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Day JA, Limaye V. Immune-mediated necrotising myopathy: A critical review of current concepts. Semin Arthritis Rheum 2019; 49:420-429. [PMID: 31109639 DOI: 10.1016/j.semarthrit.2019.04.002] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 03/06/2019] [Accepted: 04/22/2019] [Indexed: 01/08/2023]
Abstract
Immune-mediated necrotising myopathy (IMNM) is a relatively recently described form of idiopathic inflammatory myopathy (IIM) that is characterised by progressive proximal weakness and few extra-muscular manifestations. Prominent myonecrosis, muscle fibre regeneration and a relative paucity of intramuscular lymphocytes are seen histologically. Immunological mechanisms are believed to underpin the pathogenesis, and intense immunotherapy is frequently required. Disease is often severe and neuromuscular recovery may be poor. Recently there has been an impressive international research effort to understand and characterise this emerging condition, although much remains unknown. Significant advances in the field include the discovery of specific autoantibodies, increased understanding of the risk factors, clinical characteristics and treatment options owing to a wealth of observational studies, and the development of novel classification criteria. Herein we review the current evidence regarding the pathophysiology, clinical presentation, histological features and serological profiles associated with this condition. Diagnostic approaches are discussed, including the role of muscle MRI and antibodies targeting 3‑hydroxy-3-methylglutaryl-CoA reductase (HMGCR) and signal-recognition peptide (SRP), and a review of current treatment recommendations is provided.
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Affiliation(s)
- Jessica A Day
- Experimental Therapeutics Laboratory, University of South Australia Cancer Research Institute, Health Innovation Building, North Terrace, Adelaide, SA 5000, Australia; School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, SA 5000, Australia; Royal Adelaide Hospital, Adelaide, SA 5000, Australia.
| | - Vidya Limaye
- Royal Adelaide Hospital, Adelaide, SA 5000, Australia; Discipline of Medicine, University of Adelaide, Adelaide, SA 5000, Australia
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Liebowitz J, Christopher-Stine L. Autoimmune Necrotizing Myopathies: Subtypes and Advances in Treatment. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2017. [DOI: 10.1007/s40674-017-0080-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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A 64-Year-Old Woman with Chest Pain, Limb Weakness, and Endometrial Cancer. Case Rep Rheumatol 2017; 2017:1891897. [PMID: 28373922 PMCID: PMC5360936 DOI: 10.1155/2017/1891897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 02/22/2017] [Indexed: 11/18/2022] Open
Abstract
Necrotizing autoimmune myopathy (NAM) is a rare subgroup of idiopathic inflammatory myopathies (IIM). This pathology usually affects proximal limb muscles and in some cases the myocardium. Patients usually display proximal limb weakness. Muscular biopsy is required to confirm the diagnosis. We report the case of a 64-year-old woman with an atypical first presentation of NAM, manifested by chest pain in the context of metastatic endometrial cancer. The diagnosis of NAM was however made when she returned a second time with proximal limb weakness. A treatment with prednisone was then initiated, to which rituximab was rapidly associated, beside a specific chemotherapy.
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Tieu J, Lundberg IE, Limaye V. Idiopathic inflammatory myositis. Best Pract Res Clin Rheumatol 2016; 30:149-68. [DOI: 10.1016/j.berh.2016.04.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 04/12/2016] [Accepted: 04/18/2016] [Indexed: 12/11/2022]
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Limaye V, Bundell C, Hollingsworth P, Rojana-Udomsart A, Mastaglia F, Blumbergs P, Lester S. Clinical and genetic associations of autoantibodies to 3-hydroxy-3-methyl-glutaryl-coenzyme a reductase in patients with immune-mediated myositis and necrotizing myopathy. Muscle Nerve 2015; 52:196-203. [PMID: 25521389 DOI: 10.1002/mus.24541] [Citation(s) in RCA: 93] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2014] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Inhibition of 3-hydroxy-3-methyl-glutaryl-coenzyme A reductase (HMGCR) with statins may trigger idiopathic inflammatory myositis (IIM) or immune-mediated necrotizing myopathy (IMNM). Anti-HMGCR antibodies have been detected in patients with IIM/IMNM. We aimed to determine the associations of anti-HMGCR in IIM/IMNM. METHODS Anti-HMGCR antibodies were detected by ELISA in sera from patients with IIM/IMNM. RESULTS Anti-HMGCR antibodies were detected in 19 of 207 patients with IIM/IMNM, and there was a trend toward an association with male gender (P = 0.079). Anti-HMGCR antibodies were associated strongly with statin exposure (OR = 39, P = 0.0001) and HLA-DRB1*11 (OR = 50, P < 0.0001). The highest risk for development of anti-HMGCR antibodies was among HLA-DR11 carriers exposed to statins. Univariate analysis showed a strong association of anti-HMGCR antibodies with diabetes mellitus (P = 0.008), which was not confirmed by multiple regression. Among anti-HMGCR(+) patients there was a trend toward increased malignancy (P = 0.15). CONCLUSIONS Anti-HMGCR antibodies are seen in all subtypes of IIM and IMNM and are associated strongly with statin use and HLA-DR11. Muscle Nerve 52: 196-203, 2015.
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Affiliation(s)
- Vidya Limaye
- Rheumatology Department, Royal Adelaide Hospital, North Tce, Adelaide, South Australia SA, 5000, Australia.,Discipline of Medicine, Adelaide University, Adelaide, South Australia, Australia
| | - Chris Bundell
- PathWest Laboratory Medicine, Queen Elizabeth II Medical Centre, Perth, Western Australia, Australia
| | - Peter Hollingsworth
- PathWest Laboratory Medicine, Queen Elizabeth II Medical Centre, Perth, Western Australia, Australia.,Clinical Immunology, Sir Charles Gairdner Hospital
| | - Arada Rojana-Udomsart
- PathWest Laboratory Medicine, Queen Elizabeth II Medical Centre, Perth, Western Australia, Australia
| | - Frank Mastaglia
- West Australian Neuroscience Research Institute, Queen Elizabeth II Medical Centre, Perth, Western Australia, Australia
| | - Peter Blumbergs
- Discipline of Medicine, Adelaide University, Adelaide, South Australia, Australia
| | - Sue Lester
- Rheumatology Department, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
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García-Reynoso MJ, Veramendi-Espinoza LE, Ruiz-Garcia HJ. Paresia ascendente como comienzo de inusual asociación entre miopatía autoinmune necrosante y lupus eritematoso sistémico. ACTA ACUST UNITED AC 2014; 10:183-6. [DOI: 10.1016/j.reuma.2013.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2012] [Revised: 03/12/2013] [Accepted: 03/13/2013] [Indexed: 11/24/2022]
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Drouot L, Allenbach Y, Jouen F, Charuel JL, Martinet J, Meyer A, Hinschberger O, Bader-Meunier B, Kone-Paut I, Campana-Salort E, Eymard B, Tournadre A, Musset L, Sibilia J, Marie I, Benveniste O, Boyer O. Exploring necrotizing autoimmune myopathies with a novel immunoassay for anti-3-hydroxy-3-methyl-glutaryl-CoA reductase autoantibodies. Arthritis Res Ther 2014; 16:R39. [PMID: 24484965 PMCID: PMC3979083 DOI: 10.1186/ar4468] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Accepted: 01/20/2014] [Indexed: 11/23/2022] Open
Abstract
Introduction Necrotizing autoimmune myopathies (NAM) have recently been defined as a distinct group of severe acquired myopathies, characterized by prominent myofiber necrosis without significant muscle inflammation. Because of the lack of appropriate biomarkers, these diseases have been long misdiagnosed as atypical forms of myositis. NAM may be associated to autoantibodies directed against signal recognition particle (SRP) or 3-hydroxy-3-methyl-glutaryl-CoA reductase (HMGCR). The objective of this work was to quantify anti-HMGCR autoantibodies in patients with suspicion of NAM through the development of a new addressable laser bead immunoassay (ALBIA). Methods Recombinant HMGCR C-domain was bound to fluorescent beads. After incubation with serum, autoantibodies were revealed using class- or subclass-specific anti-human immunoglobulin G (IgG) antibodies. Anti-HMGCR levels were assayed in 150 patients with suspicion of NAM, 142 controls with different inflammatory/autoimmune diseases and 100 healthy donors. Inhibition with free recombinant HMGCR and immunoprecipitation experiments confirmed test specificity. Reproducibility and repeatability were determined from sera with various levels of anti-HMGCR autoantibodies. A multiplex assay (ALBIA-NAM) was also developed to permit the simultaneous quantification of anti-HMGCR and anti-signal recognition particle autoantibodies. Results No controls scored positive. Of 150 patients with suspicion of NAM, 24% were positive for anti-HMGCR autoantibodies with levels ranging from 24 to 2,656 AU/mL. Anti-HMGCR positivity could be associated to a cytoplasmic pattern in immunofluorescence assay on HEp-2 cells. Anti-HMGCR-positive patients had high creatine kinase (CK) levels (mean 6,630 IU/L) and only 40% of them had been exposed to statins. Multiplex ALBIA-NAM was equally as effective as monoplex anti-HMGCR and anti-SRP ALBIA. Conclusions Both monoplex ALBIA-HMGCR and multiplex ALBIA-NAM reliably detect and quantify anti-HMGCR autoantibodies. A positive result allows ascribing patients with a necrotizing myopathy to an autoimmune form. Anti-HMGCR autoantibodies may be found in patients who have not taken statins.
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Preuße C, Goebel HH, Held J, Wengert O, Scheibe F, Irlbacher K, Koch A, Heppner FL, Stenzel W. Immune-mediated necrotizing myopathy is characterized by a specific Th1-M1 polarized immune profile. THE AMERICAN JOURNAL OF PATHOLOGY 2012; 181:2161-71. [PMID: 23058368 DOI: 10.1016/j.ajpath.2012.08.033] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Revised: 08/21/2012] [Accepted: 08/30/2012] [Indexed: 12/22/2022]
Abstract
Immune-mediated necrotizing myopathy (IMNM) is considered one of the idiopathic inflammatory myopathies, comprising dermatomyositis, polymyositis, and inclusion body myositis. The heterogeneous group of necrotizing myopathies shows a varying amount of necrotic muscle fibers, myophagocytosis, and a sparse inflammatory infiltrate. The underlying immune response in necrotizing myopathy has not yet been addressed in detail. Affected muscle tissue, obtained from 16 patients with IMNM, was analyzed compared with eight non-IMNM (nIMNM) tissues. Inflammatory cells were characterized by IHC, and immune mediators were assessed by quantitative real-time PCR. We demonstrate that immune- and non-immune-mediated disease can be distinguished by a specific immune profile with significantly more prominent major histocompatibility complex class I expression and complement deposition and a conspicuous inflammatory infiltrate. In addition, patients with IMNM exhibit a strong type 1 helper T cell (T1)/classically activated macrophage M1 response, with detection of elevated interferon-γ, tumor necrosis factor-α, IL-12, and STAT1 levels in the muscle tissue, which may serve as biomarkers and aid in diagnostic decisions. Furthermore, B cells and high expression of the chemoattractant CXCL13 were identified in a subgroup of patients with defined autoantibodies. Taken together, we propose a diagnostic armamentarium that allows for clear differentiation between IMNM and nIMNM. In addition, we have characterized a Th1-driven, M1-mediated immune response in most of the autoimmune necrotizing myopathies, which may guide therapeutic options in the future.
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Affiliation(s)
- Corinna Preuße
- Department of Neuropathology, Charité-Universitätsmedizin, Charité Campus Mitte, Charitéplatz 1, Berlin, Germany
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Ellis E, Ann Tan J, Lester S, Tucker G, Blumbergs P, Roberts-Thomson P, Limaye V. Necrotizing myopathy: Clinicoserologic associations. Muscle Nerve 2012; 45:189-94. [DOI: 10.1002/mus.22279] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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