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Min S, Yen DW, Bongiovanni GL. Gastrointestinal Vasculitis in Adult Patient With Dermatomyositis Presenting as Hematemesis. ACG Case Rep J 2024; 11:e01495. [PMID: 39262620 PMCID: PMC11390040 DOI: 10.14309/crj.0000000000001495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 07/22/2024] [Indexed: 09/13/2024] Open
Abstract
Dermatomyositis (DM) is an inflammatory disease of the muscles and skin. Severe gastrointestinal (GI) involvement, characterized by GI bleeding and perforation secondary to underlying vasculopathy, is rarely seen. We describe a case of newly diagnosed DM in a 75-year-old woman who presented with a rash and muscle weakness. She then had sudden onset of hematemesis and was found to have duodenal ulcers due to leukocytoclastic vasculitis from her DM. Our aim was to highlight the need for recognition of GI involvement in adults with DM.
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Affiliation(s)
- Susie Min
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Debra W Yen
- Division of Gastroenterology, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH
| | - Gail L Bongiovanni
- Division of Gastroenterology, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH
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Xiangyuan C, Xiaoling Z, Guangchao S, Huasong Z, Dexin L. Juvenile dermatomyositis complications: navigating gastrointestinal perforations and treatment challenges, a case report. Front Pediatr 2024; 12:1419355. [PMID: 39070551 PMCID: PMC11272553 DOI: 10.3389/fped.2024.1419355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 07/01/2024] [Indexed: 07/30/2024] Open
Abstract
Juvenile dermatomyositis (JDM) is a rare autoimmune disorder with multi-system involvement, often presenting with a heliotrope rash, Gottron's papules, and proximal muscle weakness. JDM patients with anti-nuclear matrix protein 2 (anti-NXP2) positivity tend to have more severe manifestations, including a higher risk of gastrointestinal (GI) complications such as dysphagia, intestinal motility changes, edema, malabsorption, ulcers, and perforations. These complications are associated with poor outcomes and high mortality rates, particularly in patients with anti-NXP2 positivity. A case is presented of a 12-year-old girl with JDM who developed multiple GI perforations after being treated with high-dose methylprednisolone. Despite multiple surgical attempts, the patient experienced continued leakage and new perforations. The treatment approach was shifted to include jejunostomy, plasma exchanges, fresh frozen plasma support, and tofacitinib, leading to gradual improvement in muscle strength and reduction in inflammation. GI involvement in JDM is a significant concern due to its association with poor prognosis and high mortality. The use of high-dose glucocorticoids must be carefully considered in JDM patients with GI involvement, as they may contribute to the development of perforations and complicate treatment. A combination of plasma exchange, fresh frozen plasma support, low-dose glucocorticoids, and Janus kinase inhibitors may offer a safer treatment strategy for managing refractory JDM with GI complications. The case highlights the importance of a multidisciplinary approach to treatment and the need for further research to determine the necessity of high-dose glucocorticoid therapy following GI involvement in JDM.
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Affiliation(s)
- Chen Xiangyuan
- Department of Allergy, Immunology and Rheumatology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Zeng Xiaoling
- Department of Allergy, Immunology and Rheumatology, Liuzhou Hospital, Guangzhou Women and Children’s Medical Center, Liuzhou, China
| | - Sun Guangchao
- Department of Allergy, Immunology and Rheumatology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Zeng Huasong
- Department of Allergy, Immunology and Rheumatology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Liu Dexin
- Department of Allergy, Immunology and Rheumatology, Liuzhou Hospital, Guangzhou Women and Children’s Medical Center, Liuzhou, China
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Georgi I, Georgi M, Haas JP. [Advances in the diagnostics and treatment of juvenile dermatomyositis]. Z Rheumatol 2024; 83:41-51. [PMID: 38157051 DOI: 10.1007/s00393-023-01454-y] [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] [Accepted: 10/15/2023] [Indexed: 01/03/2024]
Abstract
Juvenile dermatomyositis (JDM) is by far the most frequent inflammatory myopathy in childhood and adolescence. It is clinically characterized by inflammatory changes of the skin and muscles but as a multisystemic disease can also affect the skeletal system, the gastrointestinal tract, lungs and heart. Intrinsic (multigenetic risk) and extrinsic factors (triggers) are involved in the pathogenesis resulting in endothelial damage, involvement of fascies, activation of the interferon system and autoimmune reactions including formation of myositis-specific autoantibodies (MSA). In contrast to dermatomyositis in adults, in children and adolescents there are no associations with malignant diseases. The variable expression, the rarity of the disease and the risk of long-term damage and complications necessitate pediatric rheumatological experience in the diagnostics and treatment. Recently, new approaches in drug treatment have substantially improved the outcome and prognosis but a multidisciplinary treatment (including physicians, physiotherapists, psychologists, social workers) is mandatory, especially in the first phases of the disease. Particularly important is a professionally correct treatment of the functional sequelae, which are a particular focus of this article.
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Affiliation(s)
- Ingrid Georgi
- Deutsches Zentrum für Kinder- und Jugendrheumatologie, Kinderklinik Garmisch-Partenkirchen, Gehfeldstr. 24, 82467, Garmisch-Partenkirchen, Deutschland
| | - Mathias Georgi
- Deutsches Zentrum für Kinder- und Jugendrheumatologie, Kinderklinik Garmisch-Partenkirchen, Gehfeldstr. 24, 82467, Garmisch-Partenkirchen, Deutschland
| | - Johannes-Peter Haas
- Deutsches Zentrum für Kinder- und Jugendrheumatologie, Kinderklinik Garmisch-Partenkirchen, Gehfeldstr. 24, 82467, Garmisch-Partenkirchen, Deutschland.
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Fu Y, Gu L, Chen J, Dai Y, Feng Q, Chen Z, Fan J, Gao M, Wang X, Fu Q, Ye S. Severe gastrointestinal involvements in patients with adult dermatomyositis with anti-NXP2 antibody. RMD Open 2024; 10:e003901. [PMID: 38199847 PMCID: PMC10806494 DOI: 10.1136/rmdopen-2023-003901] [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: 11/14/2023] [Accepted: 12/28/2023] [Indexed: 01/12/2024] Open
Abstract
OBJECTIVE Gastrointestinal (GI) involvements were scarcely reported in adult anti-nuclear matrix protein 2 (NXP2) dermatomyositis (NXP2+DM). In this study, we investigated the clinical, pathological and molecular features as well as treatment options of this rare yet life-threatening disease. METHODS We retrospectively collected the data of the cohort of NXP2+ DM from 2012 to 2022 in our hospital. RNA sequencing was performed in intestinal samples of perforated patients compared with healthy controls data set. RESULTS A total of 56 patients with adult NXP2+DM were collected including 10 cases with GI involvements. Abdominal pain and melena were the initial manifestations for GI involvements with a median 10-month time lag after the diagnosis of NXP2+DM when myositis largely subsided. Within weeks, GI perforation occurred in 8 of 10 patients, while five patients underwent eight surgical interventions subsequently. The short-term mortality was observed in four patients. NXP2+DM with GI involvements presented with more extramuscular systemic manifestations such as interstitial lung disease and subcutaneous calcinosis. The GI pathological features encompassed vasculitis/vasculopathy with high MxA expression, intestinal smooth muscle necrosis and serosal calcinosis. Gene expression profile validated the type-I interferon activation and revealed that epithelial mesenchymal transition and focal adhesion pathway may also contribute. Finally, vedolizumab, an anti-α4β7-integrin monoclonal antibody, exhibited promising therapeutic signals which should be further investigated. CONCLUSIONS GI involvement is a unique complication in patients with adult NXP2+DM. Timely recognition and targeted therapy may turn out to be lifesaving.
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Affiliation(s)
- Yakai Fu
- Department of Rheumatology, Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, Shanghai, China
| | - Liyang Gu
- Department of Rheumatology, Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, Shanghai, China
| | - Jie Chen
- Department of Rheumatology, Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, Shanghai, China
| | - Yuting Dai
- Shanghai Jiao Tong University Medical School Affiliated Ruijin Hospital, Shanghai, China
| | - Qi Feng
- Department of Radiology, Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, Shanghai, China
| | - Zhiwei Chen
- Department of Rheumatology, Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, Shanghai, China
| | - Jie Fan
- Department of Pathology, Huashan Hospital Fudan University, Shanghai, China
| | - Mingshi Gao
- Department of Pathology, Huashan Hospital Fudan University, Shanghai, China
| | - Xiaodong Wang
- Department of Rheumatology, Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, Shanghai, China
| | - Qiong Fu
- Department of Rheumatology, Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, Shanghai, China
| | - Shuang Ye
- Department of Rheumatology, Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, Shanghai, China
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Uchio N, Komaki S, Sudo T, Matsumoto Y, Hao A, Kojima K, Toda N, Kitamura A, Maeda MH, Kubota A, Matsumoto H. Anti-nuclear matrix protein 2 antibody-positive dermatomyositis with gastrointestinal ulcers: A case report. Int J Rheum Dis 2023; 26:2572-2575. [PMID: 37287416 DOI: 10.1111/1756-185x.14755] [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: 04/24/2023] [Revised: 05/10/2023] [Accepted: 05/17/2023] [Indexed: 06/09/2023]
Abstract
Gastrointestinal manifestations are a very rare complication of dermatomyositis (DM) and are much less frequent in adult cases than in juvenile cases. Only a few previous papers have reported adult patients who had DM with anti-nuclear matrix protein 2 (anti-NXP2) antibodies and who developed gastrointestinal ulcers. Herein, we report a similar case of a 50-year-old man who had DM with anti-NXP2 antibodies followed by relapsing multiple gastrointestinal ulcers. Even after the administration of prednisolone, his muscle weakness and myalgia deteriorated and gastrointestinal ulcers relapsed. In contrast, intravenous immunoglobulin and azathioprine improved his muscle weakness and gastrointestinal ulcers. Based on the parallel disease activity of the muscular and gastrointestinal symptoms, we considered that his gastrointestinal ulcers were a complication of DM with anti-NXP2 antibodies. We also propose that early intensive immunosuppressive therapy would be required for the muscular and gastrointestinal symptoms in DM with anti-NXP2 antibodies.
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Affiliation(s)
- Naohiro Uchio
- Department of Neurology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Shogo Komaki
- Department of Neurology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Takashi Sudo
- Department of Neurology, Mitsui Memorial Hospital, Tokyo, Japan
| | | | - Akihito Hao
- Department of Neurology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Kentaro Kojima
- Department of Gastroenterology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Nobuo Toda
- Department of Gastroenterology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Asuka Kitamura
- Department of Neurology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Meiko Hashimoto Maeda
- Department of Neurology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Akatsuki Kubota
- Department of Neurology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Xu S, Hu X, Wang J, Xu Q, Han Z, Zhou H, Gao M. Polymyositis and dermatomyositis biomarkers. Clin Chim Acta 2023; 547:117443. [PMID: 37329941 DOI: 10.1016/j.cca.2023.117443] [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: 04/04/2023] [Revised: 06/08/2023] [Accepted: 06/11/2023] [Indexed: 06/19/2023]
Abstract
Polymyositis (PM) and dermatomyositis (DM) are the two subtypes of idiopathic inflammatory myositis and are characterized as symmetrical progressive muscle weakness in the proximal extremities. PM/DM affect multiple organs and systems, including the cardiovascular, respiratory and digestive tract systems. An in-depth understanding of PM/DM biomarkers will facilitate development of simple and accurate strategies for diagnosis, treatment, and prognosis prediction. This review summarized the classic biomarkers of PM/DM, including anti-aminoacyl tRNA synthetases (ARS) antibody, anti-Mi-2 antibody, anti-melanoma differentiation-associated gene 5 (MDA5) antibody, anti-transcription intermediary factor 1-γ (TIF1-γ) antibody, anti-nuclear matrix protein 2 (NXP2) antibody, among others. Among them, anti-aminoacyl tRNA synthetases antibody is the most classic. In addition, many potential novel biomarkers were also discussed in this review, including anti-HSC70 antibody, YKL-40, interferons, myxovirus resistance protein 2, regenerating islet-derived protein 3-α, interleukin (IL)-17, IL-35, microRNA (miR)-1 and so on. Among the biomarkers of PM/DM described in this review, classic biomarkers have become the mainstream biomarkers to assist clinicians in diagnosis due to their early discovery, in-depth research, and widespread application. The novel biomarkers also have potential and broad research prospects, which will make immeasurable contributions to exploring biomarker-based classification standards and expanding their application value.
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Affiliation(s)
- Shuyue Xu
- Wuxi No. 2 People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
| | - Xiaowei Hu
- Xinwu District Center for Disease Control and Prevention, Wuxi, China
| | - Jing Wang
- Wuxi School of Medicine, Jiangnan University, Wuxi, China
| | - Qiangwei Xu
- Department of Rheumatology, The Affiliated Wuxi No. 2 People's Hospital of Nanjing Medical University, Wuxi, China
| | - Zhijun Han
- Wuxi No. 2 People's Hospital Affiliated to Nanjing Medical University, Wuxi, China; Department of Clinical Research Center, Jiangnan University Medical Center, Wuxi, China
| | - Haiyan Zhou
- Department of Cardiovascular Medicine, The Affiliated Hospital of Guizhou Medical University, Guiyang, China.
| | - Mingzhu Gao
- Department of Clinical Research Center, Jiangnan University Medical Center, Wuxi, China; Wuxi No. 2 People's Hospital Affiliated to Nanjing Medical University, Wuxi, China.
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An Unusual Cause of Necrotising Fasciitis in a Young Male with Juvenile Dermatomyositis. Case Rep Rheumatol 2022; 2022:8758263. [PMID: 35982709 PMCID: PMC9381251 DOI: 10.1155/2022/8758263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 03/28/2022] [Accepted: 07/22/2022] [Indexed: 11/17/2022] Open
Abstract
Juvenile dermatomyositis (JDM) is a rare condition worldwide, affecting children younger than 16 years. It is characterized by weakness in the proximal skeletal muscles and a pathognomonic skin rash. Patients with JDM develop complications that are usually a consequence of vasculopathy affecting multiple organ systems. Occult gastrointestinal (GI) perforation is an uncommon complication and is associated with an increased risk of mortality due to a delay in diagnosis. We report on a 14-year-old male with JDM with an aggressive course over two years and severe clinical manifestations. The patient developed necrotizing fasciitis, an unusual rapidly progressing lethal infection of the fascia resulting from bowel contents seeping from multiple intestinal perforations. This case, less commonly seen in males, highlights the occurrence of multiple phenomena—JDM complicated by skin and gastrointestinal vasculopathy with resultant development of multiple GI perforations and consequently life-threatening necrotizing fasciitis of the leg. Physicians need a high index of suspecting GI perforation in JDM patients as the delayed recognition of this complication can result in significant morbidity and/or mortality since the typical symptoms of perforation may be absent.
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Gastrointestinal Involvement in Dermatomyositis. Diagnostics (Basel) 2022; 12:diagnostics12051200. [PMID: 35626355 PMCID: PMC9139828 DOI: 10.3390/diagnostics12051200] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/27/2022] [Accepted: 05/09/2022] [Indexed: 01/27/2023] Open
Abstract
Dermatomyositis is a systemic vasculopathy mainly affecting skin, muscle and lung, but may affect the gastrointestinal tract. We aim to describe clinical characteristics of patients with severe gastrointestinal involvement related to dermatomyositis in our center and medical literature. We retrospectively analysed these patients in our center, including cases of erosions/ulcers, perforation or digestive bleeding. Reported cases from April 1990 to April 2021 were reviewed through PubMed and Cochrane. From our cohort (n = 188), only 3 presented gastrointestinal compromise. All were women (10, 46 and 68 years). The initial symptom was abdominal pain and all had ≥2 episodes of digestive bleeding. All died due to complications of gastrointestinal involvement. Available pathological samples showed vascular ectasia. From the literature review (n = 50), 77% were women with a mean age of 49 years and the main symptom was abdominal pain (65%). All presented active muscular and cutaneous involvement at complication diagnosis. Mortality was 41.7%. The underlying lesion was perforation or ulcer (n = 22), intestinal wall thickening (n = 2), macroscopic inflammation (n = 2) or intestinal pneumatosis (n = 15). In 13 cases, vasculitis was described. Gastrointestinal involvement in dermatomyositis denotes severity, so an early intensive treatment is recommended. Pathological findings suggest that the underlying pathophysiological mechanism is a vasculopathy and not a true vasculitis.
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Fanouriakis A, Lazarini A, Sofianos I, Papadopoulos C, Bagiazidou E, Balanika A, Elezoglou A. Diffuse oesophageal involvement in anti-NXP2 myositis and response to combined immunosuppressive therapy. Rheumatology (Oxford) 2021; 60:e378-e380. [PMID: 33956080 DOI: 10.1093/rheumatology/keab422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/12/2021] [Accepted: 05/05/2021] [Indexed: 11/15/2022] Open
Affiliation(s)
| | | | | | - Constantinos Papadopoulos
- 1st Department of Neurology, Eginition Hospital, Medical School, National and Kapodistrian University of Athens
| | | | - Alexia Balanika
- Department of Radiology, 'Asklepieion' General Hospital, Athens, Greece
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