Acute polymyositis after donor lymphocyte infusion

Chronic graft-versus-host disease presenting as acute polymyositis: A case series and systematic review

Chronic graft-versus-host disease (cGvHD) remains a significant complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT). Commonly targeted organs are skin, eyes, mouth, gastrointestinal tract, and liver. Muscular involvement and presentation as acute polymyositis (APM) remain a rare manifestation of cGvHD. We present a case series of three patients who presented with APM as a sole presentation of cGvHD and were treated successfully with corticosteroids and ruxolitinib. We also conducted a systematic review including 72 patients to summarize current literature regarding APM associated with cGvHD after allo-HSCT. The estimated incidence of cGvHD-associated APM is up to 3.4%, with a median time to onset of 1.6 years post-allo-HSCT. Most cases (85%) presented with myalgia and progressive bilateral proximal muscle weakness with elevated creatine kinase and/or aldolase. Over half of the patients had a prior history of acute GvHD. Isolated APM presenting without other clinical manifestations of cGvHD was rare. Biopsy of affected muscles usually shows characteristic myonecrosis, which remains the gold standard for diagnosis. Most cases respond to systemic steroids and immunosuppressive therapy. However, refractory cases remain challenging to treat and can cause significant morbidity and mortality. Ruxolitinib appears to be an effective therapy in this setting.

Polymyositis in a child with thalassemia after hematopoietic stem cell transplantation: A case report

RATIONALE

Polymyositis (PM) is a rare neuromuscular phenotype of chronic graft-versus-host disease (cGVHD). Although glucocorticoids have been shown to be effective in the treatment of PM, most people experience poor treatment response and poor prognosis.

PATIENT CONCERNS

A six-year-old boy with thalassemia received allogeneic hematopoietic stem cell transplantation (HSCT) and consequently developed sudden myasthenia of limbs 17 months after the transplant.

DIAGNOSES

Medical history, current symptoms, laboratory examinations, and imaging findings of the patient indicated cGVHD complicated with PM.

INTERVENTIONS

He was then given high-dose corticosteroid therapy, including tacrolimus, ruxolitinib, and rituximab.

OUTCOMES

Twenty-three months after transplantation, creatine kinase levels returned to normal range, and the MRI showed that the original muscle edema signal was significantly improved. The patient's muscle weakness continued to improve, and his overall condition was good.

LESSONS

This report suggests that glucocorticoids combined with immunosuppressants may be effective against polymyositis. Rituximab and ruxolitinib may be a good choice in treating polymyositis.

Neuromuscular complications after hematopoietic stem cell transplantation

PURPOSE

The aim of this study was to analyze the occurrence of neuromuscular symptoms in recipients of allogeneic hematopoietic stem cell transplantation (HSCT) for treatment of malignant hematopoietic disease.

METHODS

Among 247 outpatients after allogeneic HSCT, we conducted a prospective non-interventional study between July 2011 and August 2013. During follow-up visits, clinical and electrophysiological findings were correlated to the presence of autoantibodies/alloantibodies and to frequencies of lymphocyte subpopulations in peripheral blood.

RESULTS

Resulting in an incidence of 8.1 %, 20 patients were diagnosed with neuromuscular complications at a median onset of 12 months post-transplant. Five patients (25 %) were identified with polyneuropathy (PNP), ten patients (50 %) with combined PNP and myopathy, four patients (20 %) with myopathy or polymyositis (PM), and one patient (5 %) with myasthenia gravis (MG). Immune-mediated sensorimotor PNP after HSCT is characterized by a predominantly axonal lesion and can be overlapping with neurotoxic side effects. The latency between HSCT and development of PM varied between 60 days and 72 months. In general, PM occurs parallel to graft-versus-host disease (GvHD) after tapering of immunosuppressive medication. Typical clinical features are proximal bilateral limb weakness with muscle atrophy. Autoantibodies (Ab) were detected in 12 patients, myositis-specific Ab only in one patient. In patients with progressive neurological symptoms, a decrease in the CD4/CD8 T cell ratio was observed.

CONCLUSIONS

GvHD-related myositis appeared similar to idiopathic myositis regarding clinical and electromyographical findings. As outcome measure, sequential analysis of lymphocyte subpopulations in peripheral blood seems to be more suitable than Ab measurements. Whereas peripheral neuropathies are commonly observed shortly after HSCT, MG is a rare complication in the late post-HSCT phase.

Polymyositis after donor lymphocyte infusion

Chronic graft-versus-host disease (GVHD) is a common long-term complication of allogeneic hematopoietic stem-cell transplantation (HSCT), and is responsible for morbidity, mortality and a decrease in quality of life of patients after SCT. Polymyositis, which usually co-occurs with other manifestations of GVHD, has previously been reported. However, polymyositis as the sole manifestation of chronic GVHD following donor lymphocyte infusion (DLI) is rare. We report a 30-year-old man with Hodgkin's lymphoma who developed acute polymyositis following treatment by DLI 4 months post-allogeneic HSCT. The patient developed fever and generalized myalgia 22 days after a single dose of DLI. Laboratory testing showed elevated muscle enzymes and myopathic abnormalities on electromyographic examination. Muscle biopsy showed features of acute polymyositis, with widespread foci of muscle fiber necrosis associated with infiltration of small mononuclear cells. Twenty-four hours after diagnosis, the patient developed a fatal ventricular arrhythmia. Cardiac involvement may occur in association with polymyositis, but usually occurs in elderly patients after several months of illness. The present case highlights the importance of systematic cardiac evaluation when a diagnosis of polymyositis is initially made to exclude this infrequent presentation of chronic GVHD characteristically associated with some HLA-DR haplotypes.

Neuromuscular complications

Although direct neoplastic involvement of muscle tis-sue is surprisingly rare, considering the large amount of body mass that is represented by muscle tissue, the most important and unresolved muscle effect is muscle cachexia.Other associations, such as inflammatory, paraneo-plastic, toxic, and several extremely rare associations,have been described. Drug-induced toxicity and radiation recall syndrome need to be taken into consideration when muscle symptoms appear in patients with cancer.

The spectrum of lung involvement in collagen vascular-like diseases following allogeneic hematopoietic stem cell transplantation: report of 6 cases and review of the literature

Multisystem autoimmune diseases occurring after allogeneic hematopoietic stem cell transplantation are infrequent, late-onset manifestations that resemble well-defined collagen vascular disorders. Because the lung is frequently involved in the course of connective tissue disorders, we focused on lung manifestations occurring in autoimmune diseases following allogeneic stem cell transplantation. In the present series, we report 6 patients with systemic lupus erythematous, mixed connective tissue disease, Sjögren syndrome, polymyositis, and ANCA-positive vasculitis who presented with a spectrum of pulmonary manifestations affecting the airways, lung parenchyma, and probably respiratory muscles. We identified 3 different histopathologic patterns of interstitial pneumonia consistent with the underlying autoimmune disorder: lymphocytic interstitial pneumonia and non-specific interstitial pneumonia in 2 patients with Sjögren syndrome and diffuse alveolar damage in 1 patient with ANCA-positive vasculitis. These lung manifestations had poor prognoses. Further studies are needed to determine the optimal therapy for these complications.

Neurological manifestations of chronic graft-versus-host disease after allogeneic haematopoietic stem cell transplantation: report from the Consensus Conference on Clinical Practice in chronic graft-versus-host disease

A major obstacle of allogeneic haematopoietic stem cell transplantation is graft-versus-host disease, an immune-mediated disorder that affects multiple tissues and organs with varying severity. Neurological complications of acute and chronic graft-versus-host disease are rare but can produce severe clinical problems with significant morbidity and mortality. In this article, we review neurological manifestations of chronic graft-versus-host disease that comprise immune-mediated neuropathies, myasthenia gravis and myositis in the peripheral nervous system and various cerebrovascular complications, demyelination and immune-mediated encephalitis in the central nervous system. The National Institutes of Health consensus on criteria for clinical trials in chronic graft-versus-host disease recommended that the diagnosis of chronic graft-versus-host disease of the nervous system can be made only when other organs are affected by graft-versus-host disease and frequent neurological differential diagnoses such as drug-induced toxicities or opportunistic infections are excluded. The Consensus Conference on Clinical Practice in chronic graft-versus-host disease, held in autumn 2009 in Regensburg, aimed to summarize the literature and to provide guidelines for the diagnostic approach in children and adults with neurological manifestations of chronic graft-versus-host disease. Moreover, we present therapeutic recommendations and their level of evidence for the management of these complications. Overlapping symptoms and comorbidities after allogeneic haematopoietic stem cell transplantation and the limited knowledge about the underlying biological mechanisms of chronic graft-versus-host disease affecting the nervous system emphasize the need for further experimental and clinical investigations.

Graft-versus-host disease-related polymyositis

Chronic graft-versus-host disease (GVHD) sometimes mimics autoimmune diseases. We report the case of a 39-year-old patient who presented atypical polymyositis without elevated creatinine phosphokinase, related to a chronic GVHD following interruption of immunosuppressive treatment. Treatment with cyclosporine and corticosteroids resulted in complete and sustained remission of the polymyositis. The symptoms of chronic GVHD-related polymyositis are indistinguishable from those of idiopathic polymyositis. The context of transplantation and a decrease or interruption of prophylaxis suggest the diagnosis of GVHD-related polymyositis, especially if other manifestations of GVHD are associated. A suitably adapted treatment (association of corticotherapy and cyclosporine) improves polymyositis, and in most cases, a normal clinical state is achieved even if the symptoms were severe.

Polymyositis complicating donor lymphocyte infusion after stem cell transplantation for relapsed chronic myeloid leukemia: report of a case and review of literature

Polymyositis may occur along with other manifestations of chronic graft vs host disease after allogeneic bone marrow transplantation (BMT). Donor lymphocyte infusion (DLI) could produce durable remissions in relapsed patients with chronic myelogenous leukemia (CML) but it may contribute to the development of polymyositis. We report in this study a 25-year-old man who suffered from a relapse of CML 4 years after a sibling human leukocyte antigen-matched allogenic BMT. The patient developed polymyositis 18 months after DLI. Mini-pulse therapy with methylprednisolone was effective for his proximal weakness and elevated creatine phosphokinase. There was no relapse of symptoms of polymyositis on tapering of the medication.