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Ishiguro M, Nagatomo Y, Inoue K, Yoshikawa T, Yoshizawa S, Oya Y, Nishino I, Isobe M. Sick sinus syndrome concomitant with myopathy associated with anti-mitochondrial antibodies: a case report. Eur Heart J Case Rep 2023; 7:ytac158. [PMID: 37323533 PMCID: PMC10261722 DOI: 10.1093/ehjcr/ytac158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/18/2021] [Accepted: 04/06/2022] [Indexed: 06/17/2023]
Abstract
Background Anti-mitochondrial antibody (AMA)-associated myopathy is known to be concomitant with primary biliary cirrhosis and to cause both skeletal muscle disorders and arrhythmias, myocardium disorders, and respiratory muscle disorders. We report a case of AMA-associated myopathy in which the bradycardia-related symptoms preceded the skeletal muscle symptoms. Case summary A 59-year-old woman visited the emergency room in our hospital following a syncopal event. The patient was bradycardiac (45 b.p.m.) with a junctional rhythm resulting from sick sinus syndrome (SSS) and was suffering from heart failure. Blood tests revealed elevated creatine kinase (CK) and hepatic enzymes. She underwent permanent pacemaker implantation. However, it proved difficult to detect the electrical potential in the right atrium. Although successful atrial pacing was achieved at the lower right atrial septum, the atrial threshold was markedly high and she depended on ventricular pacing. One year later, neurological examination and muscle biopsy confirmed the diagnosis of AMA-associated myopathy. Following this diagnosis, steroid pulse therapy was initiated. Steroid administration relieved her symptoms and lowered the CK levels but the atrial standstill persisted. The patient takes low-dose prednisolone and has had an uneventful course for 3 years. Discussion To the best of our knowledge, this is the first case of AMA-associated myopathy diagnosed by the first symptom related to bradycardia due to SSS. Patients with AMA-associated myopathy can experience a variety of cardiac symptoms, including arrhythmias, and initially complain of cardiac symptoms without symptoms of skeletal myopathy. This disease should be considered when diagnosing patients with arrhythmia and elevated CK.
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Affiliation(s)
- Maya Ishiguro
- Department of Cardiology, Sakakibara Heart Institute, 3-16-1 Asahi-cho, Fuchu, Tokyo 183-0003, Japan
| | - Yuji Nagatomo
- Corresponding author. Tel: +81 4 2995 1597, Fax: +81 4 3996 5200,
| | - Kanki Inoue
- Department of Cardiology, Sakakibara Heart Institute, 3-16-1 Asahi-cho, Fuchu, Tokyo 183-0003, Japan
| | - Tsutomu Yoshikawa
- Department of Cardiology, Sakakibara Heart Institute, 3-16-1 Asahi-cho, Fuchu, Tokyo 183-0003, Japan
| | - Saeko Yoshizawa
- Department of Pathology, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666, Japan
| | - Yasushi Oya
- Department of Neurology, National Center Hospital, National Center of Neurology and Psychiatry, 4-1-1 Ogawa-Higashi, Kodaira, Tokyo 187-8551, Japan
| | - Ichizo Nishino
- Department of Neuromuscular Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry, 4-1-1 Ogawa-Higashi, Kodaira, Tokyo 187-8502, Japan
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Huang R, Zhang X, Han Z, Wu X, Li G, Chen J, Xu B, Gu R, Wang L. Refractory ventricular tachycardia and heart failure due to anti-mitochondrial antibody-positive inflammatory myopathy. BMC Cardiovasc Disord 2023; 23:57. [PMID: 36721091 PMCID: PMC9890839 DOI: 10.1186/s12872-023-03057-6] [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: 02/17/2022] [Accepted: 01/10/2023] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Anti-mitochondrial antibody (AMA)-positive inflammatory myopathy, a rare type of idiopathic inflammatory myopathy which was frequently difficult to diagnose, can affect muscles and the structure and electrical conduction of the heart. Early identification and treatment of this myopathy can prevent serious cardiovascular adverse events and improve cardiac function. CASE PRESENTATION We report a patient who experienced repeated syncope, ventricular tachycardia (VT) and heart failure accompanied by weakness and muscle atrophy. He was initially diagnosed with dilated cardiomyopathy and received implantable cardioverter-defibrillator therapy. He was subsequently misdiagnosed as muscular dystrophy due to progressive muscular atrophy. However, the patient developed repeated and refractory VT storms that were not alleviated by conventional therapy. Finally, he was diagnosed with AMA-positive inflammatory myopathy with cardiac injuries. The patient was markedly recovered by being treated with immunosuppressive and immunomodulatory therapy. CONCLUSION AMA could be screened when discovering myopathies accompanied by unexplained cardiac symptoms. Our findings provide insights into the diagnosis and therapy of this rare and severe disease.
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Affiliation(s)
- Rong Huang
- grid.412676.00000 0004 1799 0784Department of Cardiology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Xinlin Zhang
- grid.412676.00000 0004 1799 0784Department of Cardiology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Zhonglin Han
- grid.412676.00000 0004 1799 0784Department of Cardiology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Xiang Wu
- grid.412676.00000 0004 1799 0784Department of Cardiology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Guannan Li
- grid.412676.00000 0004 1799 0784Department of Cardiology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Jianzhou Chen
- grid.412676.00000 0004 1799 0784Department of Cardiology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Biao Xu
- grid.412676.00000 0004 1799 0784Department of Cardiology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Rong Gu
- grid.412676.00000 0004 1799 0784Department of Cardiology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Lian Wang
- grid.412676.00000 0004 1799 0784Department of Cardiology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
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Fujisaki S, Tsuchida K, Sekiya Y, Oyanagi N, Tsuchiya H, Nakano K, Hayashi Y, Tanaka K, Hosaka Y, Takahashi K, Oda H. A Case of Chronic Heart Failure Complicated by Primary Biliary Cholangitis and Skeletal Myopathy. Int Heart J 2022; 63:963-969. [DOI: 10.1536/ihj.21-837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
| | | | - Yuka Sekiya
- Department of Cardiology, Niigata City General Hospital
| | | | | | - Kenji Nakano
- Department of Cardiology, Niigata City General Hospital
| | - Yuka Hayashi
- Department of Cardiology, Niigata City General Hospital
| | - Komei Tanaka
- Department of Cardiology, Niigata City General Hospital
| | - Yukio Hosaka
- Department of Cardiology, Niigata City General Hospital
| | | | - Hirotaka Oda
- Department of Cardiology, Niigata City General Hospital
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Bujo S, Amiya E, Maeda MH, Ishida J, Hatano M, Ishizuka M, Uehara M, Oshima T, Kojima T, Nakanishi K, Daimon M, Shimizu J, Toda T, Komuro I. The effect of immunosuppressive therapy on cardiac involvements in anti-mitochondrial antibody-positive myositis. ESC Heart Fail 2022; 9:4112-4119. [PMID: 36068648 PMCID: PMC9773721 DOI: 10.1002/ehf2.14138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 08/17/2022] [Accepted: 08/30/2022] [Indexed: 01/19/2023] Open
Abstract
AIMS Anti-mitochondrial antibody (AMA)-positive myositis is frequently associated with various cardiac involvements, such as arrhythmia and left ventricular (LV) dysfunction. However, the efficacy of immunosuppressive therapy in these complications remains unknown. This study aimed to investigate the cardiac response to immunosuppressive therapy in patients with AMA-positive myositis. METHODS AND RESULTS The clinical data of 15 AMA-positive myositis patients with cardiac involvement were retrospectively collected at our centre. To evaluate the effects of immunosuppressive therapy, echocardiographic and laboratory data of patients who received glucocorticoid therapy with additional immunosuppressants (n = 6) and those who did not (n = 6) were compared. Also, the characteristics of patients with or without >5% LV ejection fraction (LVEF) decline during the follow-up period (n = 5 vs. n = 7) were compared. Thirteen patients (87%) had arrhythmias, and eight patients (53%) had LV wall motion abnormalities. Although arrhythmias decreased after treatment, reduced LVEF and LV wall motion abnormalities persisted. Further investigation revealed an increased LV end-systolic dimension and reduced LVEF in patients without additional immunosuppressive therapy, while those in patients with additional immunosuppressive therapy were maintained. Six of seven patients (86%) without LVEF decline received additional immunosuppressive therapy, whereas no patients with LVEF decline had additional immunosuppressive therapy. CONCLUSIONS Cardiac involvement in AMA-positive myositis may worsen even with glucocorticoid monotherapy, and there might be some associations between the change of LV function and additional immunosuppressive therapy.
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Affiliation(s)
- Satoshi Bujo
- Department of Cardiovascular Medicine, Graduate School of MedicineThe University of TokyoTokyoJapan
| | - Eisuke Amiya
- Department of Cardiovascular Medicine, Graduate School of MedicineThe University of TokyoTokyoJapan,Department of Therapeutic Strategy for Heart Failure, Graduate School of MedicineThe University of TokyoTokyoJapan
| | - Meiko Hashimoto Maeda
- Department of Neurology, Graduate School of MedicineThe University of TokyoTokyoJapan
| | - Junichi Ishida
- Department of Cardiovascular Medicine, Graduate School of MedicineThe University of TokyoTokyoJapan
| | - Masaru Hatano
- Department of Cardiovascular Medicine, Graduate School of MedicineThe University of TokyoTokyoJapan,Advanced Medical Center for Heart FailureUniversity of TokyoTokyoJapan
| | - Masato Ishizuka
- Department of Cardiovascular Medicine, Graduate School of MedicineThe University of TokyoTokyoJapan
| | - Masae Uehara
- Department of Cardiovascular Medicine, Graduate School of MedicineThe University of TokyoTokyoJapan
| | - Tsukasa Oshima
- Department of Cardiovascular Medicine, Graduate School of MedicineThe University of TokyoTokyoJapan
| | - Toshiya Kojima
- Department of Cardiovascular Medicine, Graduate School of MedicineThe University of TokyoTokyoJapan
| | - Koki Nakanishi
- Department of Cardiovascular Medicine, Graduate School of MedicineThe University of TokyoTokyoJapan
| | - Masao Daimon
- Department of Cardiovascular Medicine, Graduate School of MedicineThe University of TokyoTokyoJapan
| | - Jun Shimizu
- Department of Physical TherapyTokyo University of TechnologyTokyoJapan
| | - Tatsushi Toda
- Department of Neurology, Graduate School of MedicineThe University of TokyoTokyoJapan
| | - Issei Komuro
- Department of Cardiovascular Medicine, Graduate School of MedicineThe University of TokyoTokyoJapan
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Abstract
PURPOSE OF REVIEW Necrotizing myopathy is a broad term. It includes patients with the recently described immune-mediated necrotizing myopathies (IMNM) who have specific antibodies, such as anti-hydroxy-3-methylglutaryl-CoA reductase or anti-signal recognition particle, seronegative phenotypes that can be associated with cancer, and other types of myositis and connective tissue diseases involving necrotic muscle fibers as a characteristic pathologic feature. Necrotizing myopathies that are not immune-mediated, such as those caused by drugs, dystrophies, infections, or even hypothyroidism are also included. The purpose of this review is to address the differential diagnosis of these disorders. RECENT FINDINGS New IMNM have been described over the last few years, some of them related with checkpoint inhibitors, drugs that are being increasingly used in cancer treatment. Necrotizing myopathy has also been reported in association with specific phenotypes and autoantibodies (e.g. anti-Mi2 dermatomyositis, antisynthetase syndrome, and myositis associated with antimitochondrial antibodies). Rarer cases associated with graft-versus-host disease and severe acute respiratory syndrome coronavirus 2 infection are also emerging. SUMMARY Differentiation between patients with IMNM and those without the superimposed autoimmune phenomena helps clinicians determine the best individualized approach to use and the appropriate immunosuppressive therapy, whenever needed.
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