Central nervous system complications in two cases of juvenile onset dermatomyositis

Juvenile dermatomyositis with central nervous system involvement: two case reports from a retrospective single-center cohort, with literature review

Background

Juvenile dermatomyositis (JDM) is a systemic autoimmune disease primarily involving the muscles and skin; it can also affect the central nervous system (CNS). The relevant literature provides limited information regarding the characteristics of JDM with CNS involvement.

Method

We reviewed patients with JDM who were hospitalized at our center between January 2016 and August 2023, with a focus on those with CNS involvement. The aim was to provide detailed case reports on these patients, and to summarize the relevant literature about the characteristics of similar cases.

Results

Among 193 hospitalized patients with JDM, two (1.03%) had CNS involvement. Two patients, a 5.5-year-old girl and an 11-year-old boy, were admitted with severe proximal muscle weakness and seizures, and presented with active cutaneous vasculitis. Both were ultimately diagnosed with JDM, with CNS involvement. Both patients had confirmed presence of anti-NXP2 antibody through myositis-specific antibody analysis. Additionally, they all exhibited hyperferritinemia and thrombocytopenia. Salvage therapies like intravenous methylprednisolone (IVMP) pulse therapy and/or plasma exchange were administered successfully. At final follow-up, both patients had achieved complete clinical response and full neurological recovery. Our literature review identified nine similar case studies. CNS involvement usually occurred within the first 10 months of the disease course, and most of these patients had fatal outcomes, with a mortality rate of 66.6% (6/9). Including the two patients described herein, the median age for disease onset is 10.5 years (range 4-17 years), and the male: female ratio is 6:5. Seizures are the most common neurological symptom, accompanied by active cutaneous vasculitis. The brain biopsies showed two distinct pathological presentations: one was central nervous system vasculitis, and the other was cerebral macrophage activation syndrome.

Conclusions

CNS involvement is a rare but life-threatening JDM complication. Herein, our cases and the literature indicate that it typically occurs within the first 10 months of the disease course and manifests as seizures, often accompanied by active cutaneous vasculitis, with fatal outcomes. Timely implementation of salvage therapies, like IVMP pulse therapy and plasma exchange, may significantly impact patient outcomes.

Imaging of Childhood Cerebral Vasculitis

Childhood cerebral vasculitis is a condition that affects the blood vessels in the brain of children and is rare but life-threatening. Imaging plays a crucial role in the diagnosis and monitoring of the disease. This article describes the classification, diagnostic algorithm, and various imaging modalities used in the evaluation of childhood cerebral vasculitis and the imaging findings associated with primary and secondary vasculitis. Understanding the imaging features of this condition can assist in early diagnosis, effective treatment, and improve outcomes.

Idiopathic Inflammatory Myopathies

Idiopathic inflammatory myopathies (IIMs) are a diverse group of diseases characterized by proximal muscle weakness and inflammation in skeletal muscle. Phenotypically, the subtypes include dermatomyositis, polymyositis, inclusion body myositis, and amyopathic dermatomyositis. The most common IIM in children is juvenile dermatomyositis (JDM). In contrast to adult dermatomyositis (DM), children are likely to have frequent relapses, vasculopathy, and long-term metabolic and other complications like lipodystrophy, insulin resistance, and calcinosis. Significant advances in our understanding of pathogenesis, disease course, and treatment of JDM has changed the therapeutic landscape and improved outcomes in children. Myositis-specific autoantibodies and myositis-associated autoantibodies have unique clinical associations, disease course and help predict response to therapy. A multidisciplinary approach including exercise programs and psychosocial support is essential. The first line of treatment is a combination of corticosteroids and methotrexate (MTX). Other targeted immunosuppressive therapy is used in refractory cases. Early recognition and timely referral to a specialist center remain pivotal to improving the mortality and morbidity associated with this disease.

Epilepsy as a Comorbidity in Polymyositis and Dermatomyositis-A Cross-Sectional Study

Polymyositis (PM) and dermatomyositis (DM) are autoimmune-mediated multisystemic myopathies, characterized mainly by proximal muscle weakness. A connection between epilepsy and PM/DM has not been reported previously. Our study aim is to evaluate this association. A case–control study was conducted, enrolling a total of 12,278 patients with 2085 cases (17.0%) and 10,193 subjects in the control group (83.0%). Student’s t-test was used to evaluate continuous variables, while the chi-square test was applied for the distribution of categorical variables. Log-rank test, Kaplan–Meier curves and multivariate Cox proportional hazards method were performed for the analysis regarding survival. Of the studied 2085 cases, 1475 subjects (70.7%) were diagnosed with DM, and 610 patients (29.3%) with PM. Participants enrolled as cases had a significantly higher rate of epilepsy (n = 48 [2.3%]) as compared to controls (n = 141 [1.4%], p < 0.0005). Using multivariable logistic regression analysis, PM was found only to be significantly associated with epilepsy (OR 2.2 [95%CI 1.36 to 3.55], p = 0.0014), whereas a non-significant positive trend was noted in DM (OR 1.51 [95%CI 0.99 to 2.30], p = 0.0547). Our data suggest that PM is associated with a higher rate of epilepsy compared to controls. Physicians should be aware of this comorbidity in patients with immune-mediated myopathies.

Use of Rescue Therapy with IVIG or Cyclophosphamide in Juvenile Myositis

PURPOSE OF REVIEW

This review aims to present the literature available to date on the use of intravenous immunoglobulin and cyclophosphamide for juvenile patients with inflammatory myopathies, to evaluate the strength of the evidence so far for both these medications, and to reach conclusions about their efficacy.

RECENT FINDINGS

Juvenile idiopathic inflammatory myopathies, mainly represented by juvenile dermatomyositis (JDM), are rare diseases but quite debilitating for the patients. JDM is an autoimmune condition with predominantly muscle and skin involvement but also systemic features affecting the cardiovascular, respiratory, and gastrointestinal systems. The mainstay therapy is based on corticosteroids and methotrexate, but often other therapeutic alternatives are sought for patients with severe or refractory disease. The rarity of these conditions makes research for new medications even more challenging. Innovative trial designs or statistical methods can be used to emulate a randomized study and investigate drug effectiveness. Despite the lack of Level I evidence on the use and efficacy of intravenous immunoglobulin and cyclophosphamide, their use is advocated by a substantial number of case reports and case series as well as analyses using marginal structural models.

Treatment of Calcinosis in Juvenile Dermatomyositis

PURPOSE OF REVIEW

Juvenile dermatomyositis (JDM) is a rare autoimmune disease characterised by muscle and skin involvement. Calcinosis is a debilitating complication of JDM which is difficult to treat and may cause long-term morbidity. The purpose of this review is to provide an update for the treatment of JDM-associated calcinosis based on previously published studies.

RECENT FINDINGS

Evidence-based studies are lacking for the management of calcinosis, and current treatment modalities have been largely based on case reports, case series, cohort studies, limited controlled studies and anecdotal clinical experience. The use of early aggressive therapy for resistant cases is strongly suggested to halt persistent disease activity which may help in reducing steroid use and their associated complications. Recent insights into disease pathogenesis, myositis-specific antibodies and genetic associations have led to identification of novel therapeutic targets such as Janus kinase (JAK) 1/2. Different treatment regimens with variable outcomes are in use for the treatment of refractory calcinosis; nevertheless, the level of evidence is not sufficient to propose specific guidelines. Recently, JAK 1/2 inhibitors have shown to be effective as an emerging therapeutic option highlighting that translational and clinical research is crucial to develop targeted treatment for JDM-associated calcinosis.

CNS Vasculitis in Anti-Synthetase Syndrome

A 52-year-old woman known to have anti-synthetase syndrome (ASS) with positive anti-alanyl-tRNA synthetase antibody (anti-PL 12) for 4 years presented with headache and progressive deterioration of cognitive functions manifested predominantly by episodes of confusion and dyslexia. Clinical, laboratory and radiological evaluation as well as response to treatment was indicative of vasculitis of the central nervous system (CNS). CNS vasculitis is one of the rare manifestations of inflammatory myositis and no case has been reported to suggest CNS vasculitis in ASS.

Systemic and Tissue Inflammation in Juvenile Dermatomyositis: From Pathogenesis to the Quest for Monitoring Tools

Juvenile Dermatomyositis (JDM) is a systemic immune-mediated disease of childhood, characterized by muscle weakness, and a typical skin rash. Other organ systems and tissues such as the lungs, heart, and intestines can be involved, but may be under-evaluated. The inflammatory process in JDM is characterized by an interferon signature and infiltration of immune cells such as T cells and plasmacytoid dendritic cells into the affected tissues. Vasculopathy due to loss and dysfunction of endothelial cells as a result of the inflammation is thought to underlie the symptoms in most organs and tissues. JDM is a heterogeneous disease, and several disease phenotypes, each with a varying combination of affected tissues and organs, are linked to the presence of myositis autoantibodies. These autoantibodies have therefore been extensively studied as biomarkers for the disease phenotype and its associated prognosis. Next to identifying the JDM phenotype, monitoring of disease activity and disease-inflicted damage not only in muscle and skin, but also in other organs and tissues, is an important part of clinical follow-up, as these are key determinants for the long-term outcomes of patients. Various monitoring tools are currently available, among which clinical assessment, histopathological investigation of muscle and skin biopsies, and laboratory testing of blood for specific biomarkers. These investigations also give novel insights into the underlying immunological processes that drive inflammation in JDM and suggest a strong link between the interferon signature and vasculopathy. New tools are being developed in the quest for minimally invasive, but sensitive and specific diagnostic methods that correlate well with clinical symptoms or reflect local, low-grade inflammation. In this review we will discuss the types of (extra)muscular tissue inflammation in JDM and their relation to vasculopathic changes, critically assess the available diagnostic methods including myositis autoantibodies and newly identified biomarkers, and reflect on the immunopathogenic implications of identified markers.

Efficacy and Safety of Cyclophosphamide Treatment in Severe Juvenile Dermatomyositis Shown by Marginal Structural Modeling

OBJECTIVE

In patients with severe or refractory juvenile dermatomyositis (DM), second-line treatments may be required. Cyclophosphamide (CYC) is used to treat some connective tissue diseases, but evidence of its efficacy in juvenile DM is limited. This study was undertaken to describe clinical improvement in juvenile DM patients treated with CYC and model the efficacy of CYC treatment compared to no CYC treatment.

METHODS

Clinical data on skin, global, and muscle disease for patients recruited to the Juvenile DM Cohort and Biomarker Study were analyzed. Clinical improvement following CYC treatment was described using unadjusted analysis. Marginal structural models (MSMs) were used to model treatment efficacy and adjust for confounding by indication.

RESULTS

Compared to the start of CYC treatment, there were reductions at 6, 12, and 24 months in skin disease (P = 1.3 × 10-10 ), global disease (P = 2.4 × 10-8 ), and muscle disease (P = 8.0 × 10-10 ) for 56 patients treated with CYC in unadjusted analysis. Limited evidence suggested a reduction in glucocorticoid dose (P = 0.047) in patients treated with CYC. MSM analysis showed reduced global disease and skin disease in patients who started an ~6-month course of CYC treatment >12 months ago compared to patients never or not yet treated with CYC. In the treated patients, the modified skin Disease Activity Score for juvenile DM was 1.19 units lower (P = 0.0085) and the physician's global assessment was 0.66 units lower (P = 0.027). Minor adverse events were reported in 3 patients within 1 year of stopping CYC.

CONCLUSION

Our findings indicate that CYC is efficacious with no short-term side effects. Improvements in skin, global, and muscle disease were observed. Further studies are required to evaluate longer-term side effects.

The Vasculopathy of Juvenile Dermatomyositis

Juvenile dermatomyositis (JDM) is a rare autoimmune disease mainly characterized by muscle and skin involvement. Vasculopathy is considered central to the pathogenesis of the disease. The exact nature of vasculopathy is not yet understood but it is a complex process with both an inflammatory and a non-inflammatory, occlusive component. Impaired function of JDM vasculature includes immune complex deposition, altered expression of cell adhesion molecules predominantly inducing Th17 cell infiltration, and endothelial cell dysfunction. Development of vasculopathy is associated with the severe extra-muscular manifestations of JDM, such as gastrointestinal and cardiac manifestations, interstitial lung disease, ulcerative skin disease or development of calcinosis, and portends a poor prognosis. Correlation of histopathological findings, autoantibodies, and extensive diagnostic workup represent key elements to the early detection of vasculopathic features and early aggressive treatment. Monitoring of vasculopathy remains challenging due to the lack of non-invasive biomarkers. Current treatment approaches provide variable benefit, but better understanding of the essential pathogenic mechanisms should help lead to improved outcomes. Whilst acknowledging that evidence is limited, this review aims to describe the vasculopathy of JDM in the context of pathophysiology, clinical features, and treatment of disease.

Central nervous system vasculitis in adults: An update

Primary central nervous system vasculitis (PCNSV) is a challenging diagnosis due to broad clinical manifestations and variable specificity and sensitivity of laboratory and imaging diagnostic tools. Differential diagnosis includes reversible cerebral vasoconstriction syndrome (RCVS), secondary vasculitis of the CNS and other noninflammatory vasculopathies. Brain biopsy is essential for definitive diagnosis and to exclude mimickers. Recent data show that data large-vessel PCNSV present worse prognosis when compared to small-vessel PCNSV. Herein we review diagnosis and management of PCNSV, secondary vasculitis of CNS and RCVS.

Hemophagocytic lymphohistiocytosis with leukoencephalopathy in a patient with dermatomyositis accompanied with peripheral T-cell lymphoma: a case report

Background

Hemophagocytic lymphohistiocytosis associated with autoimmune diseases is seen in patients with systemic juvenile idiopathic arthritis, adult-onset Still’s disease, and systemic lupus erythematosus, whereas it is rarely seen in patients with dermatomyositis. In addition, central nervous system involvement with dermatomyositis is rare. To the best of our knowledge, this is the first case of hemophagocytic lymphohistiocytosis complicated by leukoencephalopathy in a patient with dermatomyositis accompanied with peripheral T-cell lymphoma.

Case presentation

A 17-year-old Asian male adolescent with dermatomyositis and hemophagocytic lymphohistiocytosis that were controlled with corticosteroid therapy presented to our hospital with high fever and altered consciousness. Brain magnetic resonance imaging revealed multiple cerebral lesions. We diagnosed the central nervous system lesions as leukoencephalopathy secondary to dermatomyositis and hemophagocytic lymphohistiocytosis. Because corticosteroid and cyclophosphamide pulse therapy was ineffective, he was treated with a modified hemophagocytic lymphohistiocytosis-2004 protocol, which resulted in the disappearance of the lesions of his central nervous system.

Conclusions

Our findings suggest that the hemophagocytic lymphohistiocytosis-2004 protocol including etoposide should be initiated immediately in patients with hemophagocytic lymphohistiocytosis who respond poorly to treatment for the underlying disease. Moreover, irrespective of the underlying disease, patients with hemophagocytic lymphohistiocytosis with central nervous system lesions might require bone marrow transplantation.

Multiple symptoms of higher brain dysfunction caused by Marchiafava-Bignami disease in a patient with dermatomyositis

A 65-year-old woman with dermatomyositis (DM) was admitted because of disorientation, mental dysfunction, and disturbance of consciousness. Prior to admission, she suffered from septic and hypovolemic shock. There was no evidence of active DM on physical examination and laboratory tests. Cerebrospinal fluid examination revealed no signs of meningitis. Because of clinical symptoms and findings on magnetic resonance images, such as the lesion in the splenium of the corpus callosum that was a low-intensity area on T1-weighted images and a high intensity on T2-weighted images; she was diagnosed as Marchiafava-Bignami disease (MBD). She received a combination of vitamin B, vitamin E, vitamin C, and nicotinic acid. Her symptoms improved gradually, and she was discharged at 1.5 months after admission. There has been no report of a case of DM with MBD. This report may provide useful data with regard to the mechanisms of central nervous system (CNS) disorders in patients with DM.

Dermatomiosite

Dermatomiosite é doença idiopática inflamatória crônica que afeta a musculatura estriada, a pele e outros órgãos. Apresenta critérios diagnósticos definidos por Bohan & Peter, podendo os pacientes ser classificados em cinco grupos: dermatomiosite juvenil, dermatomiosite primária idiopática, dermatomiosites amiopáticas, dermatomiosite associada a neoplasias e dermatomiosite associada a outras doenças do tecido conectivo. O sexo feminino é mais afetado, e a idade média do diagnóstico é 40 anos. Manifestações cutâneas são observadas em todos os pacientes. Das alterações sistêmicas, a manifestação muscular mais freqüente é a perda de força proximal, e a manifestação pulmonar mais comum é a pneumopatia intersticial. Podem ser observadas neoplasias durante o seguimento da doença, sendo mais freqüentes nos pacientes acima de 60 anos. A desidrogenase lática é a enzima muscular alterada na maioria dos casos. Para diagnóstico da dermatomiosite, pode ser realizado exame anatomopatológico de biópsia cutânea e biópsia muscular, além de eletroneuromiografia. Os corticóides são a terapia mais utilizada. As causas de óbito mais freqüentes são a neoplasia maligna, a septicemia e a infecção pulmonar.

Systemic juvenile rheumatoid arthritis: cognitive function and social adjustment

In contrast with other systemic rheumatic diseases in childhood, no systematic studies exist that focus on possible long-term risks for central nervous system involvement in systemic juvenile rheumatoid arthritis (SJRA). We investigated 31 children and adolescents with SJRA, aged 6 to 24 years (mean, 12.5 years; standard deviation, 4.3 years), with mean disease duration of 6.2 years (standard deviation, 3.5 years; range, 0.6-14 years) for their cognitive and fine motor abilities. We also examined 31 matched healthy control subjects. In addition, parents assessed social activities and social and emotional problems in their children. Patients and control subjects performed within normal limits of intelligence quotient, memory and learning, attention, and fine motor scores. Less social activities were reported for patients. Patients and control subjects, however, had normal social and emotional problem scores. SJRA, although a burdensome chronic disease, is not associated with cognitive impairment or increased social and emotional problems. Cognitive performance and social adjustment of young patients with SJRA are not affected by disease activity and duration.

Inflammatory myopathies in children

Juvenile idiopathic inflammatory myopathies are rare conditions that are probably autoimmune in nature. Juvenile dermatomyositis (JDM) is the most common inflammatory myopathy. This article describes a recent patient who presented with typical JDM and uses her case to discuss aspects of the childhood inflammatory myopathies.

Clinical outcomes in juvenile dermatomyositis

Juvenile dermatomyositis is a chronic inflammatory illness of unknown etiology that affects primarily muscle and skin. It has an incidence of 2-3 per 1,000,000, per year. The disease can affect other organ systems, including the gastrointestinal tract, lungs, and heart. In addition, calcinosis is seen in one-third of patients. The mainstay of therapy is corticosteroids; some children require additional immunosuppressive agents because of corticosteroid resistance or intolerance. Functional outcomes have become good with modern treatments, but the disease remains chronic in a large number of children and sequelae are often seen.

Clinical features and outcomes of juvenile dermatomyositis and other childhood onset myositis syndromes

The childhood myositis syndromes, primarily JDM, are relatively homogeneous diseases that have a good outcome in most cases, but are chronic, with poor outcomes, in a substantial number of cases. Because of the rarity of childhood myositis, and because there has not yet been a unified evidence-based approach to therapy, optimal treatment remains unknown. In clinic-based series the disease seems to be homogeneous but there are patients with rare clinical features, (e.g., cardiac, pulmonary, and neurologic disease), that impact prognosis. Racial, genetic, and other factors may lead to geographic variations in clinical presentations and outcomes, and perhaps further exploration of these influences will lead to a better understanding of the clinical features and outcomes seen in children. Our treatments are based on accumulated experience, but proper clinical trials have not been done. Ongoing registry studies, development of validated activity and damage assessment tools, large clinical trials, and continued investigation into the pathogenesis of the childhood myositis syndromes should lead to improved understanding and better treatments.