1
|
Fu Y, Gu L, Chen J, Dai Y, Feng Q, Chen Z, Fan J, Gao M, Wang X, Fu Q, Ye S. Severe gastrointestinal involvements in patients with adult dermatomyositis with anti-NXP2 antibody. RMD Open 2024; 10:e003901. [PMID: 38199847 PMCID: PMC10806494 DOI: 10.1136/rmdopen-2023-003901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 12/28/2023] [Indexed: 01/12/2024] Open
Abstract
OBJECTIVE Gastrointestinal (GI) involvements were scarcely reported in adult anti-nuclear matrix protein 2 (NXP2) dermatomyositis (NXP2+DM). In this study, we investigated the clinical, pathological and molecular features as well as treatment options of this rare yet life-threatening disease. METHODS We retrospectively collected the data of the cohort of NXP2+ DM from 2012 to 2022 in our hospital. RNA sequencing was performed in intestinal samples of perforated patients compared with healthy controls data set. RESULTS A total of 56 patients with adult NXP2+DM were collected including 10 cases with GI involvements. Abdominal pain and melena were the initial manifestations for GI involvements with a median 10-month time lag after the diagnosis of NXP2+DM when myositis largely subsided. Within weeks, GI perforation occurred in 8 of 10 patients, while five patients underwent eight surgical interventions subsequently. The short-term mortality was observed in four patients. NXP2+DM with GI involvements presented with more extramuscular systemic manifestations such as interstitial lung disease and subcutaneous calcinosis. The GI pathological features encompassed vasculitis/vasculopathy with high MxA expression, intestinal smooth muscle necrosis and serosal calcinosis. Gene expression profile validated the type-I interferon activation and revealed that epithelial mesenchymal transition and focal adhesion pathway may also contribute. Finally, vedolizumab, an anti-α4β7-integrin monoclonal antibody, exhibited promising therapeutic signals which should be further investigated. CONCLUSIONS GI involvement is a unique complication in patients with adult NXP2+DM. Timely recognition and targeted therapy may turn out to be lifesaving.
Collapse
Affiliation(s)
- Yakai Fu
- Department of Rheumatology, Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, Shanghai, China
| | - Liyang Gu
- Department of Rheumatology, Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, Shanghai, China
| | - Jie Chen
- Department of Rheumatology, Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, Shanghai, China
| | - Yuting Dai
- Shanghai Jiao Tong University Medical School Affiliated Ruijin Hospital, Shanghai, China
| | - Qi Feng
- Department of Radiology, Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, Shanghai, China
| | - Zhiwei Chen
- Department of Rheumatology, Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, Shanghai, China
| | - Jie Fan
- Department of Pathology, Huashan Hospital Fudan University, Shanghai, China
| | - Mingshi Gao
- Department of Pathology, Huashan Hospital Fudan University, Shanghai, China
| | - Xiaodong Wang
- Department of Rheumatology, Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, Shanghai, China
| | - Qiong Fu
- Department of Rheumatology, Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, Shanghai, China
| | - Shuang Ye
- Department of Rheumatology, Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, Shanghai, China
| |
Collapse
|
2
|
Neves A, Mendonça I, Marques J, Costa J, Almeida J. Dermatomyositis and Crohn's disease - Case report. Int J Rheum Dis 2023; 26:2576-2580. [PMID: 37243455 DOI: 10.1111/1756-185x.14757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 05/17/2023] [Indexed: 05/28/2023]
Abstract
Immune-mediated diseases tend to overlap in ways that are not completely understood. When a presentation is not entirely explained by a former condition, other hypotheses should arise. Additionally, the activity of 2 overlapping immune-mediated conditions is not always associated. We present an unusual association between Crohn's disease and dermatomyositis in a 28-year-old man. The patient presented with a 2-month history of proximal muscle weakness and a skin rash with heliotrope periorbital edema. Since the patient had already been diagnosed with Crohn's disease, he was under immunosuppressive therapy, and he had a family history of psoriasis, the diagnosis was not immediate and required an integrative approach. Laboratory analysis revealed elevated creatine kinase, aldolase, lactic dehydrogenase and transaminase levels. He had no symptoms of Crohn's disease exacerbation. Magnetic resonance imaging, electromyography, and muscle biopsy findings were consistent with inflammatory myopathy, although non-specific. Corticosteroids were initiated with clinical and laboratory improvement within 1 month.
Collapse
Affiliation(s)
- Ana Neves
- Internal Medicine Department, Centro Hospitalar Universitário de São João, Oporto, Portugal
| | - Inês Mendonça
- Intensive Care Medicine Department, Centro Hospitalar Universitário de São João, Oporto, Portugal
| | - José Marques
- Internal Medicine Department, Centro Hospitalar Universitário de São João, Oporto, Portugal
| | - José Costa
- Internal Medicine Department, Hospital Terras do Infante, Centro Hospitalar Universitário do Algarve, Lagos, Portugal
| | - Jorge Almeida
- Internal Medicine Department, Centro Hospitalar Universitário de São João, Oporto, Portugal
| |
Collapse
|
3
|
Shaik MR, Shaik NA, Mikdashi J. Autoimmune Dysphagia Related to Rheumatologic Disorders: A Focused Review on Diagnosis and Treatment. Cureus 2023; 15:e41883. [PMID: 37581141 PMCID: PMC10423619 DOI: 10.7759/cureus.41883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2023] [Indexed: 08/16/2023] Open
Abstract
Autoimmune dysphagia is defined as dysphagia caused by autoimmune processes affecting various components of the swallowing process such as muscle, neuromuscular junction, nerves, roots, brainstem, or cortex. These autoimmune causes can be classified into gastroenterological, dermatological, rheumatologic, and neurologic. Rheumatological disorders, such as scleroderma, Sjogren's syndrome, systemic lupus erythematosus, rheumatoid arthritis, sarcoidosis, Behcet's disease, anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis, or granulomatosis with polyangiitis, have been associated with dysphagia. Autoimmune dysphagia in the context of rheumatological disorders is particularly significant because it can occur as a sole manifestation or as part of a symptom complex associated with the underlying disorder and often responds to immunosuppressive therapies. However, diagnosing autoimmune dysphagia can be challenging as it requires the exclusion of structural and primary motility disorders through procedures such as endoscopy and manometry. Early diagnosis is important to improve the quality of life and prevent significant mortality and morbidity. Management focuses on treating the underlying disease activity, and a multidisciplinary approach involving various medical specialties may be necessary to achieve success. This article aims to review the autoimmune rheumatological conditions that can lead to dysphagia and discuss the associated pathophysiological mechanisms. We also outline the clinical clues and laboratory testing methods that facilitate early diagnosis, with the goal of improving patient outcomes through timely intervention and appropriate management.
Collapse
Affiliation(s)
- Mohammed Rifat Shaik
- Department of Internal Medicine, University of Maryland Medical Center Midtown Campus, Baltimore, USA
| | - Nishat Anjum Shaik
- Department of Internal Medicine, University of Maryland Medical Center Midtown Campus, Baltimore, USA
| | - Jamal Mikdashi
- Division of Rheumatology and Clinical Immunology, University of Maryland School of Medicine, Baltimore, USA
| |
Collapse
|
4
|
Nagano H, Matsumoto H, Kurono Y. Dysphonia in Polymyositis/Dermatomyositis in Adults. Indian J Otolaryngol Head Neck Surg 2023; 75:760-764. [PMID: 37274997 PMCID: PMC10235304 DOI: 10.1007/s12070-022-03240-9] [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: 09/28/2022] [Accepted: 10/11/2022] [Indexed: 01/13/2023] Open
Abstract
The purpose of this study was to examine clinical dysphonia in patients with polymyositis (PM)/dermatomyositis (DM). The subjects were 21 Japanese patients with PM/DM (11 females, 10 males; mean age ± SD, 61.4 ± 16.2 years) who visited our department between April 2009 and March 2020. Dysphonia was evaluated by laryngoscopy and histopathological examination. Eight (38.1%) patients were aware of dysphonia. These patients included one with PM and 7 with DM, 5 were male and 3 were female, and the mean age at diagnosis was 62.0 (range 48 to 72) years. White lesions on the vocal cords were found in 7 of the patients with dysphonia. The patient without these white lesions had regurgitation into the nasal cavity. Histopathological examination revealed inflammation of lamina propria in the laryngeal white lesions. White lesions on the vocal cords were found in patients with dysphonia in patients with polymyositis (PM)/dermatomyositis (DM). Histopathological examination revealed fiber necrosis and inflammatory cell infiltration in lamina propria of the laryngeal lesions. White lesions on the vocal cords were relieved by treatment. Level of Evidence 2b (Individual retrospective cohort study).
Collapse
Affiliation(s)
- Hiromi Nagano
- Department of Otolaryngology Head and Neck Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, 890-8520 Japan
| | - Hayato Matsumoto
- Department of Otolaryngology Head and Neck Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, 890-8520 Japan
| | - Yuichi Kurono
- Department of Otolaryngology Head and Neck Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, 890-8520 Japan
| |
Collapse
|
5
|
Moroz EV, Popkova TV, Moroz AE. Manifestations of the gastrointestinal tract in systemic rheumatic diseases: A narrative review. RHEUMATOLOGY SCIENCE AND PRACTICE 2022. [DOI: 10.47360/1995-4484-2022-578-586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Gastrointestinal disorders are important place among the visceral manifestations of systemic autoimmune and immunoinflammatory rheumatic diseases (RD). Pathology of the esophagus, stomach, small and large intestine can vary from moderate functional disorders to the development of severe chronic inflammation with metaplasia and dysplasia of the mucous membrane, the formation of multiple erosions, hemorrhages and deep ulcers. Complications of gastrointestinal pathology in RD, such as bleeding, perforations and strictures, can cause death. This review examines the main clinical manifestations, possibilities of diagnosis and treatment of gastrointestinal lesions in systemic scleroderma, idiopathic inflammatory myopathies, systemic vasculitis, Sjogren’s syndrome and disease, as well as systemic lupus erythematosus.
Collapse
Affiliation(s)
- E. V. Moroz
- Main Military Clinical Hospital named after N.N. Burdenko
| | | | - A. E. Moroz
- V.A. Nasonova Research Institute of Rheumatology
| |
Collapse
|
6
|
Sharif K, Ben-Shabat N, Mahagna M, Shani U, Watad A, Cohen AD, Amital H. Inflammatory Bowel Diseases Are Associated with Polymyositis and Dermatomyositis-A Retrospective Cohort Analysis. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58121727. [PMID: 36556929 PMCID: PMC9781532 DOI: 10.3390/medicina58121727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 11/19/2022] [Accepted: 11/24/2022] [Indexed: 11/27/2022]
Abstract
Background and Objectives: Polymyositis and dermatomyositis (PM/DM) are classified as polygenic autoimmune diseases, whereas inflammatory bowel disease (IBD) is considered a polygenic autoinflammatory disease. In the literature, several cases exist reporting the co-occurrence of both conditions. At the molecular level, PM/DM and IBD share common genetic determinants including interferon regulatory factor and vitamin D receptor susceptibility loci. Accumulating evidence underline several indicators that confer poor prognosis in IBD, including antinuclear antibody positivity and the presence of other autoimmune diseases, therefore the aim of this study is to assess the association between these entities. Materials and Methods: This is a population-based retrospective study using data retrieved from a large electronic medical record in Israel, the Clalit health registry. The sample included PM/DM patients and age- and sex-frequency matched controls. The prevalence of IBD in PM/DM was compared between the two groups and logistic regression was applied to control for confounding variables. Predictors of IBD in patients with PM/DM were also explored. Results: Our study included 12,278 subjects with 2085 PM/DM patients and 10,193 age- and sex- frequency-matched controls. The incidence of IBD in patients with PM/DM was significantly higher even after controlling for various confounding variables (OR of 1.73, 95% CI 1.05-2.86, p-value = 0.033). Anti-nuclear antibodies (ANA) positivity was found to be an independent predictor for IBD diagnosis in patients with PM/DM (OR 3.67, 95% CI 1.01-13.36, p = 0.048). Conclusion: Our analysis reports an association between IBD and PM/DM. Such association could point towards a common pathophysiological background. Further research is needed to further describe the clinical courses and whether a unique therapeutic approach is warranted.
Collapse
Affiliation(s)
- Kassem Sharif
- Department of Gastroenterology, Sheba Medical Centre, Tel-Hashomer 5265601, Israel
- Department of Medicine B, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer 5262100, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6209813, Israel
| | - Niv Ben-Shabat
- Department of Medicine B, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer 5262100, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6209813, Israel
| | - Muhammad Mahagna
- Department of Medicine B, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer 5262100, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6209813, Israel
| | - Uria Shani
- Department of Medicine B, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer 5262100, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6209813, Israel
| | - Abdulla Watad
- Department of Medicine B, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer 5262100, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6209813, Israel
- Section of Musculoskeletal Disease, NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Institute of Molecular Medicine, University of Leeds, Chapel Allerton Hospital, Leeds LS7 4SA, UK
| | - Arnon D. Cohen
- Chief Physicians Office, Clalit Health Services, Tel Aviv 6209813, Israel
- Siaal Research Center for Family Medicine and Primary Care, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva 8410501, Israel
| | - Howard Amital
- Department of Medicine B, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer 5262100, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6209813, Israel
- Correspondence: ; Tel.: +972-3-5302661; Fax: +972-3-5304796
| |
Collapse
|
7
|
Improvement in Tongue Pressure Precedes Improvement in Dysphagia in Dermatomyositis. Clin Pract 2022; 12:797-802. [PMID: 36286069 PMCID: PMC9600123 DOI: 10.3390/clinpract12050083] [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: 07/07/2022] [Revised: 09/24/2022] [Accepted: 09/28/2022] [Indexed: 11/23/2022] Open
Abstract
Dysphagia is known to occur in patients with dermatomyositis. However, the sudden-onset dysphagia without other symptoms can make diagnosis and treatment challenging. Two patients who did not have a severe muscle weakness complained of the sudden inability to swallow solids and liquids. The muscle biopsy results showed the perifascicular atrophy, and the patients were diagnosed with dermatomyositis. Videofluoroscopy revealed an inadequate pharyngeal contraction and a decreased upper esophageal sphincter opening with silent aspiration. Both patients showed low tongue pressures. Patient 1 received intravenous and oral methylprednisolone, and patient 2 received intravenous immunoglobulin in addition to intravenous and oral methylprednisolone. Several months after the onset of the dysphagia, the swallowing function of both patients improved. The improvement in tongue pressure preceded an improvement in the subjective and objective measurements of dysphagia. In conclusion, tongue pressure may be useful for predicting early improvement in swallowing function.
Collapse
|
8
|
Gastrointestinal Involvement in Dermatomyositis. Diagnostics (Basel) 2022; 12:diagnostics12051200. [PMID: 35626355 PMCID: PMC9139828 DOI: 10.3390/diagnostics12051200] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/27/2022] [Accepted: 05/09/2022] [Indexed: 01/27/2023] Open
Abstract
Dermatomyositis is a systemic vasculopathy mainly affecting skin, muscle and lung, but may affect the gastrointestinal tract. We aim to describe clinical characteristics of patients with severe gastrointestinal involvement related to dermatomyositis in our center and medical literature. We retrospectively analysed these patients in our center, including cases of erosions/ulcers, perforation or digestive bleeding. Reported cases from April 1990 to April 2021 were reviewed through PubMed and Cochrane. From our cohort (n = 188), only 3 presented gastrointestinal compromise. All were women (10, 46 and 68 years). The initial symptom was abdominal pain and all had ≥2 episodes of digestive bleeding. All died due to complications of gastrointestinal involvement. Available pathological samples showed vascular ectasia. From the literature review (n = 50), 77% were women with a mean age of 49 years and the main symptom was abdominal pain (65%). All presented active muscular and cutaneous involvement at complication diagnosis. Mortality was 41.7%. The underlying lesion was perforation or ulcer (n = 22), intestinal wall thickening (n = 2), macroscopic inflammation (n = 2) or intestinal pneumatosis (n = 15). In 13 cases, vasculitis was described. Gastrointestinal involvement in dermatomyositis denotes severity, so an early intensive treatment is recommended. Pathological findings suggest that the underlying pathophysiological mechanism is a vasculopathy and not a true vasculitis.
Collapse
|
9
|
Deb A, Ghosh B, Cavazos A, Songtanin B, Leelaviwat N, Nugent K. Idiopathic spontaneous pneumoperitoneum. Proc AMIA Symp 2021; 35:224-226. [DOI: 10.1080/08998280.2021.2013148] [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
Affiliation(s)
- Anasua Deb
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Binita Ghosh
- Department of Hospital Medicine, University Medical Center, Lubbock, Texas
| | - Annia Cavazos
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Busara Songtanin
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Natnicha Leelaviwat
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Kenneth Nugent
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
| |
Collapse
|
10
|
Esteban MJ, Kassar D, Padilla O, McCallum R. Dysphagia as the Presenting Symptom for Inclusion Body Myositis. J Investig Med High Impact Case Rep 2021; 9:23247096211050211. [PMID: 34886694 PMCID: PMC8669868 DOI: 10.1177/23247096211050211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Dysphagia can be one of the manifestations of inflammatory myopathies (IMs). In some patients, it can be one of the presenting symptoms or the only symptom. We present a patient with dysphagia and progressive muscle weakness who was eventually diagnosed with inclusion body myositis (IBM). Treatment with oral steroid provided no major improvement in symptoms and thus was eventually stopped. Dysphagia in IMs is associated with complications and poor prognosis. A multidisciplinary approach is needed in its diagnosis and management as this report exemplifies.
Collapse
Affiliation(s)
- Marcus Juan Esteban
- Divison of Gastroenterology, Texas Tech University Health Sciences Center El Paso, USA
| | - Darine Kassar
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, USA
| | - Osvaldo Padilla
- Department of Pathology, Texas Tech University Health Sciences Center El Paso, USA
| | - Richard McCallum
- Divison of Gastroenterology, Texas Tech University Health Sciences Center El Paso, USA
| |
Collapse
|
11
|
Abstract
The gastrointestinal tract is the second largest organ system in the body and is often affected by connective tissue disorders. Scleroderma is the classic rheumatologic disease affecting the esophagus; more than 90% of patients with scleroderma have esophageal involvement. This article highlights esophageal manifestations of scleroderma, focusing on pathogenesis, clinical presentation, diagnostic considerations, and treatment options. In addition, this article briefly reviews the esophageal manifestations of other key connective tissue disorders, including mixed connective tissue disease, myositis, Sjogren syndrome, systemic lupus erythematosus, fibromyalgia, and Ehlers-Danlos syndrome.
Collapse
Affiliation(s)
- Nitin K Ahuja
- Division of Gastroenterology and Hepatology, University of Pennsylvania, 3400 Civic Center Boulevard 7 South Pavilion, Philadelphia, PA 19104, USA
| | - John O Clarke
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway Street, Pavilion C, 3rd Floor, C-343, Redwood City, CA 94063-6341, USA.
| |
Collapse
|
12
|
Elmdaah A, Ali A, Nadeem Z, Habieb M, Pradeep J, Metangi K. Atypical Presentation of Dysphagia in a Patient Diagnosed Later With Dermatomyositis: A Case Report. Cureus 2021; 13:e19964. [PMID: 34984124 PMCID: PMC8714034 DOI: 10.7759/cureus.19964] [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] [Accepted: 11/28/2021] [Indexed: 12/04/2022] Open
Abstract
Dysphagia has been reported in 10%-73% of patients with dermatomyositis. We present the case of a 58-year-old female patient who presented to the emergency department of Peterborough City Hospital with acute-onset difficulty in swallowing. Physical examination demonstrates proximal muscle weakness of the upper limbs and symmetrical skin rash over the face, chest, and thighs. Both clinical and laboratory findings pointed towards the diagnosis dermatomyositis. Oesophagogastroduodenoscopy identified no significant abnormality reducing the possibility of dysphagia due to an intrusive lesion, such as an abscess or a malignancy. MRI scan of the lower limbs revealed evidence of proximal myositis. CT neck, chest, abdomen and pelvis exclude any associated malignancy. The patient was treated initially with intravenous pulses of methylprednisolone for three days, and then switched to oral prednisolone and cyclophosphamide cycles and was considered for intravenous immunoglobulins as her symptoms had not completely resolved.
Collapse
|
13
|
Kondoh Y, Makino S, Ogura T, Suda T, Tomioka H, Amano H, Anraku M, Enomoto N, Fujii T, Fujisawa T, Gono T, Harigai M, Ichiyasu H, Inoue Y, Johkoh T, Kameda H, Kataoka K, Katsumata Y, Kawaguchi Y, Kawakami A, Kitamura H, Kitamura N, Koga T, Kurasawa K, Nakamura Y, Nakashima R, Nishioka Y, Nishiyama O, Okamoto M, Sakai F, Sakamoto S, Sato S, Shimizu T, Takayanagi N, Takei R, Takemura T, Takeuchi T, Toyoda Y, Yamada H, Yamakawa H, Yamano Y, Yamasaki Y, Kuwana M. 2020 guide for the diagnosis and treatment of interstitial lung disease associated with connective tissue disease. Respir Investig 2021; 59:709-740. [PMID: 34602377 DOI: 10.1016/j.resinv.2021.04.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 04/20/2021] [Accepted: 04/21/2021] [Indexed: 01/29/2023]
Abstract
The prognosis of patients with connective tissue disease (CTD) has improved significantly in recent years, but interstitial lung disease (ILD) associated with connective tissue disease (CTD-ILD) remains a refractory condition, which is a leading cause of mortality. Because it is an important prognostic factor, many observational and interventional studies have been conducted to date. However, CTD is a heterogeneous group of conditions, which makes the clinical course, treatment responses, and prognosis of CTD-ILD extremely diverse. To summarize the current understanding and unsolved questions, the Japanese Respiratory Society and the Japan College of Rheumatology collaborated to publish the world's first guide focusing on CTD-ILD, based on the evidence and expert consensus of pulmonologists and rheumatologists, along with radiologists, pathologists, and dermatologists. The task force members proposed a total of 27 items, including 7 for general topics, 9 for disease-specific topics, 3 for complications, 4 for pharmacologic treatments, and 4 for non-pharmacologic therapies, with teams of 2-4 authors and reviewers for each item to prepare a consensus statement based on a systematic literature review. Subsequently, public opinions were collected from members of both societies, and a critical review was conducted by external reviewers. Finally, the task force finalized the guide upon discussion and consensus generation. This guide is expected to contribute to the standardization of CTD-ILD medical care and is also useful as a tool for promoting future research by clarifying unresolved issues.
Collapse
Affiliation(s)
- Yasuhiro Kondoh
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan.
| | - Shigeki Makino
- Rheumatology Division, Osaka Medical College Mishima-Minami Hospital, Takatsuki, Osaka, Japan
| | - Takashi Ogura
- Division of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Kanagawa, Japan
| | - Takafumi Suda
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Hiromi Tomioka
- Department of Respiratory Medicine, Kobe City Medical Center West Hospital, Kobe, Hyogo, Japan
| | - Hirofumi Amano
- Department of Internal Medicine and Rheumatology, Juntendo University Graduate School of Medicine, Bunkyo, Tokyo, Japan
| | - Masaki Anraku
- Department of Thoracic Surgery, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, Itabashi, Tokyo, Japan
| | - Noriyuki Enomoto
- Health Administration Center, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Takao Fujii
- Department of Rheumatology and Clinical Immunology, Wakayama Medical University, Wakayama, Wakayama, Japan
| | - Tomoyuki Fujisawa
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Takahisa Gono
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Bunkyo, Tokyo, Japan
| | - Masayoshi Harigai
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Shinjuku, Tokyo, Japan
| | - Hidenori Ichiyasu
- Department of Respiratory Medicine, Faculty of Life Sciences, Kumamoto University, Kumamoto, Kumamoto, Japan
| | - Yoshikazu Inoue
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai, Osaka, Japan
| | - Takeshi Johkoh
- Department of Radiology, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Hideto Kameda
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Toho University, Meguro, Tokyo, Japan
| | - Kensuke Kataoka
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan
| | - Yasuhiro Katsumata
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Shinjuku, Tokyo, Japan
| | - Yasushi Kawaguchi
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Shinjuku, Tokyo, Japan
| | - Atsushi Kawakami
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Nagasaki, Japan
| | - Hideya Kitamura
- Division of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Kanagawa, Japan
| | - Noboru Kitamura
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Tomohiro Koga
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Nagasaki, Japan
| | - Kazuhiro Kurasawa
- Department of Rheumatology, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Yutaro Nakamura
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Ran Nakashima
- Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Sakyo, Kyoto, Japan
| | - Yasuhiko Nishioka
- Department of Respiratory Medicine and Rheumatology, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Tokushima, Japan
| | - Osamu Nishiyama
- Department of Respiratory Medicine and Allergology, Kindai University Faculty of Medicine, Osakasayama, Osaka, Japan
| | - Masaki Okamoto
- Department of Respirology, National Hospital Organization Kyushu Medical Center, Fukuoka, Fukuoka, Japan
| | - Fumikazu Sakai
- Department of Diagnostic Radiology, Saitama International Medical Center, Saitama Medical University, Hidaka, Saitama, Japan
| | - Susumu Sakamoto
- Department of Respiratory Medicine, Toho University Omori Medical Center, Tokyo, Japan
| | - Shinji Sato
- Division of Rheumatology, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Toshimasa Shimizu
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Nagasaki, Japan
| | - Noboru Takayanagi
- Department of Respiratory Medicine, Saitama Cardiovascular and Respiratory Center, Kumagaya, Saitama, Japan
| | - Reoto Takei
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan
| | - Tamiko Takemura
- Department of Pathology, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Kanagawa, Japan
| | - Tohru Takeuchi
- Department of Internal Medicine (IV), Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Yuko Toyoda
- Department of Respiratory Medicine, Japanese Red Cross Kochi Hospital, Kochi, Kochi, Japan
| | - Hidehiro Yamada
- Center for Rheumatic Diseases, Seirei Yokohama Hospital, Yokohama, Kanagawa, Japan
| | - Hideaki Yamakawa
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Saitama, Saitama, Japan
| | - Yasuhiko Yamano
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan
| | - Yoshioki Yamasaki
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Bunkyo, Tokyo, Japan
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Bunkyo, Tokyo, Japan
| |
Collapse
|
14
|
Kim JG, Park Y, Lee J, Ju JH, Kim WU, Park SH, Kwok SK. Re-evaluation of the prognostic significance of oropharyngeal dysphagia in idiopathic inflammatory myopathies. Scand J Rheumatol 2021; 51:402-410. [PMID: 34470549 DOI: 10.1080/03009742.2021.1941243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To investigate the prognostic significance of videofluorographic swallowing study (VFSS)-confirmed oropharyngeal dysphagia in idiopathic inflammatory myopathies (IIMs). METHOD We reviewed the medical records of patients who were diagnosed with IIM between 2009 and 2020 at Seoul St Mary's Hospital. All oropharyngeal dysphagia cases were limited to VFSS-confirmed dysphagia found during the initial diagnostic work-up for IIM. We described the findings on VFSS and the course of the dysphagic symptoms. Logistic regression and survival analyses were performed to evaluate the risk of pneumonia and mortality, respectively. RESULTS We found 88 patients with IIM who met the criteria. Among them, 17 patients (19%) had oropharyngeal dysphagia. Except for two cases lost to follow-up and one deceased case, all of the patients with dysphagia (14 of 14) had swallowing function restored within 6 months. The risk of pneumonia within 3 months from the diagnosis of IIM was significant [odds ratio = 4.49, 95% confidence interval (CI) 1.07-18.88]. The median follow-up duration was 34 and 27 months for the groups without and with dysphagia, respectively. The survival analysis failed to demonstrate that the presence of oropharyngeal dysphagia increased the risk of death (hazard ratio = 0.77, 95% CI: 0.085-7.00). CONCLUSIONS Oropharyngeal dysphagia found at the initial diagnosis of IIM improved within 3-6 months in nearly all cases. Furthermore, IIM patients who had oropharyngeal dysphagia at the initial diagnosis of IIM were not likely to have shorter survival, even if the risk of pneumonia was increased in the short term.
Collapse
Affiliation(s)
- J G Kim
- Division of Rheumatology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Y Park
- Division of Rheumatology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - J Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - J H Ju
- Division of Rheumatology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - W-U Kim
- Division of Rheumatology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - S-H Park
- Division of Rheumatology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - S-K Kwok
- Division of Rheumatology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| |
Collapse
|
15
|
Nyborg GA, Molberg Ø. Small intestinal biopsy findings consistent with celiac disease in patients with idiopathic inflammatory myopathy: Review of existing literature. Semin Arthritis Rheum 2021; 51:1033-1044. [PMID: 34416625 DOI: 10.1016/j.semarthrit.2021.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 07/03/2021] [Accepted: 07/21/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Case reports have described patients with idiopathic inflammatory myopathies (IIM) and a concurrent diagnosis of celiac disease (CeD) for whom the muscle inflammation (myositis) component of IIM improves after the patients start standard treatment with gluten-free diet (GFD). A connection between IIM and CeD is not commonly recognized. AIM In this first systematic review of the topic, we aimed to explore all peer-reviewed publications of IIM cases and concomitant small intestinal biopsy findings consistent with CeD, published after 1975. METHODS Systematic literature searches were performed in MEDLINE, PubMed, and EMBASE, supplemented by screening of references and non-systematic searches via Google and Google Scholar. RESULTS Altogether 30 cases published between 1976 and 2017 were uncovered. Information about gastrointestinal symptoms prior to CeD diagnosis was available for 19 patients, with 6/19 (32%) reporting no GI symptoms. CeD-related serological data were available in 23/30 patients. Endomysial antibodies were present in 10/18 (56%), while only 2/9 (22%) had antibodies against tissue transglutaminase. Serum antibodies to native gliadin were present in 16/18 (89%). Clinical effects of a GFD on the IIM were reported for 24 patients, with signs of improvement in 14/24 (58%), including three patients with otherwise therapy-resistant inclusion body myositis. Longitudinal follow-up data available from the published studies indicated that 7/24 (29%) remained in clinical IIM remission with GFD as the sole therapeutic intervention. CONCLUSION In the IIM cases presented here, duodenal biopsy findings consistent with celiac disease was sometimes present without classical CeD symptoms or positive traditional CeD serology, and in the majority of cases, the IIM improved after introduction of a gluten-free diet. While extra vigilance towards CeD in IIM patients seems warranted, there is need for more research to clarify if GFD has effects on organ systems other than the small intestine in patients with IIM and small intestinal biopsy findings consistent with CeD.
Collapse
Affiliation(s)
- Gunhild Alvik Nyborg
- Department of Rheumatology, Oslo University Hospital - Rikshospitalet, P.O. box 4950 Nydalen, 0424 Oslo, Norway.
| | - Øyvind Molberg
- Department of Rheumatology, Oslo University Hospital - Rikshospitalet, P.O. box 4950 Nydalen, 0424 Oslo, Norway; Department of Rheumatology and Infectious Diseases, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| |
Collapse
|
16
|
Giannini M, Fiorella ML, Tampoia M, Girolamo F, Fornaro M, Amati A, Lia A, Abbracciavento L, D'Abbicco D, Iannone F. Long-term efficacy of adding intravenous immunoglobulins as treatment of refractory dysphagia related to myositis: a retrospective analysis. Rheumatology (Oxford) 2021; 60:1234-1242. [PMID: 32911543 DOI: 10.1093/rheumatology/keaa443] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 06/24/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Dysphagia is a life-threating manifestation of idiopathic inflammatory myopathies (IIM). However, we lack a univocal protocol for its treatment. The aim of this retrospective analysis was to evaluate the effectiveness of a step-up strategy by adding a 1-day pulse of IVIGs to immunosuppressants in IIM patients with refractory dysphagia diagnosed by Eating Assessment Tool (EAT)-10 and fibreoptic endoscopic evaluation of swallowing (FEES). METHODS Dysphagia was defined as a pharyngo-oesophageal disturbance associated with EAT-10 score ≥3 and at least one FEES abnormality among propulsion failure, solid or liquid stasis. Eighteen out of 154 IIM patients had FEES-confirmed dysphagia and underwent 1 day IVIG 2 g/kg repeated 1 month apart for 3 months, because of dysphagia refractory to high-dose glucocorticoids with methotrexate and/or azathioprine. Clinical characteristics along with myositis-specific antibodies and muscle histopathological findings were studied in FEES-dysphagia IIM and IIM control patients. RESULTS After three monthly doses of IVIG, EAT-10 score dropped with complete recover of defective propulsion and progressive decrease in percentage of both solid and liquid stasis. At 52-weeks' follow-up, reached in 12 patients, all these parameters were stable or further improved. An improvement in manual muscle strength test and a steroid-sparing effect of IVIG were also observed. Anti-PM/Scl 75/100 antibodies were much more frequent in the FEES-dysphagia group, while anti-Jo1 antibody was rarely detected. CONCLUSION Our treatment schedule with 2 g/kg IVIG was effective for IIM-associated refractory dysphagia assessed by the combination of EAT-10 and FEES. These findings need to be prospectively tested in a larger cohort of IIM patients.
Collapse
Affiliation(s)
- Margherita Giannini
- Rheumatology Unit, University of Bari, D.E.T.O, Bari, Italy.,Service de Physiologie et d'Explorations fonctionnelles, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Maria Luisa Fiorella
- Departement of Basic Medical Sciences, Neuroscience and Sense Organs, Bari, Italy
| | | | - Francesco Girolamo
- Neurophysiopathology Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari, Bari, Italy
| | - Marco Fornaro
- Rheumatology Unit, University of Bari, D.E.T.O, Bari, Italy
| | - Angela Amati
- Neurophysiopathology Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari, Bari, Italy
| | - Anna Lia
- Neurophysiopathology Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari, Bari, Italy
| | | | - Dario D'Abbicco
- Institute of General Surgery "G Marinaccio", University of Bari, D.E.T.O, Bari, Italy
| | | |
Collapse
|
17
|
Abstract
The extrinsic and autonomic nervous system intricately controls the major functions of the gastrointestinal tract through the enteric nervous system; these include motor, secretory, sensory, storage, and excretory functions. Disorders of the nervous system affecting gastrointestinal tract function manifest primarily as abnormalities in motor (rather than secretory) functions. Common gastrointestinal symptoms in neurologic disorders include sialorrhea, dysphagia, gastroparesis, intestinal pseudo-obstruction, constipation, diarrhea, and fecal incontinence. Diseases of the entire neural axis ranging from the cerebral hemispheres to the peripheral autonomic nerves can result in gastrointestinal motility disorders. The most common neurologic diseases affecting gastrointestinal function are stroke, parkinsonism, multiple sclerosis, and diabetic neuropathy. Diagnosis involves identification of the neurologic disease and its distribution, and documentation of segmental gut dysfunction, typically using noninvasive imaging, transit measurements, or intraluminal measurements of pressure activity and coordination of motility. Apart from treatment of the underlying neurologic disease, management focuses on restoration of normal hydration and nutrition and pharmacologic treatment of the gut neuromuscular disorder.
Collapse
|
18
|
Huang BB, Han LC, Liu GF, Lv XD, Gu GL, Li SQ, Chen L, Wang HQ, Zhan LL, Lv XP. Infliximab is effective in the treatment of ulcerative colitis with dermatomyositis: A case report. World J Gastroenterol 2020; 26:7425-7435. [PMID: 33362394 PMCID: PMC7739156 DOI: 10.3748/wjg.v26.i46.7425] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 10/11/2020] [Accepted: 11/04/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Joint, skin, oral cavity, and eye lesions are the most common extraintestinal manifestations of ulcerative colitis that can occur before or after its onset. The cases of ulcerative colitis with dermatomyositis (DM) are rare. In this study, we report a rare case of ulcerative colitis with DM that was effectively treated with infliximab.
CASE SUMMARY The patient was a 57-year-old female with a 2-year history of DM. The patient was admitted to hospital with abdominal pain, diarrhea, and blood in stool lasting for more than 2 mo. Colonoscopy revealed multiple erosions and ulcers in the entire colon and rectum. Pathological sections showed chronic inflammatory cell infiltration, especially neutrophil infiltration, in the colonic mucosa; therefore, the patient was diagnosed with ulcerative colitis. Preparations of 5-aminosalicylic acid was added to her treatment based on the original treatment for DM, but its effect was unsatisfactory. The patient’s discomfort was relieved after infliximab treatment.
CONCLUSION Infliximab can improve DM in the treatment of ulcerative colitis. Specialists need to raise awareness about patients with inflammatory bowel disease who have rare extraintestinal manifestations.
Collapse
Affiliation(s)
- Bin-Bin Huang
- Department of Gastroenterology, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Li-Chun Han
- Department of Gastroenterology, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Geng-Feng Liu
- Department of Gastroenterology, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Xiao-Dan Lv
- Department of Clinical Laboratory, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Guang-Li Gu
- Department of Gastroenterology, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Shi-Quan Li
- Department of Gastroenterology, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Lan Chen
- Department of Gastroenterology, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Hui-Qin Wang
- Department of Gastroenterology, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Ling-Ling Zhan
- Department of Clinical Laboratory, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Xiao-Ping Lv
- Department of Gastroenterology, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| |
Collapse
|
19
|
Adams CL, Lohan S, Bruce A, Kamalaraj N, Gunaratne S, White R. Cricopharyngeal bar and dermatomyositis: A cause of rapidly progressive dysphagia. Int J Rheum Dis 2020; 24:125-131. [PMID: 33135370 DOI: 10.1111/1756-185x.14006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 10/02/2020] [Accepted: 10/04/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Idiopathic inflammatory myopathies (IIM) are immune-mediated conditions that affect striated muscle, and are frequently associated with dysphagia. Dysphagia in these cases can be due to weakness of the muscles involved in swallowing or the presence of restrictive pharyngeal defects, such as cricopharyngeal bars. Treatment of dysphagia in IIM revolves around immunosuppressive therapies, and procedures to disrupt cricopharyngeus muscle when immunosuppressive therapies are unsuccessful. CASE REPORT A 73-year-old female presented with rapidly progressive proximal muscle weakness and dysphagia to the point she could not swallow liquids or solids. She had a rash over the extensor surfaces of the limbs, and periorbital-edema. Her creatine kinase was elevated, and skin biopsy showed an interface inflammatory reaction; however, myositis line assay revealed no autoantibodies, and a muscle biopsy was unremarkable. She was diagnosed with dermatomyositis with life-threatening dysphagia, and was admitted to our institution and treated with corticosteroids, methotrexate and intravenous immunoglobulin. A videofluoroscopic swallowing study revealed a large esophageal protrusion at the level of C5-C6, which was thought to be consistent with a cricopharyngeal bar, with large boluses unable to pass, leading to aspiration. After 10 weeks of treatment, the cricopharyngeal bar remained present, but swallowing had improved to the point that she was successfully swallowing all consistencies. CONCLUSION Dysphagia associated with IIM can be multifactorial, and can be due to the involvement of the muscles of swallowing in the inflammatory process, or due to restrictive pharyngeal defects, and determination of the cause of dysphagia can assist with management.
Collapse
Affiliation(s)
- Cameron Louis Adams
- Department of Rheumatology, Campbelltown Hospital, Sydney, NSW, Australia.,St George Hospital, Sydney, NSW, Australia
| | - Siobhan Lohan
- Department of Speech Pathology, Campbelltown Hospital, Sydney, NSW, Australia
| | - Alana Bruce
- Department of Rheumatology, Campbelltown Hospital, Sydney, NSW, Australia.,Macquarie University, Sydney, NSW, Australia
| | - Narainraj Kamalaraj
- Department of Rheumatology, Campbelltown Hospital, Sydney, NSW, Australia.,School of Medicine, Western Sydney University, Sydney, NSW, Australia
| | - Shyamini Gunaratne
- Department of Rheumatology, Campbelltown Hospital, Sydney, NSW, Australia
| | - Ray White
- Private Rheumatology Practice, Campbelltown, NSW, Australia
| |
Collapse
|
20
|
Dysphagia in Myositis: A Study of the Structural and Physiologic Changes Resulting in Disordered Swallowing. Am J Phys Med Rehabil 2020; 99:404-408. [PMID: 31764229 DOI: 10.1097/phm.0000000000001354] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Dysphagia in patients with myositis is associated with an increased risk of aspiration pneumonia. However, the pathophysiology of dysphagia is poorly understood. The aim of this study was to understand how myositis affects swallowing physiology on videofluoroscopic swallow study. DESIGN This is a retrospective review of video fluoroscopic swallowing studies on 23 myositis patients with dysphagia from 2011 to 2016. Swallow studies were analyzed by timing of swallowing events and duration of swallowing events, diameter of upper esophageal sphincter opening, Modified Barium Swallow Impairment Profile, and Penetration-Aspiration Scale. The outcome measures for patients were compared with an archived videofluoroscopic swallow study from healthy, age-matched participants by Wilcoxon rank-sum tests. RESULTS Patients with myositis had a shorter duration of upper esophageal sphincter opening (P < 0.0001) and laryngeal vestibule closure (P < 0.0001) than healthy subjects. The diameter of upper esophageal sphincter opening did not differ between groups. Patients with myositis presented with higher scores on the MBSIMP than healthy subjects, indicating great impairment particularly during the pharyngeal phase of swallowing, and a higher frequency of penetration and aspiration. CONCLUSIONS Dysphagia in patients with myositis may be attributed to reduced endurance of swallowing musculature rather than mechanical obstruction of the upper esophageal sphincter.
Collapse
|
21
|
Wu JQ, Lu MP, Reed AM. Juvenile dermatomyositis: advances in clinical presentation, myositis-specific antibodies and treatment. World J Pediatr 2020; 16:31-43. [PMID: 31556011 DOI: 10.1007/s12519-019-00313-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 08/29/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Juvenile dermatomyositis (JDM) is a chronic autoimmune disease characteristic by inflammation of small vessels within the skin, muscle and vital organs. But the clinical features and treatment of JDM have not been fully clarified. DATA SOURCES Databases underwent through PubMed for articles about the clinical features, myositis-specific antibodies of JDM and its treatment, and we selected publications written in English which were relevant to the topic of this review. RESULTS Clinical features and myositis-specific antibodies may predict the severity and prognosis of disease. Although the mortality rate has been lower with traditional treatments, such as corticosteroid, intravenous immunoglobulin, and disease-modifying anti-rheumatic drugs such as methotrexate, their usages are variable. Novel biological therapies seem to be effective for refractory JDM patients, but more clinical trials are necessary. CONCLUSIONS JDM is a sever disease of childhood. We need to better understand recent advances of JDM in the context of clinical features including skin manifestations, muscle weakness and organ damage, myositis-specific antibodies and their associated outcomes and the treatment of disease.
Collapse
Affiliation(s)
- Jian-Qiang Wu
- Department of Rheumatology Immunology and Allergy, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, 310052, China
| | - Mei-Ping Lu
- Department of Rheumatology Immunology and Allergy, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, 310052, China
| | - Ann M Reed
- Department of Pediatrics, Division of Pediatric Rheumatology, Duke University School of Medicine, Durham, 27710, USA.
| |
Collapse
|
22
|
Juvenile dermatomyositis resembling late-stage Degos disease with gastrointestinal perforations successfully treated with combination of cyclophosphamide and rituximab: case-based review. Rheumatol Int 2020; 40:1883-1890. [PMID: 31900501 DOI: 10.1007/s00296-019-04495-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 12/10/2019] [Indexed: 12/13/2022]
Abstract
Dermatomyositis (DM) is a multi-system disease that results in chronic inflammation principally of the skin and striated muscle. Small blood vessel injury in the GI tract has been described in dermatomyositis, manifesting as bleeding, ulceration, pneumatosis intestinalis, and ultimately perforation. Recent histopathological studies have shown deposits in the capillaries of the skin, gastrointestinal tract, and brain of patients with dermatomyositis similar to that found in patients with Degos disease, suggesting these disease processes are closely related or represent varying degrees of severity on the same pathologic spectrum. We report a case of juvenile dermatomyositis (JDM) resembling late-stage Degos disease with gastrointestinal perforations successfully treated with combination rituximab and cyclophosphamide therapy. We systematically reviewed the literature detailing the medical and surgical treatments for gastrointestinal perforation in dermatomyositis, Degos-like dermatomyositis, and Degos disease. In addition to our case, as of October 2019, we identified 36 cases describing gastrointestinal perforation in patients with underlying dermatomyositis, 5 cases of Degos-like dermatomyositis and 17 cases of idiopathic Degos disease. Corticosteroid therapy was used widely for dermatomyositis and Degos-like dermatomyositis, while antiplatelet and anticoagulant medications were chiefly used for patients with idiopathic Degos disease. However, there were no cases that detailed the successful treatment of dermatomyositis or Degos disease with gastrointestinal perforation with rituximab alone or combined with cyclophosphamide. We report that rituximab, in combination with cyclophosphamide, can be used as a novel adjunctive therapy to successfully treat dermatomyositis with Degos-like gastrointestinal perforation.
Collapse
|
23
|
Yang SH, Chang C, Lian ZX. Polymyositis and dermatomyositis - challenges in diagnosis and management. J Transl Autoimmun 2019; 2:100018. [PMID: 32743506 PMCID: PMC7388349 DOI: 10.1016/j.jtauto.2019.100018] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 10/04/2019] [Indexed: 02/06/2023] Open
Abstract
Polymyositis (PM) and dermatomyositis (DM) are different disease subtypes of idiopathic inflammatory myopathies (IIMs). The main clinical features of PM and DM include progressive symmetric, predominantly proximal muscle weakness. Laboratory findings include elevated creatine kinase (CK), autoantibodies in serum, and inflammatory infiltrates in muscle biopsy. Dermatomyositis can also involve a characteristic skin rash. Both polymyositis and dermatomyositis can present with extramuscular involvement. The causative factor is agnogenic activation of immune system, leading to immunologic attacks on muscle fibers and endomysial capillaries. The treatment of choice is immunosuppression. PM and DM can be distinguished from other IIMs and myopathies by thorough history, physical examinations and laboratory evaluation and adherence to specific and up-to-date diagnosis criteria and classification standards. Treatment is based on correct diagnosis of these conditions. Challenges of diagnosis and management influences the clinical research and practice of Polymyositis and dermatomyositis. Diagnostic criteria have been updated and novel therapies have been developed in PM/DM. Pathogenesis investigation and diagnosis precision improvement may help to guide future treatment strategies.
Collapse
Key Words
- APC, antigen presenting cell
- AZA, Azathioprine
- CAM, cancer associated myositis
- CK, creatine kinase
- DM, dermatomyositis
- Dermatomyositis
- Diagnosis criteria
- EMG, electromyography
- HLA, human leukocyte antigen
- IIM, idiopathic inflammatory myopathies
- ILD, interstitial lung disease
- IV, intravenous
- Idiopathic inflammatory myopathy
- JDM, juvenile dermatomyositis
- MAA, myositis associated antibody
- MAC, membrane attack complex
- MHC, major histocompatibility complex
- MMF, mycophenolate mofetil
- MRI, magnetic resonance imaging
- MSA, myositis specific antibody
- MTX, methotrexate
- MUAP, motor unit action potential
- NAM, necrotizing autoimmune myopathy
- PM, polymyositis
- Polymyositis
- TNF, tumor necrosis factor
- Treatment
- Treg, regulatory T cell
- UVR, ultraviolet radiation
- sIBM, sporadic inclusion body myositis
Collapse
Affiliation(s)
- Shu-Han Yang
- Chronic Disease Laboratory, Institutes for Life Sciences and School of Medicine, South China University of Technology, Guangzhou, 510006, China
| | - Christopher Chang
- Division of Rheumatology, Allergy and Clinical Immunology, University of California, Davis, Davis, CA, USA.,Division of Pediatric Immunology and Allergy, Joe DiMaggio Children's Hospital, Hollywood, FL, USA
| | - Zhe-Xiong Lian
- Chronic Disease Laboratory, Institutes for Life Sciences and School of Medicine, South China University of Technology, Guangzhou, 510006, China
| |
Collapse
|
24
|
Abstract
Rheumatological diseases (RDs) represent a diverse group of diseases that are inherited or related to environmental factors. RDs frequently affect the gastrointestinal (GI) tract, and gastroenterologists are often asked to evaluate patients with symptoms thought to represent an underlying or coexisting RD. GI manifestations of RDs vary based on the organ involved as well as the extent and duration of involvement. Although most manifestations of RD are nonspecific and not life-threatening, the chronicity and severity of symptoms can be debilitating and may lead to serious injury. This narrative review discusses the most common RD encountered by gastroenterologists: systemic lupus erythematosus, systemic sclerosis (scleroderma), dermatomyositis/polymyositis, rheumatoid arthritis, Sjögren syndrome, overlap syndromes, mixed connective tissue disease, Ehlers-Danlos syndromes, and other vasculitides. Each section begins with a brief overview of the condition, followed by a discussion of the etiopathophysiology, physical examination findings, GI manifestations, diagnostic tools (i.e., serologic, imaging, endoscopic, and functional), and treatment options.
Collapse
|
25
|
Antovic A, Notarnicola A, Svensson J, Lundberg IE, Holmqvist M. Venous Thromboembolic Events in Idiopathic Inflammatory Myopathy: Occurrence and Relation to Disease Onset. Arthritis Care Res (Hoboken) 2019; 70:1849-1855. [PMID: 29579357 DOI: 10.1002/acr.23560] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 03/20/2018] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To assess the incidence of venous thromboembolic events (VTEs) in patients with idiopathic inflammatory myopathies (IIMs), to compare the incidence of VTEs in IIM to the incidence in the general population, and to identify patient categories at high risk and investigate the development of risk in relation to a diagnosis of IIM. METHODS Using nationwide registers, we identified a cohort of 440 individuals with newly diagnosed IIM and 4,459 individuals from the general population. Patients with IIM were diagnosed between 2005 and 2011. The start of follow-up was the date of IIM diagnosis and the corresponding date in the general population. VTE was defined as hospital care with an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision code indicating VTE, with a filled prescription for anticoagulant medication. Incidence rates including 95% confidence intervals (95% CIs) were calculated, and Cox proportional hazards models were used to compare the risk of VTE in patients with IIM to the risk in the general population. RESULTS The incidence of VTEs was higher in patients with IIM than in the general population and was highest in patients who previously had cancer, who were ages >71 years when diagnosed with IIM, or who had dermatomyositis. The overall hazard ratio (HR) of VTE comparing the IIM cohort to the general population was 7.81 (95% CI 4.74, 12.85). The HR was highest the first year after IIM diagnosis, with HR 26.6 (95% CI 10.4, 68.0). CONCLUSION Patients with IIM are at increased risk of VTE compared to the general population, especially during the first year after the diagnosis. Preventive measures should be focused on patients who previously have had cancer, who are ages >71 years when diagnosed, or who have dermatomyositis.
Collapse
Affiliation(s)
- Aleksandra Antovic
- Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | | | | | - Ingrid E Lundberg
- Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Marie Holmqvist
- Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
26
|
Labeit B, Muhle P, Suntrup-Krueger S, Ahring S, Ruck T, Dziewas R, Warnecke T. Dysphagia as Isolated Manifestation of Jo-1 Associated Myositis? Front Neurol 2019; 10:739. [PMID: 31338062 PMCID: PMC6629889 DOI: 10.3389/fneur.2019.00739] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 06/24/2019] [Indexed: 11/13/2022] Open
Abstract
Dysphagia can be predominant or sole symptom of myositis. However, diagnostic evaluation is difficult in such cases. Here, we present evidence for dysphagia as sole manifestation of Jo-1 associated myositis. A 77-year-old patient suffering from isolated dysphagia was assessed by flexible endoscopic evaluation of swallowing, videofluoroscopy, high resolution esophageal manometry, whole body muscle MRI, electroneurographic and electromyographic examination, cerebrospinal fluid analysis, screening for autoantibodies, and body plethysmography. We detected isolated oropharyngeal dysphagia including a decreased pressure of the upper esophageal sphincter leading to cachexia in an anti-Jo-1 positive patient without any abnormalities in the other diagnostics. Immunosuppressive therapy with cortisone and azathioprine led to long-term improvement of dysphagia. This is the first report of isolated dysphagia as manifestation of Jo-1 associated myositis. Therefore, Jo-1 associated myositis should be considered as a possible differential diagnosis for isolated dysphagia. Typical signs for myositis in instrumental dysphagia assessment are presented.
Collapse
Affiliation(s)
- Bendix Labeit
- Department of Neurology, University Hospital Muenster, Muenster, Germany
| | - Paul Muhle
- Department of Neurology, University Hospital Muenster, Muenster, Germany
| | | | - Sigrid Ahring
- Department of Neurology, University Hospital Muenster, Muenster, Germany
| | - Tobias Ruck
- Department of Neurology, University Hospital Muenster, Muenster, Germany
| | - Rainer Dziewas
- Department of Neurology, University Hospital Muenster, Muenster, Germany
| | - Tobias Warnecke
- Department of Neurology, University Hospital Muenster, Muenster, Germany
| |
Collapse
|
27
|
Barsotti S, Puccini G, Tripoli A, Cardelli C, Minichilli F, Volterrani D, Mosca M, Grosso M, Neri R. Assessment of swallowing function with oro-pharyngeal-esophageal scintigraphy in patients with idiopathic inflammatory myopathies. Neurogastroenterol Motil 2019; 31:e13599. [PMID: 31012534 DOI: 10.1111/nmo.13599] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 04/01/2019] [Accepted: 04/02/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Swallowing impairment is frequently present in patients with idiopathic inflammatory myopathies (IIMs), and it represents an important cause of morbidity, dramatically reducing the quality of life of patients. Moreover, dysphagia is associated to a worst prognosis. Unfortunately, no standardized instrumental techniques for the assessment of the upper gastrointestinal tract in IIM patients are available. In this study, we explored the characteristics of the alterations in the upper gastrointestinal tract using oro-pharyngeal-esophageal scintigraphy (OPES) in a cohort of IIM patients and we correlated the alterations with clinical parameters. METHODS A total of 51 IIM patients were examined with OPES, both with liquids and semisolids, and the data acquired were examined to compute the transit time and the percentage of retention at oral, pharyngeal, and esophageal level. Patient-reported outcome data (PRO) on dysphagia, disease activity, and clinical parameters were collected. KEY RESULTS Oro-pharyngeal-esophageal scintigraphy identified at least one alteration in all patients, particularly with the semisolid test and oral and pharyngeal levels presented a higher frequency of involvement compared to the esophageal tract (P < 0.05). A very good correlation between dysphagia severity assessed by PRO and many OPES results was identified. In patients with a shorter disease duration, there was a higher prevalence of alterations at the oral and pharyngeal level and they were correlated to higher swallowing difficulties and higher disease activity parameters. CONCLUSIONS & INFERENCES Our results showed that OPES may represent a novel reproducible tool to assess dysphagia in IIM patients, thus opening new possibilities to evaluate dysphagia in these patients.
Collapse
Affiliation(s)
- Simone Barsotti
- Rheumatology Unit, University of Pisa, Pisa, Italy.,Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Giulia Puccini
- Nuclear Medicine Unit, Pisa University Hospital, Pisa, Italy
| | | | | | | | | | - Marta Mosca
- Rheumatology Unit, University of Pisa, Pisa, Italy
| | - Mariano Grosso
- Nuclear Medicine Unit, Pisa University Hospital, Pisa, Italy
| | | |
Collapse
|
28
|
Li L, Wang H, Wang Q, Wu C, Liu C, Zhang Y, Cheng L, Zeng X, Zhang F, Li Y. Myositis-specific autoantibodies in dermatomyositis/polymyositis with interstitial lung disease. J Neurol Sci 2018; 397:123-128. [PMID: 30616054 DOI: 10.1016/j.jns.2018.12.040] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 12/04/2018] [Accepted: 12/31/2018] [Indexed: 11/28/2022]
Abstract
AIM The prevalence and diagnostic values of myositis-specific autoantibodies (MSAs) and myositis-associated autoantibodies (MAAs) in dermatomyositis/polymyositis (DM/PM) were studied. METHOD A commercial immunoblot assay with 16 autoantigens was used to detect MSAs and MAAs in serum samples from 130 DM/PM patients, 100 disease controls, and 50 healthy subjects. RESULTS The prevalence of anti-Jo-1, anti-MDA5, anti-TIF1γ, anti-Mi-2α, and anti-Mi-2β was significantly higher in DM/PM than in other connective-tissue diseases (CTDs). Moreover, anti-MDA5 and anti-Ro-52 were significantly higher in DM/PM with interstitial lung disease (ILD) than in DM/PM without ILD, while that of anti-TIF1γ and anti-NXP2 were significantly lower in DM/PM with ILD than in DM/PM without ILD. For distinguishing DM/PM from other CTDs, the sensitivity, specificity, and positive predictive value (PPV) for anti-MDA5 were 28.46, 99.00, and 97.37%, respectively, with a positive likelihood ratio (LR+) of 28.46; they were 46.15, 58.00, and 58.82%, respectively, for anti-Ro-52 with an LR+ of 1.10. For distinguishing DM/PM with ILD from DM/PM without ILD, the sensitivity, specificity, and PPV for anti-MDA5 were 45.57, 100.00, and 100.00%, respectively, and for anti-Ro-52 were 60.76, 73.91, and 80.00%, respectively. CONCLUSION MSAs and MAAs serve as biomarkers for differentiating DM/PM from other CTDs as well as distinguishing DM/PM with ILD from DM/PM without ILD.
Collapse
Affiliation(s)
- Liubing Li
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, PR China
| | - Han Wang
- Clinical Diagnostic Center, 302 Military Hospital of China, Beijing 100039, PR China
| | - Qian Wang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing 100730, PR China
| | - Chanyuan Wu
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing 100730, PR China
| | - Chenxi Liu
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, PR China
| | - Yanfang Zhang
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, PR China; Department of Medical Laboratory, The First Hospital of Jilin University, Changchun 130021, PR China
| | - Linlin Cheng
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, PR China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing 100730, PR China
| | - Fengchun Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing 100730, PR China
| | - Yongzhe Li
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, PR China.
| |
Collapse
|
29
|
|
30
|
Redondo-Benito A, Curran A, Villar-Gomez A, Trallero-Araguas E, Fernández-Codina A, Pinal-Fernandez I, Rodrigo-Pendás JÁ, Selva-O'Callaghan A. Opportunistic infections in patients with idiopathic inflammatory myopathies. Int J Rheum Dis 2018; 21:487-496. [PMID: 29314762 DOI: 10.1111/1756-185x.13255] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIM To describe the prevalence, clinical characteristics and risk factors of opportunistic infection (OI) in a cohort of patients with inflammatory myopathies, and compare mortality rates between those with and without OIs. METHODS In total, 204 patients from our myositis cohort were reviewed to identify patients who had experienced an OI during the period 1986-2014. The patients' clinical characteristics, treatments received, and outcomes were systematically recorded. Disease activity at the OI diagnosis and the cumulative doses of immunosuppressive drugs were analyzed, as well as the specific pathogens involved and affected organs. RESULTS The prevalence of OI in the total cohort was 6.4%: viruses, 44.4% (varicella-zoster virus, cytomegalovirus); bacteria, 22.2% (Salmonella sp., Mycobacterium tuberculosis, M. chelonae); fungi, 16.7% (Candida albicans, Pneumocystis jirovecii); and parasites, 16.7% (Toxoplasmosis gondii, Leishmania spp.). Lung and skin/soft tissues were the organs most commonly affected (27.8%). Overall, 55.6% of OIs developed during the first year after the myositis diagnosis and OI was significantly associated with administration of high-dose glucocorticoids (P = 0.0148). Fever at onset of myositis (P = 0.0317), biological therapy (P < 0.001) and sequential administration of four or more immunosuppressive agents during myositis evolution (P = 0.0032) were significantly associated with OI. All-cause mortality in the OI group was 3.69 deaths per 100 patients/year versus 3.40 in the remainder of the cohort (P = 0.996). CONCLUSIONS The prevalence of OI was 6.4% in our myositis cohort, higher than the rest of the inpatients of our hospital (1.7%; P < 0.01). High-dose glucocorticoids at disease onset and severe immunosuppression are the main factors implicated.
Collapse
Affiliation(s)
- Ada Redondo-Benito
- Internal Medicine Department, Autonomous University of Barcelona, Barcelona, Spain
| | - Adrian Curran
- Department of Infectious Diseases, Vall d'Hebron General Hospital, Barcelona, Spain
| | - Ana Villar-Gomez
- Department of Pneumology, Vall d'Hebron General Hospital, Barcelona, Spain
| | | | | | - Iago Pinal-Fernandez
- Internal Medicine Department, Autonomous University of Barcelona, Barcelona, Spain
| | - Jose Ángel Rodrigo-Pendás
- Department of Epidemiology and Preventive Medicine, Vall d'Hebron General Hospital, Barcelona, Spain
| | | |
Collapse
|
31
|
Chinniah KJ, Mody GM. Recovery from severe dysphagia in systemic sclerosis - myositis overlap: a case report. Afr Health Sci 2017; 17:593-596. [PMID: 29062359 DOI: 10.4314/ahs.v17i2.38] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Dysphagia is common in inflammatory myopathies and usually responds to corticosteroids. Severe dysphagia requiring feeding by percutaneous endoscopic gastrostomy is associated with significant morbidity and high mortality. CLINICAL CASE A 56-year old African Black woman initially presented with systemic sclerosis (SSC) - myositis overlap and interstitial lung disease. She responded to high dose corticosteroids and cyclophosphamide followed by azathioprine, with improvement in her lung function and regression of the skin changes. Six years later she had a myositis flare with severe dysphagia. Her myositis improved after high doses of corticosteroids, azathioprine and two doses of intravenous immunoglobulin (IVIG). As her dysphagia persisted, she was fed via a percutaneous endoscopic gastrostomy (PEG) tube and given a course of rituximab. Her dysphagia gradually resolved and the PEG tube was removed within two months. She received another dose of rituximab six months later and continued low dose prednisone and azathioprine. Her muscle power improved, weight returned to normal and she remained well 20 months after hospital discharge. CONCLUSION Our patient with SSC-myositis overlap and severe dysphagia requiring PEG feeding, improved with high dose corticosteroids, azathioprine, two courses of IVIG and rituximab, and remained in remission 20 months after hospital discharge.
Collapse
Affiliation(s)
- Keith J Chinniah
- Department of Rheumatology, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal and Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Girish M Mody
- Department of Rheumatology, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal and Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| |
Collapse
|
32
|
Casal-Dominguez M, Pinal-Fernandez I, Mego M, Accarino A, Jubany L, Azpiroz F, Selva-O'callaghan A. High-resolution manometry in patients with idiopathic inflammatory myopathy: Elevated prevalence of esophageal involvement and differences according to autoantibody status and clinical subset. Muscle Nerve 2017; 56:386-392. [PMID: 27935079 DOI: 10.1002/mus.25507] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 11/30/2016] [Accepted: 12/04/2016] [Indexed: 12/27/2022]
Abstract
INTRODUCTION In this study we assessed high-resolution manometry (HRM) findings in patients with dermatomyositis and polymyositis. METHODS From 2008 to 2015, we performed a cross-sectional study of myositis patients. A survey of esophageal symptoms and HRM data were analyzed and compared among different clinical and serologic groups. RESULTS Twenty-four (45%) of the 53 patients included in the study had manometric involvement that was not correlated with any esophageal symptom (P = 0.8). Failed waves (34% vs. 0%, P = 0.004) and decreased upper esophageal sphincter pressure (50 vs. 70 mm Hg, P = 0.03) were more common in polymyositis than in dermatomyositis patients. Jackhammer esophagus was more common in anti-TIF1-γ patients (30% vs. 9%, P = 0.04), and lower esophageal sphincter involvement (47% vs. 25%, P = 0.03) was more prevalent in patients with the antisynthetase syndrome. CONCLUSIONS Esophageal involvement is common in myositis patients, but it correlates poorly with esophageal symptoms. Specific clinical and serologic groups have different manometric features. Muscle Nerve 56: 386-392, 2017.
Collapse
Affiliation(s)
- Maria Casal-Dominguez
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Iago Pinal-Fernandez
- Autoimmune Systemic Diseases Unit, Department of Internal Medicine, Vall d'Hebron University Hospital, Passeig de la Vall d'Hebron, 119-129, 08035, Barcelona, Spain.,Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès, Barcelona, Spain
| | - Marianela Mego
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd). Digestive System Research Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Anna Accarino
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd). Digestive System Research Unit, Vall d'Hebron University Hospital, Barcelona, Spain.,Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès, Barcelona, Spain
| | - Lluis Jubany
- Autoimmune Systemic Diseases Unit, Department of Internal Medicine, Vall d'Hebron University Hospital, Passeig de la Vall d'Hebron, 119-129, 08035, Barcelona, Spain
| | - Fernando Azpiroz
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd). Digestive System Research Unit, Vall d'Hebron University Hospital, Barcelona, Spain.,Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès, Barcelona, Spain
| | - Albert Selva-O'callaghan
- Autoimmune Systemic Diseases Unit, Department of Internal Medicine, Vall d'Hebron University Hospital, Passeig de la Vall d'Hebron, 119-129, 08035, Barcelona, Spain.,Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès, Barcelona, Spain
| |
Collapse
|
33
|
Abstract
Idiopathic inflammatory myopathies (IIMs) are a heterogeneous group of myositis, characterised by chronic muscle weakness, cutaneous features, different extra-muscular manifestations and circulating autoantibodies. IIMs included classical polymyositis (PM), dermatomyositis (DM) and other different types of myositis with a wide range of muscle involvement. A complete autoantibody profile and a muscle biopsy are mandatory to correctly diagnose different clinical entities and to define their different prognosis. Bohan and Peter's criteria included five items to diagnose adult onset PM and DM. The sensitivity was 74-100 %, while the specificity is low, due to a poor ability to differentiate PM from neuromuscular diseases. Other criteria included a more accurate histological definition of PM, DM or amyopathic DM, obtaining a higher specificity. Autoantibodies' association, interstitial lung disease and clinical cardiac involvement represent the main items that could define the prognosis of these patients. On the other hand, inclusion body myositis is a different myopathy characterised by a peculiar muscle mass involvement, muscle atrophy and progressive loss of function, due to complete failure to all immunosuppressive drugs used. Treatment of IIMs is based on corticosteroids (CS), which show rapid clinical response and functional improvement. Different immunosuppressant drugs are given to obtain a better control of the disease during CS tapering dose. No controlled double blind trials demonstrated the superiority of one immunesuppressant on another. The occurrence of interstitial lung involvement requires the immediate introduction of immunosuppressants in addiction to CS. Severe dysphagia seems to improve with intravenous immunoglobulins (Ig). Physical therapy could be started after the acute phase of diseases and seems to have a beneficial role in muscle strength recovery.
Collapse
|
34
|
Mallet AL, Ropert A, Bouguen G, Siproudhis L, Boutroux D, Bretagne JF, Brochard C. Prevalence and characteristics of acid gastro-oesophageal reflux disease in Jackhammer oesophagus. Dig Liver Dis 2016; 48:1136-41. [PMID: 27453169 DOI: 10.1016/j.dld.2016.06.030] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 06/14/2016] [Accepted: 06/27/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND An association between acid gastro-oesophageal reflux disease (GERD) and Jackhammer oesophagus has been suggested. AIM To assess the prevalence and characteristics of acid-GERD in Jackhammer oesophagus and the efficacy of proton pump inhibitors. METHODS Data and outcomes of patients with Jackhammer oesophagus were assessed. Two groups were compared: (i) GERD, defined by endoscopic oesophagitis or by an increase in acid exposure time or by an acid-hypersensitive oesophagus and (ii) non-GERD defined by normal oesophageal acid exposure without acid-hypersensitive oesophagus. RESULTS Among the 1994 high-resolution manometries performed, 44 Jackhammer oesophagus (2.2%) were included (sex ratio M/F: 19/25; median age: 66 [61-75] years). Nineteen patients (43.2%) had GERD, 16 (36.4%) had no GERD and 9 patients (20.4%) were undetermined. Dysphagia was the predominant symptom (37/43 (86%)). After a median follow-up of 25.3 months [9.6-31.4], dysphagia was improved in 22/36 (61.1%) patients. Dysphagia improvement as well as other symptoms improvement was not associated with GERD status or proton-pump inhibitors use. CONCLUSION The prevalence of GERD is high among patients with Jackhammer oesophagus. The rates of symptom improvement in Jackhammer oesophagus were high regardless of the use of proton-pump inhibitors treatment or of the presence of GERD.
Collapse
Affiliation(s)
- Anne-Laure Mallet
- Gastroenterology Unit, CHRU Pontchaillou, University of Rennes 1, Rennes, France
| | - Alain Ropert
- Digestive Disease Unit, CHRU Pontchaillou, University of Rennes 1, Rennes, France
| | - Guillaume Bouguen
- Gastroenterology Unit, CHRU Pontchaillou, University of Rennes 1, Rennes, France; INSERM U991, University of Rennes 1, Rennes, France; CIC 1414, INPHY, University of de Rennes 1, Rennes, France
| | - Laurent Siproudhis
- Gastroenterology Unit, CHRU Pontchaillou, University of Rennes 1, Rennes, France; INSERM U991, University of Rennes 1, Rennes, France; CIC 1414, INPHY, University of de Rennes 1, Rennes, France
| | | | | | - Charlène Brochard
- Gastroenterology Unit, CHRU Pontchaillou, University of Rennes 1, Rennes, France; Digestive Disease Unit, CHRU Pontchaillou, University of Rennes 1, Rennes, France; INSERM U991, University of Rennes 1, Rennes, France; CIC 1414, INPHY, University of de Rennes 1, Rennes, France.
| |
Collapse
|
35
|
Muchtar E, Derudas D, Mauermann M, Liewluck T, Dispenzieri A, Kumar SK, Dingli D, Lacy MQ, Buadi FK, Hayman SR, Kapoor P, Leung N, Chakraborty R, Gonsalves W, Russell S, Lust JA, Lin Y, Go RS, Zeldenrust S, Kyle RA, Rajkumar SV, Gertz MA. Systemic Immunoglobulin Light Chain Amyloidosis-Associated Myopathy: Presentation, Diagnostic Pitfalls, and Outcome. Mayo Clin Proc 2016; 91:1354-1361. [PMID: 27712634 DOI: 10.1016/j.mayocp.2016.06.027] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 06/02/2016] [Accepted: 06/21/2016] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To characterize the natural history of immunoglobulin light chain amyloidosis-associated myopathy and to provide guidelines for recognition. PATIENTS AND METHODS Fifty-one patients with systemic immunoglobulin light chain amyloidosis and biopsy-confirmed muscle amyloid deposition diagnosed between January 1, 1995, and December 31, 2015, were included in this study. RESULTS Common presenting symptoms were muscle weakness in 49 patients (96%), dysphagia in 23 (45%), myalgia in 17 (33%), macroglossia in 17 (33%), jaw claudication in 13 (25%), and hoarseness in 9 (18%). The median time from the onset of symptoms to diagnosis was almost 2 years. Less than two-thirds of the patients with an outside muscle biopsy (16 of 27) had an established pathologic confirmation of amyloidosis due to failure to routinely incorporate Congo red staining. Moreover, 12 patients were incorrectly treated before diagnosis of amyloid myopathy. More than half of the patients had normal creatine kinase levels at diagnosis. Cardiac troponin T levels were elevated above the reference range in 5 of 12 patients who lacked evidence of cardiac involvement. Median overall survival was 32 months. Factors associated with inferior survival were involvement of more than 2 organs (median survival, 13 months), cardiac involvement (median survival, 15 months), and absence of stem cell transplant (median survival, 18 months). With the exclusion of patients treated with stem cell transplant, no improvement in survival was seen over the 1995-2004 and 2005-2015 decades. CONCLUSION Immunoglobulin light chain amyloidosis-associated myopathy is rare. Delay in diagnosis is common, and there is a high rate of pathologic and clinical misdiagnosis. Awareness of elevation of cardiac troponin T levels in the absence of cardiac disease may be a clue to diagnosis.
Collapse
Affiliation(s)
- Eli Muchtar
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - Daniele Derudas
- Department of Haematology, Businco Hospital, Cagliari, Italy
| | | | | | | | | | - David Dingli
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | | | | | | | - Nelson Leung
- Division of Hematology, Mayo Clinic, Rochester, MN; Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Rajshekhar Chakraborty
- Division of Hematology, Mayo Clinic, Rochester, MN; Hospitalist Services, Essentia Health-St. Joseph's Medical Center, Brainerd, MN
| | | | | | - John A Lust
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - Yi Lin
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - Ronald S Go
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | | | | | | |
Collapse
|
36
|
Oropharyngeal Dysphagia in Dermatomyositis: Associations with Clinical and Laboratory Features Including Autoantibodies. PLoS One 2016; 11:e0154746. [PMID: 27167831 PMCID: PMC4864367 DOI: 10.1371/journal.pone.0154746] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 04/18/2016] [Indexed: 11/19/2022] Open
Abstract
Objective Dysphagia develops with low frequency in patients with dermatomyositis. Our objective was to determine the clinical and laboratory features that can estimate the development of dysphagia in dermatomyositis. Methods This study included 92 Japanese patients with adult-onset dermatomyositis. The associations between dysphagia and clinical and laboratory features including disease-specific autoantibodies determined by immunoprecipitation assays were analyzed. Results Videofluoroscopy swallow study (VFSS) was performed for all patients with clinical dysphagia (n = 13, 14.1%) but not for patients without clinical dysphagia. Typical findings of dysphagia (pharyngeal pooling, n = 11 and/or nasal regurgitation, n = 4) was detected by VFSS in all patients with clinical dysphagia. Eleven patients with dysphagia (84.6%) had anti-transcription intermediary factor 1γ (TIF-1γ) antibody. By univariate analysis, the average age and the male to female ratio, internal malignancy, and anti-TIF-1γ antibody were significantly higher and the frequency of interstitial lung diseases and manual muscle testing (MMT) scores of sternomastoid and dertoid muscles were significantly lower in patients with dysphagia than in patients without dysphagia. Among patients with anti-TIF-1γ antibody, the mean age, the ratios of male to female and internal malignancy were significantly higher and mean MMT scores of sternomastoid muscle were significantly lower in patients with dysphagia compared with patients without dysphagia. By multivariable analysis, the risk of dysphagia was strongly associated with the existence of internal malignancy and ant-TIF-1γ antibody and was also associated with reduced scores of manual muscle test of sternomastoid muscle. Dysphagia was markedly improved after the treatment against myositis in all 13 patients. Conclusion These findings indicate that dysphagia can develop frequently in patients with internal malignancy, anti-TIF-1γ antibody, or severe muscle weakness of sternomastoid muscle.
Collapse
|
37
|
Characteristic dysphagia as a manifestation of dermatomyositis on oropharyngeal muscle imaging. J Clin Rheumatol 2016; 21:105-6. [PMID: 25710866 DOI: 10.1097/rhu.0000000000000225] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
38
|
Papiris SA, Manali ED, Kolilekas L, Kagouridis K, Maniati M, Filippatos G, Bouros D. Acute Respiratory Events in Connective Tissue Disorders. Respiration 2016; 91:181-201. [PMID: 26938462 DOI: 10.1159/000444535] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Subacute-acute, hyperacute, or even catastrophic and fulminant respiratory events occur in almost all classic connective tissue disorders (CTDs); they may share systemic life-threatening manifestations, may precipitously lead to respiratory failure requiring ventilatory support as well as a combination of specific therapeutic measures, and in most affected patients constitute the devastating end-of-life event. In CTDs, acute respiratory events may be related to any respiratory compartment including the airways, lung parenchyma, alveolar capillaries, lung vessels, pleura, and ventilatory muscles. Acute respiratory events may also precipitate disease-specific extrapulmonary organ involvement such as aspiration pneumonia and lead to digestive tract involvement and heart-related respiratory events. Finally, antirheumatic drug-related acute respiratory toxicity as well as lung infections related to the rheumatic disease and/or to immunosuppression complete the spectrum of acute respiratory events. Overall, in CTDs the lungs significantly contribute to morbidity and mortality, since they constitute a common site of disease involvement; a major site of infections related to the 'mater' disease; a major site of drug-related toxicity, and a common site of treatment-related infectious complications. The extreme spectrum of the abovementioned events, as well as the 'vicious' coexistence of most of the aforementioned manifestations, requires skills, specific diagnostic and therapeutic means, and most of all a multidisciplinary approach of adequately prepared and expert scientists. Avoiding lung disease might represent a major concern for future advancements in the treatment of autoimmune disorders.
Collapse
Affiliation(s)
- Spyros A Papiris
- 2nd Department of Pneumonology, x2018;Attikon' University Hospital, Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | | | | | | | | |
Collapse
|
39
|
Kibbi N, Bekui A, Buckley LM. Colonic vasculopathy and perforation in the initial presentation of adult dermatomyositis in a patient with improving muscle weakness. BMJ Case Rep 2016; 2016:bcr-2015-213460. [PMID: 26759443 DOI: 10.1136/bcr-2015-213460] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 63-year-old woman with diabetes presented with 8 weeks of proximal muscle weakness and change in bowel habits. Muscle biopsy confirmed myositis, and serological studies were consistent with dermatomyositis (DM), without evidence of overlapping connective tissue disease or malignancy. On day 12 of prednisone therapy and after receiving one dose of IVIG with improvement in muscle strength, the patient developed abdominal pain and was diagnosed with a gastrointestinal (GI) perforation and peritonitis requiring emergent colectomy. The pathology revealed diffuse mucosal ulceration, prominent lymphoplasmacytic infiltration, venous occlusion and arterial hyperplasia. Although GI manifestations due to GI vasculopathy are rare in adult DM and are often a delayed complication, in this patient, it was one of the initial manifestations of this condition. In addition to being a fatal complication, clinicians should be aware of these complications, as immunosuppression used to control the muscular and cutaneous inflammation may not control the GI vasculopathy.
Collapse
Affiliation(s)
- Nour Kibbi
- Department of Internal Medicine, Yale University, New Haven, Connecticut, USA
| | - Amenuve Bekui
- Department of Internal Medicine, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Lenore M Buckley
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| |
Collapse
|
40
|
Findlay AR, Goyal NA, Mozaffar T. An overview of polymyositis and dermatomyositis. Muscle Nerve 2015; 51:638-56. [PMID: 25641317 DOI: 10.1002/mus.24566] [Citation(s) in RCA: 137] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2015] [Indexed: 12/23/2022]
Abstract
Polymyositis and dermatomyositis are inflammatory myopathies that differ in their clinical features, histopathology, response to treatment, and prognosis. Although their clinical pictures differ, they both present with symmetrical, proximal muscle weakness. Treatment relies mainly upon empirical use of corticosteroids and immunosuppressive agents. A deeper understanding of the molecular pathways that drive pathogenesis, careful phenotyping, and accurate disease classification will aid clinical research and development of more efficacious treatments. In this review we address the current knowledge of the epidemiology, clinical characteristics, diagnostic evaluation, classification, pathogenesis, treatment, and prognosis of polymyositis and dermatomyositis.
Collapse
Affiliation(s)
- Andrew R Findlay
- Department of Neurology, University of California, Irvine UC Irvine, MDA ALS and Neuromuscular Center, 200 South Manchester Avenue, Suite 110, Orange, California, 92868, USA
| | | | | |
Collapse
|
41
|
Tauro A, Addicott D, Foale RD, Bowman C, Hahn C, Long S, Massey J, Haley AC, Knowler SP, Day MJ, Kennedy LJ, Rusbridge C. Clinical features of idiopathic inflammatory polymyopathy in the Hungarian Vizsla. BMC Vet Res 2015; 11:97. [PMID: 25896796 PMCID: PMC4414416 DOI: 10.1186/s12917-015-0408-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 04/02/2015] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND A retrospective study of the clinicopathological features of presumed and confirmed cases of idiopathic inflammatory polymyopathy in the Hungarian Vizsla dog and guidelines for breeding. RESULTS 369 medical records were reviewed (1992-2013) and 77 Hungarian Vizslas were identified with a case history consistent with idiopathic inflammatory polymyopathy. Inclusion criteria were: group 1 (confirmed diagnosis); histopathology and clinical findings compatible with an inflammatory polymyopathy and group 2 (probable diagnosis); clinical findings compatible with a polymyopathy including dysphagia, sialorrhea, temporal muscle atrophy, elevated serum creatine kinase (CK) activity, and sufficient clinical history to suggest that other neuromuscular disorders could be ruled out. Some group 2 dogs had muscle biopsy, which suggested muscle disease but did not reveal an inflammatory process. The mean age of onset was 2.4 years; male dogs were slightly overrepresented. Common presenting signs were dysphagia, sialorrhea, masticatory muscle atrophy, and regurgitation. Common muscle histopathological findings included degenerative and regenerative changes, with multifocal mononuclear cell infiltration with lymphoplasmacytic myositis of variable severity. A positive response to immunosuppressive treatment supported an immune-mediated aetiology. The mean age at death and survival time were 6.4 and 3.9 years, respectively. Recurrence of clinical signs and aspiration pneumonia were common reasons for euthanasia. CONCLUSIONS Diagnosis of Vizsla idiopathic inflammatory polymyopathy can be challenging due to lack of specific tests, however the presence of dysphagia, regurgitation and masticatory muscle atrophy in this breed with negative serological tests for masticatory muscle myositis and myasthenia gravis, along with muscle biopsies suggesting an inflammatory process, support the diagnosis. However, there is an urgent need for a more specific diagnostic test. The average of inbreeding coefficient (CoI) of 16.3% suggests an increased expression of a Dog Leukocyte Antigen Class II haplotype, leading to an increased disease risk. The prognosis remains guarded, as treatment can only manage the disease. Recurrence of clinical signs and perceived poor quality of life are the most common reasons for humane euthanasia.
Collapse
Affiliation(s)
- Anna Tauro
- Fitzpatrick Referrals, Halfway Lane, Eashing, Godalming, GU7 2QQ, Surrey, UK.
| | | | - Rob D Foale
- Dick White Referrals, Six Mile Bottom, Suffolk, UK.
| | - Chloe Bowman
- Adelaide Veterinary Specialist and Referral Centre (AVSARC), Norwood Adelaide, South Australia.
| | - Caroline Hahn
- Royal (Dick) School of Veterinary Studies, University of Edinburgh, Roslin, UK.
| | - Sam Long
- Adelaide Veterinary Specialist and Referral Centre (AVSARC), Norwood Adelaide, South Australia.
| | | | - Allison C Haley
- The University of Georgia, College of Veterinary Medicine, Athens, USA.
| | | | | | | | - Clare Rusbridge
- Fitzpatrick Referrals, Halfway Lane, Eashing, Godalming, GU7 2QQ, Surrey, UK. .,The University of Surrey, Guildford, Surrey, UK.
| |
Collapse
|
42
|
Bodoki L, Nagy-Vincze M, Griger Z, Betteridge Z, Szöllősi L, Dankó K. Four dermatomyositis-specific autoantibodies—anti-TIF1γ, anti-NXP2, anti-SAE and anti-MDA5—in adult and juvenile patients with idiopathic inflammatory myopathies in a Hungarian cohort. Autoimmun Rev 2014; 13:1211-9. [DOI: 10.1016/j.autrev.2014.08.011] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2014] [Accepted: 07/26/2014] [Indexed: 01/30/2023]
|
43
|
Villa R, Costa S, Focchi S, Corbellini C, Vigorelli M, Avesani EC. Successful open abdomen treatment for multiple ischemic duodenal perforated ulcers in dermatomyositis. World J Emerg Surg 2014; 9:48. [PMID: 26085838 PMCID: PMC4470353 DOI: 10.1186/1749-7922-9-48] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Accepted: 08/07/2014] [Indexed: 11/10/2022] Open
Abstract
Introduction Dermatomyositis is an autoimmune disease characterized by proximal myopathy, cutaneous Gottron papules and heliotrope rash; intestinal involvement associated to acute vasculitis is less common but could be a life-threatening condition. Methods A 21-year-old woman, affected by dermatomyositis, presented to our attention with a three-day story of severe abdominal pain, no bowel movement and biliary vomit. She was diagnosed with acute abdomen. A CT scan with bowel contrast demonstrated the presence of a leakage from the retroperitoneal aspect of duodenum. The surgical and clinical management in the light of literature review is presented. Results Our first approach consisted in primary repair of the duodenal perforation with omentopexy. Post-operative course was complicated by hemorrhage. A reintervention showed a new perforation associated with multiple ischemic intestinal areas. We performed a gastroenteric anastomosis with functional exclusion of the damaged duodenum and positioning of drainages to create a biliary fistula. A nutritional enteric tube and an open abdomen vacuum-assisted closure system to monitor the fistula creation and to prevent abdominal contamination and collections were positioned. To reduce the amount of biliary leakage, a percutaneous transhepatic biliary drainage was placed, with progressive fistula flow disappearance in four months. Conclusions In patients with dermatomyositis, when clinical findings and symptoms suggest abdominal vasculitis, it is very important to be aware of the risk of bowel and particularly duodenal perforations. Open abdomen treatment favors control of contamination by gastrointestinal contents, offers temporary abdominal closure, helps ICU care and delays definitive surgery.
Collapse
Affiliation(s)
- Roberta Villa
- Department of General and Emergency Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy ; Faculty of Medicine, Università degli Studi di Milano, Milano, Italy
| | - Stefano Costa
- Department of General and Emergency Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Sibilla Focchi
- Department of General and Emergency Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy ; Faculty of Medicine, Università degli Studi di Milano, Milano, Italy
| | - Carlo Corbellini
- Department of General and Emergency Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy ; Faculty of Medicine, Università degli Studi di Milano, Milano, Italy
| | - Massimo Vigorelli
- Department of General and Emergency Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ettore Contessini Avesani
- Department of General and Emergency Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy ; Faculty of Medicine, Università degli Studi di Milano, Milano, Italy
| |
Collapse
|
44
|
Bodoki L, Nagy-Vincze M, Griger Z, Péter A, Dankó K. [Anti-NXP2-positive dermatomyositis associated with ulcerative colitis and celiac disease]. Orv Hetil 2014; 155:1033-8. [PMID: 24954145 DOI: 10.1556/oh.2014.29940] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The authors discuss a rare case of a 25-year-old female patient having dermatomyositis associated with celiac disease and ulcerative colitis. The idiopathic inflammatory myopathies are systemic, chronic, immune-mediated diseases characterized by proximal, symmetrical muscle weakness. Many examples from the literature refer that celiac disease occurs more often in patients with myositis than in the general population, but its association with ulcerative colitis is a real rarity in the international literature.
Collapse
Affiliation(s)
- Levente Bodoki
- Debreceni Egyetem, Általános Orvostudományi Kar Belgyógyászati Intézet, Klinikai Immunológia Tanszék Debrecen Móricz Zsigmond krt. 22. 4032
| | - Melinda Nagy-Vincze
- Debreceni Egyetem, Általános Orvostudományi Kar Belgyógyászati Intézet, Klinikai Immunológia Tanszék Debrecen Móricz Zsigmond krt. 22. 4032
| | - Zoltán Griger
- Debreceni Egyetem, Általános Orvostudományi Kar Belgyógyászati Intézet, Klinikai Immunológia Tanszék Debrecen Móricz Zsigmond krt. 22. 4032
| | - Andrea Péter
- Debreceni Egyetem, Általános Orvostudományi Kar Kardiológiai Klinika Debrecen
| | - Katalin Dankó
- Debreceni Egyetem, Általános Orvostudományi Kar Belgyógyászati Intézet, Klinikai Immunológia Tanszék Debrecen Móricz Zsigmond krt. 22. 4032
| |
Collapse
|
45
|
Iwata A, Ikeda K, Hirose K, Takatori H, Takahashi K, Sanayama Y, Tanaka S, Suto A, Nakajima H. Pre-dinner administration increases the efficacy of proton pump inhibitors on refractory GERD symptoms in connective tissue disease patients. Mod Rheumatol 2014. [DOI: 10.3109/s10165-012-0662-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
46
|
Abstract
A 59-year-old man presented with a history of dysphagia and generalized myalgia and muscle weakness and a rash on the face, neck, and upper arms. Serum muscle enzymes, myoglobin, C-reactive protein, and erythrocyte sedimentation rate were elevated and antinuclear antibodies positive. Electromyographic conduction studies showed pathological changes on arm and leg muscles and magnetic resonance imaging of the oral and neck muscles. A diagnosis of dermatomyositis with severe esophageal involvement was established. Treatment with prednisolone was started and methotrexate added. Enteral feeding with a percutaneous endoscopic gastrostomy was started and a therapy with intravenous immunoglobulin (IVIG) initiated, which caused a rapid improvement of the patient's ability to swallow. This case demonstrates a patient with polymyositis/dermatomyositis who showed steroid-resistant life-threatening esophageal impairment. IVIG resulted in a dramatic improvement of symptoms.
Collapse
|
47
|
Conklin JL. Evaluation of Esophageal Motor Function With High-resolution Manometry. J Neurogastroenterol Motil 2013; 19:281-94. [PMID: 23875094 PMCID: PMC3714405 DOI: 10.5056/jnm.2013.19.3.281] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Revised: 05/09/2013] [Accepted: 05/20/2013] [Indexed: 01/20/2023] Open
Abstract
For several decades esophageal manometry has been the test of choice to evaluate disorders of esophageal motor function. The recent introduction of high-resolution manometry for the study of esophageal motor function simplified performance of esophageal manometry, and revealed previously unidentified patterns of normal and abnormal esophageal motor function. Presentation of pressure data as color contour plots or esophageal pressure topography led to the development of new tools for analyzing and classifying esophageal motor patterns. The current standard and still developing approach to do this is the Chicago classification. While this methodical approach is improving our diagnosis of esophageal motor disorders, it currently does not address all motor abnormalities. We will explore the Chicago classification and disorders that it does not address.
Collapse
Affiliation(s)
- Jeffrey L Conklin
- Division of Digestive Diseases, The David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| |
Collapse
|
48
|
Kim M, Choi SY, Lee SY, Kang KY. Spontaneous Esophageal Perforation and Hypopharyngeal Abscess in Adult Dermatomyositis: A Case Report. JOURNAL OF RHEUMATIC DISEASES 2013. [DOI: 10.4078/jrd.2013.20.6.381] [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)
- Min Kim
- Department of Internal Medicine, Chungbuk National University Hospital, Cheongju, Korea
| | - Song Yi Choi
- Department of Pathology, Chungbuk National University Hospital, Cheongju, Korea
| | - Seung Young Lee
- Department of Radiology, Chungbuk National University Hospital, Cheongju, Korea
| | - Kwi Young Kang
- Department of Internal Medicine, Incheon Saint Mary's Hospital, The Catholic University of Korea, Incheon, Korea
| |
Collapse
|
49
|
Tanaka TI, Geist SMRY. Dermatomyositis: a contemporary review for oral health care providers. Oral Surg Oral Med Oral Pathol Oral Radiol 2012; 114:e1-8. [DOI: 10.1016/j.oooo.2012.07.434] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Revised: 06/18/2012] [Accepted: 07/09/2012] [Indexed: 12/17/2022]
|
50
|
Marvi U, Chung L, Fiorentino DF. Clinical presentation and evaluation of dermatomyositis. Indian J Dermatol 2012; 57:375-81. [PMID: 23112358 PMCID: PMC3482801 DOI: 10.4103/0019-5154.100486] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Dermatomyositis (DM) is a chronic inflammatory disorder of the skin and muscles. Evidence supports that DM is an immune-mediated disease and 50–70% of patients have circulating myositis-specific auto-antibodies. Gene expression microarrays have demonstrated upregulation of interferon signaling in the muscle, blood, and skin of DM patients. Patients with classic DM typically present with symmetric, proximal muscle weakness, and skin lesions that demonstrate interface dermatitis on histopathology. Evaluation for muscle inflammation can include muscle enzymes, electromyogram, magnetic resonance imaging, and/or muscle biopsy. Classic skin manifestations of DM include the heliotrope rash, Gottron's papules, Gottron's sign, the V-sign, and shawl sign. Additional cutaneous lesions frequently observed in DM patients include periungual telangiectasias, cuticular overgrowth, “mechanic's hands”, palmar papules overlying joint creases, poikiloderma, and calcinosis. Clinically amyopathic DM is a term used to describe patients who have classic cutaneous manifestations for more than 6 months, but no muscle weakness or elevation in muscle enzymes. Interstitial lung disease can affect 35–40% of patients with inflammatory myopathies and is often associated with the presence of an antisynthetase antibody. Other clinical manifestations that can occur in patients with DM include dysphagia, dysphonia, myalgias, Raynaud phenomenon, fevers, weight loss, fatigue, and a nonerosive inflammatory polyarthritis. Patients with DM have a three to eight times increased risk for developing an associated malignancy compared with the general population, and therefore all patients with DM should be evaluated at the time of diagnosis for the presence of an associated malignancy. This review summarizes the immunopathogenesis, clinical manifestations, and evaluation of patients with DM.
Collapse
Affiliation(s)
- Umaima Marvi
- Division of Immunology and Rheumatology, Stanford University, USA
| | | | | |
Collapse
|