Tacrolimus-Associated myositis: a case report in a renal transplant patient

Purtscher-like retinopathy in a patient with systemic tacrolimus vasculopathy

INTRODUCTION

Purtscher-like retinopathy is a rare occlusive retinal microangiopathy, whose pathogenesis has not been totally defined yet. Most frequent cause of Purtscher-like retinopathy is acute pancreatitis, but it may be triggered by other systemic or toxic conditions. We report herein a case of Purtscher-like retinopathy in the context of systemic tacrolimus vasculopathy.

CASE REPORT

A 56-years old male with history of kidney transplant was referred to local emergency room because of a global worsening of health conditions, with fatigue, muscular pain and diuresis contraction. During hospitalization the patient came to our attention for sudden and severe visual acuity impairment in both eyes. Extensive ophthalmological assessment, optical coherence tomography (OCT) and fluorescein angiography (FA) were performed disclosing a marked drop in best corrected visual acuity (BCVA) (20/200 in the right eye and 10/400 in the left eye) caused by a bilateral severe occlusive retinal microangiopathy complicated by diffuse retinal ischaemia and neovascular glaucoma. Muscular biopsy showed a necrotizing myopathy with autoimmune features, as indicated by conspicuous upregulation of MHC-I complex and microangiopathic changes, consistent with tacrolimus toxicity. Tacrolimus administration was interrupted, and intravenous glucocorticoids were administered. The large areas of retinal ischemia and neovascular glaucoma were treated with pan-retinal photocoagulation and intravitreal injections of bevacizumab with complete regression of iris neovascolarization. BCVA measured 20/200 in both eyes at last follow-up visit, 20 months after symptoms onset.

CONCLUSIONS

Purtscher-like retinopathy should be suspected in patients under treatment with calcineurin inhibitors especially in case of sudden and severe bilateral visual impairment.

Chronic Graft-Versus-Host-Disease-Related Polymyositis: a 17-Months-Old Child with a Rare and Late Complication of Haematopoietic Stem Cell Transplantation

Background

Chronic graft versus host disease (cGVHD) occurs in 20–30% of paediatric patients receiving haemopoietic stem cell transplantation (HSCT). Neuromuscular disorders such as polymyositis are considered a rare and distinctive but non-diagnostic manifestation of cGVHD and, in the absence of other characteristic signs and symptoms, biopsy is highly recommended to exclude other causes.

Case report

We report a case of a 17-months-old child affected by hemophagocytic lymphohistiocytosis who underwent a matched unrelated donor haematopoietic stem cell transplantation (HSCT). She developed severe cGVHD-related polymyositis that was successfully treated with high-dose steroid therapy, rituximab and sirolimus.

Conclusions

This is the first case of cGVHD-related-polymyositis described in a pediatric patient which was successfully treated with rituximab.

How I treat refractory chronic graft-versus-host disease

Approximately 35% to 50% of patients otherwise cured of hematologic malignancies after allogeneic hematopoietic stem cell transplantation will develop the pleomorphic autoimmune-like syndrome known as chronic graft-versus-host disease (cGVHD). Since in 2005, National Institutes of Health (NIH) consensus panels have proposed definitions and classifications of disease to standardize treatment trials. Recently, the first agent was approved by the US Food and Drug Administration for steroid-refractory cGVHD. Despite these advances, most individuals do not achieve durable resolution of disease activity with initial treatment. Moreover, standardized recommendations on how to best implement existing and novel immunomodulatory agents and taper salvage agents are often lacking. Given the potential life-threatening nature of cGVHD, we employ in our practice patient assessment templates at each clinic visit to elucidate known prognostic indicators and red flags. We find NIH scoring templates practical for ongoing assessments of these complex patient cases and determination of when changes in immunosuppressive therapy are warranted. Patients not eligible or suitable for clinical trials have systemic and organ-directed adjunctive treatments crafted in a multidisciplinary clinic. Herein, we review these treatment options and offer a management and monitoring scaffold for representative patients with cGVHD not responding to initial therapy.

Polymyositis in solid organ transplant recipients receiving tacrolimus

Tacrolimus, also known as FK506, is an immunosuppressive agent widely used for the prevention of acute allograft rejection in organ transplantation and for the treatment of immunological diseases. This study reports two male patients who underwent solid organ transplantation (liver and kidney). After transplant, the patients received continuous immunosuppressive therapy with oral tacrolimus and later presented clinical manifestations and laboratory signs of myopathy. Muscle biopsies of both patients clearly documented an inflammatory myopathy with the histological features of polymyositis including CD8+ T cells which invaded healthy muscle fibers and expressed granzyme B and perforin, many CD68+ macrophages and MHC class I antigen upregulation on the surface of most fibers. Because of the temporal association while receiving tacrolimus and since other possible causes for myopathy were excluded, the most likely cause of polymyositis in our patients was tacrolimus toxicity. We suggest that patients on tacrolimus should be carefully monitored for serum CK levels and clinical signs of muscle disease.

Exercise limitation following transplantation

Organ transplantation is one of the medical miracles or the 20th century. It has the capacity to substantially improve exercise performance and quality of life in patients who are severely limited with chronic organ failure. We focus on the most commonly performed solid-organ transplants and describe peak exercise performance following recovery from transplantation. Across all of the common transplants, evaluated significant reduction in VO2peak is seen (typically renal and liver 65%-80% with heart and/or lung 50%-60% of predicted). Those with the lowest VO2peak pretransplant have the lowest VO2peak posttransplant. Overall very few patients have a VO2peak in the normal range. Investigation of the cause of the reduction of VO2peak has identified many factors pre- and posttransplant that may contribute. These include organ-specific factors in the otherwise well-functioning allograft (e.g., chronotropic incompetence in heart transplantation) as well as allograft dysfunction itself (e.g., chronic lung allograft dysfunction). However, looking across all transplants, a pattern emerges. A low muscle mass with qualitative change in large exercising skeletal muscle groups is seen pretransplant. Many factor posttransplant aggravate these changes or prevent them recovering, especially calcineurin antagonist drugs which are key immunosuppressing agents. This results in the reduction of VO2peak despite restoration of near normal function of the initially failing organ system. As such organ transplantation has provided an experiment of nature that has focused our attention on an important confounder of chronic organ failure-skeletal muscle dysfunction.

Calf cramps in a heart transplant patient during the postoperative course: a case report

The aim of study was to describe a heart transplant patient who developed calf cramps postoperatively, during the recovery of early motor activities, which limited his participation in rehabilitation. The study design was a case report. A 41-year-old male with a body mass index of 29.1, suffering from familial non-ischemic dilated cardiomyopathy, with no history of muscle disorders, underwent heart transplant The patient was given an implantable cardioverter-defibrillator as primary prevention and no significant comorbidity associated with the heart disease developed. On the second day after his discharge from the intensive care unit, the patient complained of a heavy left calf pain exacerbated by walking. On a scale of 0–10, the patient described his pain intensity as 10. Palpation of the calf muscles caused painful reaction. Manual massage of the lower limbs, emphasising the left calf, was performed. Subsequently, stretching exercises were given both in bed and in a standing position. Rapid symptom resolution was achieved, allowing the patient to continue with the postoperative recovery.

Voriconazole-associated myositis

Voriconazole is a new triazole antifungal agent that is now the treatment of choice for invasive aspergillosis. Drug-induced myopathy has never previously been reported with voriconazole, although it is recognized with other triazole agents. We present a 34-year-old female African American renal transplant recipient, with a prior history of probable statin-induced myopathy, who developed severe generalized weakness with marked elevation of muscle enzymes and inflammatory changes on T2-weighted fat-suppressed STIR sequence magnetic resonance imaging (MRI) after commencing voriconazole for treatment of invasive aspergillosis. Her symptoms resolved and creatine kinase normalized upon stopping the drug.Given the increased use of triazoles in immunosuppressed and transplant recipients, it is important for rheumatology consultants to include this entity in their differential diagnosis of weakness in such patients.

Treatment of the inflammatory myopathies: update and practical recommendations

BACKGROUND

The inflammatory myopathies are a heterogeneous group of diseases including dermatomyositis, polymyositis, and inclusion body myositis. Clinical trials in myositis are rare, making it difficult to make clear recommendations on the treatment of these rare disorders.

OBJECTIVE

To give an overview of treatment options and strategies and to provide the clinician with a framework that can be used in treating patients with myositis.

METHODS

Results of clinical trials in myositis, case series and important case reports are presented and discussed.

RESULTS/CONCLUSION

Most patients with dermatomyositis or polymyositis require treatment with oral high-dose prednisone combined with azathioprine or methotrexate to facilitate early tapering of prednisone. In case of treatment failure, intravenous immunoglobulin can be tried, followed by rituximab, mycophenolate mofetil, or tacrolimus depending on the specific clinical situation. A treatment trial with oral prednisone combined with methotrexate is advised in a subgroup of patients with inclusion body myositis.

Advances in the therapy of idiopathic inflammatory myopathies

PURPOSE OF REVIEW

To review progress in areas pertinent to the development of better therapies for the idiopathic inflammatory myopathies.

RECENT FINDINGS

New classification criteria for the idiopathic inflammatory myopathies have been proposed in an effort to define disease subsets with more uniform prognoses and responses to therapy. Diseases that may mimic the idiopathic inflammatory myopathies can be differentiated more accurately with molecular testing and biochemical and immunohistochemical analysis of muscle tissue. Advances in our understanding of the pathogenesis of the idiopathic inflammatory myopathies have served to identify potential new therapeutic targets. International collaborative study groups have reached consensus on outcome measures and on the optimal design of clinical trials in the idiopathic inflammatory myopathies. Tumor necrosis factor-alpha antagonists, rituximab, and the calcineurin inhibitors are being used to treat the idiopathic inflammatory myopathies, but their efficacy has not yet been tested in randomized clinical trials.

SUMMARY

Future advances in the development of therapies for the idiopathic inflammatory myopathies have been enabled by recent progress in myositis classification, differential diagnosis, basic science, and clinical trial design. Preliminary studies suggest that calcineurin inhibitors, tumor necrosis factor antagonists, and rituximab may be effective treatments.

[Neuromuscular complications in transplant recipients]

Neuromuscular complications in transplant recipients are common and contribute to morbidity and mortality. Complications such as acute and chronic inflammatory demyelinating polyneuropathies and toxic myopathies are related to the changes in immune modulation that occur after transplantation or result from immunosuppressive treatment toxicity. Alternatively, other complications such as myositis, myasthenia gravis, and mononeuropathy multiplex may result from a dysimmune systemic disorder such as post-transplant lymphoproliferative disorder, graft-versus-host disease or hepatitis C virus or hepatitis B virus chronic infection. Lastly, some of these complications, e.g., compression or stretch of individual nerves or plexus, are commonly seen in a postoperative setting and are not specific of patients with organ transplantation. This review focuses on the characteristic features, management, prognosis and pathophysiology of common and immune-related neuromuscular complications in organ transplant recipients.

Mycophenolate mofetil and tacrolimus: New therapeutic options in neuroimmunological diseases

Mycophenolate mofetil (MMF) and tacrolimus are novel immunosuppressive drugs, both first established in transplantation medicine and now used increasingly in neuroimmunological diseases including myasthenia gravis, dysimmune polyneuropathies, and myositis. In myasthenia gravis, the efficacy and safety of MMF has been shown by one open-label trial; one small, double-blind, placebo-controlled trial; and a few retrospective analyses. Similarly, for tacrolimus the greatest experience and evidence for efficacy and safety have been gathered in myasthenia gravis. MMF and tacrolimus have both been used as an alternative treatment for various other autoimmune diseases in which azathioprine or cyclosporine were not sufficiently effective. However, experience with tacrolimus in dysimmune polyneuropathies and myositis is limited. At this time, the available data suggest that MMF and tacrolimus are well suited for long-term immunosuppression in patients with myasthenia gravis. The spectrum of neuroimmunological diseases in which these drugs may be used has not been finally delineated and will require further controlled studies.