1
|
Granger A, Beecher G, Liewluck T, Nicolau S, Flanigan KM, Laughlin RS, Milone M. Inherited myopathy plus: Double-trouble from rare neuromuscular disorders. Neuromuscul Disord 2023; 33:153-160. [PMID: 36628841 DOI: 10.1016/j.nmd.2022.12.009] [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: 07/30/2022] [Revised: 11/21/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022]
Abstract
A rare disorder in the USA is one that affects <200,000 people, making inherited myopathies rare diseases. Increasing access to genetic testing has been instrumental for the diagnosis of inherited myopathies. Genetic findings, however, require clinical correlation due to variable phenotype, polygenic etiology of certain inherited disorders, and possible co-existing independent neuromuscular disorders. We searched the Mayo Clinic Rochester medical record (2004-2020) to identify adult patients carrying pathogenic variants or likely pathogenic variants in genes causative of myopathies and having a coexisting independent neuromuscular disorder classified as rare at https://rarediseases.info.nih.gov/. One additional patient was identified at Nationwide Children's hospital. Clinical and laboratory findings were reviewed. We identified 14 patients from 13 families fulfilling search criteria. Seven patients had a "double-trouble" inherited myopathy; two had an inherited myopathy with coexistent idiopathic myositis; three had an inherited myopathy with coexisting rare neuromuscular disorder of neurogenic type; a female DMD carrier had co-existing distal spinal muscular atrophy, which was featuring the clinical phenotype; and a patient with a MYH7 pathogenic variant had Sandhoff disease causing motor neuron disease. These cases highlight the relevance of correlating genetic findings, even when diagnostic, with clinical features, to allow precise diagnosis, optimal care, and accurate prognosis.
Collapse
Affiliation(s)
- Andre Granger
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Stefan Nicolau
- Center for Gene Therapy, Nationwide Children's Hospital, Columbus, OH, USA
| | - Kevin M Flanigan
- Center for Gene Therapy, Nationwide Children's Hospital, Columbus, OH, USA
| | | | | |
Collapse
|
2
|
Munekane A, Ohsawa Y, Okubo M, Nagai T, Nishimura H, Nishino I, Sunada Y. Becker Muscular Dystrophy Accompanied by Anti-HMGCR Antibody-positive Immune-mediated Necrotizing Myopathy. Intern Med 2022; 62:1345-1349. [PMID: 36130887 DOI: 10.2169/internalmedicine.0202-22] [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] [Indexed: 11/06/2022] Open
Abstract
Becker muscular dystrophy (BMD) is an X-linked neuromuscular disease characterized by progressive muscle weakness that currently has no cure. Immune-mediated necrotizing myopathy (IMNM) is a type of autoimmune inflammatory myopathy characterized by proximal muscle weakness that is treated with immunosuppressive therapy. We herein report a patient diagnosed with BMD complicated with IMNM by a pathological analysis. Notably, the patient had an elevated serum anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase antibody level. Oral glucocorticoid and methotrexate treatment partially improved the muscle weakness with decreased levels of serum creatine kinase. An accurate diagnosis is important for therapeutic decisions in these complicated cases.
Collapse
Affiliation(s)
| | - Yutaka Ohsawa
- Department of Neurology, Kawasaki Medical School, Japan
| | - Mariko Okubo
- Department of Neuromuscular Research, National Institute of Neuroscience (NCNP), Japan
| | - Taiji Nagai
- Department of Neurology, Kawasaki Medical School, Japan
| | | | - Ichizo Nishino
- Department of Neuromuscular Research, National Institute of Neuroscience (NCNP), Japan
| | | |
Collapse
|
3
|
Tanboon J, Uruha A, Arahata Y, Dittmayer C, Schweizer L, Goebel HH, Nishino I, Stenzel W. Inflammatory features in sporadic late-onset nemaline myopathy are independent from monoclonal gammopathy. Brain Pathol 2021; 31:e12962. [PMID: 34043258 PMCID: PMC8412091 DOI: 10.1111/bpa.12962] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 03/23/2021] [Indexed: 11/30/2022] Open
Abstract
Sporadic late-onset nemaline myopathy (SLONM) is a rare adult-onset non-hereditary disease with subacute proximal muscle and often axial muscle weakness, characterized by the presence of nemaline bodies in skeletal muscle biopsies. Considering its association with concurrent monoclonal gammopathy of undetermined significance (MGUS), the disease is classified into two major subtypes (1) SLONM without MGUS (SLONM-noMGUS) and (2) with MGUS (SLONM-MGUS) association. SLONM associated with HIV infection (SLONM-HIV) is also reported. SLONM-MGUS has been shown to be associated with poorer prognosis and required aggressive treatment including high-dose melphalan and autologous stem cell transplantation. The approach is currently debatable as recent reports suggested effectiveness of intravenous immunoglobulin as initial treatment with indifference of overall survival despite the presence of MGUS. Our study aimed to find an underlying basis by review of pathological features in 49 muscle biopsy proven-SLONM from two large tertiary centers in Japan and Germany (n = 49: SLONM-noMGUS = 34, SLONM-MGUS = 13, SLONM-HIV = 2). We compared pathological findings in SLONM-noMGUS and SLONM-MGUS and focused on the presence of any detectable inflammatory features by immunohistochemistry. The clinical and histological features in SLONM-noMGUS and SLONM-MGUS were not distinctively different except for more common regenerating fibers (>5% of myofibers) present in SLONM-MGUS (p < 0.01). HLA-ABC expression and fine granular p62 were observed in 66.7% and 78.3% of SLONM, respectively. The predominant inflammatory cells were CD68+ cells. The inflammatory cells showed positive correlations with the percentage of nemaline-containing fibers (p < 0.001). In conclusion, inflammatory features are present although rather mild in SLONM. This finding contributes to the hypothesis of an acquired inflammatory disease pathogenesis and opens the possibility to offer immunotherapy in SLONM with inflammatory features regardless of the monoclonal gammopathy status.
Collapse
Affiliation(s)
- Jantima Tanboon
- Department of Neuromuscular Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry (NCNP), Tokyo, Japan.,Department of Genome Medicine Development, Medical Genome Center, National Center of Neurology and Psychiatry (NCNP), Tokyo, Japan
| | - Akinori Uruha
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Yukie Arahata
- Department of Neuromuscular Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry (NCNP), Tokyo, Japan.,Department of Genome Medicine Development, Medical Genome Center, National Center of Neurology and Psychiatry (NCNP), Tokyo, Japan
| | - Carsten Dittmayer
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Leonille Schweizer
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Hans-Hilmar Goebel
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,Department of Neuropathology, Universitätsmedizin Mainz, Mainz, Germany
| | - Ichizo Nishino
- Department of Neuromuscular Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry (NCNP), Tokyo, Japan.,Department of Genome Medicine Development, Medical Genome Center, National Center of Neurology and Psychiatry (NCNP), Tokyo, Japan
| | - Werner Stenzel
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,Leibniz ScienceCampus Chronic Inflammation, Berlin, Germany
| |
Collapse
|
4
|
Concurrent positive anti-3-hydroxy-3-methylglutaryl-coenzyme a reductase antibody with reducing body myopathy: Possible double trouble. Neuromuscul Disord 2019; 29:543-548. [PMID: 31204143 DOI: 10.1016/j.nmd.2019.05.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 05/20/2019] [Indexed: 12/23/2022]
Abstract
Anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase myopathy is less common in children but has been associated with more favorable prognosis than adult patients after immunotherapies. We report anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase antibody positivity in a 6-year-old boy with progressive muscle weakness, scoliosis, spinal rigidity, multiple joint contractures, mild left ventricular hypertrophy, and elevated serum creatine kinase. In contrast to most of previously reported pediatric anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase myopathy, he showed little response to immunotherapies. Muscle biopsy contained changes suggestive of myofiber necrosis and regeneration and reducing bodies. The diagnosis of reducing body myopathy was later confirmed by reported c.368A>G (p.His123Arg) mutation in the FHL1 gene. Although the level of association between these two conditions is still inconclusive, this is the first report of concurrent positive anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase antibody with reducing body myopathy emphasizing the possibility of co-occurrence of immune mediated necrotizing myopathy and muscular dystrophy and importance of comprehensive diagnostic investigations in unusual cases.
Collapse
|
5
|
Tiniakou E, Pinal-Fernandez I, Lloyd TE, Albayda J, Paik J, Werner JL, Parks CA, Casciola-Rosen L, Christopher-Stine L, Mammen AL. More severe disease and slower recovery in younger patients with anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase-associated autoimmune myopathy. Rheumatology (Oxford) 2017; 56:787-794. [PMID: 28096458 PMCID: PMC5850825 DOI: 10.1093/rheumatology/kew470] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 11/18/2016] [Indexed: 12/21/2022] Open
Abstract
Objective To study disease severity and response to therapy in a large cohort of patients with anti-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR)-associated myositis. Methods Muscle strength, creatine kinase levels and treatments were assessed in anti-HMGCR-positive patients at each clinical visit. Univariate and multivariate analyses were used to analyse the influence of clinical characteristics on strength and the change in strength over time. Whole exome sequencing was performed in a subset of patients. Results . Among 50 patients followed for ⩾2 years, only 22 (44%) reached full strength with immunosuppressive therapy; even among those with full strength, 55% continued to have CK levels in excess of 500 IU/l and only three could be tapered off immunosuppressive therapy. Both univariate and multivariate analysis showed that patients who were older at disease onset were stronger at all time points (P < 0.001) and improved faster (P < 0.008) than younger patients; a history of statin exposure was not independently associated with the improvement rate. Younger patients were more likely to have refractory disease (P = 0.02) than older patients. Among eight refractory patients with DNA available for testing, whole exome sequencing did not reveal pathogenic mutations in known dystrophy genes. The risk of cancer was not increased in anti-HMGCR myositis patients compared with the general population. Conclusions Anti-HMGCR myositis is usually a chronic disease requiring long-term immunosuppression. Although younger patients had more severe disease and a worse prognosis than older patients, they did not have evidence of a known co-existing muscular dystrophy to explain their persistent, and sometimes progressive, muscle weakness.
Collapse
Affiliation(s)
- Eleni Tiniakou
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore
| | | | - Thomas E. Lloyd
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore
| | - Jemima Albayda
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore
| | - Julie Paik
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore
| | - Jessie L. Werner
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore
| | - Cassie A. Parks
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda and
| | | | - Lisa Christopher-Stine
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andrew L. Mammen
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda and
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
6
|
Allenbach Y, Benveniste O, Goebel HH, Stenzel W. Integrated classification of inflammatory myopathies. Neuropathol Appl Neurobiol 2017; 43:62-81. [DOI: 10.1111/nan.12380] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 01/04/2017] [Accepted: 01/11/2017] [Indexed: 12/25/2022]
Affiliation(s)
- Y. Allenbach
- Department of Internal Medicine and Clinical Immunology; Pitié-Salpêtrière Hospital; DHU I2B; AP-HP; Paris France
- INSERM U974; UPMC Sorbonne Universities; Paris France
| | - O. Benveniste
- Department of Internal Medicine and Clinical Immunology; Pitié-Salpêtrière Hospital; DHU I2B; AP-HP; Paris France
- INSERM U974; UPMC Sorbonne Universities; Paris France
| | - H-H. Goebel
- Department of Neuropathology; Charité - Universitätsmedizin; Berlin Germany
| | - W. Stenzel
- Department of Neuropathology; Charité - Universitätsmedizin; Berlin Germany
| |
Collapse
|
7
|
Abstract
BACKGROUND Immune-mediated necrotizing myopathy (IMNM) is a newly identified subgroup of idiopathic inflammatory myopathies. It is defined as a rare and severe disease, with symmetrical and proximal muscle weakness and a characteristic histology. An autoimmune aspect of IMNM is suggested by its association with autoantibodies directed against signal recognition particle (SRP) and 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR) in the majority of patients. Statin use is strongly associated with anti-HMGCR-positive IMNM. The pathophysiological mechanisms of this disease are still poorly understood, and as a result, no therapeutic strategy has been validated to date. OBJECTIVE The aim of this article is to provide an overview of the current knowledge about epidemiology, clinical features, and pathophysiology of IMNM, as well as treatment strategies. RESULTS AND CONCLUSION IMNM is a subject of widespread interest, with quick and meaningful advances being made. In recent years, huge progress has been made in terms of diagnosis and patient management. However, the understanding of pathophysiological mechanisms and treatment strategies still requires further investigation.
Collapse
|
8
|
Mammen AL, Casciola-Rosen L, Christopher-Stine L, Lloyd TE, Wagner KR. Myositis-specific autoantibodies are specific for myositis compared to genetic muscle disease. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2015; 2:e172. [PMID: 26668818 PMCID: PMC4676353 DOI: 10.1212/nxi.0000000000000172] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 09/16/2015] [Indexed: 11/22/2022]
Abstract
Objective: To determine the specificity of myositis-specific autoantibodies (MSAs) for autoimmune myopathy compared with inherited muscle diseases. Methods: Serum samples from 47 patients with genetically confirmed inherited muscle diseases were screened for the most common MSAs, including those recognizing TIF1γ, NXP2, Mi2, MDA5, Jo1, SRP, and HMGCR. We compared these results with the findings in a cohort of patients with dermatomyositis (DM) previously screened for anti-TIF1γ, -NXP2, -Mi2, -MDA5, and -Jo1. Results: Overall, the presence of anti-TIF1γ, -NXP2, -Mi2, -MDA5, or -Jo1 was 96% specific and 67% sensitive for DM compared to patients with genetic muscle diseases. No patients with inherited muscle disease had anti-SRP or anti-HMGCR autoantibodies. Only 2 patients with genetic muscle disease had a MSA. One patient with anti-Mi2 autoantibodies had both genetically confirmed facioscapulohumeral dystrophy and dermatomyositis based on a typical skin rash and partial response to immunosuppressive medications. A second patient with anti-Jo-1 autoantibodies had both genetically defined limb-girdle muscular dystrophy type 2A (i.e., calpainopathy) and a systemic autoimmune process based on biopsy-confirmed lupus nephritis, sicca symptoms, and anti-Ro52 autoantibodies. Conclusions: The MSAs tested for in this study are highly specific for autoimmune muscle disease and are rarely, if ever, found in patients who only have genetic muscle disease. In patients with genetic muscle disease, the presence of a MSA should suggest the possibility of a coexisting autoimmune process.
Collapse
Affiliation(s)
- Andrew L Mammen
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (A.L.M.), NIH, Bethesda; the Departments of Neurology (A.L.M., L.C.-S., T.E.L., K.R.W.), Medicine (L.C.-R., L.C.-S.), and Neuroscience (T.E.L., K.R.W.), Johns Hopkins University School of Medicine, Baltimore; and The Hugo W. Moser Research Institute (K.R.W.), Kennedy Krieger, Baltimore, MD
| | - Livia Casciola-Rosen
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (A.L.M.), NIH, Bethesda; the Departments of Neurology (A.L.M., L.C.-S., T.E.L., K.R.W.), Medicine (L.C.-R., L.C.-S.), and Neuroscience (T.E.L., K.R.W.), Johns Hopkins University School of Medicine, Baltimore; and The Hugo W. Moser Research Institute (K.R.W.), Kennedy Krieger, Baltimore, MD
| | - Lisa Christopher-Stine
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (A.L.M.), NIH, Bethesda; the Departments of Neurology (A.L.M., L.C.-S., T.E.L., K.R.W.), Medicine (L.C.-R., L.C.-S.), and Neuroscience (T.E.L., K.R.W.), Johns Hopkins University School of Medicine, Baltimore; and The Hugo W. Moser Research Institute (K.R.W.), Kennedy Krieger, Baltimore, MD
| | - Thomas E Lloyd
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (A.L.M.), NIH, Bethesda; the Departments of Neurology (A.L.M., L.C.-S., T.E.L., K.R.W.), Medicine (L.C.-R., L.C.-S.), and Neuroscience (T.E.L., K.R.W.), Johns Hopkins University School of Medicine, Baltimore; and The Hugo W. Moser Research Institute (K.R.W.), Kennedy Krieger, Baltimore, MD
| | - Kathryn R Wagner
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (A.L.M.), NIH, Bethesda; the Departments of Neurology (A.L.M., L.C.-S., T.E.L., K.R.W.), Medicine (L.C.-R., L.C.-S.), and Neuroscience (T.E.L., K.R.W.), Johns Hopkins University School of Medicine, Baltimore; and The Hugo W. Moser Research Institute (K.R.W.), Kennedy Krieger, Baltimore, MD
| |
Collapse
|
9
|
Significant response to immune therapies in a case of subacute necrotizing myopathy and FKRP mutations. Neuromuscul Disord 2015; 25:865-8. [PMID: 26363967 DOI: 10.1016/j.nmd.2015.08.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 08/16/2015] [Accepted: 08/19/2015] [Indexed: 10/23/2022]
Abstract
Necrotizing myopathies can be encountered in various conditions as acquired myopathies (toxic or autoimmune) or muscular dystrophies. We report a twenty-year-old Caucasian woman who presented with clinical findings suggestive of an inflammatory myopathy: subacute onset of lower limb muscle weakness, myalgia, weight loss and absence of family history. The serum creatine kinase level was elevated at 4738 IU/L (normal range, 25-175 IU/L). Muscle biopsy was consistent with necrotizing myopathy. The patient showed significant clinical improvement following corticosteroid, azathioprine and intravenous immunoglobulin treatments. Biological tests revealed no specific autoantibodies associated with necrotizing autoimmune myopathies. Immunohistochemical staining for sarcolemmal proteins in muscle biopsy samples finally led to a diagnosis of limb-girdle muscular dystrophy 2I (fukutin-related protein gene mutations). The response to immune therapies suggested a possible inflammatory component associated with the muscular dystrophy and highlighted the potential benefit of corticosteroid treatment in patients with LGMD2I and subacute onset.
Collapse
|
10
|
Neuromuscular issues in systemic disease. Curr Neurol Neurosci Rep 2015; 15:48. [PMID: 26008813 DOI: 10.1007/s11910-015-0565-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The neuromuscular system can be involved in several systemic conditions. Clinical manifestations can appear at onset or throughout the course of the disease process. New investigational methods, including imaging of peripheral nerves, new laboratory tests, and antibodies, are available. In addition to symptomatic therapies, specific treatment options, such as for familial amyloid neuropathy and Fabry's disease, are becoming increasingly available. Pathomechanisms vary depending on the underlying disease process. In addition to metabolic, hormonal, immune, and antibody-mediated mechanisms, in some generalized diseases, genetic causes need to be considered. This review focuses on different aspects of the peripheral nervous system including the nerve roots, plexuses, mononeuropathies and generalized neuropathies, neuromuscular junction disorders, muscle, and autonomic nervous system.
Collapse
|
11
|
Roda RH, Schindler AB, Blackstone C, Mammen AL, Corse AM, Lloyd TE. Laing distal myopathy pathologically resembling inclusion body myositis. Ann Clin Transl Neurol 2014; 1:1053-8. [PMID: 25574480 PMCID: PMC4284131 DOI: 10.1002/acn3.140] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 10/13/2014] [Accepted: 10/14/2014] [Indexed: 11/18/2022] Open
Abstract
Mutations in MYH7 cause autosomal dominant Laing distal myopathy. We present a family with a previously reported deletion (c.5186_5188delAGA, p.K1729del). Muscle pathology in one family member was characterized by an inflammatory myopathy with rimmed vacuoles, increased MHC Class I expression, and perivascular and endomysial muscle inflammation comprising CD3+, CD4+, CD8+, and CD68+ inflammatory cells. Interestingly, this biopsy specimen contained TDP-43, p62, and SMI-31-positive protein aggregates typical of inclusion body myositis. These findings should alert physicians to the possibility that patients with MYH7 mutations may have muscle biopsies showing pathologic findings similar to inclusion body myositis.
Collapse
Affiliation(s)
- Ricardo H Roda
- Neuromuscular Disorders and Neurogenetics Divisions, Department of Neurology, New York University Langone Medical Center New York, New York ; Cell Biology Section, Neurogenetics Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health Bethesda, Maryland
| | - Alice B Schindler
- Hereditary Neurological Diseases Section, Neurogenetics Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health Bethesda, Maryland
| | - Craig Blackstone
- Cell Biology Section, Neurogenetics Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health Bethesda, Maryland
| | - Andrew L Mammen
- Department of Neurology, Johns Hopkins University School of Medicine Baltimore, Maryland ; Department of Medicine, Johns Hopkins University School of Medicine Baltimore, Maryland ; Muscle Disease Unit, Laboratory of Muscle Stem Cells and Gene Regulation, National Institutes of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health Bethesda, Maryland
| | - Andrea M Corse
- Department of Neurology, Johns Hopkins University School of Medicine Baltimore, Maryland
| | - Thomas E Lloyd
- Department of Neurology, Johns Hopkins University School of Medicine Baltimore, Maryland ; Department of Neuroscience, Johns Hopkins University School of Medicine Baltimore, Maryland
| |
Collapse
|
12
|
Mygland Å, Ljøstad U, Krossnes BK. Persisting weakness after withdrawal of a statin. BMJ Case Rep 2014; 2014:bcr-2013-203094. [PMID: 24713712 DOI: 10.1136/bcr-2013-203094] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
An 81-year-old woman treated with simvastatin for several years followed by atorvastatin for about 1 year presented with fatigue, weakness and unsteady gait. The finding of elevated creatine kinase (CK) and symmetric muscle weakness around shoulders and hips led to suspicion of a toxic statin-associated myopathy. Atorvastatin was withdrawn, but her weakness persisted. Owing to persisting weakness, an autoimmune myopathy (myositis) was suspected, but initially disregarded since a muscle biopsy showed necrotic muscle fibres without inflammatory cell infiltrates and myositis-specific autoantibodies were absent. After 18 months with slowly progressive weakness and increasing CK values, awareness of new knowledge about autoimmunity as a cause of necrotic myopathy, led to a successful treatment trial with intravenous immunoglobulines, followed by steroids and metothrexate. Antibodies to the target enzyme of statins (HMGCR (3-hydroksy-3-methylglutaryl-coenzyme A reductase)) were detected in her serum, and she was diagnosed with autoimmune necrotic myositis probably triggered by atorvastatin.
Collapse
Affiliation(s)
- Åse Mygland
- Department of Neurology, Sørlandet Hospital, University of Bergen, Kristiansand, Norway
| | | | | |
Collapse
|