A first case report of a patient with paraneoplastic dermatomyositis developing diffuse alveolar haemorrhage

The presentation, etiologies, pathophysiology, and treatment of pulmonary renal syndrome: A review of the literature

Pulmonary renal syndrome (PRS) is a constellation of different disorders that cause both rapidly progressive glomerulonephritis and diffuse alveolar hemorrhage. While antineutrophil cytoplasmic antibody associated vasculitis and anti-glomerular basement membrane disease are the predominant causes of PRS, numerous other mechanisms have been shown to cause this syndrome, including thrombotic microangiopathies, drug exposures, and infections, among others. This syndrome has high morbidity and mortality, and early diagnosis and treatment is imperative to improve outcomes. Treatment generally involves glucocorticoids and immunosuppressive agents, but treatment targeted to the underlying disorder can improve outcomes and mitigate side effects. Familiarity with the wide range of possible causes of PRS can aid the clinician in workup, diagnosis and early initiation of treatment. This review provides a summary of the clinical presentation, etiologies, pathophysiology, and treatment of PRS.

Polymyositis Presenting as Rhabdomyolysis After the Initiation of Omeprazole

Rhabdomyolysis is a clinical syndrome with a wide range of presentations; it results in muscle necrosis and release of intracellular muscle contents into the circulation. Inflammatory myopathies are a rare cause of rhabdomyolysis. We present a case of a 46-year-old male with a two-week history of progressively worsening diffuse muscle pain after he had been prescribed omeprazole one month prior. A creatine phosphokinase (CPK) elevation was noted, which persisted despite treatment with IV fluids, sodium bicarbonate, and close correction of electrolytes. Further workup, including autoimmune and infectious etiologies, was notable for elevated antinuclear antibodies (ANA), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP). Furthermore, a muscle biopsy showed evidence of endomysial inflammatory cells, consistent with a diagnosis of polymyositis. Steroids were initiated with significant improvement in symptoms and a decrease in CPK levels. The patient was discharged on a tapering dose of steroids and, on follow-up with the rheumatologist, transitioned to methotrexate with control of symptoms. In patients with rhabdomyolysis who do not respond to first-line therapy, obtaining a detailed medication history and screening with ANA and ESR are encouraged. Given the link between medication and autoimmune disease, clinicians should consider autoimmune myopathy in the differential for cases with persistently elevated creatine kinase. Prompt diagnosis with early initiation of immunosuppressive medication may improve outcomes and avoid complications associated with untreated rhabdomyolysis or polymyositis.

Diffuse Alveolar Hemorrhage in a Patient with Antisynthetase Syndrome

An alveolar hemorrhage case is reported as the initial manifestation of antisynthetase syndrome in a 40-year-old man, who is admitted to the Emergency Department for diagnostic approach of chronic cough and progressive dyspnea. The diagnosis of the alveolar hemorrhage was based on the presence of acute respiratory failure, decrease in hemoglobin levels, and observation of macrophages filled with hemosiderin. The antisynthetase syndrome was classified through a tomographic image compatible with a nonspecific interstitial pneumonia, along with antibodies associated to myositis (PL-12 and Ro-52). The study protocol was completed with the result of a myopathic pattern showed in electromyography. This patient presented a good response to steroids and disease-modifying antirheumatic drug (DMARD).

[Case of dermatomyositis with anti-CADM-140 antibody and alveolar hemorrhage]

A-47-year-old woman was admitted to our hospital because of eruption, severe arthritis, myalgia, pharyngalgia and the elevation of serum creatine kinase. She was diagnosed with dermatomyositis based on a biopsied specimen and clinical symptoms. Serum anti CADM-140 antibody was detected by immunoprecipitation. Pulse therapy with methylprednisolone and cyclophophamide could transiently improve myalgia and so on, but she died of rapidly progressive interstitial lung disease. Autopsy findings demonstrated diffuse alveolar damage and alveolar hemorrhage. It is said that patients with anti CADM-140 antibody show poor muscle symptoms and alveolar hemorrhage has been described very rarely. This patient is the rare case of dermatomyositis with anti CADM-140 antibody developing severe muscle symptoms, pharyngalgia and aleveolar hemorrhage in autopsy findings.