Rare complications of anti-melanoma differentiation-associated gene 5 antibody-positive dermatomyositis: Time to nip them in the bud

Anti-melanoma Differentiation-Associated Gene 5 (Anti-MDA5) Dermatomyositis-Associated Interstitial Lung Disease Complicated by Pneumomediastinum: A Case Report and Literature Review

Anti-melanoma differentiation-associated gene 5 (anti-MDA5) dermatomyositis (DM) is a subset of amyopathic myositis and is associated with unique cutaneous manifestations and rapidly progressive interstitial lung disease (RP-ILD). A rare complication associated with high mortality is the occurrence of pneumomediastinum. We present a case of a 58-year-old female with anti-MDA5 DM-associated interstitial lung disease (ILD) complicated by pneumomediastinum. Treatment with pulse dose steroids and intravenous cyclophosphamide led to clinical improvement and resolution of the pneumomediastinum. Our case emphasizes the recognition of ILD-associated pneumomediastinum in patients with anti-MDA5 DM. Swift diagnosis and aggressive treatment are crucial due to the associated high mortality.

Evaluation of the frequency and risk factors of spontaneous intramuscular hemorrhage associated with dermatomyositis

Dermatomyositis (DM) is an idiopathic inflammatory myositis (IIM) characterized by skin manifestations and muscle involvement. Spontaneous intramuscular hemorrhage (SIH) is a fatal complication that is very rare in the course of DM, but not well known to rheumatologists. Our aim was to determine the frequency and possible risk factors of DM-related SIH. A retrospective analysis was conducted on a cohort of DM patients who were observed in the rheumatology department of the university hospital between 1998 and January 2024. The clinical, laboratory, radiological data of the patients and the treatments they received during the follow-up were analyzed. To determine possible risk factors for the development of SIH in the course of DM, our patients with DM were analyzed together with other rare SIH cases in the literature. The study included 42 of our DM patients. 32 of the patients (76.2%) were female. The median age of the patients was 53 (24-82) years, the median age of DM diagnosis of the patients was 47 (18-75) years, and the median duration of DM of the patients was 36 (2-276) months. 7.1% of patients had dysphagia, and 16.7% had intertitial lung disease (ILD). 5 (11.9%) patients were diagnosed with malignancy. The incidence rate of SIH development in our DM cohort was 0.238/100 patient years (95% CI 0.006-1.256). We tried to identify independent risk factors for SIH development by comparing our 41 DM patients without SIH with the data of patients with 23 DM-related SIH collected from the literature by adding our 1 patient (24 pts). Male sex (OR 4.97, 95% CI 1.66-14.92, p = 0.003), ILD presence (OR 9.71, 95% CI 2.99-31.47, p < 0.001), anti-MDA5 positivity (OR 16.0, 95% CI 1.60-159.3, p = 0.006), anti-Ro52 positivity (OR 11.6, 95% CI 2.93-46.34, p < 0.001), heparin use (OR 4.42, 95% CI 2.68-7.24, p < 0.001), intravenous immunoglobulin (IVIG) use (OR 11.7, 95% CI 2.26-60.54, p < 0.001), and steroid dose (OR 1.03, 95% CI 1.00-1.05, p = 0.005) were identified as risk factors for the development of SIH in the univariate analysis. The death rate due to hemorrhage was 50%. No single risk factor was found to be associated with death. As a result, SIH may occasionally arise in patients with DM. Rheumatologists should be aware that patients with dysphagia and/or ILD, who are on heparin, getting high doses of steroids, and test positive for anti-MDA5 and/or anti-Ro52 antibodies may develop SIH in the early stages of DM.

A Case of Dermatomyositis with Coexistence of Positive Anti-MDA5 Antibodies and Anti-SSA/RO52 Antibodies, Combined with Necrotic Skin Ulcers

Background

Dermatomyositis (DM) is an idiopathic inflammatory myopathy that is clinically challenging to diagnose and has a poor prognosis. It is characterized by symmetric proximal muscle weakness, muscle tenderness, dysphagia, characteristic skin rash (heliotrope rash, Gottron's sign), elevated muscle enzyme levels, abnormal electromyography, and muscle biopsy findings. DM with positive anti-MDA5 antibodies is mainly characterized by Gottron's sign, skin ulcers, facial erythema, mechanic's hands, and V-sign. In this case, the patient presented with the rare manifestation of severe necrotic skin ulcers in association with Gottron's sign, prompting us to report this case.

Case Presentation

A 45-year-old female was admitted to the hospital with systemic joint pain, fatigue, multiple ulcers, and purulent discharge on both hands. Her myositis-specific antibody profile revealed positive anti-MDA5 and anti-SSA/RO52 antibodies. Treatment included a combination of glucocorticoids, immunosuppressants, gastric and liver protection, infection control, and wound care. After two weeks of treatment, the patient showed improvement in symptoms. However, on the 24th day of hospitalization, the wound at the right elbow joint ruptured and became infected, requiring debridement and skin grafting in the appropriate department.

Conclusion

There has been limited research and reported cases of dermatomyositis with coexistence of positive anti-MDA5 and anti-SSA/RO52 antibodies combined with severe skin ulcers. Therefore, we present this rare case and emphasize the need for close follow-up on pulmonary involvement and skin ulcer progression, as well as timely implementation of new treatment strategies to actively improve the prognosis.

Spontaneous intramuscular hemorrhage in cancer-associated dermatomyositis: a case and literature review

BACKGROUND

Spontaneous intramuscular hemorrhage (SIH) is a rare but life-threatening complication of dermatomyositis (DM). The pathogenetic mechanism and management of intramuscular hematoma in these patients remains unclear. Here we discuss a case of recurrent hemorrhage in a patient with cancer-associated DM, and review the relevant literature for timely diagnosis and treatment.

CASE PRESENTATION

A 53-year-old male patient presented with rashes, muscle weakness, and dysphagia and was diagnosed with DM. During treatment, he developed SIH of the arm and right psoas major muscle successively. MRI showed extensive edema of the right shoulder girdle muscle and muscle groups of the upper arm. During the second SIH, a CT scan showed new-onset hematoma formation in the right psoas major muscle. The detection of D-dimer, thrombin-antithrombin III complex (TAT), plasmin-α2-plasmininhibitor complex (PIC) and tissue plasminogen activator-inhibitor complex (t-PAIC) indicated predominant hyperfibrinolysis over thrombosis. Blood transfusion and supportive treatment were immediately performed, and the hematoma did not expand. However, his abdominal distension was not relieved after active treatment. Further electronic gastroscopy discovered gastric sinus ulcers, and histopathology of the biopsy confirmed signet-ring cell carcinoma.

CONCLUSIONS

Although patients with cancer-associated DM have an increased risk of thrombosis, prophylactic anticoagulation therapy needs deliberate consideration. It is important to monitor the coagulation parameters dynamically during anticoagulation therapy. Especially when the level of D-dimer is high, and it is uncertain whether the patient is in a state of thrombosis or hyperfibrinolysis, the detection of TAT, PIC, t-PAIC can help to determine whether to initiate anticoagulation therapy.

A Case of Hemorrhagic Myositis Associated With Prophylactic Heparin Use in Dermatomyositis

Dermatomyositis (DM) is a rare systemic autoimmune disease that is associated with inflammation of the skin and muscles. It typically presents with weakness of the proximal muscles along with characteristic skin lesions such as Gottron's papules and heliotrope rash. One of the most feared complications of this disease is the appearance of spontaneous hemorrhagic myositis, as most reported cases are fatal. The mechanism or risk factors of this condition have not been elucidated; however, prophylactic anticoagulation has been correlated with it in previous case reports, although idiopathic hemorrhagic myositis may also be present. We present a case of spontaneous intramuscular hemorrhage (SIH) in a recently diagnosed DM patient. A 59-year-old Hispanic male with a medical history of recently diagnosed prostate cancer and DM presented to the emergency department (ED) due to worsening anemia. His previous hemoglobin (Hgb) was 9 g/dl, but repeated laboratory tests revealed a level of 6.5 g/dl and later 5.5 g/dl at the ED. On admission, the patient was afebrile, tachycardic, and normotensive, with no overt sign of gastrointestinal bleeding. The physical exam revealed an ecchymosis on the right medial aspect of the thigh, and a digital rectal exam was negative. Computer tomography (CT) of the abdomen and pelvis without contrast was ordered due to suspicion of a retroperitoneal hematoma, revealing an interval development of a right groin complex fluid collection of up to 6 cm, concerning a possible hematoma. The patient did not have any previous vascular procedures in the area but was exposed to deep vein thrombosis (DVT) prophylaxis during the previous admission. Vascular surgery was consulted, and the recommendation was made to proceed with conservative management. On the third day, the patient developed new-onset, left-sided pleuritic chest pain. Upon examination, significant swelling and tenderness were noted in his left pectoral region, which was not present on admission. A CT chest without contrast was ordered due to concerns of underlying hematomas, revealing bilateral thickening of the pectoralis muscles, more on the right side, with a fluid collection of 2.5 cm × 1.3 cm. In addition, there was thickening of the right lateral chest wall muscles in the posterior right trapezius or supraspinatus muscles, most likely from intramuscular hemorrhage. The patient was transferred to the step-down unit for close monitoring. Conservative management was continued with as-needed transfusions for three days until hemoglobin stabilized at 9.8 mg/dL. Once stable, the patient was resumed on steroids and immunosuppressive therapy with posterior resolution of the SIH. SIH has been reported in DM, particularly more prominent in those with anti-MDA-5 antibodies. A case series and literature review showed 60.9% mortality within six months in those presenting with SIH, with a poorer prognosis (80% mortality) in those with deep muscle bleeding versus superficial (25%). There is currently no consensus on the treatment approach, and arterial embolization has not been proven effective. In our patient, conservative management with close surveillance and frequent transfusions helped achieve hemodynamic stability. Clinicians should be more aware of these rare but life-threatening complications in patients presenting with DM.

Clinical and Radiological Features of Interstitial Lung Diseases Associated with Polymyositis and Dermatomyositis

Polymyositis and dermatomyositis are autoimmune idiopathic systemic inflammatory diseases, characterized by various degrees of muscle inflammation and typical cutaneous lesions-the latter found in dermatomyositis. The underlying pathogenesis is characterized by a high level of uncertainty, and recent studies suggest diseases may have different immunopathological mechanisms. In polymyositis, components of the cellular immune system are involved, whereas in dermatomyositis, the pathogenesis is mainly mediated by the humoral immune response. The interstitial lung disease occurs in one-third of polymyositis and dermatomyositis patients associated with worse outcomes, showing an estimated excess mortality rate of around 40%. Lung involvement may also appear, such as a complication of muscle weakness, mainly represented by aspiration pneumonia or respiratory insufficiency. The clinical picture is characterized, in most cases, by progressive dyspnea and non-productive cough. In some cases, hemoptysis and chest pain are found. Onset can be acute, sub-acute, or chronic. Pulmonary involvement could be assessed by High Resolution Computed Tomography (HRCT), which may identify early manifestations of diseases. Moreover, Computed Tomography (CT) appearances can be highly variable depending on the positivity of myositis-specific autoantibodies. The most common pathological patterns include fibrotic and cellular nonspecific interstitial pneumonia or organizing pneumonia; major findings observed on HRCT images are represented by consolidations, ground-glass opacities, and reticulations. Other findings include honeycombing, subpleural bands, and traction bronchiectasis. In patients having Anti-ARS Abs, HRCT features may develop with consolidations, ground glass opacities (GGOs), and reticular opacities in the peripheral portions; nonspecific interstitial pneumonia or nonspecific interstitial pneumonia mixed with organizing pneumonia have been reported as the most frequently encountered patterns. In patients with anti-MDA5 Abs, mixed or unclassifiable patterns are frequently observed at imaging. HRCT is a sensitive method that allows one not only to identify disease, but also to monitor the effectiveness of treatment and detect disease progression and/or complications; however, radiological findings are not specific. Therefore, aim of this pictorial essay is to describe clinical and radiological features of interstitial lung diseases associated with polymyositis and dermatomyositis, emphasizing the concept that gold standard for diagnosis and classification-should be based on a multidisciplinary approach.