1
|
Muacevic A, Adler JR, Chaudhari J, Panchal V, Shah A. An Unusual Presentation of Juvenile Polymyositis in an Adolescent Girl. Cureus 2023; 15:e33249. [PMID: 36741666 PMCID: PMC9890880 DOI: 10.7759/cureus.33249] [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] [Accepted: 01/02/2023] [Indexed: 01/03/2023] Open
Abstract
Juvenile idiopathic inflammatory myopathies (JIIMs) are a group of diverse, systemic autoimmune diseases that manifest in childhood and are characterized by weakness and chronic inflammation of skeletal muscles. One of the relatively rare variants of JIIMs is juvenile polymyositis (JPM). JPM patients present with proximal and distal muscle weakness, gait instability with falls, muscle pain and tenderness, and high levels of creatine kinase (CK) during adolescence. There are currently few people being diagnosed with JPM, which raises the question of whether or not it is a distinct disease. We discuss the case of a 13-year-old girl who presented to the hospital with generalized body swelling and difficulty swallowing solid food. She also had drooling of saliva during the presentation and a history of difficulty climbing up and down the stairs for three months. Her extensive laboratory workup showed a positive antinuclear antibody (ANA) test and increased muscle enzyme. A muscle biopsy was ordered, and she was diagnosed with JPM. Such a unique presentation has rarely been reported in the pediatric literature. This case report outlines an unusual JPM presentation that could help clinicians identify the condition and start treatment as soon as possible to minimize complications.
Collapse
|
2
|
Karaca Ö, Güngör M, Sakarya Güneş A, Eser Şimşek I, Anık Y, Kara B. Angioedema-like presentation as the presenting finding of juvenile myositis and juvenile dermatomyositis in 2 patients. Int J Rheum Dis 2022; 25:617-625. [PMID: 35238477 DOI: 10.1111/1756-185x.14311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 02/01/2022] [Accepted: 02/07/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Juvenile dermatomyositis (JDM) is the most common subtype of idiopathic inflammatory myopathies in childhood. Gottron's papules, shawl sign, periorbital heliotrope rash, and periungual telengiectasis are characteristic skin findings of the disease. Besides characteristic skin involvement, some other skin findings, such as angioedema, may be seen prior or in the course of the disease. The presence of angioedema in JDM is emphasized in this report. CASE PRESENTATIONS We present 2 unrelated girls, aged 2 (case 1) and 12 years (case 2), who had developed symmetrical weakness in the proximal muscles, muscle pain, elevated muscle enzymes and angioedema. Both cases had abnormal muscle magnetic resonance imaging findings, suggestive of inflammatory myositis. Muscle biopsy was performed only in case 1, and major histocompatibility complex-1 expression on myofibers was shown consistent with JDM. Cases were diagnosed as probable and definite JDM, respectively. Angioedema was prominent, particularly in the lips and extremities of both cases, without laboratory evidence of C1 inhibitor deficiency or capillary leak syndrome, and absence of family history. Mast cell-mediated, acquired angioedema was the most likely diagnosis. In both cases, skin and muscle findings improved significantly with steroid treatment. CONCLUSION We suggest that angioedema may be among the characteristic skin findings in JDM, and may be included in subsequent definitions.
Collapse
Affiliation(s)
- Ömer Karaca
- Kocaeli University Medical Faculty, Division of Child Neurology, Department of Pediatrics, Izmit, Turkey
| | - Mesut Güngör
- Kocaeli University Medical Faculty, Division of Child Neurology, Department of Pediatrics, Izmit, Turkey
| | - Ayfer Sakarya Güneş
- Division of Child Neurology, Department of Pediatrics, Sakarya Education and Research Hospital, Sakarya, Turkey
| | - Işıl Eser Şimşek
- Kocaeli University Medical Faculty, Division of Child Allergy and Immunology, Department of Pediatrics, Izmit, Turkey
| | - Yonca Anık
- Kocaeli University Medical Faculty, Department of Radiology, Izmit, Turkey
| | - Bülent Kara
- Kocaeli University Medical Faculty, Division of Child Neurology, Department of Pediatrics, Izmit, Turkey
| |
Collapse
|
3
|
Schildt EE, De Ranieri D. Anasarca as the presenting symptom of juvenile dermatomyositis: a case series. Pediatr Rheumatol Online J 2021; 19:120. [PMID: 34389019 PMCID: PMC8361657 DOI: 10.1186/s12969-021-00604-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 05/23/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Juvenile Dermatomyositis (JDM) is an autoimmune disease that typically presents with classic skin rashes and proximal muscle weakness. Anasarca is a rare manifestation of this disease and is associated with a more severe and refractory course, requiring increased immunosuppression. Early recognition of this atypical presentation of JDM may lead to earlier treatment and better outcomes. CASE PRESENTATION We present two female patients, ages 11 years old and 4 years old, who presented to the ED with anasarca and were subsequently diagnosed with JDM. Both patients required ICU-level care and significant immunosuppression, including prolonged courses of IV methylprednisolone, IVIG, and Rituximab. CONCLUSIONS Anasarca is a rare presentation of Juvenile Dermatomyositis, but it is important for clinicians to recognize this manifestation of the disease. Early recognition and treatment will lead to better outcomes in these children and hopefully decrease the need for prolonged hospitalization and ICU level care.
Collapse
Affiliation(s)
- Emily E. Schildt
- grid.413808.60000 0004 0388 2248Department of Rheumatology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL United States
| | - Deirdre De Ranieri
- Department of Rheumatology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States.
| |
Collapse
|
4
|
Castillo RL, Femia AN. Covert clues: the non-hallmark cutaneous manifestations of dermatomyositis. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:436. [PMID: 33842657 PMCID: PMC8033358 DOI: 10.21037/atm-20-5252] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Dermatomyositis (DM) is a strikingly heterogenous disease characterized by a broad and ever-evolving spectrum of cutaneous manifestations that transcend the classic “hallmarks” defined by Peter and Bohan in 1975. Despite the increasing preponderance and ubiquity of autoantibody, radiologic, and electrophysiologic testing, the diagnosis of DM still hinges largely on prompt detection of cutaneous manifestations of this condition. While pathognomonic cutaneous features of DM are more readily recognizable, many patients present with subtle and/or atypical skin manifestations, and diagnosis of DM may require clinician identification of these cutaneous clues. In this review, we highlight several of the lesser-known skin manifestations of DM, specifically, panniculitis, diffuse subcutaneous edema, erythroderma, calcinosis, ulceration, flagellate erythema, Wong-type DM, gingival telangiectasias, and the ovoid palatal patch. We describe the clinical and histopathologic presentation of these cutaneous findings. While manifesting less frequently than the heliotrope rash, Gottron’s papules, and Gottron’s sign, these cutaneous clues are equally important for clinicians to recognize in order to facilitate timely diagnosis and early intervention.
Collapse
Affiliation(s)
- Rochelle L Castillo
- Department of Medicine, Division of Rheumatology, NYU Grossman School of Medicine, New York, NY, USA
| | - Alisa N Femia
- Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, New York, NY, USA
| |
Collapse
|
5
|
Wu JQ, Lu MP, Reed AM. Juvenile dermatomyositis: advances in clinical presentation, myositis-specific antibodies and treatment. World J Pediatr 2020; 16:31-43. [PMID: 31556011 DOI: 10.1007/s12519-019-00313-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 08/29/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Juvenile dermatomyositis (JDM) is a chronic autoimmune disease characteristic by inflammation of small vessels within the skin, muscle and vital organs. But the clinical features and treatment of JDM have not been fully clarified. DATA SOURCES Databases underwent through PubMed for articles about the clinical features, myositis-specific antibodies of JDM and its treatment, and we selected publications written in English which were relevant to the topic of this review. RESULTS Clinical features and myositis-specific antibodies may predict the severity and prognosis of disease. Although the mortality rate has been lower with traditional treatments, such as corticosteroid, intravenous immunoglobulin, and disease-modifying anti-rheumatic drugs such as methotrexate, their usages are variable. Novel biological therapies seem to be effective for refractory JDM patients, but more clinical trials are necessary. CONCLUSIONS JDM is a sever disease of childhood. We need to better understand recent advances of JDM in the context of clinical features including skin manifestations, muscle weakness and organ damage, myositis-specific antibodies and their associated outcomes and the treatment of disease.
Collapse
Affiliation(s)
- Jian-Qiang Wu
- Department of Rheumatology Immunology and Allergy, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, 310052, China
| | - Mei-Ping Lu
- Department of Rheumatology Immunology and Allergy, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, 310052, China
| | - Ann M Reed
- Department of Pediatrics, Division of Pediatric Rheumatology, Duke University School of Medicine, Durham, 27710, USA.
| |
Collapse
|
6
|
Ueki M, Kobayashi I, Takezaki S, Tozawa Y, Okura Y, Yamada M, Kuwana M, Ariga T. Myositis-specific autoantibodies in Japanese patients with juvenile idiopathic inflammatory myopathies. Mod Rheumatol 2018. [PMID: 29532710 DOI: 10.1080/14397595.2018.1452353] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVES The aim of our study is to clarify the association of myositis-specific autoantibodies (MSAs) with clinical and laboratory features in Japanese patients with juvenile idiopathic inflammatory myopathies (JIIMs). METHODS We retrospectively analyzed the frequency of MSAs and their association with clinical or laboratory findings in 25 Japanese patients with JIIMs in Hokkaido district. RESULTS Eighteen of the 25 patients (72%) were positive for MSAs; seven with anti-melanoma differentiation associated gene (MDA) 5 (28%), five with anti-transcriptional intermediary factor (TIF)-1γ (20%), four with anti-MJ/nuclear matrix protein (NXP)-2 (16%), two with anti-Jo-1 (8%), one with anti- HMG-CoA reductase, one with anti-signal recognition peptide (SRP) antibodies (4% each), including co-existence and transition of MSAs in one patient each. Anti-MDA5 antibodies were related to interstitial lung disease (ILD) and arthritis but not to amyopathic juvenile dermatomyositis. Drug-free remission was achieved, once ILD was overcome in this group. Anti-TIF-1γ antibodies were associated with typical rashes and mild myositis. Anti-MJ/NXP2 and anti-SRP antibodies were associated with severe muscle weakness. No patient was complicated with malignancy. CONCLUSION Anti-MDA5 antibodies are prevalent and closely associated with ILD in our series compared with other countries. There was no apparent difference in clinical features associated with other MSAs among races.
Collapse
Affiliation(s)
- Masahiro Ueki
- a Department of Pediatrics, Faculty of Medicine and Graduate School of Medicine , Hokkaido University , Sapporo , Japan
| | - Ichiro Kobayashi
- a Department of Pediatrics, Faculty of Medicine and Graduate School of Medicine , Hokkaido University , Sapporo , Japan.,b Center for Pediatric Allergy and Rheumatology , KKR Sapporo Medical Center , Sapporo , Japan
| | - Shunichiro Takezaki
- a Department of Pediatrics, Faculty of Medicine and Graduate School of Medicine , Hokkaido University , Sapporo , Japan
| | - Yusuke Tozawa
- a Department of Pediatrics, Faculty of Medicine and Graduate School of Medicine , Hokkaido University , Sapporo , Japan
| | - Yuka Okura
- b Center for Pediatric Allergy and Rheumatology , KKR Sapporo Medical Center , Sapporo , Japan
| | - Masafumi Yamada
- a Department of Pediatrics, Faculty of Medicine and Graduate School of Medicine , Hokkaido University , Sapporo , Japan
| | - Masataka Kuwana
- c Department of Allergy and Rheumatology , Nippon Medical School Graduate School of Medicine , Tokyo , Japan
| | - Tadashi Ariga
- a Department of Pediatrics, Faculty of Medicine and Graduate School of Medicine , Hokkaido University , Sapporo , Japan
| |
Collapse
|
7
|
Barsell A, Librizzi J. A 5-Year-Old Girl with Fatigue, Diffuse Edema, and Weakness. Pediatr Ann 2015; 44:471-6. [PMID: 26587813 DOI: 10.3928/00904481-20151112-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
8
|
Gitiaux C, De Antonio M, Aouizerate J, Gherardi RK, Guilbert T, Barnerias C, Bodemer C, Brochard-Payet K, Quartier P, Musset L, Chazaud B, Desguerre I, Bader-Meunier B. Vasculopathy-related clinical and pathological features are associated with severe juvenile dermatomyositis. Rheumatology (Oxford) 2015; 55:470-9. [PMID: 26424834 DOI: 10.1093/rheumatology/kev359] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE Outcome of JDM is highly heterogeneous. Our objective was to determine clinical and muscle biopsy features associated with poor outcome and response to treatment. METHODS Clinical data and muscle biopsy were obtained from a monocentric cohort of 29 patients. Clinical subgroups were defined by latent class model analysis of initial and follow-up parameters. Myopathological features were analysed using validated scores. Capillary loss was determined on reconstructions of transversal sections and assessed in the different age groups to take into account variations of muscle capillarization during post-natal development. Regression models were used to identify initial predictors of therapeutic response. RESULTS Two distinct homogeneous subgroups of patients were identified according to clinical severity and pathological findings. The smallest group of patients (7/29) presented with severe JDM. Compared with the other group (22/29), patients had more severe muscle weakness at disease onset, low remission rate at 12 months, frequent subcutaneous limb oedema or gastrointestinal (GI) involvement and higher myopathological scores (capillary dropout, perifascicular necrosis/regeneration, fibres with internal myonuclei and fibrosis subscores). Relevance of capillary dropout to JDM severity was substantiated by age-based analysis, confirming its major role in JDM pathophysiology. Most of these manifestations could be related to vasculopathy (limb oedema, GI involvement, capillary dropout). Furthermore, Childhood Myositis Assessment Scale <34 with either GI involvement or muscle endomysial fibrosis at disease onset were the best predictors of poor response to treatment. CONCLUSION Vasculopathy is prominent in severe JDM. Simple criteria can be used at initial evaluation to identify patients requiring a more intensive therapy.
Collapse
Affiliation(s)
- Cyril Gitiaux
- Department of Pediatric Neurology and Pediatric Neurophysiology, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Université Paris Descartes, Paris, AP-HP, Referral Center for Neuromuscular Diseases 'Garches-Necker-Mondor-Hendaye', Créteil, INSERM U1016, Genetics and development, Institut Cochin, Paris-Descartes University, CNRS UMR 8104, Genetics and development, Institut Cochin, Paris-Descartes University,
| | - Marie De Antonio
- Department of Pathology, AP-HP, Albert Chenevier-Henri Mondor Hospital, Créteil, INSERM UMRS1138-Team 22, Centre de Recherche des Cordeliers, Paris-Descartes University, UPMC University, Paris
| | - Jessie Aouizerate
- Department of Pathology, AP-HP, Albert Chenevier-Henri Mondor Hospital, Créteil
| | - Romain K Gherardi
- Department of Pathology, AP-HP, Albert Chenevier-Henri Mondor Hospital, Créteil, INSERM U955-Team 10, Department of Neurosciences, 'Mondor Biomedical Research Institute', Paris-Est University, Faculty of Medicine, Créteil
| | - Thomas Guilbert
- INSERM U1016, Genetics and development, Institut Cochin, Paris-Descartes University, CNRS UMR 8104, Genetics and development, Institut Cochin, Paris-Descartes University
| | - Christine Barnerias
- Department of Pediatric Neurology and Pediatric Neurophysiology, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Université Paris Descartes, Paris, AP-HP, Referral Center for Neuromuscular Diseases 'Garches-Necker-Mondor-Hendaye', Créteil
| | - Christine Bodemer
- Department of Dermatology, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Université Paris Descartes, Paris
| | - Karine Brochard-Payet
- Department of Pediatric Internal Medicine and Nephrology, Hôpital des Enfants, CHU de Toulouse, Toulouse
| | - Pierre Quartier
- Department of Pediatric Immunology-Hematology and Rheumatology, Paris-Descartes University, INSERM U 1163, Institut Imagine, AP-HP, Necker Hospital and
| | - Lucile Musset
- Department of Immunology, CHU Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Bénédicte Chazaud
- INSERM U1016, Genetics and development, Institut Cochin, Paris-Descartes University, CNRS UMR 8104, Genetics and development, Institut Cochin, Paris-Descartes University
| | - Isabelle Desguerre
- Department of Pediatric Neurology and Pediatric Neurophysiology, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Université Paris Descartes, Paris, AP-HP, Referral Center for Neuromuscular Diseases 'Garches-Necker-Mondor-Hendaye', Créteil, INSERM U1016, Genetics and development, Institut Cochin, Paris-Descartes University, CNRS UMR 8104, Genetics and development, Institut Cochin, Paris-Descartes University
| | - Brigitte Bader-Meunier
- Department of Pediatric Immunology-Hematology and Rheumatology, Paris-Descartes University, INSERM U 1163, Institut Imagine, AP-HP, Necker Hospital and
| |
Collapse
|
9
|
Edemas generalizados como forma de presentación de dermatomiositis juvenil. An Pediatr (Barc) 2013; 79:271-2. [DOI: 10.1016/j.anpedi.2013.01.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Revised: 06/11/2012] [Accepted: 01/25/2013] [Indexed: 11/19/2022] Open
|
10
|
Limb edema and anasarca associated with severe dermatomyositis: Report of four cases. Neuromuscul Disord 2011; 21:439-42. [DOI: 10.1016/j.nmd.2011.03.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2010] [Revised: 03/01/2011] [Accepted: 03/14/2011] [Indexed: 11/23/2022]
|
11
|
|