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Ruffer N, Kleefeld F, Holzer MT, Krusche M, Kötter I, Schneider U, Stenzel W. [Vasculitic involvement of the skeletal muscle and the peripheral nervous system: clinical and neuropathologic perspective]. Z Rheumatol 2024:10.1007/s00393-024-01567-y. [PMID: 39316132 DOI: 10.1007/s00393-024-01567-y] [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: 08/07/2024] [Indexed: 09/25/2024]
Abstract
The peripheral nervous system is a classic target organ in systemic vasculitis. In addition, the skeletal muscle can also be affected. Myalgia, muscle weakness and sensory deficits are typical signs, which can lead to severe functional limitations and impaired of quality of life. Vasculitic involvement of the skeletal muscle (vasculitic myopathy [VM]) and peripheral nerves (vasculitic neuropathy [VN]) occurs predominantly in polyarteritis nodosa and small-vessel vasculitis. VM presents with elevated markers of inflammation and is typically characterized by immobilizing myalgia with normal creatine kinase activity and diffuse or patchy areas of hyperintensity on T2-weighted MRI ("MRI myositis without myositis"). In VN, sensor motor deficits predominantly affect the lower extremity in the area supplied by several peripheral nerves (e.g., mononeuritis multiplex) with acute to subacute history. The histopathological examination of nerve and muscle biopsies is the gold standard for the diagnosis of vasculitic manifestations and has a significant impact on the therapeutic approach.
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Affiliation(s)
- Nikolas Ruffer
- III. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland.
| | - Felix Kleefeld
- Klinik für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Marie-Therese Holzer
- III. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
| | - Martin Krusche
- III. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
| | - Ina Kötter
- III. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
- Klinik für Rheumatologie und Immunologie, Klinikum Bad Bramstedt, Bad Bramstedt, Deutschland
| | - Udo Schneider
- Medizinische Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie, Charité - Universitätsmedizin, Berlin, Deutschland
| | - Werner Stenzel
- Institut für Neuropathologie, Charité - Universitätsmedizin, Berlin, Deutschland
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Shimojima Y, Nomura S, Ushiyama S, Ichikawa T, Takamatsu R, Kishida D, Sekijima Y. Early skeletal muscle manifestations in polyarteritis nodosa and ANCA-associated vasculitis. Autoimmun Rev 2024; 23:103602. [PMID: 39153646 DOI: 10.1016/j.autrev.2024.103602] [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: 04/01/2024] [Revised: 08/03/2024] [Accepted: 08/14/2024] [Indexed: 08/19/2024]
Abstract
Skeletal muscle involvement is common in patients with small- and medium-sized vasculitis, particularly polyarteritis nodosa (PAN) and antineutrophil cytoplasmic antibody-associated vasculitis (AAV). Despite being not included in the standard classification criteria for PAN and AAV, skeletal muscle involvement is an important clinical indicator, particularly when vasculitic myopathy is the only pathological evidence in the absence of other organ involvement. Herein, we comprehensively reviewed and compared the clinical features of 71 and 135 patients with PAN and AAV, respectively, with skeletal muscle involvement at the time of disease onset. Most patients with PAN and AAV exhibited skeletal muscle involvement, often characterized by myalgia and occasional muscular weakness, predominantly in the lower extremities. Myalgia and weakness were observed more frequently in the distal lower extremities in patients with PAN than in those with AAV. In contrast, skeletal muscle involvement tended to exhibit a more dispersed distribution across all four extremities in those with AAV. Muscle magnetic resonance imaging T2-weighted and short-tau inversion recovery sequences can effectively identify hyperintense areas attributed to hypervascularity of affected muscle tissues and serve as a sensitive and useful modality for visually determining the suitable biopsy site. >90% of patients with PAN and AAV demonstrated perivascular inflammation in their affected muscle tissues, whereas fibrinoid necrosis of the vessel walls was reported in two-thirds of patients. Serum creatine kinase (CK) levels were within the normal range in approximately 80% of patients presenting with skeletal muscle involvement in PAN and AAV. Furthermore, muscle fiber damage was milder in patients with skeletal muscle involvement in PAN and AAV than those with idiopathic inflammatory myositis. Meanwhile, serum CK levels were elevated in 65-85% of patients with PAN and AAV who had myofiber necrosis and degeneration in the affected muscles. Most patients with PAN and AAV showed improvement in skeletal muscle involvement following glucocorticoids (GCs) administration; however, relapse was observed in some patients during the tapering of GCs. In summary, skeletal muscle involvement is a potential indicator for establishing PAN and AAV diagnoses during the early phases of the disease.
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Affiliation(s)
- Yasuhiro Shimojima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan.
| | - Shun Nomura
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Satoru Ushiyama
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Takanori Ichikawa
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Ryota Takamatsu
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Dai Kishida
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
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Conticini E, d'Alessandro M, Al Khayyat SG, D'Alessandro R, D'Ignazio E, Pata AP, Vallifuoco G, Falsetti P, Baldi C, Bardelli M, Gentileschi S, Fabiani C, Mazzei MA, Guarnieri A, Bargagli E, Cantarini L, Frediani B. Inflammatory muscle involvement in systemic vasculitis: A systematic review. Autoimmun Rev 2021; 21:103029. [PMID: 34971804 DOI: 10.1016/j.autrev.2021.103029] [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: 12/04/2021] [Revised: 12/20/2021] [Accepted: 12/25/2021] [Indexed: 11/02/2022]
Abstract
Vasculitis are severe systemic autoimmune diseases which may involve different organs and systems. Conversely, muscles do not represent an organ commonly involved by systemic vasculitis and myositis is not include among any classification or diagnostic criterion of vasculitis. In this regard, we aimed to review the literature in order to report all the available evidence concerning the inflammatory involvement of muscle in patients affected by systemic vasculitis. We collected a total of 108 papers, for a sum of 395 patients affected by muscle vasculitis. Most of them suffered from medium and small vessels vasculitis (mainly polyarteritis nodosa and ANCA-associated vasculitis) or from vasculitis secondary to rheumatoid arthritis. Conversely, muscle involvement in case of large vessel vasculitis occurred seldom, while only few papers reported such occurrence in Kawasaki or Behçet's disease. Histological findings may differ, but the most common ones displayed a necrotizing vasculitis of perimysium vessels, while granulomatous vasculitis was assessed only in case of ANCA-associated vasculitis patients. Creatine kinase were usually within normal range, seldom elevated, while imaging findings were generally undistinguishable from the ones found in idiopathic inflammatory myopathies: magnetic resonance imaging displays signal hyperintensity in T2 and STIR scans, while few data exist for positron emission tomography. The presentation of the disease may be fearsome and severe, sometimes life-threatening, but an overall good response to conventional immunosuppressants and/or glucocorticoids has been reported.
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Affiliation(s)
- Edoardo Conticini
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Italy
| | - Miriana d'Alessandro
- Respiratory Diseases and Lung Transplantation Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Italy
| | | | - Roberto D'Alessandro
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Italy
| | - Emilio D'Ignazio
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Italy
| | - Anna Paola Pata
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Italy
| | - Giulia Vallifuoco
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Italy
| | - Paolo Falsetti
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Italy
| | - Caterina Baldi
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Italy
| | - Marco Bardelli
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Italy
| | - Stefano Gentileschi
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Italy
| | - Claudia Fabiani
- Ophthalmology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Italy
| | - Maria Antonietta Mazzei
- Unit of Diagnostic Imaging Unit, Department of Medicine, Surgery and Neurosciences and Radiological Sciences, University of Siena, Italy
| | - Andrea Guarnieri
- Nephrology, Dialysis and Transplantation Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Italy
| | - Elena Bargagli
- Respiratory Diseases and Lung Transplantation Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Italy
| | - Luca Cantarini
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Italy.
| | - Bruno Frediani
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Italy
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Dutcher JS, Bui A, Ibe TA, Umadat G, Harper EP, Middlebrooks EH, Mohseni MM, Phillips MB. ANCA-associated vasculitis and severe proximal muscle weakness. Proc AMIA Symp 2021; 34:384-386. [PMID: 33953470 DOI: 10.1080/08998280.2020.1871177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
ANCA-associated vasculitis is a multiorgan autoimmune inflammatory disease that has a heterogeneous clinical presentation. Our case report provides additional evidence supporting the association between granulomatosis with polyangiitis and myositis. In our patient with proximal muscle weakness and pain, a normal creatine kinase and lack of antibodies to muscular fiber units ruled out primary myositis. Distinct magnetic resonance imaging of the brain within the deep gray matter in addition to positive serologies were consistent with a diagnosis of granulomatosis with polyangiitis. ANCA-associated vasculitis, specifically granulomatosis with polyangiitis, may be overlooked if musculoskeletal manifestations are the presenting symptoms. Prompt and aggressive treatment prevented this patient from experiencing multiorgan failure.
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Affiliation(s)
| | - Albert Bui
- Department of Internal Medicine, Mayo Clinic, Jacksonville, Florida
| | - Tochukwu A Ibe
- Department of Internal Medicine, Mayo Clinic, Jacksonville, Florida
| | - Goyal Umadat
- Department of Internal Medicine, Mayo Clinic, Jacksonville, Florida
| | - Eugene P Harper
- Department of Internal Medicine, Mayo Clinic, Jacksonville, Florida
| | | | - Michael M Mohseni
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, Florida
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Granulomatosis with Polyangiitis Restricted to the Back Muscle: The First Case Report. ACTA ACUST UNITED AC 2020; 56:medicina56090431. [PMID: 32867138 PMCID: PMC7557577 DOI: 10.3390/medicina56090431] [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] [Received: 07/29/2020] [Revised: 08/24/2020] [Accepted: 08/26/2020] [Indexed: 12/29/2022]
Abstract
Granulomatosis with polyangiitis (GPA) is an autoimmune disease which is a type of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis that frequently affects the lungs and kidneys. However, GPA limited to a single organ has also been reported. A 71-year-old man was admitted for back pain and fever. We detected elevated levels of inflammatory markers and myeloperoxidase-ANCA. Magnetic resonance imaging indicated diffuse inflammation of the back and psoas muscles. Histology showed degenerated muscle fibers and granulomatosis vasculitis with mixed lymphoplasma cell infiltration. High-dose methylprednisolone therapy improved his symptoms. A final diagnosis of GPA limited to the muscles was made.
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Nagiah S, Saranapala DMM. Severe proximal muscle weakness with normal CK as a presenting feature of ANCA-associated vasculitis. BMJ Case Rep 2020; 13:13/1/e232854. [PMID: 31969410 PMCID: PMC7021126 DOI: 10.1136/bcr-2019-232854] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Antineutrophil cytoplasmic antibodies associated vasculitis (AAV) presenting with muscle weakness is rarely reported. We report a case of myeloperoxidase positive vasculitis presenting with severe proximal muscle weakness with normal creatine kinase and no positron-emission tomography uptake. There was a significant delay in the diagnosis of AAV due to atypical presentation. We propose AAV be considered in the differential diagnosis of proximal muscle weakness after excluding the common causes.
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Affiliation(s)
- Sureshkumar Nagiah
- General Medicine, Flinders Medical Centre, Bedford Park, South Australia, Australia
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Calvo R, Negri M, Ortiz A, Roverano S, Paira S. Myositis as the initial presentation of panarteritis nodosa. REUMATOLOGIA CLINICA 2019; 15:e24-e26. [PMID: 28755909 DOI: 10.1016/j.reuma.2017.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 06/01/2017] [Accepted: 06/16/2017] [Indexed: 06/07/2023]
Abstract
A 47-year-old man presented with weight loss, bilateral calf pain, fever, hypertension, orchitis and oligoarthritis. Lab tests: anemia and elevated muscle enzymes. Resonance magnetic imaging: hyperintensity in gastrocnemius muscles (myositis). Histologic exam of the muscles: inflammatory infiltrate with atrophy and perifascicular regeneration. Treatment: methylprednisone (bolus) and cyclophosphamide. Muscle pain and swelling and difficulty in walking are common in panarteritis nodosa (PAN), whereas histologically demonstrated myositis is not. Even more rare is myositis as the initial presentation of this vasculitis.
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Affiliation(s)
- Romina Calvo
- Servicio de Reumatología, Hospital J.M. Cullen, Santa Fe, Argentina
| | - Melina Negri
- Servicio de Reumatología, Hospital J.M. Cullen, Santa Fe, Argentina
| | - Alberto Ortiz
- Servicio de Reumatología, Hospital J.M. Cullen, Santa Fe, Argentina
| | - Susana Roverano
- Servicio de Reumatología, Hospital J.M. Cullen, Santa Fe, Argentina
| | - Sergio Paira
- Servicio de Reumatología, Hospital J.M. Cullen, Santa Fe, Argentina.
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Ojima Y, Sawada K, Fujii H, Shirai T, Saito A, Kagaya S, Aoki S, Takeuchi Y, Ishii T, Nagasawa T. Anti-neutrophil Cytoplasmic Antibody-associated Vasculitis (AAV) Restricted to the Limbs. Intern Med 2018; 57:1301-1308. [PMID: 29279515 PMCID: PMC5980815 DOI: 10.2169/internalmedicine.9848-17] [Citation(s) in RCA: 5] [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: 01/03/2023] Open
Abstract
A previously healthy 58-year-old man was admitted for muscle pain and weakness [manual muscle testing (MMT) of 4/4 for upper and lower limbs]. We detected elevated levels of inflammatory makers and PR3-anti-neutrophil cytoplasmic antibody (ANCA). Subsequently, the muscle weakness rapidly progressed to an MMT of 2 for all limbs. Magnetic resonance imaging indicated muscle edema, and the creatine kinase (CK) level increased to 29,998 U/L. Methylprednisolone (mPSL) and cyclophosphamide pulse therapy improved the patient symptoms. MMT recovered to 4 for all limbs. A muscle biopsy showed degenerated muscle fibers surrounded by neutrophil-predominant infiltration. In addition, lamina elastic breakdown and fibrinoid necrosis of arterioles were observed. A final diagnosis of microscopic polyangiitis (MPA) limited to the muscles was made.
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Affiliation(s)
- Yoshie Ojima
- Department of Nephrology, Japanese Red Cross Ishinomaki Hospital, Japan
| | - Kinya Sawada
- Department of Radiology, Takeda General Hospital, Japan
| | - Hiroshi Fujii
- Department of Hematology and Rheumatology, Tohoku University School of Medicine, Japan
| | - Tsuyoshi Shirai
- Department of Hematology and Rheumatology, Tohoku University School of Medicine, Japan
| | - Ayako Saito
- Department of Nephrology, Hypertension and Endocrinology, Tohoku University School of Medicine, Japan
| | - Saeko Kagaya
- Department of Nephrology, Japanese Red Cross Ishinomaki Hospital, Japan
| | - Satoshi Aoki
- Department of Nephrology, Japanese Red Cross Ishinomaki Hospital, Japan
| | - Yoichi Takeuchi
- Department of Nephrology, Japanese Red Cross Ishinomaki Hospital, Japan
| | - Tomonori Ishii
- Clinical Research, Innovation and Education Center, Tohoku University Hospital, Japan
| | - Tasuku Nagasawa
- Department of Nephrology, Japanese Red Cross Ishinomaki Hospital, Japan
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Akagi T, Nishimura H, Mukai T, Morita Y. Necrosis of the gastrocnemius muscle in microscopic polyangiitis. BMJ Case Rep 2018; 2018:bcr-2017-223585. [PMID: 29374653 DOI: 10.1136/bcr-2017-223585] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Takahiko Akagi
- Department of Rheumatology, Kawasaki Medical School, Kurashiki, Japan
| | | | - Tomoyuki Mukai
- Department of Rheumatology, Kawasaki Medical School, Kurashiki, Japan
| | - Yoshitaka Morita
- Department of Rheumatology, Kawasaki Medical School, Kurashiki, Japan
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