Muscular involvement in systemic rheumatoid vasculitis

Inflammatory muscle involvement in systemic vasculitis: A systematic review

Vasculitis are severe systemic autoimmune diseases which may involve different organs and systems. Conversely, muscles do not represent an organ commonly involved by systemic vasculitis and myositis is not include among any classification or diagnostic criterion of vasculitis. In this regard, we aimed to review the literature in order to report all the available evidence concerning the inflammatory involvement of muscle in patients affected by systemic vasculitis. We collected a total of 108 papers, for a sum of 395 patients affected by muscle vasculitis. Most of them suffered from medium and small vessels vasculitis (mainly polyarteritis nodosa and ANCA-associated vasculitis) or from vasculitis secondary to rheumatoid arthritis. Conversely, muscle involvement in case of large vessel vasculitis occurred seldom, while only few papers reported such occurrence in Kawasaki or Behçet's disease. Histological findings may differ, but the most common ones displayed a necrotizing vasculitis of perimysium vessels, while granulomatous vasculitis was assessed only in case of ANCA-associated vasculitis patients. Creatine kinase were usually within normal range, seldom elevated, while imaging findings were generally undistinguishable from the ones found in idiopathic inflammatory myopathies: magnetic resonance imaging displays signal hyperintensity in T2 and STIR scans, while few data exist for positron emission tomography. The presentation of the disease may be fearsome and severe, sometimes life-threatening, but an overall good response to conventional immunosuppressants and/or glucocorticoids has been reported.

Severe Proximal Myopathy and Mononeuritis Multiplex in Rheumatoid Arthritis

Vascular injury is considered to be a key finding in the pathogenesis of rheumatoid arthritis (RA). Manifestations are varied depending on the vessel size and the organ system involved. Vasculitis leading to symptomatic inflammatory myositis is a rare complication of RA. We describe a 62-year-old man with seropositive erosive RA of 1-year duration, who presented with severe proximal weakness and mononeuritis multiplex. His joint disease was clinically mild at the time of presentation. Creatine kinase was normal and the electromyogram did not suggest myopathy. However, muscle biopsy revealed extensive small vessel vasculitis and severe inflammatory myositis. This report emphasizes the importance of fully evaluating patients with RA who present with proximal myopathy. The myopathy in our patient was not related to active joint disease, disuse atrophy, or complication of therapy. Rheumatoid vasculitis leading to myositis is a rare and not well-recognized complication of RA for which aggressive immunosuppressive therapy is warranted.

Neurologic manifestations of connective tissue disease

The clinical features, diagnosis, and treatment of systemic lupus erythematosus, scleroderma, rheumatoid arthritis, Sjögren's syndrome, mixed connective tissue disease, Behcet's disease, Cogan's syndrome, and relapsing polychondritis are reviewed from a neurological perspective with an emphasis on pathogenic mechanisms and their relationship to treatment.

ICAM-1, E-selectin, and TNF alpha expression in labial salivary glands of patients with rheumatoid vasculitis

OBJECTIVE

To assess the expression of ICAM1, VCAM1, E-selectin, CD44, and TNF alpha in labial salivary glands of patients with rheumatoid vasculitis.

METHODS

Labial salivary glands from six patients with rheumatoid vasculitis before and after treatment, six aged matched rheumatoid arthritis patients without clinical evidence of rheumatoid vasculitis, 10 patients with primary Sjögren syndrome, 10 patients with rheumatoid arthritis and proven secondary Sjögren syndrome, and six controls were tested with specific antibodies.

RESULTS

ICAM1, E-selectin, and TNF alpha were significantly expressed in endothelial cells and perivascular cellular infiltrate only in rheumatoid vasculitis before treatment.

CONCLUSIONS

The expression of ICAM1, E-selectin, and TNF alpha allows an assessment of the activity of the vasculitic process in rheumatoid vasculitis. Labial salivary gland biopsy findings in patients with rheumatoid arthritis and visceral vasculitis without purpura or neuropathy (that is, mesenteric, coronary, or cerebral vasculitis) would be of interest and are examples where labial salivary gland tissue is more accessible than the affected tissue.

Muscle involvement in rheumatoid arthritis: clinicopathological study of 21 symptomatic cases

The aim of the current study was to analyze the frequency and characteristics of symptomatic myopathies occurring in rheumatoid arthritis (RA) patients, to correlate these findings with clinical data, and to evaluate their therapeutic implications. All RA patients from a cohort of 350 RA patients from a single institution who developed muscular symptomatology during an 8-year period were included in the study (n = 21). Clinical and laboratory data and electromyographic results were recorded in all cases, and an open muscle biopsy was performed. Weakness and muscle atrophy were the most common symptoms. Serum creatine kinase was increased in 8 cases (38%). Histopathologic study showed type 2 atrophy in 12 cases. In 13 cases, a treatable disease was diagnosed: dermatomyositis (n = 2), d-penicillamine-related dermatomyositis (n = 2), polymyositis (n = 1), muscular mononuclear cell infiltration (n = 3), polyarteritis nodosa (n = 1), glucocorticoid myopathy (n = 3), and toxic chloroquine myopathy (n = 1). In all but 1 patient, muscular clinical response to new therapy and/or drug withdrawal was satisfactory. Although symptomatic muscular involvement in RA is low (6% in the current series), we have found that nearly two thirds of cases were caused by potentially treatable conditions, mainly myositis or toxic myopathies.