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Raaphorst J, Gullick NJ, Pipitone N, Shokraneh F, Brassington R, Ali SS, Gordon PA. Immunosuppressive and immunomodulatory therapies for idiopathic inflammatory myopathies. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2023; 2023:CD014510. [PMCID: PMC9885519 DOI: 10.1002/14651858.cd014510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
This is a protocol for a Cochrane Review (intervention). The objectives are as follows: This protocol is for two separate reviews to assess the effects (benefits and harms) of immunosuppressant and immunomodulatory treatments for the idiopathic inflammatory myopathies.
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Affiliation(s)
| | - Joost Raaphorst
- Department of NeurologyAmsterdam UMC, University of Amsterdam, Amsterdam NeuroscienceAmsterdamNetherlands
| | - Nicola J Gullick
- Department of RheumatologyUniversity Hospitals Coventry and Warwickshire NHS TrustCoventryUK,Warwick Medical SchoolUniversity of WarwickCoventryUK
| | - Nicolo Pipitone
- Rheumatology Unit, Department of Internal MedicineAzienda USL-IRCCS di Reggio EmiliaReggio EmiliaItaly
| | - Farhad Shokraneh
- Cochrane Neuromuscular GroupUniversity College London Hospitals TrustLondonUK
| | - Ruth Brassington
- Queen Square Centre for Neuromuscular DiseasesNational Hospital for Neurology and NeurosurgeryLondonUK
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Coexistence of Multiple Myositis-Specific Antibodies in Patients with Idiopathic Inflammatory Myopathies. J Clin Med 2022; 11:jcm11236972. [PMID: 36498547 PMCID: PMC9739947 DOI: 10.3390/jcm11236972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/21/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022] Open
Abstract
The mutual exclusivity of myositis-specific antibodies (MSAs) has been reported before, but the coexistence of 2 or more MSAs was still found in a few case reports. This study aims to confirm the existence and prevalence of double MSAs in patients with idiopathic inflammatory myopathy (IIM) and to clarify the clinical features of these patients. One hundred fifty-one patients with IIM diagnosed from 1 July 2018 to 31 July 2022, at National Cheng Kung University Hospital, Taiwan, were enrolled and divided into two groups, patients with ≤1 MSA (n = 128, 84.8%) and those with ≥2 MSAs (n = 23, 15.2%) according to the initial serology results. After being re-examined by ANA-IIF assay, 8 out of 23 patients were confirmed to have ≥2 MSAs. The demographic data and clinical features were presented. The prevalence of double-positive MSAs among IIM was 5.3% in this cohort. The coexistence of two MSAs in an IIM patient does exist but is rare. Patients with two MSAs belonging to two distinct IIM subtypes presented clinical features skewed to one subtype instead of "mixed phenotypes". No apparent difference in clinical severity was found between patients with ≥2 MSAs and ≤1 MSA. Longer follow-ups and more studies are required to characterize the patients of IIM with ≥2 MSAs.
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Abstract
When asked to assess patients in an intensive care unit (ICU) who have respiratory muscle weakness, oropharyngeal weakness and a vulnerable airway, our immediate thought may be of Guillain-Barré syndrome or myasthenia gravis, but there are many other possible causes. For example, previously unrecognised chronic neurological conditions may decompensate and require ICU admission. Clinicians can use various clinical clues to help recognise them and need to understand how patterns of weakness reflect differing causes of reduced consciousness on ICU. Additionally, patients admitted to ICU for any reason may develop weakness during their stay, the most likely cause being ICU-acquired weakness. Assessing patients in ICU is challenging, hampered by physical barriers (machines, tubes), medication barriers (sedatives) and cognitive barriers (delirium, difficulty communicating). Nonetheless, we need to reach a clinical diagnosis, organise appropriate tests and communicate clearly with both patients and ICU colleagues.
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Pathophysiological Mechanisms and Treatment of Dermatomyositis and Immune Mediated Necrotizing Myopathies: A Focused Review. Int J Mol Sci 2022; 23:ijms23084301. [PMID: 35457124 PMCID: PMC9030619 DOI: 10.3390/ijms23084301] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 03/31/2022] [Accepted: 04/05/2022] [Indexed: 12/15/2022] Open
Abstract
Idiopathic inflammatory myopathies (IIM), collectively known as myositis, are a composite group of rare autoimmune diseases affecting mostly skeletal muscle, although other organs or tissues may also be involved. The main clinical feature of myositis is subacute, progressive, symmetrical muscle weakness in the proximal arms and legs, whereas subtypes of myositis may also present with extramuscular features, such as skin involvement, arthritis or interstitial lung disease (ILD). Established subgroups of IIM include dermatomyositis (DM), immune-mediated necrotizing myopathy (IMNM), anti-synthetase syndrome (ASyS), overlap myositis (OM) and inclusion body myositis (IBM). Although these subgroups have overlapping clinical features, the widespread variation in the clinical manifestations of IIM suggests different pathophysiological mechanisms. Various components of the immune system are known to be important immunopathogenic pathways in IIM, although the exact pathophysiological mechanisms causing the muscle damage remain unknown. Current treatment, which consists of glucocorticoids and other immunosuppressive or immunomodulating agents, often fails to achieve a sustained beneficial response and is associated with various adverse effects. New therapeutic targets have been identified that may improve outcomes in patients with IIM. A better understanding of the overlapping and diverging pathophysiological mechanisms of the major subgroups of myositis is needed to optimize treatment. The aim of this review is to report on recent advancements regarding DM and IMNM.
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Essouma M, Noubiap JJ, Singwe-Ngandeu M, Hachulla E. Epidemiology of Idiopathic Inflammatory Myopathies in Africa: A Contemporary Systematic Review. J Clin Rheumatol 2022; 28:e552-e562. [PMID: 33843773 DOI: 10.1097/rhu.0000000000001736] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The epidemiology of idiopathic inflammatory myopathies (IIMs) has been extensively studied in America, Europe, and Asia, but remains unclear in Africa. OBJECTIVE The aim of this review was to summarize available data on the epidemiology of IIMs in Africa. METHODS We searched MEDLINE, EMBASE, and African Journals Online for studies published up to December 30, 2020, and reporting epidemiological data on IIMs in Africa. Data were combined through narrative synthesis. The review protocol was registered with PROSPERO, CRD42020186781. RESULTS We included 39 studies reporting 683 cases (71.7% adults) of IIMs. Incidence rates of ~7.5/1,000,000 person-years and 1.2/1,000,000 person-years were estimated for dermatomyositis (DM), whereas polymyositis (PM) had an incidence rate of 8.8/1,000,000 person-years. Prevalence estimates of 11.49/100,000 and 11/100,000 (95% confidence interval, 0-32) were provided for IIMs and the PM subtype, respectively. Mean age at diagnosis ranged from 7.9 to 57.2 years, and 50% to 100% of the patients were females. Main subtypes of adult-onset IIMs were DM (21%-93%) and PM (12%-79%), whereas the commonest juvenile subtype was juvenile DM (5.8%-9%). Skeletal muscle involvement (56%-100%) was the main disease feature, and esophagus was the most commonly affected internal organ (6%-65.2%). Anti-Jo1/histidyl tRNA synthetase (7%-100%) and anti-Mi2 (17%-45%) antibodies were the most frequent myositis specific antibodies. Early mortality was high (7.8%-45%), and main death causes were infections, cancers and organ damage in respiratory and cardiovascular domains. CONCLUSIONS Apart from a potential younger age at onset of adult IIMs in Africa, current sparse data mostly suggest a similar epidemiology between Africa and other regions. Further high-quality studies are required to validate these findings.
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Affiliation(s)
| | - Jean Jacques Noubiap
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Eric Hachulla
- Department of Internal Medicine and Clinical Immunology, CHRU Lille, Referral Centre for rare systemic autoimmune diseases North and Northwest of France, Univ. Lille, INSERM U995, LIRIC-Lille Inflammation Research International Centre, Lille, France
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Walter HAW, Kamperman RG, Raaphorst J, Verhamme C, Koelman JHTM, Potters WV, Hemke R, Smithuis FF, Aronica E, van Leeuwen EMM, Baars PA, de Visser M, van Schaik IN, Bossuyt PMM, van der Kooi AJ. OptimisAtion of Diagnostic Accuracy in idioPathic inflammaTory myopathies (ADAPT study): a protocol for a prospective diagnostic accuracy study of multimodality testing in patients suspected of a treatable idiopathic inflammatory myopathy. BMJ Open 2021; 11:e053594. [PMID: 34903547 PMCID: PMC8671992 DOI: 10.1136/bmjopen-2021-053594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Idiopathic inflammatory myopathies (IIMs) excluding inclusion body myositis (IBM) are a group of heterogeneous autoimmune disorders characterised by subacute-onset and progressive proximal muscle weakness, which are frequently part of a multisystem autoimmune disorder. Reaching the diagnosis can be challenging, and no gold standard for the diagnosis of IIM exists. Diagnostic modalities include serum creatine kinase activity, muscle imaging (MRI or ultrasound (US)), electromyography (EMG), myositis autoantibody testing and muscle biopsy. Several diagnostic criteria have been developed for IIMs, varying in reported sensitivity and specificity. HYPOTHESIS We hypothesise that an evidence-based diagnostic strategy, using fewer and preferably the least invasive diagnostic modalities, can achieve the accuracy of a complete panel of diagnostic tests, including MRI, US, EMG, myositis-specific autoantibody testing and muscle biopsy. METHODS AND ANALYSIS The OptimizAtion of Diagnostic Accuracy in idioPathic inflammaTory myopathies study is a prospective diagnostic accuracy study with an over-complete study design. 100 patients suspected of an IIM excluding IBM will be included. A reference diagnosis will be assigned by an expert panel using all clinical information and all results of all ancillary tests available, including 6 months of follow-up. Several predefined diagnostic strategies will be compared against the reference diagnosis to find the optimal diagnostic strategy. ETHICS AND DISSEMINATION Ethical approval was obtained from the medical ethics committee of the Academic Medical Centre, University of Amsterdam, The Netherlands (2019-814). The results will be distributed through conference presentations and peer-reviewed publications. TRIAL REGISTRATION NUMBER Netherlands trial register; NL8764.
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Affiliation(s)
- Hannah A W Walter
- Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam Neuroscience, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Renske G Kamperman
- Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam Neuroscience, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Joost Raaphorst
- Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam Neuroscience, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Camiel Verhamme
- Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam Neuroscience, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Johannes H T M Koelman
- Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam Neuroscience, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Wouter V Potters
- Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam Neuroscience, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Robert Hemke
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centre, Amsterdam Movement Sciences, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Frank F Smithuis
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centre, Amsterdam Movement Sciences, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Eleonora Aronica
- Department of (Neuro)Pathology, Amsterdam University Medical Centre, Amsterdam Neuroscience, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Ester M M van Leeuwen
- Department of Experimental Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam UMC, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Paul A Baars
- Department of Experimental Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam UMC, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Marianne de Visser
- Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam Neuroscience, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Ivo N van Schaik
- Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam Neuroscience, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
- Board, Spaarne Gasthuis, Haarlem, The Netherlands
| | - Patrick M M Bossuyt
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam University Medical Centre, Amsterdam Neuroscience, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Anneke J van der Kooi
- Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam Neuroscience, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
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Binks S, Uy C, Honnorat J, Irani SR. Paraneoplastic neurological syndromes: a practical approach to diagnosis and management. Pract Neurol 2021; 22:19-31. [PMID: 34510016 DOI: 10.1136/practneurol-2021-003073] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2021] [Indexed: 01/13/2023]
Abstract
Paraneoplastic neurological syndromes (PNS) are the immune-mediated effects of a remote cancer and are characterised by an autoantibody response against antigens expressed by the tumour. Classically, well-characterised 'onconeuronal' antibodies target intracellular antigens and hence cannot access their antigens across intact cell membranes. The pathogenic mediators are likely to be neuronal-specific T cells. There is a variable response to immunotherapies and the clinical syndrome helps to direct the search for a specific set of tumours. By contrast, many newly emerging autoantibodies with oncological associations target cell surface epitopes and can exert direct pathogenic effects on both the central and peripheral nervous systems. Patients with these cell-surface directed autoantibodies often clearly respond to immunotherapies. Overall, the clinical, serological and oncological features in an individual patient helps determine the clinical relevance of the syndrome and hence guide its management. We summarise current knowledge and a practical approach to the investigation, diagnosis, treatment and outcomes of patients with suspected PNS.
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Affiliation(s)
- Sophie Binks
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, UK.,Department of Neurology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Christopher Uy
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, UK.,Department of Medicine (Division of Neurology), University of British Columbia, Vancouver, British Columbia, Canada
| | - Jerome Honnorat
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hopital Neurologique, Lyon, France.,SynatAc Team, Institute NeuroMyoGene INSERM U1217/CNRS UMR 5310, Universite de Lyon, Universit Claude Bernard Lyon 1, Lyon, France
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, UK .,Department of Neurology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Tansley SL, Li D, Betteridge ZE, McHugh NJ. The reliability of immunoassays to detect autoantibodies in patients with myositis is dependent on autoantibody specificity. Rheumatology (Oxford) 2021; 59:2109-2114. [PMID: 32030410 PMCID: PMC7382594 DOI: 10.1093/rheumatology/keaa021] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 12/30/2019] [Indexed: 12/18/2022] Open
Abstract
Objectives In order to address the reliability of commercial assays to identify myositis-specific and -associated autoantibodies, we aimed to compare the results of two commercial immunoassays with the results obtained by protein immunoprecipitation. Methods Autoantibody status was determined using radio-labelled protein immunoprecipitation for patients referred to our laboratory for myositis autoantibody characterization. For each autoantibody of interest, the sera from 25 different patients were analysed by line blot (Euroline Myositis Antigen Profile 4, EuroImmun, Lübeck, Germany) and dot blot (D-Tek BlueDiver, Diagnostic Technology, Belrose, NSW, Australia). Sera from 134 adult healthy controls were analysed. Results Overall commercial assays performed reasonably well, with high agreement (Cohen’s κ >0.8). Notable exceptions were the detection of rarer anti-synthetases with κ < 0.2 and detection of anti-TIF1γ, where κ was 0.70 for the line blot and 0.31 for dot blot. Further analysis suggested that the proportion of patients with anti-TIF1γ may recognize a conformational epitope, limiting the ability of blotting-based assays that utilize denatured antigen to detect this clinically important autoantibody. A false-positive result occurred in 13.7% of samples analysed by line blot and 12.1% analysed by dot blot. Conclusion The assays analysed do not perform well for all myositis-specific and -associated autoantibodies and overall false positives are relatively common. It is crucial that clinicians are aware of the limitations of the methods used by their local laboratory. Results must be interpreted within the clinical context and immunoprecipitation should still be considered in selected cases, such as apparently autoantibody-negative patients where anti-synthetase syndrome is suspected.
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Affiliation(s)
- Sarah L Tansley
- Department of Pharmacy and pharmacology, University of Bath, Bath, UK
- Correspondence to: Sarah Tansley, University of Bath, Claverton Down, Bath BA2 7AY, UK. E-mail:
| | - Danyang Li
- Department of Pharmacy and pharmacology, University of Bath, Bath, UK
| | - Zoe E Betteridge
- Department of Pharmacy and pharmacology, University of Bath, Bath, UK
| | - Neil J McHugh
- Department of Pharmacy and pharmacology, University of Bath, Bath, UK
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de Visser M. Late-onset myopathies: clinical features and diagnosis. ACTA MYOLOGICA : MYOPATHIES AND CARDIOMYOPATHIES : OFFICIAL JOURNAL OF THE MEDITERRANEAN SOCIETY OF MYOLOGY 2020; 39:235-244. [PMID: 33458579 PMCID: PMC7783434 DOI: 10.36185/2532-1900-027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 11/24/2020] [Indexed: 11/06/2022]
Abstract
Late-onset myopathies are not well-defined since there is no clear definition of 'late onset'. For practical reasons we decided to use the age of 40 years as a cut-off. There are diseases which only manifest as late onset myopathy (inclusion body myositis, oculopharyngeal muscular dystrophy and axial myopathy). In addition, there are diseases with a wide range of onset including 'late onset' muscle weakness. Well-known and rather frequently occurring examples are Becker muscular dystrophy, limb girdle muscular dystrophy, facioscapulohumeral dystrophy, Pompe disease, myotonic dystrophy type 2, and anoctamin-5-related distal myopathy. The above-mentioned diseases will be discussed in detail including clinical presentation - which can sometimes lead someone astray - and diagnostic tools based on real cases taken from the author's practice. Where appropriate a differential diagnosis is provided. Next generation sequencing (NGS) may speed up the diagnostic process in hereditary myopathies, but still there are diseases, e.g. with expansion repeats, deletions, etc, in which NGS is as yet not very helpful.
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Affiliation(s)
- Marianne de Visser
- Department of Neurology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
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Thomas R, Yeoh SA, Berkeley R, Woods A, Stevens M, Marino S, Radunovic A. Initial seronegative immune-mediated necrotising myopathy with subsequent anti-HMGCR antibody development and response to rituximab: case report. BMC Rheumatol 2020; 4:29. [PMID: 32613157 PMCID: PMC7325302 DOI: 10.1186/s41927-020-00128-5] [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] [Received: 01/08/2020] [Accepted: 03/31/2020] [Indexed: 11/23/2022] Open
Abstract
Background Immune-mediated necrotising myopathy (IMNM) is characterised by severe muscle weakness and necrosis with a paucity of inflammation on muscle biopsy. Around 60% of cases are associated with antibodies to the signal recognition particle (SRP) or 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR); the remainder are seronegative. IMNM is more treatment resistant than inflammatory myopathies. Case presentation A 69-year-old woman with previous statin exposure presented aged 63 with muscle weakness and raised creatinine kinase (CK). Anti-SRP and anti-HMGCR antibodies were not detected, but muscle biopsy revealed changes consistent with necrotising myopathy. Statins were discontinued, and she was treated with prednisolone and methotrexate achieving disease remission. Clinical and biochemical parameters were largely stable until 6 years after diagnosis she experienced a rapid deterioration. This was found to be associated with new development of anti-HMGCR antibody. Rituximab was commenced, resulting rapidly in remission. She has remained in remission since, following 2 cycles of rituximab. Conclusions To our knowledge, this is the first reported case of serologically negative IMNM whose subsequent rapid deterioration was associated with development of anti-HMGCR antibody. The response to rituximab and subsequent sustained remission suggests a role for early use of rituximab in aggressive cases of anti-HMGCR myopathy.
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Affiliation(s)
- Rhys Thomas
- Department of Rheumatology, Whipps Cross Hospital, Whipps Cross University Hospital, Barts Health NHS Trust, London, E11 1NR UK
| | - Su-Ann Yeoh
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Rupert Berkeley
- Department of Radiology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Andrew Woods
- Department of Immunology, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire UK
| | - Mike Stevens
- Department of Pathology, Barts Health NHS Trust, London, UK
| | - Silvia Marino
- Department of Pathology, Barts Health NHS Trust, London, UK.,Department of Neuropathology, Barts Health NHS Trust, London, UK
| | - Aleksandar Radunovic
- Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK
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Abstract
Skeletal muscle biopsy remains an important investigative tool in the diagnosis of a variety of muscle disorders. Traditionally, someone with a limb-girdle muscle weakness, myopathic changes on electrophysiology and raised serum creatine kinase (CK) would have a muscle biopsy. However, we are living through a genetics revolution, and so do all such patients still need a biopsy? When should we undertake a muscle biopsy in patients with a distal, scapuloperoneal or other patterns of muscle weakness? When should patients with myositis, rhabdomyolysis, myalgia, hyperCKaemia or a drug-related myopathy have a muscle biopsy? What does normal muscle histology look like and what changes occur in neurogenic and myopathic disorders? As with Kipling's six honest serving men, we hope that by addressing these issues we can all become more confident about when to request a muscle biopsy and develop clearer insights into muscle pathology.
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Affiliation(s)
| | - Atik Baborie
- Department of Cellular Pathology, University Hospital of Wales, Cardiff, UK
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12
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Altabás-González I, Pérez-Gómez N, Pego-Reigosa JM. How to investigate: Suspected systemic rheumatic diseases in patients presenting with muscle complaints. Best Pract Res Clin Rheumatol 2019; 33:101437. [PMID: 31810549 DOI: 10.1016/j.berh.2019.101437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Muscular symptoms, which may be due to multiple causes, are one of the most common early complaints in a rheumatology practice. Musculoskeletal symptoms in rheumatic conditions are very varied, ranging from mechanical problems to muscular symptoms derived from inflammatory and systemic autoimmune diseases. Several drugs commonly used by different specialists and certain drugs used in rheumatology can also cause a wide variety of muscle symptoms. A description of different systemic autoimmune diseases follows to describe the different forms of involvement of the musculoskeletal system that they cause, as well as the main causes with which a differential diagnosis should be made. In this chapter, we will try to give some clues to reach an early diagnosis using clinical criteria, particularly based on a directed anamnesis and physical examination, discussing possible guidelines for the complimentary tests that may be required in patients with muscle complaints.
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Affiliation(s)
- Irene Altabás-González
- Rheumatology Department, University Hospital of Vigo, IRIDIS (Investigation in Rheumatology and Immune-Mediated Diseases) Study Group, Health Research Institute from Galicia Sur (IISGS), Consulta n. 4 (Planta 0), Alto do Meixoeiro s/n, 36214, Vigo, Spain.
| | - Naír Pérez-Gómez
- Rheumatology Department, University Hospital of Vigo, IRIDIS (Investigation in Rheumatology and Immune-Mediated Diseases) Study Group, Health Research Institute from Galicia Sur (IISGS), Consulta n. 4 (Planta 0), Alto do Meixoeiro s/n, 36214, Vigo, Spain.
| | - José María Pego-Reigosa
- Rheumatology Department, University Hospital of Vigo, IRIDIS (Investigation in Rheumatology and Immune-Mediated Diseases) Study Group, Health Research Institute from Galicia Sur (IISGS), Consulta n. 4 (Planta 0), Alto do Meixoeiro s/n, 36214, Vigo, Spain.
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Platteel ACM, Wevers BA, Lim J, Bakker JA, Bontkes HJ, Curvers J, Damoiseaux J, Heron M, de Kort G, Limper M, van Lochem EG, Mulder AHL, Saris CGJ, van der Valk H, van der Kooi AJ, van Leeuwen EMM, Veltkamp M, Schreurs MWJ, Meek B, Hamann D. Frequencies and clinical associations of myositis-related antibodies in The Netherlands: A one-year survey of all Dutch patients. J Transl Autoimmun 2019; 2:100013. [PMID: 32743501 PMCID: PMC7388388 DOI: 10.1016/j.jtauto.2019.100013] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 07/25/2019] [Accepted: 07/29/2019] [Indexed: 12/27/2022] Open
Abstract
Idiopathic inflammatory myopathies (IIM) are a heterogeneous group of connective tissue diseases, collectively known as myositis. Diagnosis of IIM is challenging while timely recognition of an IIM is of utter importance considering treatment options and otherwise irreversible (severe) long-term clinical complications. With the EULAR/ACR classification criteria (2017) considerable advancement has been made in the diagnostic workup of IIM. While these criteria take into account clinical parameters as well as presence of one autoantibody, anti-Jo-1, several autoantibodies are associated with IIM and are currently evaluated to be incorporated into classification criteria. As individual antibodies occur at low frequency, the development of line blots allowing multiplex antibody analysis has improved laboratory diagnostics for IIM. The Euroline myositis line-blot assay (Euroimmun) allows screening and semi-quantitative measurement for 15 autoantibodies, i.e. myositis specific antibodies (MSA) to SRP, EJ, OJ, Mi-2α, Mi-2β, TIF1-γ, MDA5, NXP2, SAE1, PL-12, PL-7, Jo-1 and myositis associated antibodies (MAA) to Ku, PM/Scl-75 and PM/Scl-100. To evaluate the clinical significance of detection and levels of these autoantibodies in the Netherlands, a retrospective analysis of all Dutch requests for extended myositis screening within a 1 year period was performed. A total of 187 IIM patients and 632 non-IIM patients were included. We conclude that frequencies of MSA and MAA observed in IIM patients in a routine diagnostic setting are comparable to cohort-based studies. Weak positive antibody levels show less diagnostic accuracy compared to positive antibody levels, except for anti-NXP2. Known associations between antibodies and skin involvement (anti-MDA5, anti-TIF1-γ), lung involvement (anti-Jo-1), and malignancy (anti-TIF1-γ) were confirmed in our IIM study population. The availability of multiplex antibody analyses will facilitate inclusion of additional autoantibodies in clinical myositis guidelines and help to accelerate diagnosing IMM with rare but specific antibodies.
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Affiliation(s)
- Anouk C M Platteel
- St. Antonius Hospital, Department of Medical Microbiology and Immunology, Nieuwegein, the Netherlands
| | - Brigitte A Wevers
- Sanquin Diagnostic Services, Amsterdam, the Netherlands.,Atalmedial, Medical Diagnostic Center, Amsterdam, the Netherlands.,Amsterdam UMC, University of Amsterdam, Department of Experimental Immunology, Amsterdam Infection & Immunity Institute, Amsterdam, the Netherlands
| | - Johan Lim
- Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Department of Neurology, Amsterdam, the Netherlands
| | - Jaap A Bakker
- Leiden University Medical Center, Department of Clinical Chemistry and Laboratory Medicine, Leiden, the Netherlands
| | - Hetty J Bontkes
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Clinical Chemistry, Amsterdam, the Netherlands
| | - Joyce Curvers
- Catharina Hospital Eindhoven, Clinical Laboratory, Eindhoven, the Netherlands
| | - Jan Damoiseaux
- Maastricht University Medical Center, Central Diagnostic Laboratory, Maastricht, the Netherlands
| | - Michiel Heron
- Elisabeth-TweeSteden Hospital, Department of Medical Microbiology and Immunology, Tilburg, the Netherlands
| | | | - Maarten Limper
- University Medical Center Utrecht, Department of Rheumatology and Clinical Immunology, Utrecht, the Netherlands
| | - Ellen G van Lochem
- Rijnstate Hospital, Department of Microbiology and Immunology, Arnhem, the Netherlands
| | | | - Christiaan G J Saris
- Radboud University Medical Center, Donders Institute for Brain Cognition and Behaviour, Department of Neurology, Nijmegen, the Netherlands
| | - Hester van der Valk
- University Medical Center Groningen, Department of Rheumatology and Clinical Immunology, Groningen, the Netherlands
| | - Anneke J van der Kooi
- Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Department of Neurology, Amsterdam, the Netherlands
| | - Ester M M van Leeuwen
- Amsterdam UMC, University of Amsterdam, Department of Experimental Immunology, Amsterdam Infection & Immunity Institute, Amsterdam, the Netherlands
| | - Marcel Veltkamp
- St Antonius Hospital, Interstitial Lung Diseases Center of Excellence, Department of Pulmonology, Nieuwegein, the Netherlands.,Division of Heart&Lungs, University Medical Center, Utrecht, the Netherlands
| | - Marco W J Schreurs
- Erasmus MC University Medical Centre Rotterdam, Department of Immunology, Rotterdam, the Netherlands
| | - Bob Meek
- St. Antonius Hospital, Department of Medical Microbiology and Immunology, Nieuwegein, the Netherlands
| | - Dörte Hamann
- Sanquin Diagnostic Services, Amsterdam, the Netherlands
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