Magnetic resonance imaging and serum aldolase concentration in eosinophilic fasciitis

Disease spectrum of myopathies with elevated aldolase and normal creatine kinase

BACKGROUND AND PURPOSE

Elevation of serum creatine kinase (CK) or hyperCKemia is considered a biological marker of myopathies. However, selective elevation of serum aldolase with normal CK has been reported in a few myopathies, including dermatomyositis, immune-mediated myopathy with perimysial pathology and fasciitis with associated myopathy. The aim was to investigate the disease spectrum of myopathies with isolated aldolase elevation.

METHODS

Medical records were reviewed to identify patients >18 years old seen between December 1994 and June 2020 who had pathologically proven myopathies with elevated aldolase and normal CK level. Patients with alternative causes of aldolase elevation were excluded.

RESULTS

Thirty-four patients with various types of myopathies were identified. Myopathies were treatable in 27 patients. The three most common etiologies were dermatomyositis (n = 8), overlap myositis (n = 4) and nonspecific myopathy (n = 4). Perimysial pathology comprising inflammation, fragmentation, vasculitis, calcified perimysial vessels or extracellular amyloid deposition was found in 17/34 patients (50%). Eight dermatomyositis patients with selective elevated aldolase were compared to 24 sex- and age-matched patients with dermatomyositis and hyperCKemia. Dermatomyositis patients with normal CK significantly (p < 0.05) had less frequent cutaneous involvement (50.0% vs. 100.0%) and fibrillation potentials (50.0% vs. 90.5%) but higher median erythrocyte sedimentation rate (33.5 vs. 13.5 mm/h) and more common perifascicular mitochondrial pathology (37.5% vs. 4.2%).

CONCLUSION

Isolated aldolase elevation can be found in a greater variety of myopathies than initially thought and most were treatable. Dermatomyositis is the most common myopathy with selective elevation of aldolase in our cohort, which features some unique characteristics compared to dermatomyositis with hyperCKemia.

Clinical Characteristics of Myositis Associated with Graft-Versus-Host Disease

PURPOSE OF REVIEW

Recipients of allogeneic hematopoietic stem cell transplantation (HSCT) are at increased risk for inflammatory myositis; histological subsets reported include dermatomyositis, necrotising myopathy and chronic graft-versus-host disease (cGVHD)-related myositis. Though corticosteroids and various immunosuppressive therapies have been used, there is a lack of consensus guidelines dictating therapy.

RECENT FINDINGS

Recent evidence suggests the fascia as a preferential target in cGVHD myositis, with conditioning regimens promoting fascial microtrauma. Positron emission tomography (PET) can be a useful diagnostic tool, and case reports suggest that the Bruton's tyrosine kinase inhibitor ibrutinib may have therapeutic potential. Emerging therapies include targeted B cell depletion with rituximab, and extracorporeal photophoresis. Clinicians need to be vigilant for the development of inflammatory myositis post-allogeneic HSCT as most patients respond to treatment. Advances in immunohistochemistry to determine the dominant cell type and cytokine profile may enable targeted and individualised therapies.

Diagnostic criteria, severity classification and guidelines of eosinophilic fasciitis

We established diagnostic criteria and severity classification of eosinophilic fasciitis because there is no established diagnostic criteria or widely accepted severity classification of the disease. Also, there has been no clinical guideline for eosinophilic fasciitis, so we established its clinical guideline ahead of all over the world. In particular, the clinical guideline was established by clinical questions based on evidence-based medicine according to the New Minds Clinical Practice Guideline Creation Manual (version 1.0). We aimed to make the guideline easy to use and reliable based on the newest evidence, and to present guidance as specific as possible for various clinical problems in treatment of eosinophilic fasciitis.

The use of an elevated aldolase in diagnosing and managing eosinophilic fasciitis

Eosinophilic fasciitis (EF) is a rare localized fibrosing disorder of the fascia whose diagnosis is often suspected based on clinical findings and laboratory values. These lab abnormalities can be transient in early disease and may not always be present. We have reviewed a case series of patients to assess the utility of the various laboratory abnormalities in diagnosing EF. We performed a retrospective review of EF patients seen at Georgetown University Hospital in the Division of Rheumatology during 2009 and 2013. This review included 15 adult patients with EF with a mean age at diagnosis of 45 years (range 18 to 77 years). The majority of patients 13/15 had classic skin thickening documented on all four extremities Only eight patients had peripheral eosinophilia ranging between 8 and 38 %. In these patients, the peripheral eosinophilia was an early but transient finding. Inflammatory markers including the erythrocyte sedimentation rate (ESR) was elevated in 5/14 and C-reactive Protein (CRP) was elevated in 7/11. At disease presentation, only one of eleven patients checked had an elevated creatine phosphokinase (CPK). Aldolase levels were available for 12 of the 15 patients, and they were increased in 11 out of 12 patients. We have found that in this case series, aldolase was more likely to be abnormal than peripheral eosinophilia, hypergammaglobulinemia, and ESR particularly after starting treatment. Aldolase should be measured in all patients suspected of having EF, and may also play a useful role in following disease activity.

[Elevated serum aldolase activity in a patient of non-eosinophilic myofasciitis and synovitis with perifascicular atrophy]

A 35-year-old man suffered from myalgia and joint pain on walking for 5 months. Physical and neurological examinations revealed dermal sclerosis, skin swelling, redness of forearms, Raynaud's phenomenon, joint pain, myalgia and muscle weakness. Eosinophilia was not found and serum creatine kinase activity was normal, while aldolase was markedly elevated. Abnormal signals suggesting synovitis and myofasciitis were found on MRI images. Biopsy of the fascia of quadriceps femoris showed perivascular mononuclear cell infiltration. A muscle biopsy showed mononuclear cell infiltration mainly in the perimysium extending to the endmysium. Eosinophilic cells were not found, Perifascicular atrophy was observed. Corticosteroid therapy improved clinical symptoms and serum aldolase level. We diagnosed him as non-eosinophilic myofasciitis and synovitis with perifascicular atrophy. The serum aldolase activity is usuful for diagnosis and for monitoring the disease activity.

Eosinophilic fasciitis: report of two cases and a systematic review of the literature dealing with clinical variables that predict outcome

We reported two patients with refractory eosinophilic fasciitis (EF) and provided a systematic review of the literature to determine the clinical variables associated with prognosis of EF. We enrolled 88 cases, whose clinical characteristics were analyzed by separating the patients into two or three groups based on outcome. The incidence of certain clinical and pathological features differed among the groups. In particular, the incidence of morphea-like skin lesions in patients with refractory fibrosis was significantly higher than in patients without refractory fibrosis (p = 0.003). Patients with morphea-like skin lesions were 1.9 times more likely to develop persistent fibrosis than patients without these lesions (95% confidence intervals, 1.5-2.5). A younger age (under 12 years) at onset was associated with a 1.6 times greater risk of residual fibrosis (95% confidence interval, 1.1-2.2). Trunk involvement was associated with a 1.4 times greater risk of residual fibrosis (95% confidence interval, 1.0-2.0). Histopathologically, the presence of dermal fibrosclerosis was associated with a 1.4 times greater risk of refractory fibrosis (95% confidence interval, 1.0-2.1). We consider these clinical characteristics, notably the presence of morphea-like skin lesions may be an important risk factor for developing residual fibrosis in EF patients.

Fascitis eosinofílica: estudio de 10 pacientes

BACKGROUND AND OBJECTIVE

Eosinophilic fasciitis is an uncommon scleroderma-like syndrome with unknown etiology and pathogenesis. We report the clinical manifestations and response to therapy in a series of patients diagnosed with eosinophilic fasciitis.

PATIENTS AND METHOD

The records of 10 eosinophilic fasciitis patients seen at our hospital between 1996-2004 were reviewed.

RESULTS

Five patients were males, ages ranged from 20 years to 67 years, with a mean of 59 years. Patients were followed for 33.4 (27.1) months (SD). Nailfold capillaroscopy was near normal in all patients. Only one patient had antinuclear antibody positivity, and another had an autoimmune thyroiditis. No significant relationship was detected between the eosinophil count and the extent of skin induration. The clinical course was inadequate and the treatment response poor in patients with spreading cutaneous induration (p = 0.008). These patients had more often ventilatory restriction and perimyositis.

CONCLUSIONS

Eosinophilic fasciitis does not always have a good prognosis. Ventilatory restriction, perimyositis and poor treatment response are not infrequent in a series of patients attended in a general hospital.

Eosinophilic Fasciitis: Spectrum of MRI Findings

OBJECTIVE

Our objective was to describe the spectrum of MRI features of eosinophilic fasciitis.

CONCLUSION

MRI findings in eosinophilic fasciitis are characteristic and consist of abnormal fascial signal intensity and enhancement, both of which are directly proportional to disease activity. MRI provides a useful aid for diagnosis and a marker for disease activity and response to treatment.

MRI for Diagnosis and Monitoring of Patients with Eosinophilic Fasciitis

OBJECTIVE

The objective of this study was to describe MRI findings in patients with eosinophilic fasciitis (EF) and to correlate clinical and laboratory findings with the MRI findings.

MATERIALS AND METHODS

Six patients with histologically proven EF underwent MRI at the time of diagnosis and after therapy (15 MRI examinations). Unenhanced T1-weighted, T2-weighted, and STIR sequences were performed using a 1.5-T MRI system. In addition, all patients were imaged with contrast-enhanced T1-weighted sequences. MRI findings, clinical findings, and laboratory parameters were retrospectively reviewed.

RESULTS

At the time the six patients presented, all eight MRI examinations revealed symmetric thickening and hyperintensity of the superficial muscle fasciae of the thigh, calves, or arms on unenhanced T1-weighted, T2-weighted, or STIR sequences, with strong enhancement after administration of IV contrast agent. In seven of the eight MRI examinations, similar signal changes were also present in the deep muscle fasciae. After treatment, the fascial abnormalities found on MRI disappeared on six of eight MRI examinations performed in five patients-a rate that correlated well with the clinical findings. In one patient with EF involvement of the thigh, the MRI abnormalities showed partial remission, which also correlated well with the clinical findings.

CONCLUSION

In EF, MRI reveals characteristic findings including thickening, signal abnormalities, and contrast enhancement of the superficial and, to a lesser extent, deep muscle fasciae. MRI is useful for establishing the diagnosis, guiding the choice of biopsy site, and assessing treatment response.

Ultrasound and magnetic resonance imaging features in a patient with eosinophilic fasciitis

Eosinophilic fasciitis is a rare rheumatological disorder. We present a case of a young male patient who presented with this disease, and we describe how the findings on ultrasound and MRI correlated with the underlying pathology and assisted the diagnosis and the management of the patient.