Generalized acute subcutaneous edema as a rare cutaneous manifestation of severe dermatomyositis

Anasarca and spontaneous intramuscular haemmorhage in a dermatomyositis patient: case report and review of the literature

Dermatomyositis is a rare, autoimmune systemic disorder of unknown aetiology that presents as a constellation of clinical symptoms and signs primarily affecting skin and muscles. Patients with dermatomyositis can present with rare "non-canonical" manifestations. Focal or generalised oedema is an infrequent and often overlooked symptom of the disease, while spontaneous intramuscular haemorrhage is an even rarer and under-recognised, life-threatening complication that constitutes a medical emergency for clinical physicians. There are no known predisposing factors able to predict which patients will develop this complication and specific instructions considering treatment approach are currently lacking. Herein, we present a case of a patient with dermatomyositis complicated by both anasarca and spontaneous intramuscular haemorrhage. In order to raise awareness and timely diagnosis of such patients, we provide a review of the relevant literature and of the cases reported this far.

The Impact of Dysphagia in Myositis: A Systematic Review and Meta-Analysis

(1) Background: Dysphagia is a clinical hallmark and part of the current American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) diagnostic criteria for idiopathic inflammatory myopathy (IIM). However, the data on dysphagia in IIM are heterogenous and partly conflicting. The aim of this study was to conduct a systematic review on epidemiology, pathophysiology, outcome and therapy and a meta-analysis on the prevalence of dysphagia in IIM. (2) Methods: Medline was systematically searched for all relevant articles. A random effect model was chosen to estimate the pooled prevalence of dysphagia in the overall cohort of patients with IIM and in different subgroups. (3) Results: 234 studies were included in the review and 116 (10,382 subjects) in the meta-analysis. Dysphagia can occur as initial or sole symptom. The overall pooled prevalence estimate in IIM was 36% and with 56% particularly high in inclusion body myositis. The prevalence estimate was significantly higher in patients with cancer-associated myositis and with NXP2 autoantibodies. Dysphagia is caused by inflammatory involvement of the swallowing muscles, which can lead to reduced pharyngeal contractility, cricopharyngeal dysfunction, reduced laryngeal elevation and hypomotility of the esophagus. Swallowing disorders not only impair the quality of life but can lead to serious complications such as aspiration pneumonia, thus increasing mortality. Beneficial treatment approaches reported include immunomodulatory therapy, the treatment of associated malignant diseases or interventional procedures targeting the cricopharyngeal muscle such as myotomy, dilatation or botulinum toxin injections. (4) Conclusion: Dysphagia should be included as a therapeutic target, especially in the outlined high-risk groups.

Edematous myositis: a clinical presentation first suggesting dermatomyositis diagnosis

AIMS

Edema of the limbs is uncommon in idiopathic inflammatory myopathies (IIM). The few reported cases have been associated with severe and refractory dermatomyositis (DM), sometimes in association with cancers. We aimed to determine if edematous myositis is a homogeneous subtype based on clinical, serological and pathological features.

METHODS

This is a retrospective observational study performed between 2008 and 2015 in the French national referral center for myositis. All adult patients with an inflammatory muscle biopsy and upper limbs edema were included as well as IIM cases without limb edema as controls. Clinical, biological and pathological features were collected.

RESULTS

Seventeen edematous myositis were included and compared to 174 IIM without edema, including 50 DM controls. Edema was the first manifestation in 23% of patients. Muscle weakness was severe and symmetric, 71% of patients presented dysphagia and a restrictive ventilatory pattern was found in 40%. Fifty-two percent of patients had a typical DM skin rash and 23% had cancer within 3 years of diagnosing myositis. Fifty-three percent of patients presented a myositis specific antibody and only DM-specific antibodies were detected. Classic pathological DM features (perifascicular atrophy, perifascicular/perimysial perivascular inflammation) were uncommon but capillary C5b-9 deposition and MxA expression were seen in 79% and 73% of cases, respectively. A perimysial edema was found in 82% of cases. Seventeen percent of patients died (median follow up of 18 months). Edematous myositis demonstrated more marked capillary C5b-9 deposition compared to IIM controls. There was no clinical, biological or pathological difference with DM controls except for limb edema.

CONCLUSION

Our study underlines that limb edema could be a symptom of IIM and that edematous myositis are mostly DM. The vasculopathy seems to play a key role in its pathophysiology. Limb edema associated with muscle impairment should suggest the diagnosis of DM in clinical settings.

Subcutaneous oedema of upper limbs heralding an aggressive form of dermatomyositis

Subcutaneous oedema is a rare presenting clinical manifestation of dermatomyositis. In this case, we report a 44-year-old man presenting with bilateral upper extremity predominant swelling and weakness. The proximal muscle weakness, dysphagia and presence of Gottron's papules as well poikiloderma like skin changes led to the clinical diagnosis of dermatomyositis. He received aggressive treatment with high-dose glucocorticoids and required intravenous immunoglobulin with improvement in his symptoms.

Hepatocellular Carcinoma-Associated Polymyositis Presenting With Unilateral Upper Limb Subcutaneous Edema

Localized subcutaneous edema is a rare manifestation of inflammatory myopathy. In general, the incidence of malignancy in dermatomyositis is higher than that in polymyositis (PM). The association between malignancy and dermatomyositis has been established; however, it is less convincing in PM. In this article, we report on a case of malignancy-associated PM with an initial presentation of localized subcutaneous edema. A 66-year-old male patient with a history of chronic hepatitis B was presented to us with both left arm swelling and progressive proximal muscle weakness. A multi-detector row computed tomography showed prominent left arm edema, while a venography demonstrated no venous thrombosis or stenosis. A diagnosis of PM was established according to its typical symptoms, high serum creatine kinase level, positive electromyography findings, and systemic inflammatory signs. Magnetic resonance imaging of the liver revealed infiltrative hepatocellular carcinoma. After undergoing systemic corticosteroid therapy, in combination with hydroxychloroquine, the left arm edema was resolved. However, patient died from hepatocellular carcinoma three months after the date of diagnosis. It is important to recognize that hepatocellular carcinoma-associated PM may initially present itself with localized non-pitting edema. Although such localized edema may be responsive to corticosteroids, a patient's overall prognosis remains poor. We presume that PM with localized subcutaneous edema may be a predictor of malignancy, and therefore recommend a tumor survey.

Cutaneous and Systemic Findings Associated With Nuclear Matrix Protein 2 Antibodies in Adult Dermatomyositis Patients

OBJECTIVE

To characterize the cutaneous and systemic clinical phenotype of dermatomyositis patients with antinuclear matrix protein 2 (anti-NXP-2) antibodies.

METHODS

We conducted a retrospective cohort analysis of 178 dermatomyositis patients seen at the Stanford University Clinic. An electronic chart review employing a keyword search strategy was performed to collect clinical and laboratory data. Anti-NXP-2 antibodies were assayed by immunoprecipitation using NXP-2 produced by in vitro transcription/translation.

RESULTS

Antibodies to NXP-2 were detected in 20 of the 178 patients (11%). Anti-NXP-2 antibodies were associated with male sex (50% versus 25%; P = 0.02), dysphagia (74% versus 39%; P = 0.006), myalgia (89% versus 52%; P = 0.002), peripheral edema (35% versus 11%; P = 0.016), and calcinosis (37% versus 11%; P = 0.007). These patients were less likely to be clinically amyopathic (5% versus 23%; P = 0.08). Five of the 20 patients with anti-NXP-2 antibodies (25%) had an associated internal malignancy. No other cutaneous characteristics were associated with anti-NXP-2 antibodies, except a decreased frequency of Gottron's sign (44% versus 75%; P = 0.012) and a greater likelihood of having mild skin disease.

CONCLUSION

Dermatomyositis patients with anti-NXP-2 antibodies have a distinct and often severe systemic phenotype that includes myalgia, peripheral edema, and significant dysphagia, despite having milder inflammatory skin disease.