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Azzam M, Awad A, Abugharbyeh A, Kahaleh B. Myocarditis in connective tissue diseases: an often-overlooked clinical manifestation. Rheumatol Int 2023; 43:1983-1992. [PMID: 37587233 DOI: 10.1007/s00296-023-05428-w] [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: 06/13/2023] [Accepted: 08/08/2023] [Indexed: 08/18/2023]
Abstract
To discuss what is currently known about myocarditis in the context of major connective tissue diseases, including Systemic lupus erythematosus, Rheumatoid Arthritis, Sjogren, Dermato-myositis and Polymyositis, Systemic Sclerosis, and Mixed connective tissue disease. Variability exists between studies regarding the incidence of myocarditis in connective tissue diseases, which is hypothesized to be the result of its subclinical course in most cases. Extensive gaps of knowledge exist in the field of pathophysiology. Although endomyocardial biopsy remains to be the gold standard for diagnosis, the advancement in non-invasive modalities such as cardiac MRI, echocardiography, and nuclear medicine has allowed for earlier and more frequent detection of myocarditis. A lack of treatment guidelines was found across the different connective tissue diseases. Most of the literature available revolved around myocarditis in the context of Systemic lupus erythematosus. Numerous recent studies were published that contributed to advancements in diagnosis and treatment however, there remains a lack of diagnostic and treatment guidelines.
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Affiliation(s)
- Muayad Azzam
- Faculty of Medicine, The University of Jordan, Amman, 11942, Jordan.
| | - Amro Awad
- Faculty of Medicine, The University of Jordan, Amman, 11942, Jordan
| | - Aya Abugharbyeh
- Division of Rheumatology and Immunology, University of Toledo Medical Center, Toledo, USA
| | - Bashar Kahaleh
- Division of Rheumatology and Immunology, University of Toledo Medical Center, Toledo, USA
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Ohad M, Shemer A, Lavie I, Ozeri D, Shoenfeld Y, Kivity S. Intravenous Immunoglobulin for Inflammatory Myositis: Experience in a Tertiary Medical Center. J Clin Rheumatol 2021; 27:e616-e621. [PMID: 32501943 DOI: 10.1097/rhu.0000000000001418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Inflammatory myopathies are treated with glucocorticoids and other immunosuppressive medications. Intravenous immunoglobulin (IVIG) is increasingly used for refractory or severe cases; however, the evidence for their effectiveness is limited. We assessed effectiveness and safety of IVIG when used with other immunomodulatory agents in the treatment of inflammatory myopathies. METHODS This study reviewed records of patients diagnosed with dermatomyositis or polymyositis and treated with IVIG, from 2009 through 2016 in 1 tertiary medical center. Mixed-effects general linear regression models were applied to determine effectiveness of treatment on muscle strength, creatinine phosphokinase levels, and steroid dosage. RESULTS Twenty-three patients with dermatomyositis/polymyositis treated with IVIG were followed up for a mean of 31 (SD, ±25) months. During this period, a significant improvement in muscle strength was demonstrated, with a mean increase of 0.92 Medical Research Council scale points (β = 0.14; confidence interval [CI], 0.136-0.149; p < 0.0001), a significant reduction of creatinine phosphokinase levels and steroid dosage with a mean decrease of 1140 IU/L (β = -0.274; CI, -0.354 to -0.195; p < 0.0001), and 36 mg/d (β = -0.008; CI, -0.011 to -0.006; p < 0.0001), respectively. Overall, remission was observed in 10 patients (43.5%), and partial remission in 6 patients (26%), whereas 1 patient (17%) remained refractory to treatment, and 6 patients (27%) were lost to follow-up. CONCLUSIONS The majority of patients with inflammatory myopathies experienced a clinical and laboratory improvement during IVIG treatment. In addition, a steroid-sparing effect was noticed in most patients. These results encourage the use of IVIG as an alternative treatment option for patients with limited responsiveness to conventional methods.
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Affiliation(s)
- Maayan Ohad
- From the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
| | | | - Inbar Lavie
- From the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
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Hoff LS, de Souza FHC, Miossi R, Shinjo SK. Long-term effects of early pulse methylprednisolone and intravenous immunoglobulin in patients with dermatomyositis and polymyositis. Rheumatology (Oxford) 2021; 61:1579-1588. [PMID: 34302454 DOI: 10.1093/rheumatology/keab597] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 06/21/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To evaluate the long-term effects of pulse intravenous methylprednisolone (IVMP) or intravenous immunoglobulin (IVIG) administered during the first year of diagnosis in dermatomyositis (DM) and polymyositis (PM) patients. METHODS This is a retrospective single-center cohort study of patients with DM/PM followed for up to 4 years from 2001 to 2017. We used Cox regression models to estimate hazard ratios (HRs) and assess the effects of early pulse IVMP or IVIG on 3 outcomes: complete clinical response, corticosteroid discontinuation, and survival. Analysis was adjusted for clinical, laboratory, and treatment covariates. RESULTS A total of 204 patients were included and categorized into 4 initial treatment groups: pulse IVMP (n = 46), pulse IVMP+IVIG (n = 55), IVIG (n = 10), and without IVMP or IVIG (n = 93). The groups of early pulse IVMP and pulse IVMP+IVIG had a higher HR for complete clinical response in the multivariate models (HR = 1.56, 95% CI = 1.05-2.33, p = 0.029; and HR = 1.58, 95% CI = 1.02-2.45, p = 0.041, respectively). Only the group of pulse IVMP+IVIG had a significant association with corticosteroid discontinuation in the multivariate analysis (HR = 1.65, 95% CI = 1.02-2.68, p = 0.043). Early pulse IVMP or IVIG had no impact on mortality. CONCLUSION Despite having a more severe disease profile, patients with DM/PM submitted to pulse IVMP or pulse IVMP+IVIG during the first year of diagnosis had a higher HR for complete clinical response, whereas the combination of pulse IVMP+IVIG had an association with corticosteroid discontinuation. Prospective long-term studies are warranted to confirm these benefits of early pulse IVMP and IVIG on patients with DM/PM.
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Affiliation(s)
- Leonardo S Hoff
- Division of Rheumatology, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil (BR).,School of Medicine, Universidade Potiguar (UnP), Natal, Brazil (BR)
| | | | - Renata Miossi
- Division of Rheumatology, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil (BR)
| | - Samuel K Shinjo
- Division of Rheumatology, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil (BR)
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Barsotti S, Cavazzana I, Zanframundo G, Neri R, Taraborelli M, Cioffi E, Cardelli C, Tripoli A, Codullo V, Tincani A, Cavagna L, Franceschini F, Mosca M. Real life picture of the use of intravenous immunoglobulins in idiopathic inflammatory myopathies: Results of a multicentric study. Autoimmun Rev 2021; 20:102757. [PMID: 33476815 DOI: 10.1016/j.autrev.2021.102757] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 11/30/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND despite the absence of specific guidelines, the treatment with intravenous immunoglobulins (IvIg) is considered effective in patients with refractory idiopathic inflammatory myopathies (IIM). The aim of our study is to evaluate the effectiveness and the safety of IvIg and define the possible profile of IIM patients candidate to IvIg treatment. METHODS we performed a retrospective study of IIM pts. treated with IvIg (2 g/kg/month). We collected demographic, epidemiological, laboratory and clinical data. Additionally, to evaluate the toxicity, the adverse events occurred during the treatment were collected. RESULTS 123 patients with IIM were included in the study. The main indications for the prescription of IvIg were muscle (83.7% of patients) and esophageal involvement (45.5% of patients). IvIg were started mainly for refractory disease. At the end of treatment (mean duration 14 months), muscular necrosis enzymes decreased significantly and dysphagia VAS decreased significantly (p < 0.001), while MMT value increased (104.6 ± 24.2 vs. 127.0 ± 22.2 p < 0.001). Ninety-six pts. (78%) responded to IvIg. They had a shorter disease duration (p < 0.001), higher creatine kinase levels (p < 0.001), and higher prevalence of myalgias at the baseline (p = 0.023) compared to non-responders. The presence of Raynaud's phenomenon (p = 0.023-odds ratio 0.28 [0.11-0.72]) and skin involvement (p = 0.004, odds ratio 0.18 [0.06-0.55]), were associated to a worse response. Adverse events were mostly mild and transitory. CONCLUSIONS Despite their high cost, IvIg confirmed their effectiveness in refractory IIM pts., particularly in muscular and esophageal manifestations. Specific clinical characteristics at the baseline may identify the patients with higher probability of response to the treatment.
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Affiliation(s)
| | - Ilaria Cavazzana
- Rheumatology and Clinical Immunology Unit, University of Brescia, ASST SpedaliCivili Brescia, Italy
| | - Giovanni Zanframundo
- Division of Rheumatology, University and IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
| | | | - Mara Taraborelli
- Internal Medicine Unit, ASST Franciacorta, Chiari Hospital, Brescia, Italy
| | - Elisa Cioffi
- Rheumatology Unit, Pisa University Hospital, Italy
| | | | | | - Veronica Codullo
- Division of Rheumatology, University and IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, University of Brescia, ASST SpedaliCivili Brescia, Italy
| | - Lorenzo Cavagna
- Division of Rheumatology, University and IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
| | - Franco Franceschini
- Rheumatology and Clinical Immunology Unit, University of Brescia, ASST SpedaliCivili Brescia, Italy
| | - Marta Mosca
- Rheumatology Unit, Pisa University Hospital, Italy
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Kwan C, Milosevic S, Benham H, Scott IA. A rare form of dermatomyositis associated with muscle weakness and normal creatine kinase level. BMJ Case Rep 2020; 13:13/2/e232260. [PMID: 32033996 PMCID: PMC7021146 DOI: 10.1136/bcr-2019-232260] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
We present a case study of a 61-year-old Vietnamese woman who presents with features of dermatomyositis (DM), including Gottron’s papules, heliotrope rash, cutaneous ulcers, generalised weakness and pain, and weight loss with normal levels of creatine kinase (CK). She demonstrated features of interstitial lung disease and subsequently tested positive for anti-melanoma differentiation-associated gene 5 and anti-small ubiquitin-like modifier 1 activating enzyme antibodies, which belong to a DM subtype known as clinically amyopathic dermatomyositis and do not present with raised CK. She received standard treatment for DM, including oral prednisolone, hydroxychloroquine, mycopheonlate and topical betamethasone. The treatment successfully reversed skin changes; however, the patient remained generally weak and unable to carry out her activities of daily living.
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Affiliation(s)
- Christopher Kwan
- Department of General Medicine, Princess Alexandra Hospital Health Service District, Brisbane, Queensland, Australia
| | - Suzana Milosevic
- Department of General Medicine, Princess Alexandra Hospital Health Service District, Brisbane, Queensland, Australia
| | - Helen Benham
- Department of Rheumatology, Princess Alexandra Hospital Health Service District, Brisbane, Queensland, Australia
| | - Ian A Scott
- Department of General Medicine, Princess Alexandra Hospital Health Service District, Brisbane, Queensland, Australia
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Chérin P, Pindi Sala T, Clerson P, Dokhan A, Fardini Y, Duracinsky M, Crave JC, Chassany O. Recovering autonomy is a key advantage of home-based immunoglobulin therapy in patients with myositis: A qualitative research study. Medicine (Baltimore) 2020; 99:e19012. [PMID: 32049796 PMCID: PMC7035045 DOI: 10.1097/md.0000000000019012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Immunoglobulins are 2nd or 3rd-line treatments in dermatomyositis (DM) or polymyositis (PM) refractory to high-dose corticosteroids and immunosuppressants. Immunoglobulins (2 g/kg/mo) are usually administered intravenously (IVIg) once a month and the patients stay at hospital for a few days. Recently, subcutaneous injections (SCIg) were proposed 2 to 3 times per week, in some dysimmune diseases. SCIg are administered at home preferably by the patient or by a nurse. We investigated the needs and attitudes of DM and PM patients with experience of IVIg and SCIg.Seven patients (6 PM and 1 DM) from a single center participated in a focus group (N = 6) or underwent in-depth interview (N = 1). Six had the experience of both IVIg at hospital and SCIg at home; 1 has received only IVIg at hospital. Verbatim was recorded and transcribed for further content analysis and computer-aided textual analysis.Clinical profiles and stories were heterogeneous. At diagnosis, muscle weakness, severe pain, and fatigue were at the forefront of patients' complaints impairing daily life. Patients reported considerable improvement with immunoglobulins. SCIg were described as easy, less disruptive for daily life, well tolerated, and less time-consuming. SCIg self-administration at home restored the feeling of autonomy and control.Interviews of DM and PM patients revealed that recovering autonomy and control was a central advantage of home-based SCIg that were efficient, well tolerated, and perceived as a good compromise between treatment burden and efficacy.
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Affiliation(s)
- Patrick Chérin
- Department of Internal Medicine and Clinical Immunology, La Pitié Salpétrière Hospital
| | | | | | | | | | | | | | - Olivier Chassany
- University Paris-Diderot, Patient-Centered Outcomes Research, Paris
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Abstract
Intravenous immunoglobulin (IVIg) is used in the treatment of autoimmune diseases, including immune-mediated central and peripheral nervous system disorders. This article will review the indications, proposed mechanism of actions, and administration of immunoglobulin treatment in various neuropathies, neuromuscular junction disorders, and myopathies. IVIg may have more than one mechanism of action to alter the pathogenesis of underlying neuromuscular disease. IVIg treatment has been used as a first-line treatment in Guillain-Barre syndrome, chronic inflammatory demyelinating polyradiculoneuropathy, multifocal motor neuropathy, and second-line off-label treatment in medically refractory cases of polymyositis, dermatomyositis, and myasthenia gravis. IVIg is a well-tolerated and effective treatment for these neuromuscular diseases. With this review article, we hope to increase clinicians' awareness of the indications and efficiencies of IVIg in a broad spectrum of neuromuscular diseases.
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Affiliation(s)
- Ahmet Z Burakgazi
- Department of Internal Medicine, Neuroscience Section, Virginia Tech Carilion School of Medicine, Carilion Clinic Neurology, Roanoke, VA
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Abstract
PURPOSE OF REVIEW The purpose of this review was to give an update on treatment modalities for patients with idiopathic inflammatory myopathies, or shortly myositis, excluding the subgroup inclusion body myositis, based on a literature survey on therapies used in myositis. Few controlled trials have been performed in patients with myositis; therefore, we also included a summary of open-label trials, case series, and case reports. RECENT FINDINGS Glucocorticoid (GC) in high doses is still the first-line treatment of patients with myositis. There is a general recommendation to combine GCs with another immunosuppressive agent in the early phase of disease to better control disease activity and possibly to reduce the risk for GC-related side effects. Furthermore, combining pharmacological treatment with individualized and supervised exercise can be recommended based on evidence. There is some evidence for the effect of rituximab in patients with certain myositis-specific autoantibodies, whereas other biologic agents are currently being tested in clinical trials. SUMMARY Immunosuppressive treatment in combination with exercise is recommended for patients with myositis to reduce disease activity and improve muscle performance. Subgrouping of patients into clinical and serological subtypes may be a way to identify biomarkers for response to specific immunosuppressive and biological agents and should be considered in future trials.
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Affiliation(s)
- Simone Barsotti
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
- Department of Medical Biotechnology, University of Siena, Siena, Italy
| | - Ingrid E. Lundberg
- Division of Rheumatology, Department of Medicine, Karolinska Institutet and Karolinska University Hospital, Solna, SE-171 76 Stockholm, Sweden
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Abstract
INTRODUCTION The idiopathic inflammatory myopathies (IIM) dermatomyositis (DM) and polymyositis (PM) are chronic diseases affecting the striated muscles with variable involvement of other organs. Glucocorticoids are considered the cornerstone of treatment, but some patients require adjunctive immunosuppressive agents because of insufficient response to glucocorticoids, flares upon glucocorticoid tapering, or glucocorticoid-related adverse events. Areas covered: The aim of this article was to review (PubMed search until February 2018) the evidence on established and new therapies derived from randomized controlled trials (RCTs) on adult DM and PM. In addition, key data from open-label trials, case reports, and abstracts were included where data from RCT were lacking. Expert commentary: Numerous synthetic and biological immunosuppressive agents are currently available to treat the IIM, sometimes in combination. The choice of the specific medication in the individual patient depends upon the disease phenotype and patient's characteristics. Exercise improves muscle performance without causing disease flares and should be an integral part of the treatment of the IIM. Prompt diagnosis and treatment can lead to better outcome.
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Affiliation(s)
- Nicolò Pipitone
- a SC di Reumatologia, Dipartimento Medicina Interna e Specialità Mediche, Azienda Unità Sanitaria Locale di Reggio Emilia - Istituto di Ricerca e Cura a Carattere Scientifico , Reggio , Emilia-Romagna , Italy
| | - Carlo Salvarani
- a SC di Reumatologia, Dipartimento Medicina Interna e Specialità Mediche, Azienda Unità Sanitaria Locale di Reggio Emilia - Istituto di Ricerca e Cura a Carattere Scientifico , Reggio , Emilia-Romagna , Italy.,b Rheumatology Department , University of Modena and Reggio Emilia , Italy
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IFN-β-induced reactive oxygen species and mitochondrial damage contribute to muscle impairment and inflammation maintenance in dermatomyositis. Acta Neuropathol 2017. [PMID: 28623559 DOI: 10.1007/s00401-017-1731-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Dermatomyositis (DM) is an autoimmune disease associated with enhanced type I interferon (IFN) signalling in skeletal muscle, but the mechanisms underlying muscle dysfunction and inflammation perpetuation remain unknown. Transcriptomic analysis of early untreated DM muscles revealed that the main cluster of down-regulated genes was mitochondria-related. Histochemical, electron microscopy, and in situ oxygraphy analysis showed mitochondrial abnormalities, including increased reactive oxygen species (ROS) production and decreased respiration, which was correlated with low exercise capacities and a type I IFN signature. Moreover, IFN-β induced ROS production in human myotubes was found to contribute to mitochondrial malfunctions. Importantly, the ROS scavenger N-acetyl cysteine (NAC) prevented mitochondrial dysfunctions, type I IFN-stimulated transcript levels, inflammatory cell infiltrate, and muscle weakness in an experimental autoimmune myositis mouse model. Thus, these data highlight a central role of mitochondria and ROS in DM. Mitochondrial dysfunctions, mediated by IFN-β induced-ROS, contribute to poor exercise capacity. In addition, mitochondrial dysfunctions increase ROS production that drive type I IFN-inducible gene expression and muscle inflammation, and may thus self-sustain the disease. Given that current DM treatments only induce partial recovery and expose to serious adverse events (including muscular toxicity), protecting mitochondria from dysfunctions may open new therapeutic avenues for DM.
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Anh-Tu Hoa S, Hudson M. Critical review of the role of intravenous immunoglobulins in idiopathic inflammatory myopathies. Semin Arthritis Rheum 2016; 46:488-508. [PMID: 27908534 DOI: 10.1016/j.semarthrit.2016.07.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 07/20/2016] [Accepted: 07/21/2016] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The aim of this review was to summarize key findings from the literature concerning the therapeutic role of intravenous immunoglobulins (IVIg) in idiopathic inflammatory myopathies (IIM), dissecting the evidence according to disease subtype and treatment indication, and to review the evidence relating to the mechanism of action of IVIg in IIM to ascertain rationale for continued research. METHODS Medline (Ovid) and Pubmed databases were searched from inception to July 2016 using relevant keywords. Original and review articles were retrieved for full-text review. Bibliographies of selected articles were also hand-searched for additional references. Data were summarized qualitatively and in tabular form. RESULTS The efficacy of IVIg in IIM is supported by 3 randomized controlled trials, involving dermatomyositis and polymyositis subjects, in refractory, relapsed, or steroid-dependent disease, as well as part of first-line therapy in elderly dermatomyositis subjects. Other indications for IVIg are supported by uncontrolled evidence only. Limitations of studies include open, uncontrolled or retrospective study designs, small and selected samples, short-term follow-up and ad hoc outcome measures. Despite the limited evidence, there is strong biological plausibility for the role of IVIg in IIM. CONCLUSION Robust, controlled evidence to support the use of IVIg using validated outcome measures is urgently required to guide therapeutic decision-making and maximize outcomes in IIM.
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Affiliation(s)
- Sabrina Anh-Tu Hoa
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada
| | - Marie Hudson
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada; Department of Medicine, Jewish General Hospital, Montreal, Quebec, Canada; Faculty of Medicine, McGill University, Montreal, Quebec, Canada.
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Abstract
Human intravenous immune globulin (IVIg), a purified IgG fraction composed of ~60% IgG1 and obtained from the pooled plasma of thousands of donors, is clinically used for a wide range of diseases. The biological actions of IVIg are incompletely understood and have been attributed both to the polyclonal antibodies therein and also to their IgG (IgG) Fc regions. Recently, we demonstrated that multiple therapeutic human IgG1 antibodies suppress angiogenesis in a target-independent manner via FcγRI, a high-affinity receptor for IgG1. Here we show that IVIg possesses similar anti-angiogenic activity and inhibited blood vessel growth in five different mouse models of prevalent human diseases, namely, neovascular age-related macular degeneration, corneal neovascularization, colorectal cancer, fibrosarcoma and peripheral arterial ischemic disease. Angioinhibition was mediated by the Fc region of IVIg, required FcγRI and had similar potency in transgenic mice expressing human FcγRs. Finally, IVIg therapy administered to humans for the treatment of inflammatory or autoimmune diseases reduced kidney and muscle blood vessel densities. These data place IVIg, an agent approved by the US Food and Drug Administration, as a novel angioinhibitory drug in doses that are currently administered in the clinical setting. In addition, they raise the possibility of an unintended effect of IVIg on blood vessels.
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Tsurikisawa N, Oshikata C, Tsuburai T, Sugano S, Nakamura Y, Shimoda T, Tamama S, Adachi K, Horita A, Saito I, Saito H. Th17 cells reflect colon submucosal pathologic changes in active eosinophilic granulomatosis with polyangiitis. BMC Immunol 2015; 16:75. [PMID: 26714881 PMCID: PMC4696253 DOI: 10.1186/s12865-015-0138-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 12/22/2015] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Chronic eosinophilic pneumonia (CEP) or eosinophilic gastroenteritis (EG), or both, with asthma precede the onset of eosinophilic granulomatosis with polyangiitis (EGPA) in half of all EGPA patients. It is not known what determines whether patients with CEP or with EG following asthma will develop EGPA. METHODS We studied 17 EGPA patients and 12 patients with CEP but without EGPA. We assayed serum ICAM-1, VCAM-1, and VEGF, and the percentage of peripheral blood CD4(+) T cells producing IL-17 (Th17 cells), at both onset and remission. We also examined the numbers of submucosal eosinophils and the basement membrane-to-crypt and crypt-to-crypt distance to evaluate edema in the colon submucosa at onset and remission in EGPA and at onset in CEP. RESULTS Nine of 12 (75.0%) CEP patients had symptoms or endoscopic findings. Colonic submucosal eosinophil counts and edema in EGPA at onset were greater than at remission or in CEP at onset. Th17 cells (%) and serum ICAM-1 levels at onset were greater in EGPA than in CEP. In EGPA, peripheral blood Th17 cells (%) were significantly correlated with serum ICAM-1 level, colonic submucosal eosinophil count, and degree of edematous change; inversely correlated with serum VEGF level; but not correlated with VCAM-1 level. CONCLUSIONS Eosinophilia and colonic submucosal edematous change were greater in EGPA than in CEP. The mechanism of vasculitis in EGPA appears related to increases in serum Th17 cell numbers and ICAM-1 levels and decreases in VEGF levels.
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Affiliation(s)
- Naomi Tsurikisawa
- Departments of Allergy and Respirology, Sagamihara, Kanagawa, Japan.
| | - Chiyako Oshikata
- Departments of Allergy and Respirology, Sagamihara, Kanagawa, Japan.
| | - Takahiro Tsuburai
- Departments of Allergy and Respirology, Sagamihara, Kanagawa, Japan.
| | - Satoshi Sugano
- Department of Medical Gastroenterology, Sagamihara, Kanagawa, Japan.
| | - Yoko Nakamura
- Department of Medical Gastroenterology, Sagamihara, Kanagawa, Japan.
| | - Takuya Shimoda
- Department of Medical Gastroenterology, Sagamihara, Kanagawa, Japan.
| | - Shunpei Tamama
- Department of Medical Gastroenterology, Sagamihara, Kanagawa, Japan.
| | - Ken Adachi
- Department of Medical Gastroenterology, Sagamihara, Kanagawa, Japan.
| | - Ayako Horita
- Department of Diagnostic Pathology, Sagamihara, Kanagawa, Japan.
| | - Ikuo Saito
- Department of Diagnostic Pathology, Sagamihara, Kanagawa, Japan.
| | - Hiroshi Saito
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization, Sagamihara National Hospital, 18-1 Sakuradai, Minami-ku, Sagamihara, Kanagawa, 252-0392, Japan.
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The heart in rheumatic disease. Rheumatology (Oxford) 2015. [DOI: 10.1016/b978-0-323-09138-1.00035-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Souza PVSD, Pinto WBVDR, Oliveira ASB. Clinical applications of immunoglobulin in neuromuscular diseases: focus on inflammatory myopathies. ARQUIVOS DE NEURO-PSIQUIATRIA 2014; 72:966-71. [PMID: 25465778 DOI: 10.1590/0004-282x20140160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 09/01/2014] [Indexed: 11/22/2022]
Abstract
UNLABELLED During recent years, an increasing number of neuromuscular diseases have been recognized either to be caused primarily by autoimmune mechanisms, or to have important autoimmune components. The involved pathophysiological mechanisms and clinical manifestations have been better recognized and many of these disorders are potentially treatable by immunosuppression or by immunomodulation with intravenous immunoglobulin (IVIg). IVIg has been tried in a variety of immune-mediated neurological diseases, being target of widespread use in central and peripheral nervous systems diseases. OBJECTIVE To give an overview of the main topics regarding the mechanism of action and different therapeutic uses of IVIg in neurological practice, mainly in neuromuscular diseases.
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Affiliation(s)
- Paulo Victor Sgobbi de Souza
- Divisão de Doencas Neuromusculares, Departamento de Neurologia e Neurocirurgia, Universidade Federal de São Paulo, SP, Brazil
| | | | - Acary Souza Bulle Oliveira
- Divisão de Doencas Neuromusculares, Departamento de Neurologia e Neurocirurgia, Universidade Federal de São Paulo, SP, Brazil
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Ernste FC, Reed AM. Idiopathic inflammatory myopathies: current trends in pathogenesis, clinical features, and up-to-date treatment recommendations. Mayo Clin Proc 2013; 88:83-105. [PMID: 23274022 DOI: 10.1016/j.mayocp.2012.10.017] [Citation(s) in RCA: 112] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Revised: 10/30/2012] [Accepted: 10/31/2012] [Indexed: 01/13/2023]
Abstract
Recently, there have been important advances in the understanding of the pathophysiologic features, assessment, and management of patients with a newly diagnosed idiopathic inflammatory myopathy (IIM). Myositis-specific autoantibodies have been identified to define patient subgroups and offer prognostic implications. Similarly, proinflammatory cytokines, such as interleukin 6 and type 1 interferon-dependent genes, may serve as potential biomarkers of disease activity in adult and juvenile patients with dermatomyositis (DM). Moreover, magnetic resonance imaging has become an important modality for the assessment of muscle inflammation in adult IIM and juvenile DM. Immune-mediated necrotizing myopathies also are being recognized as a subset of IIM triggered by medications such as statins. However, confusion exists regarding effective management strategies for patients with IIM because of the lack of large-scale, randomized, controlled studies. This review focuses primarily on our current management and treatment algorithms for IIM including the care of pediatric patients with juvenile DM. For this review, we conducted a search of PubMed and MEDLINE for articles published from January 1, 1970, to December 1, 2011, using the following search terms: idiopathic inflammatory myopathies, dermatomyositis, polymyositis, juvenile dermatomyositis, sporadic inclusion body myositis, inclusion body myositis, inflammatory myositis, myositis, myopathies, pathogenesis, therapy, and treatment. Studies published in English were selected for inclusion in our review as well as additional articles identified from bibliographies.
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Intravenous immunoglobulin therapy in adult patients with polymyositis/dermatomyositis: a systematic literature review. Clin Rheumatol 2012; 31:801-6. [DOI: 10.1007/s10067-012-1940-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Revised: 12/12/2011] [Accepted: 01/09/2012] [Indexed: 11/25/2022]
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Abstract
PURPOSE OF REVIEW To review recent advances in the treatment of idiopathic inflammatory myopathies (IIMs) with emphasis on new biological agents and on some less commonly used immunosuppressive drugs. RECENT FINDINGS Double-blinded comparison of oral high-dose pulse dexamethasone with standard high daily prednisolone doses showed similar efficacy in the composite score, significantly longer median time to relapse with prednisolone and fewer side effects with dexamethasone treatment. Use of intravenous immunoglobulins (IVIGs) in IIMs is associated with variable results; however, recent retrospective evaluation of IVIGs administration to steroid-resistant patients with esophageal involvement showed good effect. Whereas smaller open studies with rituximab reported a very good efficacy, even in notoriously difficult-to-treat anti-signal recognition particle-positive cases, the double-blind trial has not reached the primary endpoint. Studies with TNF neutralization are reporting results ranging from only a modest or no effect to a promising outcome in the most recent trial with etanercept. Pilot studies suggest efficacy of alemtuzumab in inclusion body myositis and allogeneic mesenchymal stem cell transplantation in polymyositis/dermatomyositis. SUMMARY Unmet need for efficacious therapy in IIMs exists and therefore a coordinated effort is necessary to properly evaluate various new classical and biological agents.
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Bayry J, Negi VS, Kaveri SV. Intravenous immunoglobulin therapy in rheumatic diseases. Nat Rev Rheumatol 2011; 7:349-59. [PMID: 21556030 DOI: 10.1038/nrrheum.2011.61] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Prepared from the collective plasma of several thousand people, therapeutic intravenous immunoglobulin (IVIg) consists mostly of human polyspecific IgG. In addition to its use in primary and secondary immune deficiencies, IVIg is used in the treatment of several rheumatic conditions, including Kawasaki disease, dermatomyositis and antineutrophil cytoplasmic antibody (ANCA)-positive vasculitis. In these diseases, IVIg therapy generally involves the use of 2 g/kg administered over either 2 or 5 consecutive days. However, dosage regimens have not been thoroughly explored, and indications for IVIg in most rheumatic diseases, such as systemic lupus erythematosus, polymyositis and catastrophic antiphospholipid syndrome, derive from its off-label usage. Randomized clinical trials are warranted to support the evidence-based use of IVIg, and to identify the ideal administration protocols to maximize the benefits of what is a limited resource. Further research to improve the therapeutic application of IVIg relies essentially on the conception of next-generation immunoglobulin preparations and optimization of combined therapies with immunomodulatory drugs and biologic agents.
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Affiliation(s)
- Jagadeesh Bayry
- Institut National de Santé et de Recherche Médicale Unité 872 (INSERM U872), Université Pierre et Marie Curie and Université René Descartes, 15 rue de l'Ecole de Médicine, Paris, F-75006, France
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Zong M, Lundberg IE. Pathogenesis, classification and treatment of inflammatory myopathies. Nat Rev Rheumatol 2011; 7:297-306. [DOI: 10.1038/nrrheum.2011.39] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Bazzani C, Cavazzana I, Ceribelli A, Vizzardi E, Dei Cas L, Franceschini F. Cardiological features in idiopathic inflammatory myopathies. J Cardiovasc Med (Hagerstown) 2011; 11:906-11. [PMID: 20625308 DOI: 10.2459/jcm.0b013e32833cdca8] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Idiopathic inflammatory myopathies (IIMs) represent a heterogeneous group of autoimmune systemic diseases characterized by chronic muscle weakness and inflammatory cell infiltrates in skeletal muscle. The most frequent IIMs, such as adult-onset polymyositis and dermatomyositis, display a wide range of clinical manifestations other than myositis, including skin changes, Raynaud's phenomenon and interstitial lung disease. Cardiac involvement is now well recognized as a clinically important manifestation in patients with polymyositis or dermatomyositis, although its actual frequency is still uncertain. Cardiovascular complications represent one of the most frequent causes of death in myositis, apart from cancer and lung involvement. Despite the fact that clinical manifestations are relatively rare, asymptomatic cardiovascular features are frequently reported in patients with polydermatomyositis and dermatomyositis. They are characterized by isolated electrocardiographic changes, valve disease, coronary vasculitis, ischemic abnormalities, heart failure and myocarditis. Chronic inflammation producing myocyte degeneration, tissues fibrosis and vascular alterations can explain the majority of reported cardiac features in myositic patients. Although previous works reported an association between heart involvement and some myositis-specific autoantibodies (namely anti-signal recognition particle), electrocardiography, echocardiography and, where necessary, heart magnetic resonance remain the mainstay for diagnosing and monitoring myocardial inflammation in these diseases. Anyway, a complete multiorgan assessment and a careful analysis of autoantibodies should be performed in every patient in order to define any possible distinct disease entities with different prognosis within the spectrum of IIMs.
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Affiliation(s)
- Chiara Bazzani
- Rheumatology Unit, University of Brescia, Piazzale Spedali Civili, Brescia, Italy
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Myositis: When Weakness Can Kill. Autoimmune Dis 2011. [DOI: 10.1007/978-0-85729-358-9_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Nader GA, Dastmalchi M, Alexanderson H, Grundtman C, Gernapudi R, Esbjörnsson M, Wang Z, Rönnelid J, Hoffman EP, Nagaraju K, Lundberg IE. A longitudinal, integrated, clinical, histological and mRNA profiling study of resistance exercise in myositis. Mol Med 2010; 16:455-64. [PMID: 20809047 DOI: 10.2119/molmed.2010.00016] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2010] [Accepted: 08/11/2010] [Indexed: 12/20/2022] Open
Abstract
Polymyositis and dermatomyositis are orphan, chronic skeletal muscle disorders characterized by weakness, infiltrations by mononuclear inflammatory cells, and fibrosis. Until recently, patients were advised to refrain from physical activity because of fears of exacerbation of muscle inflammation. However, recent studies have shown that moderate exercise training in combination with immunosuppressive drugs can improve muscle performance. Despite the positive effects of exercise training, the molecular mechanisms underlying the exercise-associated clinical improvements remain poorly understood. The present study was designed to define, at the molecular level, the effects of resistance exercise training on muscle performance and disease progression in myositis patients. We evaluated changes in muscle strength, histology and genome-wide mRNA profiles to determine the beneficial effects of exercise and determine the possible molecular changes associated with improved muscle performance. A total of 8 myositis patients underwent a 7-wk resistance exercise training program that resulted in improved muscle strength and increased maximal oxygen uptake (VO(2max)). Training also resulted in marked reductions in gene expression, reflecting reductions in proinflammatory and profibrotic gene networks, changes that were also accompanied by a reduction in tissue fibrosis. Consistent with the exercise-associated increase in VO(2max), a subset of transcripts was associated with a shift toward oxidative metabolism. The changes in gene expression reported in the present study are in agreement with the performance improvements induced by exercise and suggest that resistance exercise training can induce a reduction in inflammation and fibrosis in skeletal muscle.
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Affiliation(s)
- Gustavo A Nader
- Research Center for Genetic Medicine, Children's National Medical Center, Washington, DC, USA
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Mann HF, Vencovsky J, Lundberg IE. Treatment-resistant inflammatory myopathy. Best Pract Res Clin Rheumatol 2010; 24:427-40. [DOI: 10.1016/j.berh.2009.12.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Haroon M, Devlin J. Rituximab as a first-line agent for the treatment of dermatomyositis. Rheumatol Int 2010; 32:1783-4. [PMID: 20340018 DOI: 10.1007/s00296-010-1458-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2009] [Accepted: 03/12/2010] [Indexed: 10/19/2022]
Abstract
B cells may play a pivotal role in the pathophysiology of DM, and reports have claimed that targeting B cells is a viable treatment option in patients with dermatomyositis. A 20-year-old girl presented in October 2007, with few weeks' history of proximal muscle weakness. Gottron's papules were noted on her knuckles. She had normal inflammatory markers and negative autoantibody screen. Her CPK was 7,000 U/L (normal range 0-170) with an LDH of 1,300 U/L (normal range 266-500). EMG and muscle biopsy was consistent with active myositis. She had normal pulmonary function tests. HRCT showed no interstitial lung disease. She was started with 60 mg glucocorticoids (1 mg/kg), with a good clinical response. However, any attempt to taper down the steroid dose led to recurrence of her symptoms. The options of available immunosuppressive therapies, including the experimental usage of rituximab, were discussed with her; averse to long-term systemic treatments, she opted to try a course of rituximab. She had rituximab 1,000 mg on days 0 and 14, and her glucocorticoids were tapered in next few weeks. Now, 24 months since her rituximab infusions, she remains in complete clinical and biochemical remission and is naïve to other immunosuppressive agents apart from glucocorticoids and rituximab. Depleting peripheral B cells with rituximab (one course) in our patient has led not only to complete resolution of muscle and skin disease (induction) but also remains off all immunosuppressives including glucocorticoids.
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Affiliation(s)
- Muhammad Haroon
- Department of Rheumatology, Waterford Regional Hospital, Waterford, Republic of Ireland.
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Levy DM, Bingham CA, Kahn PJ, Eichenfield AH, Imundo LF. Favorable outcome of juvenile dermatomyositis treated without systemic corticosteroids. J Pediatr 2010; 156:302-7. [PMID: 19846111 PMCID: PMC2938791 DOI: 10.1016/j.jpeds.2009.09.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2009] [Revised: 08/06/2009] [Accepted: 09/02/2009] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To describe the course of patients with juvenile dermatomyositis (JDM) treated effectively without systemic corticosteroids. STUDY DESIGN A retrospective study of 38 patients with JDM treated at a tertiary care children's hospital identified 8 patients who had never received corticosteroids. Disease presentation and course, pharmacologic, and ancillary treatments were recorded. RESULTS Patients in the no corticosteroid group were followed for a median of 2.8 years (range, 2.1 to 9.5 years). Treatment was primarily with intravenous immunoglobulin (IVIG) (75%) and methotrexate (50%), with favorable response in all. No serious treatment complications were observed; headaches were reported by 3 patients receiving IVIG. Two patients had a myositis flare after discontinuing all medications for more than 1 year; complete resolution of symptoms was observed after either 1 or 2 further doses of IVIG. Two patients had calcinosis (at 1 and 9 years of disease); however, no patient had joint contractures, muscle atrophy, lipodystrophy, or functional limitations. CONCLUSIONS Systemic corticosteroids can be avoided in a select group of patients with JDM. Alternative agents such as methotrexate and IVIG may be prescribed to effectively treat JDM and prevent complications.
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Affiliation(s)
- Deborah M. Levy
- Morgan Stanley Children’s Hospital of New York-Presbyterian, Columbia University Medical Center
| | - C. April Bingham
- Milton S. Hershey Medical Center, Penn State College of Medicine
| | | | - Andrew H. Eichenfield
- Morgan Stanley Children’s Hospital of New York-Presbyterian, Columbia University Medical Center
| | - Lisa F. Imundo
- Morgan Stanley Children’s Hospital of New York-Presbyterian, Columbia University Medical Center
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Treatment of inclusion body myositis: is low-dose intravenous immunoglobulin the solution? Rheumatol Int 2010; 32:469-72. [PMID: 20044785 DOI: 10.1007/s00296-009-1290-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2009] [Accepted: 11/29/2009] [Indexed: 10/20/2022]
Abstract
Inclusion body myositis (IBM), the most common inflammatory myopathy in the elderly, is often resistant to various forms of therapy. Placebo-controlled treatment trials with high dose intravenous immunoglobulins (IVIG) have shown disease amelioration in some but not all patients. Here, we present the informative case of a 70-year-old woman with diagnosed inclusion body myositis that showed progressive muscle weakness without treatment and following immuno-suppressive treatment with corticosteroids and azathioprine. A trial with low-dose intravenous immunoglobulins was started at that time. The patient responded rapidly to low dose IVIG treatment with amelioration of muscle strength and normalization of CK serum activities. Our results demonstrate that IBM patients may respond to low-dose IVIG treatment which has important clinical and economic consequences.
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Grundtman C, Lundberg IE. Vascular involvement in the pathogenesis of idiopathic inflammatory myopathies. Autoimmunity 2009; 42:615-26. [DOI: 10.1080/08916930903002511] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Bibliography. Current world literature. Systemic lupus erythematosus and Sjögren's syndrome. Curr Opin Rheumatol 2008; 20:631-2. [PMID: 18698190 DOI: 10.1097/bor.0b013e3283110091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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