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Sener S, Cam V, Ozen S, Batu ED. Biologic drugs in the treatment of juvenile dermatomyositis: a literature review. Clin Rheumatol 2024; 43:591-602. [PMID: 37582998 DOI: 10.1007/s10067-023-06740-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 08/07/2023] [Accepted: 08/08/2023] [Indexed: 08/17/2023]
Abstract
There is no clear consensus in the literature regarding the choice of biologic therapies and efficacy in juvenile dermatomyositis (JDM). In this review, we aimed to examine previous studies regarding biologic drug use in JDM patients. We screened MEDLINE and Scopus for articles involving JDM patients treated with biologic drugs. We identified 74 articles describing 495 JDM patients treated with biologic drugs (538 biologic treatments) during our literature search. The median (min-max) age of these patients was 9.8 (1-17) years (F/M:1.8). The most frequently used biologic drugs were rituximab (RTX, 50%) and tumor necrosis factor (TNF) inhibitors (34.8%). In a few cases, abatacept (4.3%), anti-interleukin-1 agents (0.9%), tocilizumab (0.9%), bortezomib (0.4%), ustekinumab (0.2%), eculizumab (0.2%), and golimumab (0.2%) were used. RTX was most frequently preferred in patients with severe skin involvement (46.3%). Improvement with RTX was obtained in 60.1% of RTX treatments. Infliximab was most frequently preferred in calcinosis (43.3%), while adalimumab in skin involvement (50%) and etanercept in resistant/recurrent diseases (80%). Improvement was achieved in 44.4% of anti-TNF treatments. Adverse events were observed in 46.8% (58/124) of all treatments. Our results suggest that biologic agents may be a promising alternative for the treatment of particularly resistant JDM cases. Controlled studies are required to provide higher level of evidence for the timing of biologic use in JDM treatment. Key Points • There is no consensus on the choice and efficacy of biologic therapies in JDM. • RTX and TNF inhibitors are the most commonly used biologic drugs. • Biologics were especially preferred in severe skin involvement, calcinosis, and resistant diseases.
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Affiliation(s)
- Seher Sener
- Department of Pediatrics, Division of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Veysel Cam
- Department of Pediatrics, Division of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Seza Ozen
- Department of Pediatrics, Division of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ezgi Deniz Batu
- Department of Pediatrics, Division of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey.
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Balan S, Madan S. Idiopathic Inflammatory Myopathies. Indian J Pediatr 2023:10.1007/s12098-023-04896-z. [PMID: 37919486 DOI: 10.1007/s12098-023-04896-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 10/05/2023] [Indexed: 11/04/2023]
Abstract
Idiopathic inflammatory myopathies (IIMs) are a diverse group of diseases characterized by proximal muscle weakness and inflammation in skeletal muscle. Phenotypically, the subtypes include dermatomyositis, polymyositis, inclusion body myositis, and amyopathic dermatomyositis. The most common IIM in children is juvenile dermatomyositis (JDM). In contrast to adult dermatomyositis (DM), children are likely to have frequent relapses, vasculopathy, and long-term metabolic and other complications like lipodystrophy, insulin resistance, and calcinosis. Significant advances in our understanding of pathogenesis, disease course, and treatment of JDM has changed the therapeutic landscape and improved outcomes in children. Myositis-specific autoantibodies and myositis-associated autoantibodies have unique clinical associations, disease course and help predict response to therapy. A multidisciplinary approach including exercise programs and psychosocial support is essential. The first line of treatment is a combination of corticosteroids and methotrexate (MTX). Other targeted immunosuppressive therapy is used in refractory cases. Early recognition and timely referral to a specialist center remain pivotal to improving the mortality and morbidity associated with this disease.
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Affiliation(s)
- Suma Balan
- Department of Rheumatology and Clinical Immunology, Amrita Institute of Medical Sciences and Research Centre, Ponekkara, Kochi, Kerala, 682 041, India.
| | - Sumanth Madan
- Department of Rheumatology and Clinical Immunology, Amrita Institute of Medical Sciences and Research Centre, Ponekkara, Kochi, Kerala, 682 041, India
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Fujita Y, Kuwashima S, Sakurai R, Suzuki A, Imataka G, Matsuda H, Ishida K, Matsushita T, Nishino I, Yoshihara S. Whole-body MRI revealed generalized subcutaneous oedema in a patient with juvenile dermatomyositis. Rheumatol Adv Pract 2023; 7:rkad063. [PMID: 37538928 PMCID: PMC10393869 DOI: 10.1093/rap/rkad063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2023] [Indexed: 08/05/2023] Open
Affiliation(s)
- Yuji Fujita
- Correspondence to: Yuji Fujita, Department of Paediatrics, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Shimotsuga, Tochigi 321-0293, Japan. E-mail:
| | | | - Ryosuke Sakurai
- Department of Paediatrics, Dokkyo Medical University, Tochigi, Japan
| | - Atsushi Suzuki
- Department of Radiology, Dokkyo Medical University, Tochigi, Japan
| | - George Imataka
- Department of Paediatrics, Dokkyo Medical University, Tochigi, Japan
| | - Hadzki Matsuda
- Department of Diagnostic Pathology, Dokkyo Medical University, Tochigi, Japan
| | - Kazuyuki Ishida
- Department of Diagnostic Pathology, Dokkyo Medical University, Tochigi, Japan
| | - Takashi Matsushita
- Department of Dermatology, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Ichizo Nishino
- Department of Neuromuscular Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Shigemi Yoshihara
- Department of Paediatrics, Dokkyo Medical University, Tochigi, Japan
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Sunny N, Kashyap K, Kumar A, Parchani A, Dhar M. Dermatomyositis Masquerading As Generalized Body Swelling: A Case Report. Cureus 2023; 15:e38895. [PMID: 37303433 PMCID: PMC10257481 DOI: 10.7759/cureus.38895] [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: 05/11/2023] [Indexed: 06/13/2023] Open
Abstract
Dermatomyositis (DM) is a systemic autoimmune disease that primarily affects the skin and muscles. The hallmark skin manifestation is a violaceous rash on the face, neck, shoulders, upper chest, and extensor surfaces of the arms and legs, which is often accompanied by edema and can be exacerbated by exposure to sunlight. Generalized limb edema and dysphagia are rare presentations of dermatomyositis. Here we present a case of a 69-year-old woman presenting with generalized limb swelling, periorbital swelling, and dysphagia which was diagnosed as dermatomyositis based on a combination of clinical, laboratory, and imaging findings. The patient had an absence of complaints of limb weakness and a predominance of complaints of edema and dysphagia which posed a diagnostic challenge. The patient was treated with high-dose steroids and immunosuppressive therapy, leading to a significant improvement in her symptoms. Edematous dermatomyositis has been associated with underlying malignancy in 25% of the cases and this warrants close follow-up and malignancy screening for such patients. In some cases, subcutaneous edema might be the only manifestation of the disease. This case underscores the importance of recognizing DM as a potential differential diagnosis in patients presenting with generalized edema and dysphagia, particularly in the initial absence of classic skin findings. This rare presentation of dermatomyositis may be a hallmark of a severe form of the disease and requires prompt recognition and aggressive treatment.
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Affiliation(s)
- Neethu Sunny
- Geriatrics, All India Institute of Medical Sciences, Rishikesh, IND
| | - Kritartha Kashyap
- Internal Medicine, All India Institute of Medical Sciences, Rishikesh, IND
| | - Arjun Kumar
- Internal Medicine, All India Institute of Medical Sciences, Rishikesh, IND
| | - Ashwin Parchani
- Internal Medicine, All India Institute of Medical Sciences, Rishikesh, IND
| | - Minakshi Dhar
- Internal Medicine, All India Institute of Medical Sciences, Rishikesh, IND
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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.
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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
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Toplak N, Pimpale Chavan P, Rosina S, Dallos T, Rotem Semo O, Aguiar CL, Khubchandani R, Ravelli A, Patwardhan A. Is Anti-NXP2 Autoantibody a Risk Factor for Calcinosis and Poor Outcome in Juvenile Dermatomyositis Patients? Case Series. Front Pediatr 2021; 9:810785. [PMID: 35280444 PMCID: PMC8904416 DOI: 10.3389/fped.2021.810785] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 12/20/2021] [Indexed: 11/27/2022] Open
Abstract
Juvenile dermatomyositis (JDM) has a wide spectrum of clinical presentations. In the last decade, several myositis-specific antibodies have been identified in patients with JDM and connected with specific organ involvement or specific clinical picture. It has been published that the presence of anti-NXP2 autoantibodies presents a risk for calcinosis in patients with JDM. We aimed to investigate the prevalence of calcinosis and response to the treatment in JDM patients with anti-NXP2. In a retrospective, multinational, multicenter study, data on 26 JDM (19 F, 7 M) patients with positive anti-NXP2 were collected. The mean age at disease presentation was 6.5 years (SD 3.7), the median diagnosis delay was 4 months (range 0.5-27 months). Patients were divided into two groups (A and B) based on the presence of calcinosis, which occurred in 42% of anti-NXP2 positive JDM patients (group A). Four patients already had calcinosis at presentation, one developed calcinosis after 4 months, and 6 developed calcinosis later in the disease course (median 2 years, range 0.8-7.8). The differences in laboratory results were not statistically significant between the groups. The mean age at disease presentation (5.2/7.5 years) trended toward being younger in group A. Children with calcinosis were treated with several combinations of drugs. In four cases, rituximab and, in one case, anti-TNF alpha agents were used successfully. Disease outcome (by evaluation of the treating physician) was excellent in four, good in two, stable in two, and poor in three patients. None of the patients from group B had a poor disease outcome. In conclusion, JDM patients with anti-NXP2 are prone to develop calcinosis, especially if they present with the disease early, before 5 years of age. The development of calcinosis is associated with worse disease outcomes. The combination of several immunomodulatory drugs and biologic drugs can stop calcinosis progression; however, there are no evidence-based therapies for treating calcinosis in JDM patients.
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Affiliation(s)
- Natasa Toplak
- Department of Allergology, Rheumatology and Clinical Immunology, Faculty of Medicine, University Children's Hospital, University Medical Centre, Ljubljana, Slovenia
| | | | - Silvia Rosina
- Pediatric Rheumatology, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Tomas Dallos
- Department of Paediatrics, Comenius University Medical School, National Institute of Children's Diseases, Bratislava, Slovakia
| | - Oz Rotem Semo
- Section of Pediatric Rheumatology, University of Chicago Medical Center, Chicago, IL, United States
| | - Cassyanne L Aguiar
- Pediatric Rheumatology, Eastern Virginia Medical School (EVMS), Children's Hospital of The King's Daughters, Norfolk, VA, United States
| | | | - Angelo Ravelli
- Direzione Scientifica, IRCCS Istituto Giannina Gaslini, Genoa, Italy.,Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DiNOGMI), Universita Degli Studi di Genova, Genoa, Italy
| | - Anjali Patwardhan
- Pediatric Rheumatology, University of Missouri, School of Medicine, Columbia, MO, United States
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