete clinical response, corticosteroid discontinuation, and survival. Analysis was adjusted for clinical, laboratory, and treatment covariates.

RESULTS

A total of 204 patients were included and categorized into 4 initial treatment groups: pulse IVMP (n = 46), pulse IVMP+IVIG (n = 55), IVIG (n = 10), and without IVMP or IVIG (n = 93). The groups of early pulse IVMP and pulse IVMP+IVIG had a higher HR for complete clinical response in the multivariate models (HR = 1.56, 95% CI = 1.05-2.33, p = 0.029; and HR = 1.58, 95% CI = 1.02-2.45, p = 0.041, respectively). Only the group of pulse IVMP+IVIG had a significant association with corticosteroid discontinuation in the multivariate analysis (HR = 1.65, 95% CI = 1.02-2.68, p = 0.043). Early pulse IVMP or IVIG had no impact on mortality.

CONCLUSION

Despite having a more severe disease profile, patients with DM/PM submitted to pulse IVMP or pulse IVMP+IVIG during the first year of diagnosis had a higher HR for complete clinical response, whereas the combination of pulse IVMP+IVIG had an association with corticosteroid discontinuation. Prospective long-term studies are warranted to confirm these benefits of early pulse IVMP and IVIG on patients with DM/PM.

Persistent premature mortality gap in dermatomyositis and polymyositis: a United Kingdom general population-based cohort study

OBJECTIVE

DM and PM are associated with substantial morbidity and mortality. We aimed to examine recent trends.

METHODS

Using The Health Improvement Network, we identified patients with incident DM/PM (defined by ≥1 Read diagnosis code) aged 18-89 years with ≥1 year of continuous enrolment prior to the cohort entry date and up to 10 comparators matched on age, sex and entry year. The cohort was divided in two based on the year of DM/PM diagnosis: the early cohort (1999-2006) and late cohort (2007-2014). We calculated multivariable hazard ratios (HR) for death using a Cox-proportional hazards model and multivariable rate differences (RD) using an additive hazard model.

RESULTS

We identified 410 DM cases (mean age: 58 years, 66% female) and 407 PM cases (mean age: 59 years, 61% female). Both DM cohorts had excess mortality compared with the comparison cohorts (71.5 vs 12.9 deaths/1000 person-years [PY] in the early cohort and 49.1 vs 10.4 deaths/1000 PY in the late cohort). The multivariable HRs were 7.51 (95% CI: 4.20, 13.42) in the early cohort and 5.42 (95% CI: 3.11, 9.45) in the late cohort (P-value for interaction = 0.59), and multivariable RDs were 56.2 (95% CI: 31.8, 81.2) in the early cohort and 36.3 (95% CI: 19.6, 53.0) in the late cohort (P-value for interaction = 0.15). A similar trend existed in PM.

CONCLUSION

The premature mortality gap in DM/PM has not considerably improved in recent years, highlighting an unmet need for therapeutic improvement.

Analysis of risk factors of interstitial lung disease and mortality rates in Chinese patients with idiopathic inflammatory myopathy

Aim

To investigate the risk factors for interstitial lung disease (ILD) and prognosis in patients with idiopathic inflammatory myopathy (IIM).

Methods

A retrospective longitudinal study was performed in patients diagnosed with IIM between January 2012 and December 2018.

Results

The study cohort included 91 men and 195 women who were classified as having dermatomyositis (DM, n = 183), polymyositis (PM, n = 77), or clinical amyopathic DM (CADM, n = 26). ILD was identified in 46.5% (n = 133) of patients with IIM. The independent risk factors for ILD were age at disease onset, presence of anti‐Ro‐52 antibody, Gottron's papules, elevated serum immunoglobulin M levels and hypoalbuminemia. Older age at disease onset, ILD, malignancy, and increased serum aspartate aminotransferase and neutrophil‐to‐lymphocyte ratio (NLR) were identified as the independent predictors for mortality, whereas elevated serum albumin level was associated with a better prognosis. A total of 73 deaths (25.5%) occurred after a median follow‐up time of 33 months. Infection (49.3%) was the leading cause of death. In the overall cohort, the 1‐year, 5‐year and cumulative survival rates were 83.2%, 74.2% and 69.4%, respectively. The receiver operating characteristic curve indicated that the optimal cut‐off value of NLR for predicting death in IIM was 6.11.

Conclusion

IIM patients have a poor prognosis with substantial mortality, especially in patients who have older age at onset, ILD, malignancy and higher NLR. Close monitoring and aggressive therapies are required in patients having poor predictive factors.

Comparison of the 2017 EULAR/ACR Criteria with Clinicoserologic Criteria for the Classification of Idiopathic Inflammatory Myopathies in Korean Patients

PURPOSE

To investigate correlations between myositis-specific autoantibodies (MSA) or myositis-associated antibodies (MAA) and clinical features, thereby demonstrating the utility of clinicoserologic classification in idiopathic inflammatory myopathies (IIM) patients.

MATERIALS AND METHODS

We conducted a multicenter study of 108 adult patients (age ≥18 years) who were diagnosed with IIM by Peter and Bohan criteria or 2004 European Neuromuscular Centre (ENMC) criteria. Clinical data were obtained by medical record review. Immunoblot assay with Euroline strip (EUROIMMUN, Germany) was performed using the sera of dermatomyositis (DM, n=56), polymyositis (PM, n=45), amyopathic DM (n=5), DM sine dermatitis (n=1), and immune mediated necrotizing myopathy (n=1) patients. Patients were classified based on two classifications: 2017 EULAR/ACR and novel clinicoserologic classification.

RESULTS

According to 2017 EULAR/ACR criteria, DM and PM were the most and the second most frequent entities. Overlap myositis was the major entity of IIM, and the frequency of PM was significantly lower when applying clinicoserologic classification criteria. Sixty-nine (63.9%) patients had one or more MSA, and 61 (56.5%) patients had one or more MAA. Interstitial lung disease was closely associated with anti-MDA5 and anti-ARS, and DM-specific skin lesions were frequently observed in patients with anti-TIF1γ, anti-SRP, and anti-MDA5.

CONCLUSION

The clinicoserologic criteria based on MSA/MAA positivity could reflect more precise clinical features of IIM. Establishment of a laboratory system routinely available to screen for MSA/MAA status will be beneficial to provide precise diagnosis and proper management of IIM patients.

Infections Are Leading Cause of In-Hospital Mortality in Indian Patients With Inflammatory Myopathy

OBJECTIVES

We explored causes of in-hospital mortality in patients with inflammatory myositis at a tertiary care center in Northern India.

METHODS

Records of adults and children diagnosed with dermatomyositis (DM), polymyositis, or anti-synthetase syndrome (ASSD) who died between 2000 and 2018 were reviewed, and causes of death were determined.

RESULTS

Of the 38 patients, 20 had DM (including 2 clinically amyopathic DM), 4 juvenile DM, 12 polymyositis, whereas 2 had ASSD. Median age at death was 42.0 (interquartile range, 32.8-52.5) years. Median disease duration at death was 18.5 (interquartile range, 2.0-23.5) months. Twenty-four (63.2%) had infection as the primary cause of death. Other causes of death included pharyngeal muscle weakness and aspiration (n = 6), myocarditis (n = 2), respiratory failure (n = 2), cerebral bleed (n = 2), and pulmonary embolism (n = 1). One patient succumbed to rapidly progressive interstitial lung disease, whereas another patient with ASSD died following respiratory distress after rituximab infusion. In post hoc analysis, although thrombocytopenia appeared to be a risk factor for early mortality (odds ratio, 13.3; 95% confidence interval, 1.4-123.8; p = 0.01), this was not supported in the multivariate analysis.

CONCLUSIONS

Infections are the most common cause of in-hospital mortality in myositis patients.

[Epidemiological profile of dermatomyositis and polymyositis: a study conducted in the Department of Rheumatology in Marrakech]

La dermatomyosite (DM) et la polymyosite (PM) sont des affections rares mais graves. Le but de ce travail est d'étudier, à travers la revue d'une série hospitalière, leur profil épidémiologique, clinique et évolutif. Il s´agit d´une étude rétrospective, conduite sur une période de 15 ans, entre janvier 2004 et décembre 2019. Ont été retenus les cas où le diagnostic était certain ou probable selon les critères de Bohan et Peter. Un total de 14 patients ont été inclus (8 DM et 6 PM), l´âge moyen était de de 48,7 ans. La sex-ratio était de 13F/1H. Les signes généraux existaient dans 71%. Le déficit moteur touchait les muscles des ceintures dans 71% des cas; 85,7% avaient des arthralgies et 14% des arthrites. L´érythème et l´œdème périorbitaire étaient les signes cutanés prédominants. Au bilan, la vitesse de sédimentation était accélérée chez tous les malades et les enzymes musculaires augmentées dans 80%. Les anticorps anti-nucléaires étaient positifs dans 63%. La biopsie musculaire a retrouvé une myosite inflammatoire dans 75%. L'atteinte cardiaque existait dans 14% des cas et pulmonaire dans 21%. Un cancer était associé dans 21,4% des cas. Tous les patients ont reçu une corticothérapie. L´évolution s´est faite vers l´amélioration dans 88%, avec une rechute chez 4 patientes. Dans notre contexte, la DM est plus fréquente que la PM, avec nette prédominance féminine. L'atteinte pulmonaire reste une complication lourde. L´association aux cancers semble fréquente d´où la nécessité d´un bilan systématique de néoplasie au moment du diagnostic et lors du suivi.

Mycophenolate in idiopathic inflammatory myositis: outcome data of a large South Asian cohort

BACKGROUND

Consensus on treatment of idiopathic inflammatory myositis (IIM), particularly with regard to flares and interstitial lung disease (ILD), does not exist. We studied the long-term outcome and treatment response in our large, retrospective cohort of adult South-Asian patients exclusively with IIM.

METHODOLOGY

Electronic records of IIM patients satisfying inclusion and exclusion criteria were studied longitudinally at presentation, at 3, 6, 12, 18 and 24 months and thereafter yearly till their last follow up (F/u) visit. Depending on clinical, imaging, and muscle enzyme profile during the F/u period, patients were categorised as complete (CR) and partial responders (PRs). Parameters favouring CR were assessed using multivariate logistic regression analysis. Outcome parameters and flares on immunosuppressants (IS) were then assessed in patients with/without ILD.

RESULTS

Two hundred thirty-two patients with median F/u duration of 44.5 months (25-80.25) were included. ILD was seen in 40.1%. Patients with non-Jo1 anti-synthetase antibodies (n=26) were numerically more than those with Jo-1 antibody (n=24). CR status was attained by 50.9% patients. Absence of pericardial effusion (p=0.042, OR 4.223, 95% CI: 1.05-16.9) and presence of Gottron's rash (p=0.044, OR 1.78, 95% CI 1.017-3.121) at baseline predicted CR by multivariate regression. Majority received mycophenolate during the entire F/u period. Discontinuation of steroids was feasible in 51.7% after a median duration of 24 months (18-42). After excluding patients with ILD, flares were numerically lesser in patients only on mycophenolate compared with those only on methotrexate (p=0.06). Further flares were curtailed when switched from other agents to mycophenolate.

CONCLUSION

Mycophenolate is an effective treatment option in IIM patients with and without co-existing ILD. Presence of Gottron's rash and absence of pericardial effusion were found to be predictors of favourable clinical outcome in this largest single-centre study.

Concern about malignancy contributes to the psychosocial toll of dermatomyositis

Objective: Dermatomyositis (DM) is associated with increased morbidity and mortality, decreased quality of life, and an increased incidence of psychiatric illness. We performed a pilot study to investigate whether concern about malignancy contributes to the psychosocial toll of DM.Method: Patients with a recent DM diagnosis at our institution between 2013 and 2018 and no history of DM-associated malignancy completed standardized questionnaires and a novel survey generated by our group, and participated in focus groups.Results: Seventeen patients (14 females and three males) completed the surveys. The mean Dermatology Life Quality Index (DLQI) score was 2.75. The mean score on the Patient Health Questionnaire-9 (PHQ-9) was 5.35, with a range of 0-20. Our independent DM-specific questionnaire revealed a mean of 17.41 (range 2-40).Conclusion: Concern about the increased risk of malignancy contributes to the psychosocial toll of DM. Individual impacts are highly variable and patient specific. Clinicians should assess for depression and anxiety in patients with DM, understanding that concern for malignancy adds to the total psychosocial burden in some patients.

An extragonadal germ cell tumor with dermatomyositis: A case report and literature review

The risk of malignancy in inflammatory myopathy patients is well recognized. However, the incidence of germ cell tumor (GCT) with inflammatory myopathy is low, and most reported cases of GCT also exhibit testicular tumors. Therefore, a case of extragonadal GCT with dermatomyositis (DM) is reported in the current study to better understand this paraneoplastic syndrome. A 53-year-old man presented with bilateral cervical lymph node enlargement. A lymph node biopsy showed embryonal carcinoma, and computed tomography showed multiple lymph node and lung metastases. A period of one month after bleomycin, etoposide and cisplatin (BEP) chemotherapy, this patient developed an erythematous eruption over the extensor surfaces of bilateral fingers, or Gottron's sign and facial erythema. The patient was diagnosed with DM with a positive anti-TIF-1γ-antibody result. High-dose prednisolone was effective, and there has been no evidence of cancer recurrence for over one year. The literature review identified 17 cases of GCT with inflammatory myopathy that have been reported so far, and it was indicated that this is the first case of extragonadal GCT with DM following chemotherapy. This case highlights the importance of monitoring after the completion of cancer treatment, as distinctive dermal and muscular symptoms should cause us to consider the possibility of paraneoplastic inflammatory myopathy.

CMR T1 mapping and strain analysis in idiopathic inflammatory myopathy: evaluation in patients with negative late gadolinium enhancement and preserved ejection fraction

OBJECTIVES

To investigate whether cardiovascular magnetic resonance (CMR) T₁ mapping and strain parameters can detect early histological and functional myocardial changes in idiopathic inflammatory myopathy (IIM) with negative late gadolinium enhancement (LGE) and preserved ejection fraction.

METHODS

Thirty consecutive patients with IIM (41.5 ± 15.4 years, 24 females) who did not have LGE or reduced left ventricular ejection fraction (LVEF) and 30 age- and gender-matched healthy controls (40.6 ± 14.2 years, 20 females) were recruited. Patients with IIM were further classified into two subgroups according to high-sensitivity cardiac troponin I (hs-cTnI) values: elevated hs-cTnI subgroup (n = 10) and normal hs-cTnI subgroup (n = 20). Myocardial native T₁ values, extracellular volume (ECV) fractions, and strain parameters were analyzed in patients with IIM and healthy controls.

RESULTS

Compared with healthy controls, patients with IIM had significantly prolonged native T₁ values and increased ECV in each LV segment (p < 0.05). In further subgroup analysis, LV mid-slice native T₁ values had the most power to discriminate between patients with elevated hs-cTnI and healthy controls (area under the curve = 0.92). There was no significant difference of global LV strain or strain rates between IIM patients and controls.

CONCLUSIONS

Diffuse interstitial fibrosis can be detected by CMR T₁ mapping in patients with IIM who do not have LGE or reduced LVEF or elevated hs-cTnI, and it may be a promising method for screening subclinical cardiac involvement in IIM.

KEY POINTS

• Myocardial abnormality in IIM is often subclinical and leads to poor prognosis. • Conventional CMR parameters have limitations in early detection of cardiac function and tissue changes. • CMR T₁ mapping techniques and myocardial strain analysis have the potential to provide detailed information on cardiac histology and function.

Mortality trends in polymyositis and dermatomyositis: A general population-based study

OBJECTIVE

To evaluate mortality trends in polymyositis (PM) and dermatomyositis (DM) between January 1, 1997, and December 31, 2014.

METHODS

Using an administrative health database from the province of British Columbia, Canada, we identified all patients with incident PM/DM and up to 10 age-, sex-, and index date matched non-PM/DM individuals. Study cohorts for both PM and DM were divided into two subgroups based on the year of diagnosis (i.e., early cohort [1997-2005] and late cohort [2006-2014]). Mortality rates, hazard ratios (HRs), and rate differences were compared between these cohorts.

RESULTS

Mortality rates (per 1000 person-years) in the early cohorts for PM and DM patients were higher than those in the late cohorts (for PM: 58.6 vs. 39.4; for DM: 80.6 vs. 51.3), whereas smaller improvements were observed in the comparison cohorts (for non-PM: 15.5 vs. 12.5; for non-DM: 14.1 vs. 11.5). Corresponding to these two time periods, multivariable HRs for PM were 2.4 (95% CI, 1.7 to 3.4) and 2.0 (95% CI, 1.4 to 2.9), respectively (P-value for interaction=0.62). The corresponding absolute mortality rate differences were 32.6 (95% CI, 20.8 to 44.4) and 18.6 (95% CI, 9.2 to 28.0), respectively (P-value for interaction=0.02). Similar results with higher HRs and risk differences were seen in DM.

CONCLUSIONS

In this general population study, we found a declining excess mortality in PM or DM patients in recent years, although there was a considerable residual premature mortality gap in the late cohort.

Malignancy in dermatomyositis: A retrospective paired case-control study of 202 patients from Central China

Dermatomyositis (DM) is an idiopathic inflammatory myopathy that is closely related to malignant diseases. Our study aims to investigate the incidence and predictive factors for occurrence of malignancy among DM patients from Central China.We performed a retrospective, paired, case-control study of 736 DM patients admitted to the First Affiliated Hospital of Zhengzhou University between 2010 and 2017. We paired the 65 patients with malignancy with age-matched and sex-matched patients without malignancy in a ratio of 1:2. Two hundred two patients were finally enrolled and their clinical and laboratory data were collected.The incidence of malignancy in DM patients was 8.83% (65/736). Most malignancies were detected in the most recent 1 year before (9/65, 13.85%) or within 3 years after (40/65, 61.54%) the onset of DM. Males (35/65, 53.85%) and patients aged between 50 and 69 years (43/65, 66.15%) were prone to develop malignancies. Lung cancer (n = 11, 31.43%) was the most common malignancy in male patients, while for females, thyroid, breast and cervical cancer (n = 4 each, 13.33%) were more prevalent. Adenocarcinoma and squamous cell carcinoma (both 18/65, 27.69%) were the top two most common pathological types. Univariate analysis demonstrated that Gottron's sign (P = .02), dysphagia (P = .04), albumin (ALB) reduction (P = .003), aspartate aminotransferase (AST, P = .03), creatine kinase-MB (P = .02), absence of fever (P = .02), arthralgia (P = .04) and interstitial lung disease (ILD, P = .05) were closely related to the occurrence of malignancy. Multivariate analysis revealed the independent risk factors of ALB reduction (odds ratio = 1.546, P = .04) and the protective factor of ILD (odds ratio = 0.349, P = .003). There was no significant difference in the follow-up period between patients with and without ILD (P = .38).ALB reduction and the absence of ILD were the risk factors for malignancy in DM patients. The protective mechanism of ILD for DM patients needs further study.

Interstitial lung disease in dermatomyositis complicated by right ventricular thrombus secondary to macrophage activation syndrome- a case report

The course of dermatomyositis (DM) can be complicated by multi-organ failure, by complex pathophysiological mechanisms involving autoantibodies. Pulmonary complications are the leading cause of mortality, accounting for 30% of deaths. There is a strong association between DM and interstitial lung disease (ILD); clinically amyopathic dermatomyositis (CADM) has a stronger association with ILD as compared to a classic form of DM. ILD can be in the form of fibrosing alveolitis, interstitial pneumonia, and desquamative interstitial pneumonia or diffuse alveolar hemorrhage. Autoantibodies linked to ILD are anti Jo-1, PL12, PL7, EJ, and OJ and anti Mi 2. Our case describes a fifty-three years old woman who presented with symptoms of lower respiratory tract infection, diagnosed with CADM based on typical skin rash and polyarthritis and anti-CADM 140 antibodies. Systemic steroid therapy (initiated after ruling out sepsis) failed to provide improvement. The medical course was complicated by multisystem involvement (respiratory failure, cerebral edema, renal failure, coagulopathy, hepatic failure, and thromboembolism). Transthoracic echocardiogram revealed thrombus in the right ventricle, which was the result of the prothrombotic state, and the patient expired on day tenth of hospitalization. Our case describes a unique case of right ventricular thrombosis secondary to macrophage activation syndrome (MAS).

Demographic and clinical characteristics of cytomegalovirus reactivation in dermatomyositis

Dermatomyositis (DM) patients are known to have various infectious complications, such as cytomegalovirus (CMV) reactivation, due to immune dysfunction caused by DM itself and immunosuppressants used for treatment. Although CMV reactivation has been known to be a major cause of mortality in immunocompromised hosts, there has not been sufficient study of CMV reactivation in DM patients. The objective of this study was to examine the frequency of CMV reactivation in DM patients and to investigate risk factors potentially associated with development of CMV reactivation. We analyzed 52 Japanese DM patients, and CMV reactivation was observed in 21 (40.4%). The mean duration from the initiation of prednisolone (PSL) to the diagnosis of CMV reactivation was 6.1 ± 0.5 weeks. The total amount of oral PSL before the diagnosis of CMV reactivation was 2000.3 ± 169.3 mg. Using a univariate analysis, we found that the prevalence of interstitial lung disease and the frequency of diabetes mellitus complications in DM patients with CMV reactivation was significantly higher than that in DM patients without CMV. We identified that low lymphocytes (<900/μL) in DM patients was significantly associated with developing CMV reactivation. The use of immunosuppressants, including tacrolimus, cyclosporin and/or i.v. cyclophosphamide, was significantly associated with CMV reactivation in DM patients. Using a multivariate analysis, low lymphocytes at the time of DM diagnosis was found to be a risk factor for CMV reactivation. In addition, there was a tendency for diabetes mellitus to be a risk factor for CMV reactivation in DM patients. There was no difference in the prognosis for those with or without CMV reactivation in this study. These results suggest that in the DM patients with risk factors such as low lymphocytes and diabetes mellitus complications, regularly monitoring CMV reactivation and adequate treatment with antiviral agents may be necessary to prevent a poor prognosis.

A Complex Case of Polymyositis Overlapping With Hypothyroid Myopathy Without Underlying Autoimmune Thyroid Disorder

A 78-year-old woman with a past medical history of hypothyroidism and Sjogren's syndrome presented with a two-month history of gradually progressive bilateral lower extremity weakness. Significant elevation in thyroid-stimulating hormone (TSH) and muscle enzyme, such as creatine kinase, was noticed on presentation. Due to concerns of hypothyroid myopathy, the patient was started on thyroxine and triiodothyronine supplementation. The patient reported no significant improvement in her weakness in the one-month follow-up. Laboratory workup revealed improving TSH levels but worsening creatine kinase levels. Electromyography study showed primarily myopathic features, such as abnormal insertional activity concerning for mild inflammatory myopathy. Muscle biopsy showed mild inflammatory exudate and features of myopathy with ongoing denervation. The patient was diagnosed with polymyositis and started on prednisone 0.5 mg/kg daily with a taper course and methotrexate. The patient reported significant improvement in her weakness when seen in six weeks with normalizing creatine kinase levels. The hallmark difference between hypothyroid myopathy (including polymyositis-like syndrome) and conventional polymyositis is the complete clinical recovery and resolution of laboratory abnormalities after treatment with thyroid hormone replacement in hypothyroid myopathy. There was no evidence of underlying autoimmune thyroid disorder which makes this case unique. This case highlights the complex case of polymyositis overlapping with hypothyroid myopathy with no underlying autoimmune disorder.

Incidence, survival, and risk of cardiovascular events in adult inflammatory myopathies in South Korea: a nationwide population-based study

OBJECTIVE

Epidemiological studies on inflammatory myopathies (IMs) show widely variable results, and studies on Asians are lacking. Despite emerging interest in the cardiovascular disease (CVD) risk associated with IMs, the prevalence of CVD in IM patients and its impact on mortality remain unclear. We conducted a nationwide, population-based study on the incidence, mortality, and associated major CVD events of IMs in the Republic of Korea over 11 years.

METHOD

Using the nationwide, population-based National Health Insurance claims database and the Rare Intractable Disease registration programme, we estimated incidence, mortality, and CVD occurrence. Survival was examined using the Kaplan-Meier method. Mortality rate in IMs with CVD was analysed by Cox proportional hazards regression.

RESULTS

There were 3014 incident cases, 640 of whom died during the study period. The mean annual incidence was 7.16/10⁶. Dermatomyositis (DM) and polymyositis (PM) had 5 year survival rates of 76.8% and 79.3%, respectively. Cardiovascular events occurred in 155 patients and 40.6% of IM patients with CVD died. Acute myocardial infarction in men had the highest risk of any CVD event in both DM [standardized incidence ratio (SIR) 4.2, 95% confidence interval (95% CI) 2.4-7.2] and PM (SIR 3.5, 95% CI 1.8-7.0). Haemorrhagic stroke had the highest hazard ratio (HR) in both DM (HR 2.31, 95% CI 1.13-4.70) and PM patients (HR 2.10, 95% CI 1.03-4.27) compared with the general population with CVD.

CONCLUSION

We found persistently low incidence, poor survival, and high major CVD incidence in IMs, and increased mortality in IMs with CVD.

The spectrum of idiopathic inflammatory myopathies in South Africa

INTRODUCTION

There are many reports on idiopathic inflammatory myopathies (IIM) but little information from sub-Saharan Africa. We conducted a retrospective study of IIM in a multi-ethnic cohort seen at a single centre in Durban, South Africa.

METHOD

The study included patients who fulfilled the Bohan and Peter or European League Against Rheumatism/American College of Rheumatology criteria for IIM. The information recorded included demographic data, clinical findings, results of investigations, treatment and outcome. Patients with overlap myositis (OM) had myositis and criteria for another connective tissue disease.

RESULTS

There were 104 patients with IIM; 82.7% female and 70.2% African blacks. They included 41 (39.4%) with OM, 26 (25%) polymyositis (PM), 26 (25%) dermatomyositis (DM), six (5.8%) juvenile dermatomyositis and five (4.8%) cancer-associated myositis. Our patients had a younger mean age at diagnosis (36.8 ± 14.7 years) compared with 45-55 years in most other studies. Scleroderma-myositis overlap accounted for 26 (63.4%) of the patients with OM. Patients with OM were significantly younger than PM (p = 0.004) and DM (p = 0.044) and had lower, but not statistically significant, creatine kinase levels at diagnosis compared with PM (p = 0.052) and DM (p = 0.073). Interstitial lung disease was more common in OM (p = 0.001) and PM (p = 0.024) than DM. Oropharyngeal weakness was more common in DM than OM (p = 0.001) and PM (p = 0.032). African blacks were younger (p = 0.028) at diagnosis and had more cardiac abnormalities (p = 0.034) than Indians.

CONCLUSION

The spectrum of IIM in our cohort of mainly African blacks is similar to other studies, with OM being the most frequent subtype. Key Points • As there is limited information on idiopathic inflammatory myopathies (IIM) in sub-Saharan Africa, this study reports the spectrum of IIM in a South African cohort of predominantly African blacks. • Our patients were younger at diagnosis, and overlap myositis was the most common phenotype. • Comparisons with other studies show similarities in the manifestations of IIM.

Jejunal perforation complicating dermatomyositis

•

Jejunal perforation in dermatomyositis is very rare but fatal.

•

The authors describe an unusual case of jejunal perforation due to ischemic change, which is a very rare complication of DM.

•

To minimize mortality via an early diagnosis and a timely treatment, it is important to examine clinical history and to employ a proper medical imaging modality such as CT even when lab findings are nonspecific and atypical.

Introduction

Small bowel perforation is rare in dermatomyositis (DM). However, it is associated with high rates of morbidity and mortality. In line with the SCARE criteria, we describe a case of jejunal perforation for a DM patient (Agha et al., 2018 [1]).

Case presentation

A 63-year-old woman had been treated for DM with high dose steroid 1 month prior to the onset of severe abdominal pain. Computed tomography (CT) revealed free air in abdominal cavity and fluid around the small bowel. She was diagnosed with small bowel perforation and underwent emergency surgery. Emergent surgery showed perforated jejunum which was resected. Pathologic reports revealed mesenteric small-vessel vasculitis with a perivascular inflammatory cell infiltration.

Conclusion

Perforation of the small bowel for DM patients is rare. However, the early diagnosis of bowel perforation is difficult in DM because it can mimic other gastrointestinal manifestations such as ileus, ischemic colitis and peritonitis. To minimize mortality via an early diagnosis and a timely treatment, it is important to examine the patient’s clinical history and employ a proper medical imaging modality such as CT even when lab findings are nonspecific and atypical.

Increased risk of coronary heart disease among patients with idiopathic inflammatory myositis: a nationwide population study in Taiwan

OBJECTIVE

To evaluate the risk of incident coronary heart disease (CHD) among patients with DM and PM in a general population context.

METHODS

We conducted a retrospective cohort study using the Taiwan National Health Insurance Research Database containing records covering the years from 2000 to 2010. DM and PM were confined for the purposes of this study to those aged ⩾18 years who were eligible for the Taiwan catastrophic illness certificate. The diagnoses, CHD outcomes and cardiovascular risk factors were identified from electronic claims data. We conducted two cohort analyses: CHD and DM, and CHD and PM, excluding for each analysis individuals with CHD already identified at baseline. Data for the comparison group was obtained from the Longitudinal Health Insurance database, comprising 1 million persons randomly sampled from the total beneficiaries during 2000. We estimated hazard ratios comparing myositis with comparison cohorts, adjusting for potential cardiovascular risk factors.

RESULTS

A total of 1145 patients with idiopathic myositis were identified, along with 732 723 control patients aged ⩾18 years. The incidence rates of CHD were 15.1 in DM and 30.1 in PM per 1000 person-years, vs 8.4 and 10.5 per 1000 person-years in the comparison cohort. The adjusted hazard ratios for CHD in patients with idiopathic myositis were 2.21 (95% CI 1.64, 2.99) for DM and 3.73 (95% CI 2.83, 4.90) for PM.

CONCLUSION

Results of this general population-based cohort study suggest that DM and PM are associated with an increased risk of CHD.

Clinical characteristics and prognosis of polymyositis and dermatomyositis associated with malignancy: a 25-year retrospective study

The objective of this study was to identify factors predictive of malignancy in patients with polymyositis (PM) and dermatomyositis (DM) in Japan. We conducted a retrospective study of PM and DM patients who were admitted to our hospital between January 1992 and September 2017. Among 134 patients, 29 (21.6%) were diagnosed with cancer in the 3 years prior to and 3 years after the initial diagnosis of PM or DM. According to multivariate analyses, male sex [odds ratio (OR) = 3.65, p = 0.03], old age (OR = 1.05, p = 0.02), and a past history of diabetes mellitus (OR = 10.4, p = 0.005) were associated with an increased risk of malignancy. The absence of interstitial lung disease (ILD) (OR = 0.25, p = 0.03) was also associated with an increased risk of malignancy. Diabetes mellitus was observed in 28.6% of PM and DM patients with malignancy, but in only 7.3% of those with malignancy. Survival was significantly lower in patients with malignancy than in those without malignancy (p < 0.001). Independent factors associated with malignancies in patients with PM or DM were male sex, old age, the absence of ILD, and, especially, a past history of diabetes mellitus.

Integrated therapy decreases the mortality of patients with polymyositis and dermatomyositis: A Taiwan-wide population-based retrospective study

ETHNOPHARMACOLOGICAL RELEVANCE

The issue of whether integrated treatment with conventional medicine (CM) and herbal medicine (HM) can reduce mortality in patients with polymyositis/dermatomyositis (PM/DM) had not been addressed.

AIM OF THE STUDY

In this study, we investigated the effect of integrated therapy on mortality in a retrospective PM/DM cohort in the Taiwan National Health Insurance Research Database (NHIRD).

MATERIALS AND METHODS

Patients with PM/DM were retrospectively enrolled from the PM/DM Registry of Catastrophic Illnesses cohort in the Taiwan NHIRD between 1997 and 2011. The patients were divided into an integrated medicine (IM) group that received CM and HM and a non-IM group that received CM alone. The Cox proportional hazards regression model and Kaplan-Meier method were used to evaluate the hazard ratio (HR) for mortality.

RESULTS

Three hundred and eighty-five of 2595 patients with newly diagnosed PM/DM had received IM and 99 had received non-IM. The adjusted HR for mortality was lower in the IM group than in the non-IM group (0.42, 95% confidence interval 0.26-0.68, p < 0.001). The adjusted HR for mortality was also lower in the IM group that had received CM plus HM than in the group that received CM alone (0.48, 95% confidence interval 0.28-0.84, p < 0.05). The core pattern of HM prescriptions integrated with methylprednisolone, methotrexate, azathioprine, or cyclophosphamide to decrease mortality included "San-Qi" (Panax notoginseng), "Bai-Ji" (Bletilla striata), "Chen-Pi" (Citrus reticulata), "Hou-Po" (Magnolia officinalis), and "Dan-Shan" (Salvia miltiorrhiza).

CONCLUSION

Integrated therapy has reduced mortality in patients with PM/DM in Taiwan. Further investigation of the clinical effects and pharmaceutical mechanism involved is needed.

Overlap myositis, a distinct entity beyond primary inflammatory myositis: A retrospective analysis of a large cohort from the REMICAM registry

BACKGROUND

Inflammatory idiopathic myositis (IIM) comprises a heterogeneous group of systemic muscular diseases that can occur together with other connective tissue diseases (CTD), named overlap myositis (OM). The question of whether OM is a distinct entity still remains controversial.

AIM

The present study was conducted to assess the clinical and prognostic differences between patients diagnosed with OM, primary polymyositis (PM) and primary dermatomyositis (DM).

METHOD

The study consists of a retrospective longitudinal and multicenter series of IIM patients. Patients were classified as OM, PM and DM. Overlap myositis was defined as patients fulfilling criteria for IIM plus criteria for other CTD (namely systemic sclerosis, systemic lupus erythematosus, mixed connective tissue disease, rheumatoid arthritis and primary Sjögren's syndrome).

RESULT

A total of 342 patients were included (98 OM, 137 PM and 107 DM). Overlap myositis patients, in comparison with PM and DM, showed significant differences, with more extramuscular involvement, particularly more arthritis (66%, 34.6% and 48.1%, respectively), puffy fingers (49.5%, 11.1% and 24.3%), sclerodactyly (45.4%, 2.2% and 2%), dysphagia (41.8%, 18.2% and 26.4%), Raynaud phenomenon (65.3%, 16.9% and 19.8%), leucopenia (28.9%, 2.2% and 8.4%), thrombocytopenia (8.2%, 2.2% and 1.9%), interstitial lung disease (ILD) (48%, 35% and 30.8%), renal manifestations (13.4%, 3.7% and 1.9%), and more severe infections (41.3%, 26.7% and 21%). No significant differences were found in survival between groups in log rank test (P = 0.106). Multivariate adjusted survival analyses revealed a worse prognosis for severe infections, ILD and baseline elevation of acute phase reactants.

CONCLUSION

Overlap myositis stands out as a distinct entity as compared to PM and DM, featuring more extramuscular involvement and more severe infections. Close monitoring is recommended in this subset for early detection and treatment of possible complications.

Treatment consensus for management of polymyositis and dermatomyositis among rheumatologists, neurologists and dermatologists

Although rheumatologists, neurologists and dermatologists see patients with polymyositis (PM) and dermatomyositis (DM), their management appears to vary depending on the physician's specialty. The aim of the present study was to establish the treatment consensus among specialists of the three fields to standardize the patient care. We formed a research team supported by a grant from the Ministry of Health, Labor and Welfare, Japan. Clinical questions (CQ) on the management of PM and DM were raised. A published work search on CQ was performed primarily using PubMed. Using the nominal group technique, qualified studies and results in the published work were evaluated and discussed to reach consensus recommendations. They were sent out to the Japan College of Rheumatology, Japanese Society of Neurology and Japanese Dermatological Association for their approval. We reached a consensus in 23 CQ and made recommendations and a decision tree for management was proposed. They were officially approved by the three scientific societies. In conclusion, a multidisciplinary treatment consensus for the management of PM and DM was established for the first time.

Long-term follow-up of 76 Iranian patients with idiopathic inflammatory myopathies

AIM

This study aimed to follow up patients with polymyositis (PM) and/or dermatomyositis (DM) to determine survival rate, pattern of disease, response to treatment, malignancy incidence and poor prognostic factors (PPFs).

METHOD

A total of 76 patients with PM (n = 47) and/or DM (n = 29) based on Bohan and Peter diagnostic criteria referred to the Imam-Reza Hospital were followed up from 2004 to 2016. The follow-up period was considered from diagnosis to patient's death or last visit. All patients underwent physical examinations and data including age, sex, disease duration, disease subtype, pattern of disease, PPFs and malignancy incidence were collected.

RESULTS

Mean age at diagnosis was 45.49 ± 10.88 years and women were predominant (84.2%). Course of disease in the majority of patients (52.6%) was polyphasic, followed by monophasic (31.6%) and chronic-progressive (5.3%). The 1-, 5- and 10-year survival rates were 96%, 93% and 92%, respectively. Delay in treatment and dysphagia were common PPFs in the present study. The majority of patients responded to treatment (88.2%) and there were significant differences in cancer and dysphagia between responders and non-responders to treatment (P < 0.05). The most common cause of death was cancer in four of eight deaths. There was significant difference in survival rates between patients with and without pulmonary involvement (P = 0.001). Moreover, the survival rates were significantly lower in patients with malignancy (P = 0.001).

CONCLUSION

Presence of dysphagia and cancer were associated with poor response to treatment. Pulmonary involvement and cancer incidence significantly affect survival rate. Furthermore, since cancer is the most common cause of death, so this study emphasizes the importance of careful cancer screening in these patients.

Autoimmune Myopathies: Updates on Evaluation and Treatment

The major forms of autoimmune myopathies include dermatomyositis (DM), polymyositis (PM), myositis associated with antisynthetase syndrome (ASS), immune-mediated necrotizing myopathy (IMNM), and inclusion body myositis (IBM). While each of these conditions has unique clinical and histopathological features, they all share an immune-mediated component. These conditions can occur in isolation or can be associated with systemic malignancies or connective tissue disorders (overlap syndromes). As more has been learned about these conditions, it has become clear that traditional classification schemes do not adequately group patients according to shared clinical features and prognosis. Newer classifications are now utilizing myositis-specific autoantibodies which correlate with clinical and histopathological phenotypes and risk of malignancy, and help in offering prognostic information with regard to treatment response. Based on observational data and expert opinion, corticosteroids are considered first-line therapy for DM, PM, ASS, and IMNM, although intravenous immunoglobulin (IVIG) is increasingly being used as initial therapy in IMNM related to statin use. Second-line agents are often required, but further prospective investigation is required regarding the optimal choice and timing of these agents.

Characteristics and predictors of malignancy in dermatomyositis: Analysis of 239 patients from northern China

The present study aimed to determine the characteristics of patients with dermatomyositis (DM) in order to identify predictors of cancer in these patients. Data of 239 patients with DM, treated at Yuhuangding Hospital between 1997 and 2016, was retrospectively assessed. The patients' demographic, clinical, survival and laboratory data were analyzed. Of the 239 patients, 43 developed malignancies. In 30 (69.77%) patients, the malignancy was detected within 1 year before or after DM diagnosis. There were 15 (34.88%) fatalities. Lung cancer was the most common type of malignancy identified (n=6, 13.95%), and adenocarcinoma was the most common pathological type (n=6, 13.95%). Older age, absence of interstitial lung disease, and absence of arthralgia were demonstrated to be independent risk factors for malignancy. Myositis-specific autoantibody expression, specifically anti-TIF1γ positivity and/or anti-MDA5 negativity, was associated with cancer in patients with DM. The survival rate was significantly lower in patients with malignancy than in patients without malignancy. Patients with DM had a high incidence of malignancy and a poor prognosis. Lung cancer and adenocarcinoma are common among patients with DM in northern China. Cancer screening should be conducted in all DM patients, particularly within 1 year of DM diagnosis. Older age is a risk factor for malignancy in DM patients, while interstitial lung disease and arthralgia are protective factors. Myositis-specific autoantibody detection may be useful for cancer screening in patients with DM.

Hospitalization mortality and associated risk factors in patients with polymyositis and dermatomyositis: A retrospective case-control study

BACKGROUND

Polymyositis and dermatomyositis (PM/DM) are systemic autoimmune diseases with multiple organ involvements that manifest as muscular and cutaneous disorders, interstitial lung disease (ILD) and malignancies. However, information concerning the outcomes and associated factors for PM/DM patients who are hospitalized is limited.

METHODS

We retrospectively reviewed the medical charts of PM/DM patients admitted to a Chinese tertiary referral hospital (Peking Union Medical College Hospital, PUMCH) from 2008 to 2014. The deceased group included 63 patients who had "deceased discharge" status or were confirmed to have died within two weeks of hospital discharge. The demographic data, clinical manifestations, and direct causes of death were analyzed retrospectively. Medical records for 126 age- and sex-matched PM/DM patients were selected as controls from 982 inpatients successively admitted to the same center during the same period. In addition to the comparison of clinical manifestations between the two groups, binary logistic regression was conducted to explore the risk factors related to PM/DM mortality.

RESULTS

Over the past 6 years at PUMCH, the in-hospital mortality rate of PM/DM patients was 4.58%. The male gender and the elder patients had a high risk of death (P = 0.031 and P = 0.001 respectively). The three most frequent causes of death for PM/DM patients were pulmonary infection (35%), ILD exacerbation (21%) or both conditions (25%). Pulmonary infection (P<0.001, OR = 5.63, 95% CI, 2.37-13.36), pneumomediastinum (P = 0.041, OR = 11.02, 95%CI, 1.10-110.54), Gottron's papules (P = 0.010, OR = 3.24, 95%CI, 1.32-7.97), and elevated erythrocyte sedimentation rate (ESR) (P = 0.005, OR = 9.9, 95%CI 2.0-49.0) were independent risk factors for in-hospital mortality of PM/DM patients.

CONCLUSION

PM/DM patients continue to display high in-hospital mortality. Pulmonary infection is the strongest predictor of poor prognosis in PM/DM patients, followed by pneumomediastinum, Gottron's papules, and elevated ESR.

Baseline peripheral blood neutrophil-to-lymphocyte ratio could predict survival in patients with adult polymyositis and dermatomyositis: A retrospective observational study

Recent studies have suggested that neutrophil-to-lymphocyte ratio (NLR) and C-reactive protein-to-albumin ratio (CAR) are emerging markers of disease activity and prognosis in patients with chronic inflammatory diseases, cardiovascular diseases, or malignancies. Therefore, we investigated the clinical significance and prognostic value of the NLR and CAR in adult patients with polymyositis and dermatomyositis. The medical records of 197 patients with newly diagnosed polymyositis/dermatomyositis between August 2003 and November 2016 were retrospectively reviewed. Survival and causes of death were recorded during an average 33-month observational period. Clinical and laboratory findings were compared between survivors and non-survivors. Using receiver operating characteristic curves, the NLR and CAR cut-off values for predicting survival were calculated. Univariate and multivariate analyses using Cox proportional hazard models were performed to identify factors associated with survival. Twenty-six patients (13.2%) died during the study period, and the 5-year survival-rate was estimated to be 82%. The non-survivor group exhibited older age and a higher prevalence of interstitial lung disease (ILD), acute interstitial pneumonia, and acute exacerbation of ILD compared to that in the survivor group. NLR and CAR values were significantly higher in the non-survivors and in patients with polymyositis/dermatomyositis-associated ILD, and the death rates increased across NLR and CAR quartiles. Furthermore, when stratified according to the NLR or CAR optimal cut-off values, patients with a high NLR (>4.775) or high CAR (>0.0735) had a significantly lower survival rate than patients with low NLR or CAR, respectively. In addition, old age (>50 years), the presence of acute interstitial pneumonia, hypoproteinemia (serum protein <5.5 g/dL), and high NLR (but not high CAR) were independent predictors for mortality. The results indicate that a high NLR is independently associated with worse overall survival. Thus, the baseline NLR level may be a simple, cost-effective prognostic marker in patients with polymyositis/dermatomyositis.

Quantitative 3D scintigraphy shows increased muscular uptake of pyrophosphate in idiopathic inflammatory myopathy

BACKGROUND

Nuclear imaging is increasingly being used in the diagnostic work-up of idiopathic inflammatory myopathy (IIM). Increased muscular uptake of technetium-99m-pyrophosphate (^99mTc-PYP) has hitherto been assessed qualitatively by planar scintigraphy. We set out to perform quantitative tomographic scintigraphy in IIM.

RESULTS

Ninety IIM patients and 48 control subjects underwent ^99mTc-PYP single-photon emission computed tomography (SPECT)/CT of the upper and lower body. Scans were evaluated visually by an intensity score (1-4) and quantitatively by the mean standardized uptake value (SUV_mean) in thigh muscles after semi-automated segmentation of these. Furthermore, a SUV_mean gradient down along the thighs was determined by linear regression of the slice-by-slice activity. Interobserver analyses were performed on qualitative evaluations. Compared to controls, patients more often had a high intensity score (p < 0.0001), but interobserver analyses revealed only moderate agreement. The thigh muscular ^99mTc-PYP activity (SUV_mean) was 60% higher in patients than in controls, p < 0.0001, albeit with a wide range. There was an activity gradient down the thigh muscle, the proximal tracer uptake being highest, and this gradient was steeper in patients than in controls; the activity decreased by 0.00024 and 0.00010 SUV_mean mm^-1, respectively, along the thighs.

CONCLUSIONS

The muscular uptake of ^99mTc-PYP was significantly higher in patients than in healthy controls by qualitative and quantitative assessment. The tracer uptake was higher in the proximal than in the distal part of the thigh muscle, and SUV_mean gradients differed between groups. Hence, tomographic nuclear imaging allowing for quantification of the ^99mTc-PYP uptake might contribute to the diagnosis of IIM, and SPECT/CT of the lower body might suffice.

Myositis-associated Interstitial Lung Disease: Predictors of Failure of Conventional Treatment and Response to Tacrolimus in a US Cohort

Objective.

Patients with myositis-associated interstitial lung disease (MA-ILD) are often refractory to conventional treatment, and predicting their response to therapy is challenging. Recent case reports and small series suggest that tacrolimus may be useful in refractory cases.

Methods.

A retrospective cohort study of patients with MA-ILD comparing clinical characteristics between those who responded to or failed conventional treatment. In those who failed conventional treatment and received adjunctive tacrolimus, response to tacrolimus was measured by the improvement in myositis, ILD, and change in the dose of glucocorticoids.

Results.

Thirty-one of 54 patients (57%) responded to conventional treatment based on the predefined variables of improvement in myositis and/or ILD. Patients with polymyositis (PM)-ILD were more likely to respond to conventional treatment than those with dermatomyositis (DM)-ILD (67% vs 35%, p = 0.013). Twenty-three patients failed conventional treatment, 18 of whom subsequently received adjunctive tacrolimus. Ninety-four percent had improvements in ILD and 72% showed improvement in both myositis and ILD. The mean doses of prednisone decreased from baseline by 65% at 3–6 months (p = 0.002) and 81% at 1 year (p < 0.001).

Conclusion.

Patients with PM-ILD were more likely to respond to conventional treatment than patients with DM-ILD, but clinical characteristics and serology did not otherwise predict response to therapy. A majority of patients with MA-ILD refractory to conventional therapy improved while receiving tacrolimus and were able to decrease their dose of both glucocorticoids and other disease-modifying antirheumatic drugs.