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Xynogalas I, Michail P, Katsikas G, Exarhos D, Papachristos K, Karamanakos A. Anasarca and spontaneous intramuscular haemmorhage in a dermatomyositis patient: case report and review of the literature. Clin Rheumatol 2024:10.1007/s10067-024-07026-y. [PMID: 38861228 DOI: 10.1007/s10067-024-07026-y] [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: 04/09/2024] [Revised: 05/16/2024] [Accepted: 06/04/2024] [Indexed: 06/12/2024]
Abstract
Dermatomyositis is a rare, autoimmune systemic disorder of unknown aetiology that presents as a constellation of clinical symptoms and signs primarily affecting skin and muscles. Patients with dermatomyositis can present with rare "non-canonical" manifestations. Focal or generalised oedema is an infrequent and often overlooked symptom of the disease, while spontaneous intramuscular haemorrhage is an even rarer and under-recognised, life-threatening complication that constitutes a medical emergency for clinical physicians. There are no known predisposing factors able to predict which patients will develop this complication and specific instructions considering treatment approach are currently lacking. Herein, we present a case of a patient with dermatomyositis complicated by both anasarca and spontaneous intramuscular haemorrhage. In order to raise awareness and timely diagnosis of such patients, we provide a review of the relevant literature and of the cases reported this far.
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2
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Nishioka H, Shindo T, Shimizu H. Dermatomyositis Presenting with Generalized Subcutaneous Edema. Intern Med 2023; 62:2273-2277. [PMID: 37532515 PMCID: PMC10465278 DOI: 10.2169/internalmedicine.0687-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 10/03/2022] [Indexed: 08/04/2023] Open
Abstract
Generalized subcutaneous edema is rare in dermatomyositis. We herein report an 82-year-old woman with dermatomyositis who presented with generalized subcutaneous edema. Three weeks before admission, she first noticed facial edema, and the symptoms exacerbated, with limb edema occurring. On admission, muscle weakness in the limbs and skin rash were noted. Her muscle enzyme levels were elevated, and serum anti-transcriptional intermediary factor 1-γ antibody was detected. She was diagnosed with dermatomyositis and treated with corticosteroids and tacrolimus, which improved her muscle weakness, muscle enzymes, and edema. Thus, generalized subcutaneous edema can occur during dermatomyositis, with facial edema as the initial symptom.
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Affiliation(s)
- Hiroaki Nishioka
- Department of General Internal Medicine, Kobe City Medical Center General Hospital, Japan
| | - Tatsuya Shindo
- Department of General Internal Medicine, Kobe City Medical Center General Hospital, Japan
| | - Hayato Shimizu
- Department of General Internal Medicine, Kobe City Medical Center General Hospital, Japan
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3
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Grinnell M, Keyes E, Vazquez T, Concha J, Diaz D, Wat M, Elenitsas R, Werth VP. Dermatomyositis associated with hyponatremia and anasarca. JAAD Case Rep 2021; 16:86-89. [PMID: 34541273 PMCID: PMC8435987 DOI: 10.1016/j.jdcr.2021.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Affiliation(s)
- Madison Grinnell
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Emily Keyes
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Thomas Vazquez
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Josef Concha
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - DeAnna Diaz
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Margaret Wat
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rosalie Elenitsas
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Victoria P Werth
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
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4
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Castillo RL, Femia AN. Covert clues: the non-hallmark cutaneous manifestations of dermatomyositis. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:436. [PMID: 33842657 PMCID: PMC8033358 DOI: 10.21037/atm-20-5252] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Dermatomyositis (DM) is a strikingly heterogenous disease characterized by a broad and ever-evolving spectrum of cutaneous manifestations that transcend the classic “hallmarks” defined by Peter and Bohan in 1975. Despite the increasing preponderance and ubiquity of autoantibody, radiologic, and electrophysiologic testing, the diagnosis of DM still hinges largely on prompt detection of cutaneous manifestations of this condition. While pathognomonic cutaneous features of DM are more readily recognizable, many patients present with subtle and/or atypical skin manifestations, and diagnosis of DM may require clinician identification of these cutaneous clues. In this review, we highlight several of the lesser-known skin manifestations of DM, specifically, panniculitis, diffuse subcutaneous edema, erythroderma, calcinosis, ulceration, flagellate erythema, Wong-type DM, gingival telangiectasias, and the ovoid palatal patch. We describe the clinical and histopathologic presentation of these cutaneous findings. While manifesting less frequently than the heliotrope rash, Gottron’s papules, and Gottron’s sign, these cutaneous clues are equally important for clinicians to recognize in order to facilitate timely diagnosis and early intervention.
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Affiliation(s)
- Rochelle L Castillo
- Department of Medicine, Division of Rheumatology, NYU Grossman School of Medicine, New York, NY, USA
| | - Alisa N Femia
- Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, New York, NY, USA
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5
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Nakagawa Y, Odomari K, Imanaka Y, Katayama I, Ichimura Y, Okiyama N, Fujimoto M. A case of anti‐NXP‐2‐positive dermatomyositis with generalized subcutaneous edema. JOURNAL OF CUTANEOUS IMMUNOLOGY AND ALLERGY 2020. [DOI: 10.1002/cia2.12130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Yukinobu Nakagawa
- Department of Dermatology Course of Integrated Medicine Graduate School of Medicine Osaka University Osaka Japan
| | - Kaori Odomari
- Department of Dermatology Course of Integrated Medicine Graduate School of Medicine Osaka University Osaka Japan
| | - Yoko Imanaka
- Department of Dermatology Course of Integrated Medicine Graduate School of Medicine Osaka University Osaka Japan
| | - Ichiro Katayama
- Department of Dermatology Course of Integrated Medicine Graduate School of Medicine Osaka University Osaka Japan
| | - Yuki Ichimura
- Department of Dermatology Faculty of Medicine University of Tsukuba Tsukuba Japan
| | - Naoko Okiyama
- Department of Dermatology Faculty of Medicine University of Tsukuba Tsukuba Japan
| | - Manabu Fujimoto
- Department of Dermatology Course of Integrated Medicine Graduate School of Medicine Osaka University Osaka Japan
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6
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Duchesne M, Leonard-Louis S, Landon-Cardinal O, Anquetil C, Mariampillai K, Monzani Q, Benveniste O, Allenbach Y. Edematous myositis: a clinical presentation first suggesting dermatomyositis diagnosis. Brain Pathol 2020; 30:867-876. [PMID: 32323412 DOI: 10.1111/bpa.12844] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 04/07/2020] [Accepted: 04/14/2020] [Indexed: 11/29/2022] Open
Abstract
AIMS Edema of the limbs is uncommon in idiopathic inflammatory myopathies (IIM). The few reported cases have been associated with severe and refractory dermatomyositis (DM), sometimes in association with cancers. We aimed to determine if edematous myositis is a homogeneous subtype based on clinical, serological and pathological features. METHODS This is a retrospective observational study performed between 2008 and 2015 in the French national referral center for myositis. All adult patients with an inflammatory muscle biopsy and upper limbs edema were included as well as IIM cases without limb edema as controls. Clinical, biological and pathological features were collected. RESULTS Seventeen edematous myositis were included and compared to 174 IIM without edema, including 50 DM controls. Edema was the first manifestation in 23% of patients. Muscle weakness was severe and symmetric, 71% of patients presented dysphagia and a restrictive ventilatory pattern was found in 40%. Fifty-two percent of patients had a typical DM skin rash and 23% had cancer within 3 years of diagnosing myositis. Fifty-three percent of patients presented a myositis specific antibody and only DM-specific antibodies were detected. Classic pathological DM features (perifascicular atrophy, perifascicular/perimysial perivascular inflammation) were uncommon but capillary C5b-9 deposition and MxA expression were seen in 79% and 73% of cases, respectively. A perimysial edema was found in 82% of cases. Seventeen percent of patients died (median follow up of 18 months). Edematous myositis demonstrated more marked capillary C5b-9 deposition compared to IIM controls. There was no clinical, biological or pathological difference with DM controls except for limb edema. CONCLUSION Our study underlines that limb edema could be a symptom of IIM and that edematous myositis are mostly DM. The vasculopathy seems to play a key role in its pathophysiology. Limb edema associated with muscle impairment should suggest the diagnosis of DM in clinical settings.
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Affiliation(s)
- Mathilde Duchesne
- Department of Pathology, University Hospital of Limoges, Limoges, France.,Laboratory of Neurology, University Hospital of Limoges, Limoges, France.,EA6309, University of Medicine and Pharmacology of Limoges, Limoges, France
| | - Sarah Leonard-Louis
- Department of Neuropathology, APHP, Pitié-Salpêtrière University Hospital, Sorbonne University, University Pierre et Marie Curie, Paris, France.,Department of Neuromyology, National Reference Center of Neuromuscular Disorders, APHP, Pitié-Salpêtrière University Hospital, Sorbonne University, University Pierre et Marie Curie, Paris, France
| | - Océane Landon-Cardinal
- Division of Rheumatology and Research Center, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Céline Anquetil
- Department of Internal Medicine and Clinical Immunology, National Reference Center of Neuromuscular disorders, APHP, Pitié-Salpêtrière University Hospital, Sorbonne University, University Pierre et Marie Curie, Paris, France
| | - Kuberaka Mariampillai
- Department of Internal Medicine and Clinical Immunology, National Reference Center of Neuromuscular disorders, APHP, Pitié-Salpêtrière University Hospital, Sorbonne University, University Pierre et Marie Curie, Paris, France
| | - Quentin Monzani
- Department of Radiology, APHP, Pitié-Salpêtrière University Hospital, Sorbonne University, University Pierre et Marie Curie, Paris, France
| | - Olivier Benveniste
- Department of Internal Medicine and Clinical Immunology, National Reference Center of Neuromuscular disorders, APHP, Pitié-Salpêtrière University Hospital, Sorbonne University, University Pierre et Marie Curie, Paris, France
| | - Yves Allenbach
- Department of Internal Medicine and Clinical Immunology, National Reference Center of Neuromuscular disorders, APHP, Pitié-Salpêtrière University Hospital, Sorbonne University, University Pierre et Marie Curie, Paris, France.,INSERM, UMR974, Sorbonne University, University Pierre et Marie Curie, Paris, France
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7
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Hepatocellular Carcinoma-Associated Polymyositis Presenting With Unilateral Upper Limb Subcutaneous Edema. Arch Rheumatol 2018; 33:482-487. [PMID: 30874235 DOI: 10.5606/archrheumatol.2018.6688] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 01/09/2018] [Indexed: 11/21/2022] Open
Abstract
Localized subcutaneous edema is a rare manifestation of inflammatory myopathy. In general, the incidence of malignancy in dermatomyositis is higher than that in polymyositis (PM). The association between malignancy and dermatomyositis has been established; however, it is less convincing in PM. In this article, we report on a case of malignancy-associated PM with an initial presentation of localized subcutaneous edema. A 66-year-old male patient with a history of chronic hepatitis B was presented to us with both left arm swelling and progressive proximal muscle weakness. A multi-detector row computed tomography showed prominent left arm edema, while a venography demonstrated no venous thrombosis or stenosis. A diagnosis of PM was established according to its typical symptoms, high serum creatine kinase level, positive electromyography findings, and systemic inflammatory signs. Magnetic resonance imaging of the liver revealed infiltrative hepatocellular carcinoma. After undergoing systemic corticosteroid therapy, in combination with hydroxychloroquine, the left arm edema was resolved. However, patient died from hepatocellular carcinoma three months after the date of diagnosis. It is important to recognize that hepatocellular carcinoma-associated PM may initially present itself with localized non-pitting edema. Although such localized edema may be responsive to corticosteroids, a patient's overall prognosis remains poor. We presume that PM with localized subcutaneous edema may be a predictor of malignancy, and therefore recommend a tumor survey.
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8
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Lozano-Masdemont B, Pulido-Pérez A, Parra-Blanco V, Avilés-Izquierdo JA. Edema and dermatomyositis. Migratory edema and edematous and vesiculobullous dermatomyositis overlap. ACTA ACUST UNITED AC 2017; 14:313-314. [PMID: 29107577 DOI: 10.1016/j.reuma.2017.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 08/29/2017] [Accepted: 09/13/2017] [Indexed: 11/15/2022]
Affiliation(s)
- Belén Lozano-Masdemont
- Servicio de Dermatología, Hospital General Universitario Gregorio Marañón, Madrid, España.
| | - Ana Pulido-Pérez
- Servicio de Dermatología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - Verónica Parra-Blanco
- Servicio de Anatomía Patológica, Hospital General Universitario Gregorio Marañón, Madrid, España
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Flores-Terry M, García-Arpa M, Anino-Fernández J, Mínguez-Sánchez M. Edematous Dermatomyositis with Probable Evans Syndrome. ACTAS DERMO-SIFILIOGRAFICAS 2017. [DOI: 10.1016/j.adengl.2017.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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10
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Flores-Terry M, García-Arpa M, Anino-Fernández J, Mínguez-Sánchez M. Dermatomiositis edematosa asociada a probable síndrome de Evans. ACTAS DERMO-SIFILIOGRAFICAS 2017; 108:673-675. [DOI: 10.1016/j.ad.2017.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 01/17/2017] [Accepted: 01/18/2017] [Indexed: 10/19/2022] Open
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11
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Anantharajah A, Vucic S, Tarafdar S, Vongsuvanh R, Wilcken N, Swaminathan S. Prominent subcutaneous oedema as a masquerading symptom of an underlying inflammatory myopathy. Intern Med J 2017; 47:217-221. [PMID: 28201858 DOI: 10.1111/imj.13324] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 06/10/2016] [Accepted: 06/11/2016] [Indexed: 11/30/2022]
Abstract
The inflammatory myopathies are a group of immune-mediated inflammatory muscle disorders that typically present with marked proximal muscle weakness. We report four cases of inflammatory myopathies with marked subcutaneous oedema as their main complaint. Three of the four patients had normal or low levels of creatine kinase, an enzyme often markedly elevated in these disorders. Magnetic resonance imaging of the muscles, followed by a muscle biopsy were used to make a definitive diagnosis.
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Affiliation(s)
- Anthea Anantharajah
- Department of Clinical Immunology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Steve Vucic
- Department of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Surjit Tarafdar
- Department of Medicine, Western Sydney University, Sydney, New South Wales, Australia
| | - Roslyn Vongsuvanh
- Department of Medicine, University of Sydney, Sydney, New South Wales, Australia.,Department of Medicine, Western Sydney University, Sydney, New South Wales, Australia
| | - Nicholas Wilcken
- Department of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Sanjay Swaminathan
- Department of Clinical Immunology, Westmead Hospital, Sydney, New South Wales, Australia.,Department of Medicine, University of Sydney, Sydney, New South Wales, Australia.,Department of Medicine, Western Sydney University, Sydney, New South Wales, Australia
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12
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Goussot R, Wettlé C, Le Coz C, Cribier B, Lipsker D. Dermatomyosite œdémateuse sévère. Ann Dermatol Venereol 2016; 143:202-9. [DOI: 10.1016/j.annder.2015.10.594] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 07/21/2015] [Accepted: 10/02/2015] [Indexed: 10/22/2022]
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13
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Peng ACY, Huang CH, Lin TS, Lee JYY. Severe dermatomyositis with pronounced generalized subcutaneous edema and dysphagia: A rare manifestation of a highly active disease. DERMATOL SIN 2014. [DOI: 10.1016/j.dsi.2013.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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14
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Dermatomyositis presenting with severe subcutaneous edema: five additional cases and review of the literature. Semin Arthritis Rheum 2014; 44:228-33. [PMID: 24830790 DOI: 10.1016/j.semarthrit.2014.04.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 02/19/2014] [Accepted: 04/04/2014] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Dermatomyositis (DM) constitutes a subset of idiopathic inflammatory myopathies clinically characterized by proximal muscle weakness and skin involvement. Some of the dermatologic manifestations are highly prevalent and characteristic, but others such as generalized or limb edema are truly rare. The aim of the present study was to describe five cases of edematous DM diagnosed at our institution and to perform a review of the literature, as well as identify clinical, laboratory, or pathological data associated with this manifestation. METHODS We performed a retrospective clinical, laboratory, and pathological evaluation of five cases of this edematous presentation out of 86 DM cases diagnosed at our hospital from 2004 to 2013. Moreover, we undertook a medical literature search using inflammatory myopathy, dermatomyositis, and edema as key words, limited to articles published in MEDLINE, EMBASE, and LILACS database in English and Spanish from 1987 to 2013. RESULTS A total of 19 patients were identified, five diagnosed at our hospital and 14 cases from the literature. Overall, the median time from disease onset to diagnosis was 2 months, and most of the patients (16/84 patients, 21%) required more aggressive therapy, including immunosuppressive agents and intravenous immunoglobulin (12/63 patients, 15%). Microinfarction was present 2.3 times more frequently in DM patients with edema compared with those without edema. CONCLUSIONS The presence of edema in DM is uncommon but seems to be a sign of severe disease, requiring early and aggressive treatment. Microischemia-producing microinfarction may play an important pathophysiological role and determine the degree of disease severity.
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15
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Jin UR, Kwack KS, Park KJ, Kwon JE, Kim SY, Kim KC, Ban GY, Jung JY, Suh CH, Kim HA. Acute Polymyositis/systemic Lupus Erythematosus Overlap Syndrome with Severe Subcutaneous Edema and Interstitial Lung Disease. JOURNAL OF RHEUMATIC DISEASES 2014. [DOI: 10.4078/jrd.2014.21.1.25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- U-ram Jin
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - Kyu-Sung Kwack
- Department of Radiology, Ajou University School of Medicine, Suwon, Korea
| | - Kyung-Joo Park
- Department of Radiology, Ajou University School of Medicine, Suwon, Korea
| | - Ji-Eun Kwon
- Department of Pathology, Ajou University School of Medicine, Suwon, Korea
| | - Si-Yeon Kim
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - Ki-Chan Kim
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - Ga-Yong Ban
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - Ju-Yang Jung
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - Chang-Hee Suh
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - Hyoun-Ah Kim
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
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Simon OJ, Kuhlmann T, Bittner S, Müller-Tidow C, Weigt J, Wiendl H, Meuth SG. Evans syndrome associated with sterile inflammation of the central nervous system: a case report. J Med Case Rep 2013; 7:262. [PMID: 24299473 PMCID: PMC3879039 DOI: 10.1186/1752-1947-7-262] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2013] [Accepted: 10/14/2013] [Indexed: 12/05/2022] Open
Abstract
Introduction Evans syndrome is a rare hematological disease commonly defined as Coombs-positive hemolytic anemia and immune thrombocytopenia. Pathophysiology of this disease involves decreased cluster of differentiation (CD)4+ T-helper cell counts, increased CD8+ T-suppressor cell counts, a decreased CD4/CD8 ratio, and reduced serum immunoglobulin G, M and A levels - indicating a complex immune dysregulation. Association with other autoimmune diseases has been described although involvement of the central nervous system has not been reported so far. Case presentation We here present a case of a 28-year-old woman of Turkish origin with progressive, disseminated, partly mass-forming lymphoplasmacellular infiltration (CD3+ and CD138+ cells) of the brain in association with Evans syndrome. No other central nervous system disorder could be identified on neuropathological evaluation. Although treatment with rituximab was effective to normalize erythrocyte and thrombocyte levels in her peripheral blood, it failed to dampen the inflammation in her central nervous system or prevent clinical progression. Initiation of treatment with cyclophosphamide resulted in stabilization of her central nervous system inflammation and the disease course. Conclusions The complex immune dysregulation resulting in the antibody-mediated pathologies that can be regarded as the cause of both lymphoplasmacellular encephalitis and Evans syndrome renders this association to be of clinical relevance for both neurologists and hematologists. Our experience also sheds light on the effectiveness of different treatments for both disorders and we advise clinicians to take a closer look when encountering a combination of peripheral blood diseases with affection of the central nervous system.
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Affiliation(s)
| | | | | | | | | | | | - Sven G Meuth
- Department of Neurology, University of Muenster, Muenster, Germany.
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