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Yokoyama T, Inoue N, Sakumura N, Tasaki Y, Wada T. An Adolescent Case of Anti-MDA5 Antibody-Positive Juvenile Dermatomyositis With Interstitial Lung Disease Successfully Treated by Multitarget Therapy Avoiding Cyclophosphamide: A Case Report and Literature Review. Cureus 2024; 16:e62425. [PMID: 39011211 PMCID: PMC11249054 DOI: 10.7759/cureus.62425] [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: 06/15/2024] [Indexed: 07/17/2024] Open
Abstract
Juvenile dermatomyositis (JDM) patients who test positive for the antimelanoma differentiation-associated gene 5 (MDA5) antibody have a poor prognosis because of rapidly progressing interstitial lung disease (ILD). However, agreement on the best treatment for this condition remains elusive. We encountered a 13-year-old girl with anti-MDA5 antibody-positive JDM who presented with arthritis and was already showing signs of ILD when she was admitted to the hospital. While cyclophosphamide (CY) is commonly used, it can cause gonadal disorders and other complications when administered to adolescent females. Consequently, we chose multitarget therapy, which includes tacrolimus and mycophenolate mofetil. Her ILD and skin symptoms gradually improved, and she was able to maintain remission and avoid CY administration for three years. We conducted a thorough literature review to determine the efficacy and safety of multitarget therapy for anti-MDA5 antibody-positive DM and JDM. Multitarget therapy shows promise as a potentially effective and relatively safe treatment. The ability to avoid CY, which is especially important for adolescent patients concerned about fertility preservation, highlights a significant benefit of this multitarget therapy for anti-MDA5 antibody-positive DM and JDM patients.
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Affiliation(s)
| | - Natsumi Inoue
- Department of Pediatrics, Kanazawa University, Ishikawa, JPN
| | - Naoto Sakumura
- Department of Pediatrics, Kanazawa University, Ishikawa, JPN
| | - Yuko Tasaki
- Department of Pediatrics, Kanazawa University, Ishikawa, JPN
| | - Taizo Wada
- Department of Pediatrics, Kanazawa University, Ishikawa, JPN
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2
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Wang QH, Chen LH. Treatment of refractory anti-melanoma differentiation-associated gene 5 anbibody-positive dermatomyositis complicated by rapidly progressing interstitial pulmonary disease: Two case reports. World J Clin Cases 2023; 11:5345-5351. [DOI: 10.12998/wjcc.v11.i22.5345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/30/2023] [Accepted: 07/04/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND Anti-melanoma differentiation-associated gene 5 antibody-positive (anti-MDA5 Ab+) dermatomyositis complicated with rapidly progressive interstitial lung disease (anti-MDA5 Ab+ DM-RP-ILD) has an unclear underlying mechanism with no recommended unified treatment plan. Herein, one of the cases that we report (Case 2) was successfully treated with tocilizumab despite having lung infection.
CASE SUMMARY Case 1 was a 30-year-old woman who was admitted due to recurrent rash for 5 mo, fever and cough for 1 mo, and chest tightness for 3 d. She was diagnosed with non-myopathic dermatomyositis (anti-MDA5 Ab+) and interstitial pneumonia, and was treated with the combination of hormone therapy and cyclophosphamide followed by oral tacrolimus. Case 2 was a 31-year-old man admitted due to systemic rash accompanied by muscle weakness of limbs for more than 1 mo, and chest tightness and dry cough for 4 d. He was diagnosed with dermatomyositis (anti-MDA5 Ab+) and acute interstitial pneumonia with Pneumocystis jirovecii and Aspergillus fumigatus infections and was treated with hormone therapy (without cyclophosphamide) and the combination of tocilizumab and tacrolimus. The condition of both patients eventually improved and they were discharged and showed clinically stable condition at the latest follow-up.
CONCLUSION Tocilizumab could be a salvage treatment for patients with anti-MDA5 Ab+ DM-RP-ILD who are refractory to intensive immunosuppression.
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Affiliation(s)
- Qiao-Hong Wang
- Department of Rheumatology, Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
| | - Li-Heng Chen
- Department of Endocrinology, Fourth Affiliated Hospital, College of Medicine, Zhejiang University, Yiwu 322000, Zhejiang Province, China
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3
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Wang QH, Chen LH. Treatment of refractory anti-melanoma differentiation-associated gene 5 anbibody-positive dermatomyositis complicated by rapidly progressing interstitial pulmonary disease: Two case reports. World J Clin Cases 2023; 11:5351-5357. [PMID: 37621599 PMCID: PMC10445068 DOI: 10.12998/wjcc.v11.i22.5351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/30/2023] [Accepted: 07/04/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND Anti-melanoma differentiation-associated gene 5 antibody-positive (anti-MDA5 Ab+) dermatomyositis complicated with rapidly progressive interstitial lung disease (anti-MDA5 Ab+ DM-RP-ILD) has an unclear underlying mechanism with no recommended unified treatment plan. Herein, one of the cases that we report (Case 2) was successfully treated with tocilizumab despite having lung infection. CASE SUMMARY Case 1 was a 30-year-old woman who was admitted due to recurrent rash for 5 mo, fever and cough for 1 mo, and chest tightness for 3 d. She was diagnosed with non-myopathic dermatomyositis (anti-MDA5 Ab+) and interstitial pneumonia, and was treated with the combination of hormone therapy and cyclophosphamide followed by oral tacrolimus. Case 2 was a 31-year-old man admitted due to systemic rash accompanied by muscle weakness of limbs for more than 1 mo, and chest tightness and dry cough for 4 d. He was diagnosed with dermatomyositis (anti-MDA5 Ab+) and acute interstitial pneumonia with Pneumocystis jirovecii and Aspergillus fumigatus infections and was treated with hormone therapy (without cyclophosphamide) and the combination of tocilizumab and tacrolimus. The condition of both patients eventually improved and they were discharged and showed clinically stable condition at the latest follow-up. CONCLUSION Tocilizumab could be a salvage treatment for patients with anti-MDA5 Ab+ DM-RP-ILD who are refractory to intensive immunosuppression.
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Affiliation(s)
- Qiao-Hong Wang
- Department of Rheumatology, Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
| | - Li-Heng Chen
- Department of Endocrinology, Fourth Affiliated Hospital, College of Medicine, Zhejiang University, Yiwu 322000, Zhejiang Province, China
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Ye Y, Chen Z, Jiang S, Jia F, Li T, Lu X, Xue J, Lian X, Ma J, Hao P, Lu L, Ye S, Shen N, Bao C, Fu Q, Zhang X. Single-cell profiling reveals distinct adaptive immune hallmarks in MDA5+ dermatomyositis with therapeutic implications. Nat Commun 2022; 13:6458. [PMID: 36309526 PMCID: PMC9617246 DOI: 10.1038/s41467-022-34145-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 10/16/2022] [Indexed: 12/25/2022] Open
Abstract
Anti-melanoma differentiation-associated gene 5-positive dermatomyositis (MDA5+ DM) is an autoimmune condition associated with rapidly progressive interstitial lung disease and high mortality. The aetiology and pathogenesis of MDA5+ DM are still largely unknown. Here we describe the immune signatures of MDA5+ DM via single-cell RNA sequencing, flow cytometry and multiplex immunohistochemistry in peripheral B and T cells and in affected lung tissue samples from one patient. We find strong peripheral antibody-secreting cell and CD8+ T cell responses as cellular immune hallmarks, and over-stimulated type I interferon signaling and associated metabolic reprogramming as molecular immune signature in MDA5+ DM. High frequency of circulating ISG15+ CD8+ T cells at baseline predicts poor one-year survival in MDA5+ DM patients. In affected lungs, we find profuse immune cells infiltration, which likely contributes to the pro-fibrotic response via type I interferon production. The importance of type I interferons in MDA5+ DM pathology is further emphasized by our observation in a retrospective cohort of MDA5+ DM patients that combined calcineurin and Janus kinase inhibitor therapy show superior efficacy to calcineurin inhibitor monotherapy. In summary, this study reveals key immune-pathogenic features of MDA5+ DM and provides a potential basis for future tailored therapies.
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Affiliation(s)
- Yan Ye
- Department of Rheumatology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200001, China
| | - Zechuan Chen
- The Center for Microbes, Development and Health, Key Laboratory of Molecular Virology and Immunology, Institut Pasteur of Shanghai, Chinese Academy of Sciences, Shanghai, 200031, China
- University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Shan Jiang
- The Center for Microbes, Development and Health, Key Laboratory of Molecular Virology and Immunology, Institut Pasteur of Shanghai, Chinese Academy of Sciences, Shanghai, 200031, China
- University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Fengyun Jia
- The Center for Microbes, Development and Health, Key Laboratory of Molecular Virology and Immunology, Institut Pasteur of Shanghai, Chinese Academy of Sciences, Shanghai, 200031, China
- University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Teng Li
- The Center for Microbes, Development and Health, Key Laboratory of Molecular Virology and Immunology, Institut Pasteur of Shanghai, Chinese Academy of Sciences, Shanghai, 200031, China
- University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Xia Lu
- Department of Rheumatology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200001, China
| | - Jing Xue
- Department of Rheumatology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 310009, China
| | - Xinyue Lian
- Department of Rheumatology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200001, China
| | - Jiaqiang Ma
- The Center for Microbes, Development and Health, Key Laboratory of Molecular Virology and Immunology, Institut Pasteur of Shanghai, Chinese Academy of Sciences, Shanghai, 200031, China
| | - Pei Hao
- The Center for Microbes, Development and Health, Key Laboratory of Molecular Virology and Immunology, Institut Pasteur of Shanghai, Chinese Academy of Sciences, Shanghai, 200031, China
- University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Liangjing Lu
- Department of Rheumatology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200001, China
| | - Shuang Ye
- Department of Rheumatology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200001, China
| | - Nan Shen
- Department of Rheumatology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200001, China
| | - Chunde Bao
- Department of Rheumatology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200001, China
| | - Qiong Fu
- Department of Rheumatology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200001, China.
| | - Xiaoming Zhang
- The Center for Microbes, Development and Health, Key Laboratory of Molecular Virology and Immunology, Institut Pasteur of Shanghai, Chinese Academy of Sciences, Shanghai, 200031, China.
- University of Chinese Academy of Sciences, Beijing, 100049, China.
- Shanghai Huashen Institute of Microbes and Infections, Shanghai, 200052, China.
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Cole C, Amber KT. Off-Label Uses of Rituximab in Dermatology. CURRENT DERMATOLOGY REPORTS 2022; 11:209-220. [PMID: 36217351 PMCID: PMC9534735 DOI: 10.1007/s13671-022-00375-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2022] [Indexed: 11/26/2022]
Abstract
Purpose of Review Rituximab has transformed the treatment of B-cell malignancies and rheumatoid arthritis in the past 2 decades. More recently, this anti-CD20 monoclonal antibody has seen increasing usage in the field of dermatology. This review highlights the evidence supporting its use in several important dermatologic conditions. Recent Findings Key recent findings include the 2018 FDA approval of rituximab for the treatment of moderate-to-severe pemphigus. Summary Data from randomized controlled trials have demonstrated the efficacy of rituximab in pemphigus, ANCA-associated vasculitis, and cryoglobulinemic vasculitis. More limited data suggests its use in recalcitrant cases of diseases such as pemphigoid, epidermolysis bullosa acquisita, and dermatomyositis. There is scarce evidence and mixed results for rituximab when studied in cutaneous polyarteritis nodosa and cutaneous lupus erythematosus.
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Affiliation(s)
- Connor Cole
- Division of Dermatology, Rush University Medical Center, Chicago, IL USA
| | - Kyle T. Amber
- Division of Dermatology, Rush University Medical Center, Chicago, IL USA
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL USA
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6
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Casal-Dominguez M, Pinal-Fernández I, Mammen AL. Utility of Myositis-Specific Autoantibodies for Treatment Selection in Myositis. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2022. [DOI: 10.1007/s40674-022-00198-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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7
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Ohta R, Yoshioka N, Yamane F, Hayashi M, Sano C. Anti-Mi2 Antibody Positive Dermatomyositis With Hyper-Elevated Creatine Kinase: A Case Report. Cureus 2022; 14:e28899. [PMID: 36237748 PMCID: PMC9544567 DOI: 10.7759/cureus.28899] [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: 09/07/2022] [Indexed: 11/05/2022] Open
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Bobirca A, Alexandru C, Musetescu AE, Bobirca F, Florescu AT, Constantin M, Tebeica T, Florescu A, Isac S, Bojinca M, Ancuta I. Anti-MDA5 Amyopathic Dermatomyositis-A Diagnostic and Therapeutic Challenge. Life (Basel) 2022; 12:1108. [PMID: 35892910 PMCID: PMC9329888 DOI: 10.3390/life12081108] [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] [Received: 06/24/2022] [Revised: 07/15/2022] [Accepted: 07/21/2022] [Indexed: 06/15/2023] Open
Abstract
Clinically amyopathic Dermatomyositis (CADM) is a rare subtype of idiopathic inflammatory myositis, associated with no muscular manifestations, which is more frequent in Asian women. Anti-melanoma differentiation-associated gene 5 (MDA5) antibodies are a recently discovered type of specific autoantibodies associated with myositis. The anti-MDA5 DM was initially described in Japan and later it was discovered that the target antigen was a protein implicated in the innate immune response against viruses, that is encoded by the melanoma differentiation-associated gene 5. Anti-MDA5 DM is characteristically associated with distinguished mucocutaneus and systemic manifestations, including skin ulcerations, palmar papules, arthritis, and interstitial-lung disease. Patients with anti-MDA5 positivity have a high risk of developing rapid progressive interstitial-lung disease (RP-ILD), with a poor outcome. As a result, despite high mortality, diagnosis is often delayed, necessitating increased awareness of this possible condition. Despite a severe course of lung disease and an increased mortality rate, there is currently no standard treatment. Recent insights based on observational studies and case reports support combined therapy with immunosuppressive drugs and corticotherapy, as soon as the symptoms appear. The aim of this paper is to describe anti-MDA5 DM, focusing on the recent literature about the unique clinical manifestations and therapeutic options, starting from a severe clinical case diagnosed in our Rheumatology Department.
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Affiliation(s)
- Anca Bobirca
- Department of Internal Medicine and Rheumatology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.B.); (M.B.); (I.A.)
- Department of Internal Medicine and Rheumatology, “Dr. Ion Cantacuzino” Clinical Hospital, 011437 Bucharest, Romania; (C.A.); (A.T.F.)
| | - Cristina Alexandru
- Department of Internal Medicine and Rheumatology, “Dr. Ion Cantacuzino” Clinical Hospital, 011437 Bucharest, Romania; (C.A.); (A.T.F.)
| | - Anca Emanuela Musetescu
- Department of Rheumatology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania; (A.E.M.); (A.F.)
| | - Florin Bobirca
- Department of General Surgery, Carol Davila University of Medicine and Pharmacy, “Dr. Ion Cantacuzino” Clinical Hospital, 050474 Bucharest, Romania
| | - Anca Teodora Florescu
- Department of Internal Medicine and Rheumatology, “Dr. Ion Cantacuzino” Clinical Hospital, 011437 Bucharest, Romania; (C.A.); (A.T.F.)
| | - Magdalena Constantin
- 2nd Department of Dermatology, Colentina Clinical Hospital, “Carol Davila” University of Medicine and Pharmacy, 020125 Bucharest, Romania;
| | - Tiberiu Tebeica
- Department of Histopathology, “Dr. Leventer Centre”, 011216 Bucharest, Romania;
| | - Alesandra Florescu
- Department of Rheumatology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania; (A.E.M.); (A.F.)
| | - Sebastian Isac
- Department of Physiology and Neuroscience, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania;
| | - Mihai Bojinca
- Department of Internal Medicine and Rheumatology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.B.); (M.B.); (I.A.)
- Department of Internal Medicine and Rheumatology, “Dr. Ion Cantacuzino” Clinical Hospital, 011437 Bucharest, Romania; (C.A.); (A.T.F.)
| | - Ioan Ancuta
- Department of Internal Medicine and Rheumatology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.B.); (M.B.); (I.A.)
- Department of Internal Medicine and Rheumatology, “Dr. Ion Cantacuzino” Clinical Hospital, 011437 Bucharest, Romania; (C.A.); (A.T.F.)
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9
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He C, Li W, Xie Q, Yin G. Rituximab in the Treatment of Interstitial Lung Diseases Related to Anti-Melanoma Differentiation-Associated Gene 5 Dermatomyositis: A Systematic Review. Front Immunol 2022; 12:820163. [PMID: 35116041 PMCID: PMC8803653 DOI: 10.3389/fimmu.2021.820163] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 12/28/2021] [Indexed: 01/10/2023] Open
Abstract
Objective The effectiveness of rituximab in anti-melanoma differentiation-associated gene 5 (MDA5) dermatomyositis (DM) with interstitial lung disease (ILD) has been explored only in isolated case reports and small series. This paper aims to review the current evidence regarding rituximab (RTX) use in the treatment of ILD related to anti-MDA5 DM (anti-MDA5 DM-ILD). Methods We conducted a review by searching PubMed, Web of Science, Embase, and Cochrane for articles with information on patients with anti-MDA5 DM and RTX treatment, published until August 2021, in English language. The selected studies listed variation in chest high-resolution computed tomography (HRCT) and/or pulmonary function test (PFT) as a primary outcome, in patients with anti-MDA5 DM-related ILD after using RTX. Results Of the 145 potentially eligible articles, 17 were selected. The information gathered from a total of 35 patients with anti-MDA5 DM-ILD was reviewed, including 13 men and 22 women. Patient age at onset was 47.60 ± 13.72 years old. A total of 11.43% (4/35) of the patients were found to have chronic ILD (C-ILD) and 88.57% (31/30) exhibited rapidly progressive ILD (RP-ILD). Most patients (29/30) had typical DM rashes. Prior to RTX administration, the majority of patients (27/35) were treated with medium- or high-dose glucocorticoids and at least one additional immunotherapeutic agent. With regard to RTX efficacy for ILD in anti-MDA5 DM, 71.43% (25/35) of the patients responded to treatment. Skin rash also improved in more than half of the patients after RTX treatment. The most common side effects were infections, reported by 37.14% (13/35) of the patients after using RTX. Conclusion As a CD20 targeting drug, RTX is a promising therapeutic tool for anti-MDA5 DM-ILD, although the risk of infections should be considered before treatment. Further prospective controlled studies are required to evaluate the optimal RTX treatment regimen. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021289714, identifier CRD42021289714.
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Affiliation(s)
- Chenjia He
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Wenyu Li
- Health Management Center, West China Hospital, Sichuan University, Chengdu, China
| | - Qibing Xie
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Geng Yin, ; Qibing Xie,
| | - Geng Yin
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Geng Yin, ; Qibing Xie,
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10
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Selva-O'Callaghan A, Romero-Bueno F, Trallero-Araguás E, Gil-Vila A, Ruiz-Rodríguez JC, Sánchez-Pernaute O, Pinal-Fernández I. Pharmacologic Treatment of Anti-MDA5 Rapidly Progressive Interstitial Lung Disease. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2021; 7:319-333. [PMID: 34603940 PMCID: PMC8476986 DOI: 10.1007/s40674-021-00186-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2021] [Indexed: 11/15/2022]
Abstract
Purpose of the Review Idiopathic inflammatory myopathies are a heterogeneous group of autoimmune disorders. The presence of different autoantibodies allows clinicians to define distinct phenotypes. Antibodies against the melanoma differentiation-associated protein 5 gene, also called anti-MDA5 antibodies, are associated with a characteristic phenotype, the clinically amyopathic dermatomyositis with rapidly progressive interstitial lung disease. This review aims to analyze the different pharmacological options for the treatment of rapidly progressive interstitial lung disease in patients with anti-MDA5 antibodies. Recent Findings Evidence-based therapeutic recommendations suggest that the best initial approach to treat these patients is an early combination of immunosuppressive drugs including either glucocorticoids and calcineurin inhibitors or a triple therapy adding intravenous cyclophosphamide. Tofacitinib, a Janus kinase inhibitor, could be useful according to recent reports. High ferritin plasma levels, generalized worsening of pulmonary infiltrates, and ground-glass opacities should be considered predictive factors of a bad outcome. In this scenario, clinicians should consider rescue therapies such as therapeutic plasma exchange, polymyxin-B hemoperfusion, veno-venous extracorporeal membrane oxygenation, or even lung transplantation. Summary Combined immunosuppressive treatment should be considered the first-line therapy for patients with anti-MDA5 rapidly progressive interstitial lung disease. Aggressive rescue therapies may be useful in refractory patients.
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Affiliation(s)
- A Selva-O'Callaghan
- Systemic Autoimmune Diseases Unit, Medicine Department, Vall d'Hebron University Hospital, GEAS Group, Universitat Autónoma de Barcelona, 08012 Barcelona, Spain
| | - F Romero-Bueno
- Rheumatology Department, Fundación Jiménez Díaz University Hospital, Universidad Autónoma de Madrid, Madrid, Spain
| | - E Trallero-Araguás
- Rheumatology Department, Vall d'Hebron University Hospital, GEAS Group, Barcelona, Spain
| | - A Gil-Vila
- Systemic Autoimmune Diseases Unit, Medicine Department, Vall d'Hebron University Hospital, GEAS Group, Universitat Autónoma de Barcelona, 08012 Barcelona, Spain
| | - J C Ruiz-Rodríguez
- Intensive Care Department, Vall d'Hebron University Hospital, Shock, Organ Dysfunction, and Resuscitation Research Group, Vall D'Hebron Research Institute, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - O Sánchez-Pernaute
- Rheumatology Department, Fundación Jiménez Díaz University Hospital, Universidad Autónoma de Madrid, Madrid, Spain
| | - I Pinal-Fernández
- National Institutes of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, MD USA.,Johns Hopkins University School of Medicine, Baltimore, MD USA.,Faculty of Health Sciences and Faculty of Computer Science, Multimedia and Telecommunications, Universitat Oberta de Catalunya, Barcelona, Spain
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11
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Zhou J, Huang W, Ren F, Luo L, Huang D, Tang L. Evaluation of Prognostic Factors in Anti-MDA5 Antibody-Positive Patients in Chongqing, China: A Retrospective Study. Int J Gen Med 2021; 14:4775-4781. [PMID: 34466022 PMCID: PMC8403008 DOI: 10.2147/ijgm.s327751] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 08/11/2021] [Indexed: 01/01/2023] Open
Abstract
Objective The aim of our study was to elucidate the potential prognostic factors in anti-melanoma differentiation-associated gene 5 (anti-MDA5)-positive patients. Methods We divided anti-MDA5-positive patients into death and survival groups. The differences in clinical characteristics were analyzed. Results A total of 56 cases were included. The death group comprised 10 (17.9%) cases, and the survival group comprised 46 (82.1%) cases. Median age of the death group was greater than the survival group, 59.50 years vs 39.25 years, p<0.05. The death group had lower lymphocyte count and albumin and higher erythrocyte sedimentation rate, ferritin and lactate dehydrogenase initially (p<0.05, respectively). Ground-glass opacity on chest computed tomography was found more often in the death group (p<0.05), in which there was an absence of honey-combed shadow initially. The diagnosis of interstitial pneumonia with autoimmune features was higher in the death group than the survival group (70% vs 13%, p<0.05). The median dose of maximum daily methylprednisolone in the death group (160 mg/d) was higher than that in the survival group (48 mg/d) (p<0.05). Conclusion Advanced age, low lymphocyte count and albumin, and increased levels of inflammatory markers may portend poor prognosis in anti-MDA5-positive patients. Extra-large doses of glucocorticoid may have no additional benefit in these patients.
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Affiliation(s)
- Jun Zhou
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Wenhan Huang
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Feifeng Ren
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Lei Luo
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Dongmei Huang
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Lin Tang
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
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12
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Mehta AA, Paul T, Cb M, Haridas N. Anti-MDA5 antibody-positive dermatomyositis with rapidly progressive interstitial lung disease: report of two cases. BMJ Case Rep 2021; 14:14/4/e240046. [PMID: 33910791 PMCID: PMC8094376 DOI: 10.1136/bcr-2020-240046] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Melanoma differentiation-associated protein 5 (MDA5) antibody-positive dermatomyositis (DM) displays unique cutaneous and pathologic features. We describe two cases of myositis-associated rapidly progressive interstitial lung disease (RP-ILD). The patients were two women from Kerala, India. Both patients had anti-MDA5 antibody-positive myositis. Both patients presented with RP-ILD without any clinical features of myositis and succumbed to their illness despite aggressive medical treatment. Anti-MDA5-antibody-positive DM is characterised by amyopathic disease with rapidly progressive and fatal ILD.
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Affiliation(s)
- Asmita A Mehta
- Department of Respiratory Medicine, Amrita Institute of Medical Science, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Tisa Paul
- Department of Respiratory Medicine, Amrita Institute of Medical Science, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Mithun Cb
- Rheumatology, Amrita Institute of Medical Science, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Nithya Haridas
- Department of Respiratory Medicine, Amrita Institute of Medical Science, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
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Fujisawa T. Management of Myositis-Associated Interstitial Lung Disease. ACTA ACUST UNITED AC 2021; 57:medicina57040347. [PMID: 33916864 PMCID: PMC8065549 DOI: 10.3390/medicina57040347] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/01/2021] [Accepted: 04/02/2021] [Indexed: 11/30/2022]
Abstract
Idiopathic inflammatory myopathies, including polymyositis (PM), dermatomyositis (DM), and clinically amyopathic DM (CADM), are a diverse group of autoimmune diseases characterized by muscular involvement and extramuscular manifestations. Interstitial lung disease (ILD) has major pulmonary involvement and is associated with increased mortality in PM/DM/CADM. The management of PM-/DM-/CADM-associated ILD (PM/DM/CADM-ILD) requires careful evaluation of the disease severity and clinical subtype, including the ILD forms (acute/subacute or chronic), because of the substantial heterogeneity of their clinical courses. Recent studies have highlighted the importance of myositis-specific autoantibodies’ status, especially anti-melanoma differentiation-associated gene 5 (MDA5) and anti-aminoacyl tRNA synthetase (ARS) antibodies, in order to evaluate the clinical phenotypes and treatment of choice for PM/DM/CADM-ILD. Because the presence of the anti-MDA5 antibody is a strong predictor of a worse prognosis, combination treatment with glucocorticoids (GCs) and calcineurin inhibitors (CNIs; tacrolimus (TAC) or cyclosporin A (CsA)) is recommended for patients with anti-MDA5 antibody-positive DM/CADM-ILD. Rapidly progressive DM/CADM-ILD with the anti-MDA5 antibody is the most intractable condition, which requires immediate combined immunosuppressive therapy with GCs, CNIs, and intravenous cyclophosphamide. Additional salvage therapies (rituximab, tofacitinib, and plasma exchange) should be considered for patients with refractory ILD. Patients with anti-ARS antibody-positive ILD respond better to GC treatment, but with frequent recurrence; thus, GCs plus immunosuppressants (TAC, CsA, azathioprine, and mycophenolate mofetil) are often needed in order to achieve favorable long-term disease control. PM/DM/CADM-ILD management is still a therapeutic challenge for clinicians, as evidence-based guidelines do not exist to help with management decisions. A few prospective clinical trials have been recently reported regarding the treatment of PM/DM/CADM-ILD. Here, the current knowledge on the pharmacologic managements of PM/DM/CADM-ILD was mainly reviewed.
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Affiliation(s)
- Tomoyuki Fujisawa
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama Higashi-ku, Hamamatsu 431-3192, Japan
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Mehta P, Machado PM, Gupta L. Understanding and managing anti-MDA 5 dermatomyositis, including potential COVID-19 mimicry. Rheumatol Int 2021; 41:1021-1036. [PMID: 33774723 PMCID: PMC8000693 DOI: 10.1007/s00296-021-04819-1] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 02/18/2021] [Indexed: 12/19/2022]
Abstract
Anti-Melanoma Differentiation-Associated gene 5 (MDA-5) Dermatomyositis (MDA5, DM) is a recently identified subtype of myositis characteristically associated with Rapidly Progressive Interstitial Lung Disease (RP-ILD) and unique cutaneous features. We reviewed PubMed, SCOPUS and Web of Science databases and selected 87 relevant articles after screening 1485 search results, aiming to gain a better understanding of the pathophysiology, clinical features, diagnosis, and treatment approaches of anti-MDA-5 DM described in the literature. The etiopathogenesis is speculatively linked to an unidentified viral trigger on the background of genetic predisposition culminating in an acquired type I interferonopathy. The clinical phenotype is highly varied in different ethnicities, with new clinical features having been recently described, expanding the spectrum of cases that should raise the suspicion of anti-MDA-5 DM. Unfortunately, the diagnosis is frequently missed despite excessive mortality, calling for wider awareness of suspect symptoms. RP ILD is the major determinant of survival, treatment being largely based on observational studies with recent insights into aggressive combined immunosuppression at the outset.
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Affiliation(s)
- Pankti Mehta
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGIMS), Rae Bareilly road, Lucknow, 226014, Uttar Pradesh, India
| | - Pedro M Machado
- National Institute for Health Research (NIHR) University College London Hospitals Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK.,Department of Rheumatology, Northwick Park Hospital, London North West University Healthcare NHS Trust, London, UK.,Centre for Rheumatology & Department of Neuromuscular Diseases, University College London, London, UK
| | - Latika Gupta
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGIMS), Rae Bareilly road, Lucknow, 226014, Uttar Pradesh, India.
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15
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Real world utilization of the myositis autoantibody panel. Clin Rheumatol 2021; 40:3195-3205. [PMID: 33629202 DOI: 10.1007/s10067-021-05658-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/31/2021] [Accepted: 02/16/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Myositis autoantibody panel results can offer diagnostic and prognostic information in patients with concern for idiopathic inflammatory myopathy (IIM). However, there has been widespread utilization of myositis autoantibody testing clinically, often in situations where concern for an IIM is unclear. We sought to determine ordering practices and factors predicting positive results on ordered myositis antibody panels. METHODS We included all patients in the Duke University Health System who had a "myositis antibody panel" ordered from October 2014 through December 2016. Retrospective chart review was performed evaluating antibody positivity, provider specialty, ordering location, demographics, medical history, review of systems (ROS), physical examination (PE), and laboratory values. Fisher's exact and t test tests and backward multivariable regression analysis were performed for statistical analysis. RESULTS There were 642 unique tests obtained with 114 positive autoantibodies (17.7%) over the 26-month period. Myositis-specific autoantibodies (MSAs) were the most common and anti-Mi-2 was the most frequent (40% of MSAs). Pulmonology providers ordered the majority of tests (383; 59.6%). Adult Rheumatology had the highest antibody positivity rate (34.3%, p=0.0001) among specialties with at least 10 panels ordered. In backward multivariable regression analysis, factors independently associated with a positive myositis antibody panel were chronic corticosteroid use (OR: 2.10, 95% CI: 1.30-3.38) and sclerodermoid skin changes (OR: 6.89; 95% CI: 2.02-23.47). CONCLUSION The positivity rate of myositis antibody panel testing in this real-world clinical setting was 18%. Anti-Mi-2 antibody was the most frequent autoantibody present. Specific factors associated with positive results can be utilized to identify patients at higher risk for IIM. KEY POINTS • Only eighteen percent of all myositis antibody panel tests ordered returned positive. • Anti-Mi-2 antibody was the most frequent autoantibody in our cohort. • Specific factors associated with positive results can help identify patients at higher risk for IIM, particularly for non-rheumatologists.
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16
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Elferjani B, Liaqat A, Zaman M, Sexton M. Anti-Synthetase Syndrome-Related Interstitial Lung Disease With Anti-PL-12 Antibodies. Cureus 2021; 13:e12936. [PMID: 33654616 PMCID: PMC7916638 DOI: 10.7759/cureus.12936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Anti-synthetase syndrome usually comprises interstitial lung disease, myositis, arthralgias, and Raynaud phenomenon. The anti-PL-12 antibody is directed against the enzyme alanyl-tRNA synthetase and has been associated with interstitial lung disease in the absence of inflammatory myositis. We report the case of a 33-year-old woman with complaints of progressive dyspnea, a persistent dry cough, along with intermittent low-grade fever for a few months. A computed tomography (CT) scan of the chest showed the presence of patchy bilateral airspace opacities and infiltrates. It also showed significant mediastinal and hilar lymphadenopathy. Bronchoscopy with transbronchial biopsy was performed, and histopathology changes were consistent with connective tissue disease related to interstitial lung disease. Further workup revealed the presence of anti-PL-12 antibodies. This case illustrates a rare association of interstitial lung disease with the anti-PL-12 antibody.
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Affiliation(s)
| | - Adnan Liaqat
- Internal Medicine, Southeast Health Medical Center, Dothan, USA
| | - Mohammed Zaman
- Internal Medicine, Southeast Health Medical Center, Dothan, USA
| | - Marvin Sexton
- Pulmonology, Dothan Pulmonary Associates, Dothan, USA
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Vacchi C, Manfredi A, Cassone G, Erre GL, Salvarani C, Sebastiani M. Efficacy and safety of rituximab in the treatment of connective tissue disease-related interstitial lung disease. Drugs Context 2021; 10:2020-8-7. [PMID: 33505478 PMCID: PMC7813433 DOI: 10.7573/dic.2020-8-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 11/30/2020] [Indexed: 02/07/2023] Open
Abstract
Interstitial lung disease (ILD) represents a severe pulmonary complication of connective tissue diseases, rheumatoid arthritis (RA), and antineutrophil cytoplasmic antibody-associated vasculitis. Treatment of ILD, mainly based on immunosuppression, remains challenging. Rituximab (RTX), a monoclonal antibody binding to CD20, is considered a valuable therapeutic choice in cases of refractory ILD. Here, we review the available efficacy and safety data on the use of RTX in the treatment of rheumatic disease-related ILD. Despite controversial efficacy data, RTX seems to be able to stabilize or improve ILD related to RA and antisynthetase syndrome and in established and severe ILD complicating systemic sclerosis. Fewer data are available regarding ILD related to Sjögren syndrome, systemic lupus erythematosus, and antineutrophil cytoplasmic antibody-associated vasculitis. To date, few prospective studies are available and randomized trials are still ongoing with the purpose of exploring the role of RTX in this condition, including the supposed relationship between efficacy and ILD radiologic patterns and safety data, up to now derived mainly from RA studies. Despite an overall acceptable safety profile, concerns remain regarding an increased infectious disease risk in patients with ILD as well as possible lung toxicity and the increased rate of immune-mediated reactions in patients with connective tissue diseases. In conclusion, RTX is a relevant therapeutic option for rheumatic disease-related ILD despite the existing uncertainties; ongoing trials are expected to clarify its use.
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Affiliation(s)
- Caterina Vacchi
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
- Chair and Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy
| | - Andreina Manfredi
- Chair and Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy
| | - Giulia Cassone
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
- Chair and Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy
- Rheumatology Unit, IRCCS Arcispedale Santa Maria Nuova, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Gian Luca Erre
- Rheumatology Unit, Azienda Ospedaliero-Universitaria di Sassari, Sassari, Italy
| | - Carlo Salvarani
- Chair and Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy
- Rheumatology Unit, IRCCS Arcispedale Santa Maria Nuova, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Marco Sebastiani
- Chair and Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy
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18
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Anti-melanoma differentiation-associated gene 5 (MDA5) antibody-positive dermatomyositis responds to rituximab therapy. Clin Rheumatol 2021; 40:2311-2317. [PMID: 33411136 DOI: 10.1007/s10067-020-05530-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 11/11/2020] [Accepted: 11/29/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES The purpose of this study was to assess the efficacy of rituximab (RTX) in the management of anti-melanoma differentiation-associated gene 5 (anti-MDA5) antibody-positive dermatomyositis (DM), with or without rapidly progressive interstitial lung disease (RP-ILD). METHODS Medical records of DM patients with anti-MDA5 antibodies treated with RTX therapy were reviewed retrospectively. Skin rash data, lung function tests, chest high-resolution computed tomography (HRCT), and serum markers were compared before and after RTX. RESULTS Eleven consecutive cases, including 5 males and 6 females, were identified. One hundred percent of patients had a typical DM rash and about 45% presented with skin ulceration. All the patients had ILD, 73% had RP-ILD, and 27% had mild or asymptomatic ILD. Ro-52 antibodies were found in 55% of this group. Lymphopenia was present in 10/11 patients (91%). Around half (55%) had a level of ferritin greater than 1000 ng/ml. Nine patients (82%) were refractory. These patients received intravenous RTX (375 mg/m2) at 0 and 14 days (conventional dose) or 100 mg once a week for 4 weeks (low dose). After RTX treatment, 2 patients (18%) with mild ILD showed complete remission, and 6 (55%) showed improvement in lung HRCT and/or lung function. Skin rash in 4 patients (100%) and ILD in 3 (75%) showed improvement in the low-dose group. Infection episodes occurred in four (57%) and one (25%) of the conventional-dose and low-dose group, respectively. CONCLUSIONS Our study found that RTX is sufficient to improve skin rash and ILD or RP-ILD. Our results also suggest that lower RTX doses may be a useful therapy for anti-MDA5 antibody-positive DM patients. Key Points • To clarify efficacy of RTX in the management of anti-MDA5 antibody-positive DM, we performed a retrospective chart review of DM patients with anti-MDA5 antibodies who were treated with RTX. • This study found that RTX is sufficient to improve skin rash and ILD or RP-ILD. • The results suggest that low-dose RTX in treatment of MDA5-DM results in better responses and fewer adverse events.
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Nishio M, Endo Y, Kosaka K, Saito S, Uehara A, Yamazaki S, Sekiguchi A, Ishikawa O, Motegi SI. Anti-aminoacyl-tRNA synthetases antibody positive overlap syndrome of systemic sclerosis and dermatomyositis associated with rapidly progressive interstitial lung disease. J Dermatol 2020; 48:e110-e111. [PMID: 33179348 DOI: 10.1111/1346-8138.15692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/17/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Mayu Nishio
- Department of Dermatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Yukie Endo
- Department of Dermatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Keiji Kosaka
- Department of Dermatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Shintaro Saito
- Department of Dermatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Akihito Uehara
- Department of Dermatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Sahori Yamazaki
- Department of Dermatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Akiko Sekiguchi
- Department of Dermatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Osamu Ishikawa
- Department of Dermatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Sei-Ichiro Motegi
- Department of Dermatology, Gunma University Graduate School of Medicine, Maebashi, Japan
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20
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Kang YR, Kim KH, Nam TS, Lee KH, Kang KW, Lee SJ, Choi SY, Chandrasekaran G, Kim MK. Fulminant Course of Neuromyelitis Optica in a Patient With Anti-MDA5 Antibody-Positive Dermatomyositis: A Case Report. Front Med (Lausanne) 2020; 7:576436. [PMID: 33262991 PMCID: PMC7686760 DOI: 10.3389/fmed.2020.576436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 10/07/2020] [Indexed: 11/21/2022] Open
Abstract
Anti-melanoma differentiation-associated gene 5 (anti-MDA5) antibody is a myositis-specific marker detected in clinically amyopathic dermatomyositis (DM). DM with anti-MDA5 antibody can be accompanied by rapidly progressive interstitial lung disease (RP-ILD) and other autoimmune disorders. Until now, only one case of neuromyelitis optica (NMO) with anti-MDA5-positive DM has been reported worldwide, in which the patient achieved a favorable outcome with intensive immunotherapy. We report a case of NMO in a patient with anti-MDA5-positive DM complicated by ILD and rheumatoid arthritis. Our patient experienced a fulminant course of NMO, rather than RP-ILD, in the presence of hyperferritinemia, which resulted in profound neurological sequelae despite immunotherapy including rituximab.
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Affiliation(s)
- You-Ri Kang
- Department of Neurology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, South Korea
| | - Kun-Hee Kim
- Department of Biomedical Sciences, Chonnam National University Medical School, Gwangju, South Korea
| | - Tai-Seung Nam
- Department of Neurology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, South Korea
| | - Kyung-Hwa Lee
- Department of Pathology, Chonnam National University Medical School, Gwangju, South Korea
| | - Kyung Wook Kang
- Department of Neurology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, South Korea
| | - Seung-Jin Lee
- Department of Radiology, Chonnam National University Medical School, Gwangju, South Korea
| | - Seok-Yong Choi
- Department of Biomedical Sciences, Chonnam National University Medical School, Gwangju, South Korea
| | | | - Myeong-Kyu Kim
- Department of Neurology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, South Korea
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21
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Fisser C, Wiest C, Hamer OW, Müller T, Lubnow M, Pfeifer M, Lerzer C, Dvorak I. Die Diagnose liegt auf der Hand. Pneumologie 2020; 74:780-786. [DOI: 10.1055/a-1177-4209] [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
ZusammenfassungEine seltene Form der Dermatomyositis ist die klinische amyopathische Dermatomyositis (CADM). Charakterisiert ist sie durch das Fehlen einer bzw. durch eine nur sehr gering ausgeprägte Muskelbeteiligung. Dementsprechend sind die Kreatinkinase-Werte meist im Normalbereich. Typische Hautmanifestationen sind Gottron-Papeln und Mechanikerhände. Bei Nachweis eines MDa5 (Melanoma-differentiation-associated gene 5 intracellular pathogen sensor)-Antikörpers ist die CADM häufig mit einer rasch progredienten und schweren Verlaufsform einer interstitiellen Lungenerkrankung assoziiert. In der Lungenfunktion lässt sich eine Restriktion und eine Hypoxämie unterschiedlichen Ausmaßes nachweisen. Die HRCT-Bildgebung ist nicht spezifisch. Es lassen sich u. a. Milchglas, Retikulationen und Konsolidierungen beobachten. In der bronchioloalveolären Lavage zeigen sich gelegentlich vermehrt Lymphozyten. Histologisch ähnelt das Bild einer nicht-spezifischen interstitiellen Pneumonie oder einer organisierenden Pneumonie. Die Therapie richtet sich nach der Schwere der Ausprägung der klinischen Manifestation. Im Allgemeinen ist eine ausgeprägte immunsuppressive Therapie notwendig. Meist müssen verschiedene Immunsuppressiva kombiniert werden. Ein neuer Therapieansatz stellt die Verwendung des Januskinase-Inhibitors Tofacitinib dar. Zur Therapiekontrolle können der Ferritinspiegel und der MDa5-Antikörper-Titer verwendet werden. Es besteht eine hohe Mortalität von bis zu 84 %.
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Affiliation(s)
- C. Fisser
- Klinik und Poliklinik für Innere Medizin II, Universitätsklinik Regensburg, Regensburg
- Abteilung für Pneumologie, Fachklinik für Lungenerkrankungen Donaustauf, Donaustauf
| | - C. Wiest
- Klinik und Poliklinik für Innere Medizin II, Universitätsklinik Regensburg, Regensburg
| | - O. W. Hamer
- Institut für Röntgendiagnostik, Universitätsklinik Regensburg, Regensburg
- Abteilung für Radiologie, Fachklinik für Lungenerkrankungen Donaustauf, Donaustauf
| | - T. Müller
- Klinik und Poliklinik für Innere Medizin II, Universitätsklinik Regensburg, Regensburg
| | - M. Lubnow
- Klinik und Poliklinik für Innere Medizin II, Universitätsklinik Regensburg, Regensburg
| | - M. Pfeifer
- Klinik und Poliklinik für Innere Medizin II, Universitätsklinik Regensburg, Regensburg
- Abteilung für Pneumologie, Fachklinik für Lungenerkrankungen Donaustauf, Donaustauf
- Abteilung für Pneumologie, Krankenhaus der Barmherzigen Brüder Regensburg, Regensburg
| | - C. Lerzer
- Abteilung für Pneumologie, Fachklinik für Lungenerkrankungen Donaustauf, Donaustauf
| | - I. Dvorak
- Abteilung für Pneumologie, Fachklinik für Lungenerkrankungen Donaustauf, Donaustauf
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22
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Stager K, Wise L. MDA-5 dermatomyositis complicated by interstitial lung disease and cutaneous ulcers: successful treatment with corticosteroids, mycophenolate mofetil and intravenous immunoglobulin. BMJ Case Rep 2020; 13:13/9/e236431. [DOI: 10.1136/bcr-2020-236431] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Antimelanoma differentiation-associated gene 5 (MDA-5) dermatomyositis is a subtype of dermatomyositis that is associated with rapidly progressive interstitial lung disease (RP-ILD), as well as with a variety of cutaneous manifestations. Patients with MDA-5 dermatomyositis tend to have a poor prognosis that is often attributed to the high rates of concurrent RP-ILD. Given the severity of disease, early diagnosis and aggressive management is pivotal. We present a case of a 40-year-old woman diagnosed with MDA-5 dermatomyositis who presented with weakness, painful cutaneous ulcerations and interstitial lung disease. She was treated with monthly intravenous Ig (IVIg), weight-based prednisone and mycophenolate mofetil (MMF). After approximately 2 years of treatment, her interstitial lung disease remains stable and she has had significant improvement in weakness and cutaneous ulcerations. Our case provides evidence for early and aggressive treatment of MDA-5 dermatomyositis with a combination of weight-based prednisone, MMF and IVIg.
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Recommendations for the treatment of anti-melanoma differentiation-associated gene 5-positive dermatomyositis-associated rapidly progressive interstitial lung disease. Semin Arthritis Rheum 2020; 50:776-790. [PMID: 32534273 DOI: 10.1016/j.semarthrit.2020.03.007] [Citation(s) in RCA: 105] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 02/16/2020] [Accepted: 03/08/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVES The study aimed to develop evidence-based recommendations for the treatment of rapidly progressive interstitial lung disease (RPILD) associated with the anti-Melanoma Differentiation-Associated Gene 5-positive dermatomyositis (DM) syndrome. METHODS The task force comprised an expert panel of specialists in rheumatology, intensive care medicine, pulmonology, immunology, and internal medicine. The study was carried out in two phases: identifying key areas in the management of DM-RPILD syndrome and developing a set of recommendations based on a review of the available scientific evidence. Four specific questions focused on different treatment options were identified. Relevant publications in English, Spanish or French up to April 2018 were searched systematically for each topic using PubMed (MEDLINE), EMBASE, and Cochrane Library (Wiley Online). The experts used evidence obtained from these studies to develop recommendations. RESULTS A total of 134 studies met eligibility criteria and formed the evidentiary basis for the recommendations regarding immunosuppressive therapy and complementary treatments. Overall, there was general agreement on the initial use of combined immunosuppressive therapy. Combination of high-dose glucocorticoids and calcineurin antagonists with or without cyclophosphamide is the first choice. In the case of calcineurin antagonist contraindication or treatment failure, switching or adding other immunosuppressants may be individualized. Plasmapheresis, polymyxin B hemoperfusion and/or intravenous immunoglobulins may be used as rescue options. ECMO should be considered in life-threatening situations while waiting for a clinical response or as a bridge to lung transplant. CONCLUSIONS Thirteen recommendations regarding the treatment of the anti-MDA5 positive DM-RPILD were developed using research-based evidence and expert opinion.
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Abstract
Dermatomyositis is a rare inflammatory disease with characteristic cutaneous findings and varying amounts of systemic involvement. Patients may present with skin disease alone, have concomitant muscle disease, or have extracutaneous manifestations such as pulmonary disease or an associated malignancy. Given such diverse presentations, dermatomyositis is both a diagnostic and therapeutic challenge. However, a prompt diagnosis is of utmost importance to institute adequate therapy and screen patients for an associated malignancy. Dermatologists should play a crucial role in the diagnosis and management of patients with dermatomyositis as cutaneous disease tends to be chronic, negatively impact quality of life, and be more recalcitrant to therapy. In this review, we discuss diagnosis, with a focus on myositis-specific antibodies and their associated phenotypes. We also review therapies available for this often refractory skin disease.
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Affiliation(s)
- Gabriela A Cobos
- Autoimmune Skin Disease Program, Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Avenue, Boston, MA, 02115, USA
| | - Alisa Femia
- Ronald O. Perelman Department of Dermatology, New York University Langone Medical Center, New York University School of Medicine, New York, NY, USA
| | - Ruth Ann Vleugels
- Autoimmune Skin Disease Program, Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Avenue, Boston, MA, 02115, USA.
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25
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Ultra-low dose rituximab as add-on therapy in anti-MDA5-positive patients with polymyositis /dermatomyositis associated ILD. Respir Med 2020; 172:105983. [PMID: 33032789 DOI: 10.1016/j.rmed.2020.105983] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 04/17/2020] [Accepted: 04/18/2020] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To evaluate the efficacy and safety of ultra-low dose (100 mg) rituximab (RTX) administration in anti-melanoma differentiation-associated gene 5 (MDA5) positive patients with polymyositis/dermatomyositis (PM/DM) associated interstitial lung disease. METHODS This retrospective study included anti-MDA5 antibody positive ILD subjects in the First Affiliated Hospital of Guangzhou Medical University from November 2017 to March 2019. Independent predictors for 180-day mortality were measured by Cox regression analysis. Patients were divided into 3 groups: Group 1 (non-cyclophosphamide (CTX)/RTX) (n = 10), Group 2 (CTX only) (n = 19) and Group 3 (RTX with/without CTX) (n = 11). The 180-day mortality was compared among 3 groups with Kaplan-Meier analysis. Post-RTX serological parameters as well as adverse events were evaluated. RESULTS Forty patients were included with the mean age of 51.3 years. Elevated IL-10 level and CD4+/8+ ratio were considered as risk factors of 180-day mortality. Kaplan-Meier analysis showed a trend toward decrease, albeit non-significant, in 180-day mortality in Group 3 (P = 0.26). The administration of 100 mg RTX brought down B cell within 7 days that lasted for 180 days. There were 7 and 6 infection events observed within 2 months of CTX/RTX treatment in Group 2 and 3, with 5 and 2 fatal cases respectively. Cytomegalovirus infection accounted for half infection events in Group 3. CONCLUSION We found a pronounced and prolonged B cell depletion following 100 mg RTX infusion and RTX add-on may be effective in anti-MDA5 positive ILD patients. However, infection, especially opportunistic infection, should be concerned during the treatment.
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Liang J, Cao H, Ke Y, Sun C, Chen W, Lin J. Acute Exacerbation of Interstitial Lung Disease in Adult Patients With Idiopathic Inflammatory Myopathies: A Retrospective Case-Control Study. Front Med (Lausanne) 2020; 7:12. [PMID: 32083087 PMCID: PMC7005087 DOI: 10.3389/fmed.2020.00012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 01/13/2020] [Indexed: 12/16/2022] Open
Abstract
Objective: This study aimed at clarifying the prevalence, risk factors, outcome, and outcome-related factors of acute exacerbation of interstitial lung disease (AE-ILD) in patients with idiopathic inflammatory myopathy (IIM). Methods: Data of IIM patients who were admitted to the First Affiliated Hospital of Zhejiang University (FAHZJU) from September 2007 to September 2019 were retrospectively collected. And the IIM patients with AE-ILD formed the case group. In addition, age and sex matched IIM patients without AE-ILD were randomly selected to constitute the control group. A 1:2 case-control study and intragroup analysis were performed to identify risk factors for development of AE-ILD in IIM patients and unfavorable short-term outcome in AE-ILD patients through comparison, univariate and multivariate logistic regression analysis. Results: AE-ILD occurred in 64 out of 665 IIM patients (9.6%) with a short-term mortality rate of 39.1%. And the 64 IIM patients with AE-ILD formed the case group. Besides, 128 age and sex matched IIM patients without AE-ILD were randomly selected to constitute the control group. The retrospective case-control study revealed that elevated on-admission disease activity (P < 0.001), lower percent-predicted diffusing capacity of the lung for carbon monoxide (DLCO%, P = 0.013) and diagnosis of clinically amyopathic dermatomyositis (CADM, P = 0.007) were risk factors for development of AE-ILD in IIM patients. The following intragroup analysis indicated that elevated on-admission disease activity (P = 0.008) and bacterial infection (P = 0.003) were significantly correlated with the unfavorable short-term outcome of patients complicated with AE-ILD. In addition, combined use of steroid and disease modifying antirheumatic drugs (DMARDs, P = 0.006) was found to significantly reduce the short-term mortality in IIM patients with AE-ILD. Conclusion: AE-ILD is a less frequent but fatal complication in IIM patients with elevated on-admission disease activity, lower DLCO% and diagnosis of CADM working as risk factors, indicating the potential roles of autoimmune abnormality and hypoxia in development of AE-ILD. Elevated on-admission disease activity and bacterial infection could predict unfavorable short-term outcome of IIM patients with AE-ILD. A therapeutic regimen of steroid and DMARDs was found to reduce short-term death in these patients.
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Affiliation(s)
- Junyu Liang
- Department of Rheumatology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Heng Cao
- Department of Rheumatology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yini Ke
- Department of Rheumatology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Chuanyin Sun
- Department of Rheumatology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Weiqian Chen
- Department of Rheumatology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jin Lin
- Department of Rheumatology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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So H, Mok CC. Cyclophosphamide Versus Obinutuzumab for the Treatment of Anti-MDA5 Positive Inflammatory Myopathy with Interstitial Lung Disease: A Study Protocol and Literature Review. JOURNAL OF CLINICAL RHEUMATOLOGY AND IMMUNOLOGY 2019. [DOI: 10.1142/s2661341719300040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
In patients with idiopathic inflammatory myopathy, the presence of the melanoma differentiation-associated gene 5 (MDA5) antibody carries an extremely poor prognosis as a result of the associated interstitial lung disease (ILD) that is often rapidly progressive and refractory to therapies. Management of anti-MDA5 associated ILD is a challenging task as there is a paucity of clinical data and treatment guidelines in the literature. We hereby describe a proposed protocol for a multicenter randomized controlled trial to compare the efficacy of intravenous cyclophosphamide and obinutuzumab in combination with high-dose glucocorticoids and tacrolimus in terms of mortality at six months (primary outcome). The epidemiology, pathogenesis and treatment options of anti-MDA5 associated ILD are briefly reviewed.
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Affiliation(s)
- Ho So
- Medicine and Geriatrics, Kwong Wah Hospital, Hong Kong SAR, China
| | - Chi Chiu Mok
- Department of Medicine, Tuen Mun Hospital, Hong Kong SAR, China
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Khoo T, Limaye V. Biologic therapy in the idiopathic inflammatory myopathies. Rheumatol Int 2019; 40:191-205. [PMID: 31680207 DOI: 10.1007/s00296-019-04467-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 10/24/2019] [Indexed: 11/29/2022]
Abstract
The idiopathic inflammatory myopathies (IIM) are a group of autoimmune diseases resulting from inflammation of muscle and manifesting as weakness, though a range of extra-muscular manifestations are observed. These are often correlated closely with disease subtype and the presence of myositis-specific/myositis-associated antibodies. IIM are notoriously difficult to treat and often refractory to glucocorticoid therapy and synthetic immunosuppressants. Both the innate and adaptive immune systems are implicated in the pathogenesis of IIM. A growing understanding of the key cytokines as well as the cell-mediated and antibody effectors of disease has identified multiple potential targets for biologic therapy. The most widely used of these is B-cell depletion via rituximab though the tumour necrosis factor inhibitors and other biologic therapies used in diseases such as rheumatoid arthritis, systemic lupus erythematosus and multiple sclerosis have also been trialled. This review summarises the literature thus far on biologic therapy in IIM, highlighting both the significant trials that influence current treatment regimens and also the continuing need for further research to inform more effective therapies.
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Affiliation(s)
- Thomas Khoo
- Central Adelaide Local Health Network, Adelaide, Australia
| | - Vidya Limaye
- Rheumatology Unit, Royal Adelaide Hospital, Adelaide, Australia. .,Discipline of Medicine, School of Medicine, University of Adelaide, Adelaide, Australia.
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Clinical spectrum and therapeutics in Canadian patients with anti-melanoma differentiation-associated gene 5 (MDA5)-positive dermatomyositis: a case-based review. Rheumatol Int 2019; 39:1971-1981. [DOI: 10.1007/s00296-019-04398-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 07/26/2019] [Indexed: 10/26/2022]
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Deitchman AR, Kalchiem-Dekel O, Todd N, Reed RM. Rapidly progressive interstitial lung disease due to anti-melanoma differentiation associated protein-5 requiring a bilateral lung transplant, and complicated by kennel cough. Respir Med Case Rep 2019; 28:100886. [PMID: 31249780 PMCID: PMC6586988 DOI: 10.1016/j.rmcr.2019.100886] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 06/13/2019] [Accepted: 06/13/2019] [Indexed: 11/02/2022] Open
Abstract
The association between inflammatory myopathies anti-synthetase syndrome and interstitial lung disease has been recognized since the 1950s. Patients generally present with gradual onset of symptoms and slow progression of fibrosis over months to years. Herein, we describe a previously well 51-year-old man who presented with three months of progressive small joint arthritis, cough, dyspnea, and eventually hypoxemic respiratory failure following a viral prodrome. He continued to decompensate despite high dose corticosteroids and mycophenolate mofetil, ultimately requiring extracorporeal membranous oxygenation as a bridge to bilateral lung transplantation. Clinically amyopathic dermatomyositis (CADM) was confirmed through serum positivity for anti-Melanoma Differentiation Associated Protein-5 (MDA-5) antibody. Interestingly, his post-operative course was complicated by a zoonotic infection with Bordetella bronchiseptica. This case highlights the importance of identifying rare autoimmune diseases, and the utility of transfer to a lung transplant center.
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Affiliation(s)
- Andrew R Deitchman
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Or Kalchiem-Dekel
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nevins Todd
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Robert M Reed
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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De Backer E, Gremonprez F, Brusselle G, Depuydt P, Van Dorpe J, Van Haverbeke C, Goeminne PC, Derom E. Anti-MDA5 positive dermatomyositis complicated with rapidly progressive interstitial lung disease - a case report. Acta Clin Belg 2018; 73:413-417. [PMID: 29287518 DOI: 10.1080/17843286.2017.1420521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
CASE PRESENTATION We present a case of a 55-year-old Caucasian male with manifestations of dermatomyositis complicated with rapidly progressive interstitial lung disease (RP-ILD). Diagnosis of anti-MDA5 positive dermatomyositis was made. DISCUSSION Myositis specific antibodies (MSA) can be used for diagnosis and predicting prognosis in patients with polymyositis and dermatomyositis. Anti-MDA5 positive dermatomyositis should be considered in patients presenting with dermatomyositis and a disease course resembling antisynthetase syndrome in the absence of antisynthetase autoantibodies, especially if a remarkably high ferritin is noted. Anti-MDA5 autoantibodies have been associated with RP-ILD and adverse outcome. In patients with anti-MDA5 autoantibodies, early diagnosis and aggressive immunosuppressive treatment may improve prognosis. CONCLUSION This case highlights the importance of determining MSA in patients with dermatomyositis and associated interstitial lung disease, as this has implications for diagnosis, prognosis and therapy.
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Affiliation(s)
| | | | - Guy Brusselle
- Pneumology Department, Ghent University Hospital, Ghent, Belgium
| | - Pieter Depuydt
- Intensive Care Department, Ghent University Hospital, Ghent, Belgium
| | - Jo Van Dorpe
- Department of Pathology, Ghent University Hospital, Ghent, Belgium
| | | | | | - Eric Derom
- Pneumology Department, Ghent University Hospital, Ghent, Belgium
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Interstitial Lung Disease and Pulmonary Fibrosis: A Practical Approach for General Medicine Physicians with Focus on the Medical History. J Clin Med 2018; 7:jcm7120476. [PMID: 30477216 PMCID: PMC6306719 DOI: 10.3390/jcm7120476] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 11/21/2018] [Accepted: 11/22/2018] [Indexed: 12/26/2022] Open
Abstract
Interstitial lung disease (ILD) and pulmonary fibrosis comprise a wide array of inflammatory and fibrotic lung diseases which are often confusing to general medicine and pulmonary physicians alike. In addition to the myriad of clinical and radiologic nomenclature used in ILD, histopathologic descriptors may be particularly confusing, and are often extrapolated to radiologic imaging patterns which may further add to the confusion. We propose that rather than focusing on precise histologic findings, focus should be on identifying an accurate etiology of ILD through a comprehensive and detailed medical history. Histopathologic patterns from lung biopsy should not be dismissed, but are often nonspecific, and overall treatment strategy and prognosis are likely to be determined more by the specific etiology of ILD rather than any particular histologic pattern. In this review, we outline a practical approach to common ILDs, highlight important aspects in obtaining an exposure history, clarify terminology and nomenclature, and discuss six common subgroups of ILD likely to be encountered by general medicine physicians in the inpatient or outpatient setting: Smoking-related, hypersensitivity pneumonitis, connective tissue disease-related, occupation-related, medication-induced, and idiopathic pulmonary fibrosis. Accurate diagnosis of these forms of ILD does require supplementing the medical history with results of the physical examination, autoimmune serologic testing, and chest radiographic imaging, but the importance of a comprehensive environmental, avocational, occupational, and medication-use history cannot be overstated and is likely the single most important factor responsible for achieving the best possible outcomes for patients.
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Hornig J, Weinhage T, Schmidt LH, Buerke B, Schneider U, Pavenstädt H, Becker H, Gabriëls G. Ansprechen einer Dermatomyositis mit Lungenbeteiligung auf eine Januskinase-Inhibitor-Therapie. Z Rheumatol 2018; 77:952-957. [DOI: 10.1007/s00393-018-0565-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
PURPOSE OF REVIEW Anti-melanoma differentiation-associated gene 5 (anti-MDA5) is a novel and highly specific myositis-associated autoantibody, which defines a unique phenotype among patients with dermatomyositis (DM). RECENT FINDINGS Anti-MDA5 was originally characterized in Japan in DM patients with hallmark cutaneous features and no proximal muscle weakness and termed clinically amyopathic DM (CADM). Anti-MDA5 has characteristic cutaneous manifestations which include tender palmar papules and cutaneous ulcerations, along with an increased frequency of interstitial lung disease (ILD) that can be rapidly progressive (RPILD) and fatal. This review will highlight the clinical significance of anti-MDA5 autoantibodies in Caucasian DM patients.
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So H, Wong VTL, Lao VWN, Pang HT, Yip RML. Rituximab for refractory rapidly progressive interstitial lung disease related to anti-MDA5 antibody-positive amyopathic dermatomyositis. Clin Rheumatol 2018; 37:1983-1989. [PMID: 29713969 DOI: 10.1007/s10067-018-4122-2] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 04/16/2018] [Accepted: 04/20/2018] [Indexed: 11/28/2022]
Abstract
To report our experience in using rituximab (RTX) for treating refractory rapidly progressive interstitial lung disease (RP-ILD) complicating anti-melanoma differentiation-associated gene 5 antibody (anti-MDA5 Ab)-positive amyopathic dermatomyositis (ADM). Medical records of four ADM patients with refractory RP-ILD treated with RTX therapy were reviewed retrospectively. All four patients were tested positive for anti-MDA5 Ab and failed to respond to high-dose systemic steroid and other intensive immunosuppressive therapies. Respiratory symptoms, lung function tests, and high-resolution computed tomography (HRCT) of the chest were compared before and after the first course of RTX. After RTX treatment, all four patients had improvement in the respiratory symptoms in terms of New York Heart Association classification. Two patients successfully had their supplementary oxygen therapy weaned off. The lung function tests were significantly better in all patients. The HRCT showed improvement in three patients while the other one remained static. The recalcitrant vasculitic rashes associated with the anti-MDA5 Ab were also better in all patients. The average daily prednisolone dose dropped from 20 to 6.25 mg post-treatment. None of the patients died throughout the follow-up period which ranged from 6 months to 2 years. However, two patients developed chest infection and one wound infection within 6 months after the RTX infusion. Our results suggest that RTX may be a useful therapy for anti-MDA5 Ab-positive ADM associated with RP-ILD. However, infection is the major risk.
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Affiliation(s)
- Ho So
- Department of Medicine and Geriatrics, Kwong Wah Hospital, 25 Waterloo Road, Kowloon, Hong Kong.
| | - Victor Tak Lung Wong
- Integrated Diagnostic and Medical Centre, Tung Wah Group of Hospitals, Kowloon, Hong Kong
| | - Virginia Weng Nga Lao
- Department of Medicine and Geriatrics, Kwong Wah Hospital, 25 Waterloo Road, Kowloon, Hong Kong
| | - Hin Ting Pang
- Department of Medicine and Geriatrics, Kwong Wah Hospital, 25 Waterloo Road, Kowloon, Hong Kong
| | - Ronald Man Lung Yip
- Integrated Diagnostic and Medical Centre, Tung Wah Group of Hospitals, Kowloon, Hong Kong
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Isak V, Jorizzo JL. Recent developments on treatment strategies and the prognosis of dermatomyositis: a review. J DERMATOL TREAT 2017; 29:450-459. [DOI: 10.1080/09546634.2017.1403549] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Verena Isak
- Department of Dermatology, Wake Forest School of Medicine, Winston Salem, New York, NY, USA
- Medical University of Vienna, Vienna, Austria
| | - Joseph L. Jorizzo
- Department of Dermatology, Wake Forest School of Medicine, Winston Salem, New York, NY, USA
- Department of Dermatology, Weill Cornell Medical College, New York, NY, USA
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Effective Administration of Rituximab in Anti-MDA5 Antibody-Positive Dermatomyositis with Rapidly Progressive Interstitial Lung Disease and Refractory Cutaneous Involvement: A Case Report and Literature Review. Case Rep Rheumatol 2017; 2017:5386797. [PMID: 29225988 PMCID: PMC5684540 DOI: 10.1155/2017/5386797] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 09/24/2017] [Indexed: 12/27/2022] Open
Abstract
We describe the case of a 48-year-old man with dermatomyositis (DM) who demonstrated rapidly progressive interstitial lung disease (RP-ILD) and refractory cutaneous involvement together with high levels of anti-melanoma differentiation-associated gene 5 antibody (anti-MDA5-Ab). Even after combination immunosuppressive therapy including a corticosteroid, cyclosporine A, and intravenous cyclophosphamide, his respiratory insufficiency and cutaneous involvement progressively worsened. However, the administration of rituximab (RTX) resulted in clinical remission as well as a visible reduction in anti-MDA5-Ab levels, suggesting that RTX could be a useful remedy in cases refractory to conventional immunosuppressive agents, especially those of RP-ILD related to anti-MDA5-Ab–positive DM.
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