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Cavusoglu D, Talim B, Ekinci G, Topaloglu H. Six Years Follow-Up of an 11-Year-Old Girl with Anti-HMGCR Myopathy. J Neuromuscul Dis 2024; 11:883-887. [PMID: 38759023 PMCID: PMC11307026 DOI: 10.3233/jnd-240022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2024] [Indexed: 05/19/2024]
Abstract
Anti-HMGCR myopathy is decribed as an immune-mediated necrotizing myopathy which is characterised by subacute, progressive proximal muscle weakness and elevated creatine kinase (CK) level. In pediatric population, anti-HMGCR myopathy has been reported solely as small case reports, albeit rare. Although treatment consensus has not yet been established, proper treatment with several immunomodulators to include IVIg can show remarkable improvement. We report an 11-year-old-girl diagnosed with anti-HMGCR myopathy with 6 years of follow-up.
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Affiliation(s)
- Dilek Cavusoglu
- Department of Pediatric Neurology, Faculty of Medicine, Afyonkarahisar Health Sciences University, Afyon, Turkey
| | - Beril Talim
- Department of Pediatrics, Pathology Unit, Hacettepe University, Ankara, Turkey
| | - Gazanfer Ekinci
- Department of Radiology, Yeditepe University School of Medicine, Istanbul, Turkey
| | - Haluk Topaloglu
- Department of Pediatrics, Yeditepe University, Istanbul, Turkey
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2
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Watanuki K, Koga H. Case report: Diagnostic clues for anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase myopathy in pediatric patients. Front Pediatr 2023; 11:1102539. [PMID: 36994439 PMCID: PMC10040642 DOI: 10.3389/fped.2023.1102539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 02/27/2023] [Indexed: 03/31/2023] Open
Abstract
Introduction Anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR) myopathy is a recently recognized pathology, but appears less common in children and the characteristics of pediatric cases remain unclear. Case report We report a pediatric case of anti-HMGCR myopathy accompanied by skin rash. Motor function and serum creatine kinase level normalized after combinational treatment including early intravenous immunoglobulin, methotrexate, and corticosteroid. Literature review We searched PubMed and identified reports with detailed clinical information of 33 pediatric patients <18 years old with anti-HMGCR myopathy. Among these 33 patients and our own case, skin rash and maximum serum creatine kinase level >5,000 IU/L were observed in 44% (15 patients) and 94% (32 patients), respectively. Skin rash was present in 15 of the 22 patients (68%) ≥7 years old and none of the 12 patients (0%) <7 years old. Among the 15 patients with skin rash, 12 (80%) presented with erythematous rash. Conclusion Erythematous skin rash may offer a clue to the diagnosis of anti-HMGCR myopathy in children with muscle weakness and serum creatine kinase level >5,000 IU/L in the absence of other myositis-specific antibodies, particularly in patients ≥7 years old. Our results suggest the importance of early anti-HMGCR testing in pediatric patients with these manifestations.
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Affiliation(s)
- Keisuke Watanuki
- Department of Pediatrics, National Hospital Organization Beppu Medical Center, Beppu, Japan
| | - Hiroshi Koga
- Department of Pediatrics, National Hospital Organization Beppu Medical Center, Beppu, Japan
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Sener S, Batu ED, Sari S, Kasap Cuceoglu M, Yildiz AE, Talim B, Aydingoz U, Ozen S, Haliloglu G. A Child with Refractory and Relapsing Anti-3-Hydroxy-3-Methylglutaryl-Coenzyme A Reductase Myopathy: Case-Based Review. J Neuromuscul Dis 2023; 10:279-291. [PMID: 36617789 DOI: 10.3233/jnd-221557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND/OBJECTIVE Anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase (anti-HMGCR) myopathy is rare in children. Here, we present a boy with relapsing refractory anti-HMGCR myopathy along with a systematic literature review. CASE REPORT 17-year-old boy with five years of muscle weakness, rash, high creatinine kinase (CK) levels, and muscle biopsy compatible with inflammatory myopathy was diagnosed with juvenile dermatomyositis. He was treated with corticosteroids, intravenous immunoglobulin (IVIG), and methotrexate. His muscle weakness improved with this treatment although never completely resolved. CK levels decreased from ∼15000 U/L to ∼3000 U/L. At the age of 15, muscle weakness relapsed after an upper respiratory tract infection; pulse corticosteroid treatment was administered. The re-evaluated muscle biopsy showed a necrotizing pattern and the HMGCR antibody was positive confirming anti-HMGCR myopathy when he was 16. The diagnostic delay was 50 months. Disease activity was monitored by Medical Research Council score, MRI and functional tests. Despite corticosteroids, methotrexate, IVIG, cyclosporine A, and rituximab therapies, muscle weakness improved only slightly during the first three months and remained stable afterwards.Results of the Literature Search:We identified 16 articles describing 50 children (76% female) with anti-HMGCR myopathy by reviewing the English literature up to March 1st, 2022. Proximal muscle weakness was the most common clinical symptom (70.8%). Corticosteroids (84.8%), IVIG (58.7%), and methotrexate (56.5%) were preferred in most cases. Complete remission was achieved in nine patients (28.1%). CONCLUSION Diagnosis and management of children with anti-HMGCR myopathy are challenging. Complete remission is achieved in only one third of these patients. Imaging biomarkers may aid treatment.
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Affiliation(s)
- Seher Sener
- Department of Pediatrics, Division of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ezgi Deniz Batu
- Department of Pediatrics, Division of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Seher Sari
- Department of Pediatrics, Division of Pediatric Neurology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Muserref Kasap Cuceoglu
- Department of Pediatrics, Division of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Adalet Elcin Yildiz
- Department of Radiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Beril Talim
- Division of Pediatric Pathology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ustun Aydingoz
- Department of Radiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Seza Ozen
- Department of Pediatrics, Division of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Goknur Haliloglu
- Department of Pediatrics, Division of Pediatric Neurology, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Wang CH, Liang WC. Pediatric immune-mediated necrotizing myopathy. Front Neurol 2023; 14:1123380. [PMID: 37021281 PMCID: PMC10067916 DOI: 10.3389/fneur.2023.1123380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 03/03/2023] [Indexed: 04/07/2023] Open
Abstract
Immune-mediated necrotizing myopathy (IMNM) is a type of inflammatory myopathy. Most patients with IMNM produce anti-3-hydroxy-3-methylglutaryl coenzyme A reductase or anti-signal-recognition particle autoantibodies. IMNM is much rarer in children than in adults. We conducted this mini review focusing on pediatric IMNM to present current evidence regarding its epidemiology, clinical characteristics, diagnosis, and treatment. Our findings indicate that pediatric IMNM often causes severe muscle weakness and is refractory to corticosteroids alone. Furthermore, delayed diagnosis is common because of the clinicopathological similarity between IMNM and inherited myopathy. Raising awareness regarding pediatric IMNM may facilitate early diagnosis and effective treatment.
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Affiliation(s)
- Chen-Hua Wang
- Department of Pediatrics, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wen-Chen Liang
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Pediatrics, School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- *Correspondence: Wen-Chen Liang,
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Mekmangkonthong A, Amornvit J, Numkarunarunrote N, Veeravigrom M, Khaosut P. Dengue infection triggered immune mediated necrotizing myopathy in children: a case report and literature review. Pediatr Rheumatol Online J 2022; 20:40. [PMID: 35672822 PMCID: PMC9175479 DOI: 10.1186/s12969-022-00699-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 05/29/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Immune-mediated necrotizing myopathy (IMNM) is a subgroup of idiopathic inflammatory myopathies manifesting with progressive weakness, elevated serum creatine kinase (CK) levels, and necrotizing myopathic features on muscle biopsy. There is a paucity of data on the clinical presentation of IMNM in children. We report a paediatric patient who developed anti-3-hydroxy-3-methylglutaryl-CoA reductase (anti-HMGCR)-positive necrotizing myopathy after recent dengue infection. CASE PRESENTATION A previously healthy 9-year-old boy presented with acute proximal muscle weakness after recovery from dengue infection. Five days after the fever subsided, he could not stand from a squatting position. He denied having skin rash, arthritis, or other systemic features. He had marked elevation of CK level of 30,833 mg/dL and was put on steroid therapy. The patient initially responded to oral prednisolone, however the weakness persisted and muscle enzymes increased as steroids were decreased. He was then referred to our hospital for further assessment. Subsequent investigation revealed anti-HMGCR positivity along with specific histopathological findings consistent with IMNM. The patient was treated with six cycles of intravenous immunoglobulin (IVIG) monthly, then followed by a gradual taper of prednisolone and oral methotrexate weekly with complete recovery in motor power. CONCLUSIONS Our report presents a child with clinical manifestations of IMNM which can be categorized as acute onset of muscle weakness following dengue infection. Two key points supporting a diagnosis in this case are clinical response after immunosuppressive therapy and absence of rashes found in juvenile dermatomyositis.
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Affiliation(s)
- Aphirak Mekmangkonthong
- grid.7922.e0000 0001 0244 7875Division of Paediatric Neurology, Department of Paediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ,grid.411628.80000 0000 9758 8584Division of Paediatric Neurology, Department of Paediatrics, King Chulalongkorn Memorial Hospital/The Thai Red Cross Society, Bangkok, Thailand
| | - Jakkrit Amornvit
- grid.7922.e0000 0001 0244 7875Division of Neurology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ,grid.419934.20000 0001 1018 2627Division of Neurology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital/The Thai Red Cross Society, Bangkok, Thailand
| | - Numphung Numkarunarunrote
- grid.7922.e0000 0001 0244 7875Department of Radiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Montida Veeravigrom
- grid.7922.e0000 0001 0244 7875Division of Paediatric Neurology, Department of Paediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ,grid.411628.80000 0000 9758 8584Division of Paediatric Neurology, Department of Paediatrics, King Chulalongkorn Memorial Hospital/The Thai Red Cross Society, Bangkok, Thailand ,grid.170205.10000 0004 1936 7822Section of Child Neurology, Department of Paediatrics, Comer Children’s Hospital, The University of Chicago, Chicago, IL USA
| | - Parichat Khaosut
- Division of Paediatric Allergy, Immunology and Rheumatology, Department of Paediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand. .,Center of Excellence for Allergy and Clinical Immunology, Division of Paediatric Allergy, Immunology and Rheumatology, Department of Paediatrics, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital/The Thai Red Cross Society, Bangkok, Thailand. .,Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, 1873 Rama IV Road, Pathum Wan District, Bangkok, 10330, Thailand.
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Hou Y, Shao K, Zhao B, Dai T, Wang Q, Zhao Y, Yan C, Yan Y, Ma X, Li W. Juvenile idiopathic inflammatory myopathies with anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase antibodies in a Chinese cohort. CNS Neurosci Ther 2021; 27:1041-1047. [PMID: 33932258 PMCID: PMC8339526 DOI: 10.1111/cns.13658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 04/18/2021] [Accepted: 04/19/2021] [Indexed: 12/03/2022] Open
Abstract
AIMS To characterize the clinical and histopathological characteristics and treatment outcomes of juvenile idiopathic inflammatory myopathies (JIIMs) with anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR) antibodies in a Chinese cohort. METHODS We detected anti-HMGCR antibodies in a series of Chinese JIIM by ELISA and indirect immunofluorescence assay on HEK293 cells, and summarized the clinical findings of these anti-HMGCR antibody-positive patients. RESULTS Of 32 JIIM patients, 5 (15.63%) were found to be anti-HMGCR antibody-positive. The disease duration was 1.20 ± 0.45 months. Statin exposure was not found. Four patients had skin lesions, while typical pathological features of dermatomyositis such as perifascicular atrophy or myxovirus resistance protein A expression were not found. The mean creatine kinase level was 16771.60 U/L. Among the four patients who received long-term (10.46 ± 1.42 years) follow-up, three exhibited favorable outcomes with prednisone and additional immunosuppressants. CONCLUSIONS Our study indicates that anti-HMGCR antibodies may not be rare in Chinese JIIM. These anti-HMGCR-positive JIIMs were characterized by acute onset, substantially elevated creatine kinase level, and skin lesions without perifascicular changes in muscle pathology. The treatment outcome is generally favorable with the combination of steroid and immunosuppressant.
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Affiliation(s)
- Ying Hou
- Research Institute of Neuromuscular and Neurodegenerative Diseases and Department of NeurologyQilu HospitalCheeloo College of MedicineShandong UniversityJinanChina
| | - Kai Shao
- Department of Central Laboratory and Mitochondrial Medicine LaboratoryQilu Hospital (Qingdao)Cheeloo College of MedicineShandong UniversityQingdaoChina
| | - Bing Zhao
- Research Institute of Neuromuscular and Neurodegenerative Diseases and Department of NeurologyQilu HospitalCheeloo College of MedicineShandong UniversityJinanChina
| | - Tingjun Dai
- Research Institute of Neuromuscular and Neurodegenerative Diseases and Department of NeurologyQilu HospitalCheeloo College of MedicineShandong UniversityJinanChina
| | - Qinzhou Wang
- Research Institute of Neuromuscular and Neurodegenerative Diseases and Department of NeurologyQilu HospitalCheeloo College of MedicineShandong UniversityJinanChina
| | - Yuying Zhao
- Research Institute of Neuromuscular and Neurodegenerative Diseases and Department of NeurologyQilu HospitalCheeloo College of MedicineShandong UniversityJinanChina
| | - Chuanzhu Yan
- Research Institute of Neuromuscular and Neurodegenerative Diseases and Department of NeurologyQilu HospitalCheeloo College of MedicineShandong UniversityJinanChina
- Department of Central Laboratory and Mitochondrial Medicine LaboratoryQilu Hospital (Qingdao)Cheeloo College of MedicineShandong UniversityQingdaoChina
- Brain Science Research InstituteShandong UniversityJinanChina
| | - Yaping Yan
- Key Laboratory of the Ministry of Education for Medicinal Resources and Natural Pharmaceutical ChemistryNational Engineering Laboratory for Resource Development of Endangered Crude Drugs in Northwest of ChinaCollege of Life SciencesShaanxi Normal UniversityXi'anChina
| | - Xiaotian Ma
- Department of Central Laboratory and Mitochondrial Medicine LaboratoryQilu Hospital (Qingdao)Cheeloo College of MedicineShandong UniversityQingdaoChina
| | - Wei Li
- Research Institute of Neuromuscular and Neurodegenerative Diseases and Department of NeurologyQilu HospitalCheeloo College of MedicineShandong UniversityJinanChina
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Barp A, Velardo D, Ciscato P, Sansone VA, Lunetta C. Anti-HMGCR myopathy misdiagnosed as motor neuron disease and complicated with COVID-19 infection. Neurol Sci 2021; 42:1679-1682. [PMID: 33646438 PMCID: PMC7917165 DOI: 10.1007/s10072-021-05146-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 02/22/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Andrea Barp
- Neurorehabilitation Unit, NeMO Clinical Center, University of Milano, Piazza Ospedale Maggiore 3, 20162, Milano, Italy.
| | - Daniele Velardo
- Neuromuscular and Rare Diseases Unit, Department of Neuroscience, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milano, Italy
| | - Patrizia Ciscato
- Neuromuscular and Rare Diseases Unit, Department of Neuroscience, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milano, Italy
| | - Valeria Ada Sansone
- Neurorehabilitation Unit, NeMO Clinical Center, University of Milano, Piazza Ospedale Maggiore 3, 20162, Milano, Italy
| | - Christian Lunetta
- Neurorehabilitation Unit, NeMO Clinical Center, University of Milano, Piazza Ospedale Maggiore 3, 20162, Milano, Italy
- NeMO LAB S.r.l., Piazza Ospedale Maggiore 3, Milano, 20162, Italy
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