The red face: dermatomyositis

A novel grey Scale and Power Doppler ultrasonographic score for idiopathic inflammatory myopathies: Siena Myositis Ultrasound Grading Scale

OBJECTIVES

No clear-cut guidelines exist about the use of diagnostic procedures for idiopathic inflammatory myopathies (IIM) and only scanty and conflicting data report the use of ultrasound (US). In this regard, we aimed to assess if grey-scale (GS) and Power Doppler (PD) US, graded with a 0-3-points-scale, may be a reliable tool in a cohort of patients affected by IIM.

METHODS

All patients underwent US examination of both thighs in axial and longitudinal scans. Edema and atrophy, both assessed in GS, and PD, were graded with a 0-3-points-scale. Spearman test was used to identify the correlations between US and clinical and serological variables.

RESULTS

A total of 20 patients was included. Six and 2 of them were evaluated twice and 3 times, respectively. Muscle edema was found to be directly correlated with physician global assessment (PhGA), serum myoglobin and PD and negatively with disease duration. PD score was positively correlated to PhGA and negatively to disease duration. Muscle atrophy directly correlated with Myositis Damage Index, disease duration and patients' age. The single-thigh sub-analysis evidenced a direct correlation between PD score and Manual Muscle Test.

CONCLUSIONS

In our cohort, we found that edema and PD are strictly related to early, active myositis, suggesting that an inflamed muscle should appear swollen, thickened and with Doppler signal. Conversely, muscle atrophy reflects the age of the patient and the overall severity of the disease. Such findings shed a new, promising, light in the role of US in diagnosis and monitoring of IIMs.

Spontaneously remitting dermatomyositis

Dermatomyositis (DM) is an inflammatory myopathy of skeletal muscle with characteristic cutaneous findings. It is a rare disorder with a bimodal age distribution that affects almost twice as many women as men. One category of DM, normal-enzyme DM, is characterized by cutaneous changes only at baseline, normal serum muscle enzyme levels and myositis demonstrated by electromyography (EMG) and/or muscle biopsy specimens. Typically, patients with normal-enzyme DM progress to severe muscle involvement and require systemic corticosteroid therapy. The patient we report has normal-enzyme DM confirmed by serial serum enzymes, EMG, and skin and muscle biopsies but is unique in that she never experienced progression of muscle weakness although muscle involvement was documented histologically and by EMG. Follow-up examination after 1 year revealed near-complete resolution of cutaneous involvement after topical therapy and no evidence of muscle weakness.

Topical tacrolimus 0.1% ointment for refractory skin disease in dermatomyositis: a pilot study

BACKGROUND

Dermatomyositis is an inflammatory disease primarily involving the striated muscles and skin. Muscle disease usually responds to aggressive therapy with systemic corticosteroids. However, cutaneous lesions can be very resistant to systemic and topical therapies, even in combination. More treatment options are needed. Tacrolimus is an immunomodulator now available in a topical ointment.

OBJECTIVE

To study the treatment of patients with refractory cutaneous lesions of dermatomyositis using topical tacrolimus 0.1% ointment.

METHODS

Six patients with recalcitrant cutaneous lesions of dermatomyositis were included in this brief observational study: five adults and one pediatric patient. Five patients had classic dermatomyositis and one had dermatomyositis sine myositis.

RESULTS

All had some degree of improvement of their dermatologic disease following 6-8 weeks of treatment with topical tacrolimus 0.1% ointment. Two had dramatic responses (>90% improvement), one had moderate (40-90%) improvement and three had minimal (20-40%) improvement.

CONCLUSIONS

The dermatologic manifestations of dermatomyositis can be very difficult to treat. Multiple systemic and topical therapies have been studied. Combinations of treatments are often used, sometimes still not successfully. The results of this brief observational study using topical tacrolimus ointment for the treatment of refractory cutaneous lesions of dermatomyositis are encouraging. Topical tacrolimus was a useful adjunct in the treatment of the dermatologic component of dermatomyositis in adults and children in this pilot study.

Utility of magnetic resonance imaging in the evaluation of patients with inflammatory myopathies

Magnetic resonance imaging (MRI) and P-31 magnetic resonance spectroscopy (P-31 MRS) provide unique, quantitative data that cannot be obtained from routine laboratory tests. MRI is the method of choice for imaging of muscle abnormalities. It is also a very sensitive technique for localizing nonhomogeneous inflammation in inflammatory myopathies such as dermatomyositis, juvenile dermatomyositis, amyopathic dermatomyositis, polymyositis, and inclusion body myositis. During treatment of inflammatory myopathies, the extent and severity of inflammation may decrease at varying rates, but weakness and fatigue remain serious clinical problems. The metabolic abnormalities detected with P-31 MRS are more persistent and can be used for objective patient evaluation after the disappearance of inflammation and normalization of serum levels of muscle enzymes. With P-31 MRS, biochemical defects are quantitated, including low levels of ATP and phosphocreatine (PCr) and elevated concentrations of ADP and inorganic phosphate (Pi), which may all be related to weakness and fatigue. Thus, MRI and P-31 MRS are useful in assessing the status of patients with inflammatory myopathies during treatment with prednisone and immunosuppressive drugs.

Dermatomyositis: a dermatology-based case series

BACKGROUND

Dermatomyositis is associated with significant morbidity and occasional mortality. Currently there is no consensus on treatment for patients with dermatomyositis.

OBJECTIVE

Our purpose was to review the clinical features and response to therapy of patients with dermatomyositis and compare these data with previous series of patients with dermatomyositis/polymyositis.

METHODS

Clinical characteristics of 65 patients seen during a 10-year period were reviewed retrospectively. Twenty-one of these patients were enrolled in a prospective, uncontrolled study of treatment with high-dose prednisone followed by slow tapering.

RESULTS

Clinical features were similar to those previously described; however, muscle strength at diagnosis was on average greater in patients in this series than in patients previously reported. Malignancy was present in 5 of 43 adult patients (12%), but was not found in patients with juvenile dermatomyositis. Another connective tissue disease was present in 19% of patients. Twelve patients had dermatomyositis sine myositis. Eighteen of 21 patients (85%) in the prednisone study group had resolution of myositis.

CONCLUSION

Patients with dermatomyositis in this series had less active myositis at presentation, but were otherwise similar to patients with dermatomyositis/polymyositis previously reported. Treatment with high-dose daily prednisone followed by slow tapering was effective.

Classification and treatment of the juvenile idiopathic inflammatory myopathies

This article reviews the current status of the classification and treatment of the juvenile idiopathic inflammatory myopathies. The intent of classification is to define homogeneous groups that share similar clinical features, disease courses, and responses to therapy. The classification scheme proposed includes clinicopathologic subsets, serologic subjects based on the presence of myositis-specific and myositis-associated autoantibodies, and environmental triggers of myositis. Juvenile dermatomyositis is the most common and widely recognized of these disorders. The second part reviews the history of treatment of juvenile dermatomyositis and discusses agents to consider for patients with refractory disease, unacceptable steroid toxicity, or poor prognostic factors.

Obstructive anuria and dermatomyositis: a unique association

This case is the first reported presentation of obstructive anuria due to extrinsic ureteral compression in a patient with dermatomyositis. Further evaluation revealed disseminated sigmoid colon adenocarcinoma. Conservative treatment of ureteral obstruction by internal double-J stents achieved appropriate palliation.

Dermatomyositis treated with high-dose intravenous immunoglobulins and associated with panniculitis

Polymyositis and dermatomyositis are idiopathic inflammatory myopathies characterized by subacute symmetrical weakness of proximal limb and trunk muscles. Dermatomyositis is distinguished from polymyositis by the presence of rash. We describe an adult patient with treatment-resistant childhood-type dermatomyositis who made a good response to high dose intravenous immunoglobulins. Additionally, there was evidence of panniculitis which is an unusual histopathological finding in dermatomyositis.