1: Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina, Ioannina Greece
2: Neurosurgical Institute, University of Ioannina School of Medicine, Ioannina, Greece; Department of Neurology, University Hospital of Ioannina, Ioannina, Greece
Volume 29, Issue 2, June 2018
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https://doi.org/10.31138/mjr.29.2.92
INTRODUCTION
Sjögren Syndrome (SS) is a chronic autoimmune inflammatory disease that primarily affects the exocrine glands and has also a variety of extraglandular manifestations.1-6 SS can occur as a distinct disease entity (primary SS) or in the context of an underlying autoimmune rheumatic disease (secondary SS) mainly rheumatoid arthritis, systemic lupus erythematosus, scleroderma and others.7-10
Inflammatory myopathies (IM) is a heterogeneous group of disorders characterized by chronic inflammation of striated muscle and skin. They share features of skeletal muscle weakness and elevated serum levels of muscle enzymes.11,12 Muscle involvement is a frequent clinical manifestation in SS, expressed mainly with myalgias and muscle weakness. Frank IM is less common.13-15 In this report we present two cases of primary SS associated with IM with a literature review.
METHODS
We present two cases of female patients diagnosed with Sjögren syndrome who were followed up regularly in the Rheumatology Department of the University Hospital of Ioannina. The patients developed muscle weakness and were additionally diagnosed with IM. We also reviewed the English language literature using PubMed database and the following index terms: SS, IM, inclusion body myositis (IBM), Polymyositis (PM), Dermatomyositis (DM) and myositis in order to indentify cases of SS associated with IM.
We recorded the epidemiological features of the patients found in the literature including age, gender, age of diagnosis of SS and IM and their serological profile. All patients had to have positive muscle biopsy.
Case 1
Α 70-year-old white female with a past medical history of arterial hypertension and sinus tachycardia was diagnosed with SS in 2002. The diagnosis was based on sicca symptoms (dry eyes and dry mouth), as well as positive objective sicca parameters for dry eyes (Schirmer’s I and Rose Bengal tests), positive antinuclear antibodies (ANA) at a titer of 1/320 with a fine speckled pattern, positive anti-Ro52 and minor salivary gland biopsy compatible with SS. The patient presented also arthralgias, thus she was treated with hydroxychloroquine (HCQ) 200mg/day. In August 2014 the patient complained of proximal and distal muscle weakness. The laboratory findings showed elevated serum muscle enzymes: creatine kinase (CK) 556 IU/L (normal range: 40-190 IU/L), lactate dehydrogenate (LDH) 371 U/L (normal range: 115-230 U/L). The transaminases (AST 32 IU/L, ALT 27 IU/L) and aldolase (3,8 IU/L) were in normal range. To rule out occult malignancy, a chest computed tomography and an ultrasound of the abdomen were performed and did not reveal significant findings. An electromyogram showed diffuse atrophy and loss of muscle fibers.
Muscle biopsy showed findings compatible with inclusion body myositis (IBM) (Figure 1). The patient started treatment with methylprednisolone 48mg/day with tapering and subsequently methotrexate (MTX) 15mg/week was added as a sparing agent of steroids. In May 2015 a new electromyogram revealed improvement of muscle findings which correlated with her clinical and laboratory improvement. To date the patient continues therapy with low doses of steroids (4mg/day) and MTX (15mg/week).
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Case 2
A 67-year-old white female was diagnosed in 2002 with SS based on arthralgias, sicca symptoms (dry eyes and dry mouth), positive ocular signs (Schirmer’s I and Rose Bengal tests), positive ANA at a titer of 1/320 with fine speckled pattern. In addition, minor salivary gland biopsy was positive for SS. In January 2015, she presented to our outpatient clinic with progressive proximal muscle weakness, inability to climb stairs and elevated muscle enzymes. Her past medical history included diabetes mellitus and dyslipidemia. She was treated with HCQ, atorvastastin, metformine, saxagliptin and pilocarpine. Her family doctor had discontinued HCQ and atorvastatin 10 months ago, when abnormal laboratory findings and clinical symptoms had begun. The patient was admitted to our clinic for further investigation. Physical examination revealed mild decrease of muscle strength of biceps and iliopsoas (4/5). Laboratory evaluation showed elevation of CK: 5004 IU/L, AST: 121 IU/L (normal range: 10-35 IU/L), ALT: 97 IU/L (normal range: 10-35 IU/L), LDH: 1059 IU/L and aldolase: 40 IU/L (normal range: 0-7,6 IU/L). An electromyogram showed significant features of IM while the muscle biopsy of the left quadriceps confirmed the diagnosis of PM (Figure 2). A computed tomography of the chest and abdomen was unremarkable. The patient was treated with methylprednisolone (48mg/day) and MTX (15mg/week) as a sparing agent of steroids. Six months later, the patient had significant clinical (muscle strength 5/5) and laboratory (AST: 16 IU/L, ALT: 97 IU/L, CK: 103 IU/L, LDH: 451 IU/L) improvement, while the dose of steroids was decreased to 4mg/day and the dose of MTX was stable.
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DISCUSSION
According to the literature the percentage of patients with primary SS who manifested symptoms of IM, widely vary between 2,5% - 10%.16 Most studies showed significantly lower percentages of patients with primary SS who developed true IM (proven by biopsy). In the study of Colafrancesco et al. the percentage of the SS patients with manifestations of biopsy proven myositis was 0,75% (10 out of 1320).17 Another recent study published by Kanellopoulos et al. demonstrated 3 out of 518 (0,6%) patients with primary SS who were diagnosed with myositis.18 The study of Kraus et al. raised this rate to 3%13
Both our cases had SS fulfilling the American European consensus group criteria19 and both developed IM many years after the diagnosis of SS. In our first case the patient was diagnosed with IBM 13 years after the diagnosis of primary SS. Eight cases of SS patients, diagnosed according the performed biopsy, with IBM were reported (Table 1). The interval between the two diagnoses largely varied from 0 to 14 years. In the majority of the patients (7/8), ANA were positive. Anti Ro/SSA antibodies were positive in half of them (4/8). Anti La/SSB antibodies were positive only in one patient, while RF was positive in 5 out of 8 patients. In our case the patient was positive for ANA and anti-Ro/SSA antibodies.
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IBM differentiates its clinical presentation from the other IM. IBM affects predominantly the distal muscles and more specific the foot extensors and finger flexors. IBM is usually refractory to treatment. Corticosteroids and immunosuppressive drugs (MTX, azathioprine, cyclosporine) have failed to show long term benefits.12,20 Despite the transient effect of intravenous immune globulin, it remained ineffective in controlled trials.21,22 IBM associated with SS responded better to treatment compared to patients diagnosed with IBM alone. In the study by Colafrancesco et al., one patient diagnosed with IBM was treated with intravenous immune globulin and achieved clinical and laboratory remission.17 In a case report with biopsy proven IBM reported by Misterska-Skora et al., the patient was treated with steroids and MTX and achieved remission in 8 months.23 Kanellopoulos et al. published three cases with primary SS and IBM. Two of them were treated with HCQ and 1 received steroids and MTX. All three patients showed improvement in their muscle strength.18 In our case the patient also received corticosteroids and MTX and had significant clinical and laboratory improvement 8 months after treatment.
PM is also associated with primary SS. In the literature review we identified 15 cases of primary SS and biopsy proven PM (Table 1). Thirteen out of 15 patients had positive ANA. Anti-Ro/SSA antibodies were present in 12 patients, while anti-La/SSB antibodies and rheumatoid factor was present in 8 and 7 out of 15 patients respectively. In our second case the patient had only positive ANA. Aoki et al presented 5 cases of PM associated with primary SS. The patients received prednisolone and they achieved clinical and laboratory remission. In three of them, relapse of the disease was mentioned with muscle weakness and elevation of CK. In those patients the dose of corticosteroids was increased, and remission was achieved without additional immunosuppressive therapy.24 Colafrancesco et al. diagnosed 5 patients with PM. All patients were treated with steroids and HCQ and according to their response pulses cyclophosphamide and rituximab were used for achieving remission.17 Pulses of cyclophosphamide therapy were also used by Leroy et al in a patient with SS and PM.15 Finally, Imasaki et al. described a patient with bronchiolitis obliterans organizing pneumonia, primary SS and PM. The patient received prednisolone and two months later achieved remission.25 In our second case, the patient was diagnosed with PM and received methylprednisolone and MTX successfully.
Only one case with biopsy-proven DM in a patient with SS was identified in the literature.26
Additionally, it should be mentioned that in rare cases of myositis associated with SS, with CPK and EMG abnormalities, muscle biopsy and histology examination were mandatory, in order not to overlook a real PM-overlap syndrome, misinterpreted as extraglandular involvement of SS.27
On the other hand, it is mandatory in patients with SS who have developed IM, to rule out other disorders known to cause myopathy. To this end, one must exclude lymphoma development, statin and HCQ induced myopathy. In the first case, a careful clinical examination with the appropriate imaging tests, tissue biopsy, as well as the detection for cryoglobulins, measurement of complement levels and serum electrophoresis will help the diagnosis of lymphoma.28 In the cases of statin and HCQ-induced myopathy, a detail past medical history, the presence of antibodies against 3 -hydroxy-3 methylglutaril-coenzyme-A reductase (HMGCR), the enzyme target of statin therapy and muscle biopsy will differentiate these two entities from IM. It is reported that statin myopathy is associated with the presence of HMGCR antibodies and causes a necrotizing myopathy in the affected muscles.29,30 In addition, HCQ induced to myopathy is a rare condition which may cause proximal muscle weakness and cardiomyopathy and the muscle biopsy shows curvilinear bodies and vacuolar changes.31
Finally, novel studies highlight that anti-Ku antibodies have been reported in a wide spectrum of autoimmune diseases, sometimes in association with IM. In the study of Rigolet et al., out of 34 anti-Ku positive patients, 11 had IM, 8 of them as part of an overlap syndrome defined as IM associated with connective autoimmune disease (systemic sclerosis, SS and systemic lupus erythematosus).32 In a recent study published by Wielosz et al. are reported 3 cases of anti-Ku positive patients: it concludes that the presence of anti-Ku antibodies is associated with a wide range of non-specific symptoms regarding muscle, joint and skin involvement (33). In another recent study published by Fiorentino et al., a new 60 kDa specificity was detected by immunoblotting HeLa cell lysates, the targeted autoantigen was identified as poly(U)-binding-splicing factor 60 kDa (PUF60). In this study it is reported that the new antibody anti-PUF60 it is present in SS patients with DM.34
CONCLUSION
Patients with primary SS and symptoms of muscle weakness should be investigated for associated IM. There is evidence of clinical association of primary SS and IM especially with IBM and PM. It seems that both entities respond better to treatment when they are associated with SS than as district entities.
CONFLICT OF INTEREST
The authors declare no conflict of interest.
- Moutsopoulos H M. Sjögren’s syndrome: autoimmune epithelitis. Clin Immunol Immunopathol 1994;72:162-5.
- Moutsopoulos H M. Sjögren’s syndrome or autoimmune epithelitis? Clinic Rev Allerg Immunol 2007;32:199-200.
- Andonopoulos A P, Lagos G, Drosos A A, Moutsopoulos H M. The spectrum of neurological involvement in Sjögren's syndrome. Br J Rheumatol 1990;29:21-3.
- Papathanasiou M P, Constantopoulos S H, Tsampoulas C, Drosos A A, Moutsopoulos H M. Reappraisal of respiratory abnormalities in primary and secondary Sjögren's syndrome. A controlled study. Chest 1986;90:370-4.
- Tsianos E B, Chiras C D, Drosos A A, Moutsopoulos H M. Oesophageal dysfunction in patients with primary Sjögren's syndrome. Ann Rheum Dis 1985;44:610-3.
- Ramos-Casals N, Tzioufas A G, Font J. Primary Sjögren’s syndrome: new clinical and therapeutic concepts. Ann Rheum Dis 2005;64:347-54.
- Moutsopoulos H M, Webber B L, Vlagopoulos T P, Chused T M, Decker J L. Differences in the clinical manifestations of sicca syndrome in the presence and absence of rheumatoid arthritis. Am J Med 1979;66:733-6.
- Baer A N, Maynard J W, Shaikh F, Magder L S, Petri M. Secondary Sjögren's syndrome in systemic lupus erythematosus defines a distinct disease subset. J Rheumatol 2010;37:1143-9.
- Andonopoulos A P, Drosos A A, Skopouli F N, Acritidis N C, Moutsopoulos H M. Secondary Sjögren's syndrome in rheumatoid arthritis. J Rheumatol 1987;14:1098-103.
- Drosos A A, Andonopoulos A P, Costopoulos J S, Stavropoulos E D, Papadimitriou C S, Moutsopoulos H M. Sjögren's syndrome in progressive systemic sclerosis. J Rheumatol 1988;15:965-8.
- Bohan A, Peter J B. Polymyositis and dermatomyositis. N Engl J Med 292:344-7. https://doi.org/10.1056/NEJM197502132920706
- Dalakas M C. Inflammatory muscle diseases. N Engl J Med 2015;372:1734-47.
- Kraus A, Cifuentes M, Villa A R, Jakez J, Reyes E, Alarcón-Segovia D. Myositis in primary Sjögren syndrome. Report of 3 cases. J Rheumatol 1994;21:649-53.
- Alexander E L, Josifek L Provost T T, Alexander G E. Myositis/vasculitis in primary Sjögren’s syndrome (abstr) Arthritis Rheum 1982;25:S15.
- Leroy J P, Drosos A A, Yiannopoulos P, Moutsopoulos H M. Intravenous pulse cyclophosphamide therapy in myositis and Sjögren’s syndrome. Arthritis Rheum 1990;33:1579-81.
- Alexander E L. Neuromuscular complications of primary Sjögren’s syndrome. In: Talal N, Moutsopoulos H M, Kassan S S, editors. Sjögren’s syndrome. Clinical and immunological aspects. Berlin: Springer; 1987;61-82.
- Colafrancesco S, Priori R, Gattamelata A, et al. Myositis in primary Sjögren’s syndrome: data from a multicentre cohort. Clin Exp Rheumatol 2015;33:457-64.
- Kanellopoulos P, Baltoyiannis C, Tzioufas A G. Primary Sjögren's syndrome associated with inclusion body myositis. Rheumatology (Oxford) 2002;41:440-4.
- Vitali C, Bombardieri S, Jonsson R, et al. Classification criteria for Sjögren’s syndrome: a revised version of the European criteria proposed by the American-European Consensus Group. Ann Rheum Dis 2002;61:554-8.
- Benveniste O, Guiguet M, Freebody J, et al. Long-term observational study of sporadic inclusion body myositis. Brain 2011;134:3176-84.
- Dalakas M C, Sonies B, Dambrosia J, Sekul E, Cupler E, Sivakumar K. Treatment of inclusion-body myositis with IVIg: a double-blind, placebo-controlled study. Neurology 1997;48:712-6.
- Cherin P, Pelletier S, Teixeira A, et al. Intravenous immunoglobulin for dysphagia of inclusion body myositis. Neurology 2002;58:326.
- Misterska-Skóra M, Sebastian A, Dzięgiel P, Sebastian M, Wiland P. Inclusion body myositis associated with Sjögren's syndrome. Rheumatol Int 2013;33:3083-6.
- Aoki A, Ono S, Ueda A, et al. Myositis in primary Sjögren's syndrome: clinical and pathological report. Mod Rheumatol 2003;13:57-61.
- Imasaki T, Yoshii A, Tanaka S, Ogura T, Ishikawa A, Takahashi T. Polymyositis and Sjögren's syndrome associated with bronchiolitis obliterans organizing pneumonia. Intern Med 1996;35:231-5.
- Ringel S P, Forstot J Z, Tan E M, Wehling C, Griggs R C, Butcher D. Sjögren's syndrome and polymyositis or dermatomyositis. Arch Neurol 1982;39:157-63.
- Ferro F, Vagelli R, Bruni C, et al. One year in review 2016: Sjögren's syndrome. Clin Exp Rheumatol 2016;34:161-71.
- Ioannidis J P, Vassiliou V A, Moutsopoulos HM. Long-term risk of mortality and lymphoproliferative disease and predictive classification of primary Sjögren's syndrome. Arthritis Rheum 2002;46:741-7.
- Hamann P D, Cooper R G, McHugh N J, Chinoy H. Statin-induced necrotizing myositis - a discrete autoimmune entity within the "statin-induced myopathy spectrum". Autoimmun Rev 2013;12:1177-81. https://doi.org/10.1016/j.autrev.2013.07.001
- Dalakas M C. Necrotising autoimmune myopathy (NAM): antibodies seem to be specific markers in aiding diagnosis. J Neurol Neurosurg Psychiatry 2016;87:1037. https://doi.org/10.1136/jnnp-2016-313418
- Stein M, Bell M J, Ang L C. Hydroxychloroquine neuromyotoxicity. J Rheumatol 2000;27:2927-31.
- Rigolet A, Musset L, Dubourg O, Maisonobe T, Grenier P, Charuel J L, et al. Inflammatory myopathies with anti-Ku antibodies: a prognosis dependent on associated lung disease. Medicine (Baltimore) 2012;91:95-102.
- Wielosz E, Majdan M, Jeleniewicz R, Mazurek M. Autoimmune diseases with the presence of anti-ku antibodies - analysis of three cases. Wiad Lek 2016;69:24-6.
- Fiorentino D F, Presby M, Baer A N, Petri M, Rieger K E, Soloski M, et al. PUF60: a prominent new target of the autoimmune response in dermatomyositis and Sjögren's syndrome. Ann Rheum Dis 2016;75:1145-51.
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