Transforming growth factor-ß signaling is upregulated in sporadic inclusion body myositis.

INTRODUCTION: In this study we aimed to determine whether transforming growth factor-ß (TGF-ß) signaling is dysregulated in sporadic inclusion body myositis (sIBM) muscle samples. METHODS: We examined TGF-ß signaling markers in muscle samples from 24 sIBM patients and compared them with those from 10 dermatomyositis (DM) patients using immunohistochemistry and Western blot analyses. RESULTS: Compared with the DM muscle fibers, the sIBM muscle fibers exhibited greater TGF-ß, TGF-ß receptor type I (TßRI), and TGF-ß receptor type II (TßRII) immunoreactivity in the cytoplasm, as well as greater phosphorylated Smad2 (pSmad2) immunoreactivity in the myonuclei. The signal intensities of TGF-ß, TßRI, and TßRII immunoreactivity correlated significantly with muscle fiber cross-sectional areas. Western blot analyses indicated higher expression levels of TGF-ß, TßRI, TßRII, and pSmad2 in the sIBM muscle samples than in the DM muscle samples. CONCLUSIONS: These data indicate that upregulation of TGF-ß signaling may be an important molecular event in sIBM. Muscle Nerve 55: 741-747, 2017.

Clinicopathological features of graft versus host disease-associated myositis.

BACKGROUND AND OBJECTIVE: Chronic graft versus host disease (GVHD)-associated myositis targeting skeletal muscle is a relatively rare but potentially debilitating complication following allogeneic hematopoietic stem cell transplantation (HSCT). We reviewed the clinicopathological features of GVHD-associated myositis among patients receiving allogeneic HSCT to elucidate the cellular pathogenesis. METHODS: We retrospectively reviewed clinical data and muscle biopsy results from 17 consecutive patients diagnosed with GVHD-associated myositis at our institution between 1995 and 2019. Immunostaining findings of GVHD-associated myositis were compared to those of patients with anti-tRNA-synthetase antibody-associated myopathy (ASM) (n = 13) and dermatomyositis (DM) (n = 12). RESULTS: The majority of patients with GVHD-associated myositis showed subacute or chronic progression of mild to moderate limb weakness together with elevated serum creatine kinase. These patients also exhibited mild C-reactive protein elevation but were negative for myositis-related autoantibodies. Programmed death-1 (PD-1)-positive cells were observed in muscle interstitium adjacent to myofibers expressing human leukocyte antigen (HLA)-DR. The interstitium was also HLA-DR-positive, similar to biopsy samples from ASM patients but not DM patients. The proportions of HLA-DR-positive muscle fibers and PD-1-positive interstitial cells were significantly higher in GVHD and ASM samples than DM samples. The PD-1-positive cells were mostly CD-8-positive lymphocytes. DISCUSSION: GVHD-associated myositis is characterized by HLA-DR-positive myofibers and infiltration of PD-1-positive lymphocytes. These features distinguish GVHD-associated myositis from DM but not from ASM.

[Use of zoledronic acid for lung cancer with bone metastases - a study on reossification of osteolytic bone metastases].

Lung cancer often induces osteolytic bone metastases, and skeletal-related events(SRE)such as bone pain or fracture decrease the quality of life and survival of the patient. Zoledronic acid(ZDA)suppresses osteoclastic changes and reduces the risk of SRE. Over the last 6 years, 84 lung cancer patients who had osteolytic bone metastases were medicated with ZDA in our hospital. Effective reossification was observed in 25%of them, and they obtained longer survival term and better performance status than did patients without effective reossification. ZDA enabled enforcement of aggressive anticancer therapy(radiation± chemotherapy)by reduction of SRE following reossification of osteolytic bone metastases, and contributed to better prognoses for lung cancer patients.

Treatment of refractory localized pulmonary nocardiosis caused by Nocardia mexicana with a combination of medication and surgery.

Pulmonary nocardiosis is a rare disease that is often difficult to cure because of its tendency to recur. Here, we report a case of refractory localized pulmonary nocardiosis caused by Nocardia mexicana. A 60-year-old Japanese woman had recurring pulmonary nocardiosis four times previously and each time she was treated with antibiotics for a sufficient duration; nevertheless, the disease continued to recur, probably because of resistance to antibiotics. As a fifth treatment, we performed middle lobe resection and pre- and post-operative antimicrobial therapy for 6 months. The combination of medication and surgery was useful for treating refractory localized pulmonary nocardiosis.

Clinical implication of denervation in sporadic inclusion body myositis.

INTRODUCTION: Sporadic inclusion body myositis (sIBM) is often accompanied by signs suggestive of denervation on electromyography (EMG), which mimics neurogenic disorders. Hence, the current study aimed to assess reinnervation after denervation in sIBM and its clinical impllcation. METHODS: We retrospectively examined consecutive muscle biopsy specimens collected from 109 sIBM patients who were referred to our institution for diagnostic muscle biopsy from 2001 to 2018. Reinnervation after denervation in sIBM patients was assessed via muscle biopsy and EMG. The levels of acetylcholine receptor subunit γ (Chrng) and muscle-specific kinase (MuSK) mRNA, which are markers of denervation, were examined using real-time polymerase chain reaction. Response to treatment was defined as an increase of grade 1 or higher in two or more muscle groups as assessed using the Medical Research Council scale. RESULTS: In total, 93 (85.3%) of 109 sIBM patients had reinnervation after denervation on histological examination and/or EMG. The mean disease duration before biopsy was significantly longer in patients with reinnervation after denervation than in those without (p < 0.00001). Patients with denervation had significantly higher levels of Chrng and MuSK mRNA than those without. The proportion of patients who responded to immunosuppressive therapies was smaller in the patients with denervation than those without (p < 0.05). However, there was no significant difference regarding time from onset to using a walking aid between the two groups. DISCUSSION: Reinnervation after denervation is associated with disease duration and short-term response to therapy in individuals with sIBM.

Metabolome and transcriptome analysis on muscle of sporadic inclusion body myositis.

OBJECTIVE: Sporadic inclusion body myositis (sIBM) is the most common acquired myopathy in patients older than 50 years of age. sIBM is hardly responds to any immunosuppressing theraphies, and its pathophysiology remains elusive. This study aims to explore pathogenic pathways underlying sIBM and identify novel therapeutic targets using metabolomic and transcriptomic analyses. METHODS: In this retrospective observational study, we analyzed biopsied muscle samples from 14 sIBM patients and six non-diseased subjects to identify metabolic profiles. Frozen muscle samples were used to measure metabolites with cation and anion modes of capillary electrophoresis time of flight mass spectrometry. We validated the metabolic pathway altered in muscles of sIBM patients through RNA sequencing and histopathological studies. RESULTS: A total of 198 metabolites were identified. Metabolomic and transcriptomic analyses identified specific metabolite changes in sIBM muscle samples. The pathways of histamine biosynthesis and certain glycosaminoglycan biosynthesis were upregulated in sIBM patients, whereas those of carnitine metabolism and creatine metabolism were downregulated. Histopathological examination showed infiltration of mast cells and deposition of chondroitin sulfate in skeletal muscle samples, supporting the results of metabolomic and transcriptomic analyses. INTERPRETATION: We identified alterations of several metabolic pathways in muscle samples of sIBM patients. These results suggest that mast cells, chondroitin sulfate biosynthesis, carnitine, and creatine play roles in sIBM pathophysiology.

Prevalence of anti-NT5C1A antibodies in Japanese patients with autoimmune rheumatic diseases in comparison with other patient cohorts.

BACKGROUND: Sporadic inclusion body myositis (sIBM) is usually classified as an idiopathic inflammatory myopathies. Although the diagnosis of sIBM is sometimes challenging, recent studies have shown that the autoantibodies against cytosolic 5'-nucleotidase 1A (NT5C1A) are the possible diagnostic biomarker for sIBM. Few reports have shown the frequencies of anti-NT5C1A antibodies in systemic autoimmune rheumatic diseases (SARDs) using large cohorts of SARDs. METHODS: Serum samples obtained from 314 patients including dermatomyositis (DM) (n=144), systemic lupus erythematosus (SLE) (n=50), systemic sclerosis (SSc) (n=50), Sjögren's syndrome (SS) (n=50), polymyositis (PM) (n=10) and mixed connective tissue disease (n=10), and healthy controls (n=42) in addition to 10 patients with typical sIBM were analysed for the presence of autoantibodies using full-length recombinant NT5C1A ELISA. RESULTS: Japanese patients with DM (11%), PM (10%), SLE (6%), SSc (8%) or SS (4%) had anti-NT5C1A antibodies at lower frequencies than patients with sIBM. Interestingly, 4 of 17 DM/PM patients with anti-NT5C1A antibodies were found to have no other myositis-specific/associated autoantibodies. CONCLUSIONS: There is a wide heterogeneity of anti-NT5C1A antibody immunoreactivity. Some populations of SARDs are positive for anti-NT5C1A are also positive for anti-NT5C1A. However, the anti-NT5C1A frequencies in the patients with SARDs are low also in Japanese.

First case report of pulmonary nocardiosis caused by Nocardia mexicana.

INTRODUCTION: Nocardia species usually cause opportunistic infections, and the frequency of these infections is increasing owing to the growing population of immunocompromised hosts. However, Nocardia species may sometimes cause an infection disease in immunocompetent hosts. Nocardia mexicana infections are the least common and are very rare. CASE PRESENTATION: Herein, we report the first case of a pulmonary infection with N. mexicana in a 61-year-old Japanese woman with a history of hyperlipidaemia and bronchiectasis and a 6-month history of non-productive hacking cough. A sample of bronchial lavage fluid obtained by bronchofiberscopy showed filamentous branching gram-positive rods and acid-fast filamentous branching rods, and a colony of suspected Nocardia was cultured. Based on 16S rRNA, gyrB,rpoB, secA1 and hsp65 gene sequence analyses and biochemical and physiological properties, the strain was identified as N. mexicana. The strain was resistant to the antimicrobial agents amoxicillin-clavulanic acid, clarithromycin, minocycline, gentamycin, tobramycin, ciprofloxacin and trimethoprim-sulfamethoxazole. The patient was treated with biapenem followed by intravenous amikacin and oral linezolid. CONCLUSION: Despite its rarity, the species require attention owing to the existence of multidrug-resistant strains.

Gene Expression Profile of Inflammatory Myopathy with Malignancy is Similar to that of Dermatomyositis rather than Polymyositis.

Objective An association has been reported between inflammatory myopathies (IMs), which include polymyositis (PM) and dermatomyositis (DM), and malignancy, and the concept of cancer-associated myositis (CAM) was recently proposed. We herein attempted to determine the features and etiologies of these myopathies. Methods We analyzed the gene expression levels via microarray and real-time quantitative reverse transcription polymerase chain reaction analyses to identify genes that were specifically upregulated or downregulated with suspected inflammatory involvement and verified the microarray data via an immunohistochemical (IHC) analysis in additional cases. Patients We selected 14 patients with the following conditions: PM without malignancy (n=3), DM without malignancy (n=3), CAM (n=3), and Controls (no pathological changes or malignancy; n=5). Results PM was distinct from DM and CAM in a clustering analysis and exhibited the highest numbers of overexpressed genes and specific pathologies in a gene ontology analysis. The IHC analysis confirmed the gene expression results. Conclusion PM is associated with severe inflammatory pathological findings, primarily in the cell-mediated immune system. DM and CAM exhibit similarities in the gene expression and IHC results, which suggest that humoral immunity is the main etiology for both myopathies, indicating the importance of cancer screening in patients with IMs, particularly DM.

Impaired muscle uptake of creatine in spinal and bulbar muscular atrophy.

OBJECTIVE: The aim of this study was to explore the pathomechanism underlying the reduction of serum creatinine (Cr) concentrations in spinal and bulbar muscular atrophy (SBMA). METHODS: We evaluated blood chemistries, motor function, and muscle mass measured by dual-energy X-ray absorptiometry in male subjects with SBMA (n = 65), amyotrophic lateral sclerosis (ALS; n = 27), and healthy controls (n = 25). We also examined the intramuscular concentrations of creatine, a precursor of Cr, as well as the protein and mRNA expression levels of the creatine transporter (SLC6A8) in autopsy specimens derived from subjects who had SBMA and ALS and disease controls. Furthermore, we measured the mRNA expression levels of SLC6A8 in cultured muscle cells (C2C12) transfected with the polyglutamine-expanded androgen receptor (AR-97Q). RESULTS: Serum Cr concentrations were significantly lower in subjects with SBMA than in those with ALS (P < 0.001), despite similar muscle mass values. Intramuscular creatine concentrations were also lower in with the autopsied specimen of SBMA subjects than in those with ALS subjects (P = 0.018). Moreover, the protein and mRNA expression levels of muscle SLC6A8 were suppressed in subjects with SBMA. The mRNA levels of SLC6A8 were also suppressed in C2C12 cells bearing AR-97Q. INTERPRETATION: These results suggest that low serum Cr concentration in subjects with SBMA is caused by impaired muscle uptake of creatine in addition to being caused by neurogenic atrophy. Given that creatine serves as an energy source in skeletal muscle, increasing muscle creatine uptake is a possible therapeutic approach for treating SBMA.

Decreased Peak Expiratory Flow Associated with Muscle Fiber-Type Switching in Spinal and Bulbar Muscular Atrophy.

The aim of this study was to characterize the respiratory function profile of subjects with spinal and bulbar muscular atrophy (SBMA), and to explore the underlying pathological mechanism by comparing the clinical and biochemical indices of this disease with those of amyotrophic lateral sclerosis (ALS). We enrolled male subjects with SBMA (n = 40) and ALS (n = 25) along with 15 healthy control subjects, and assessed their respiratory function, motor function, and muscle strength. Predicted values of peak expiratory flow (%PEF) and forced vital capacity were decreased in subjects with SBMA compared with controls. In SBMA, both values were strongly correlated with the trunk subscores of the motor function tests and showed deterioration relative to disease duration. Compared with activities of daily living (ADL)-matched ALS subjects, %PEF, tongue pressure, and grip power were substantially decreased in subjects with SBMA. Both immunofluorescence and RT-PCR demonstrated a selective decrease in the expression levels of the genes encoding the myosin heavy chains specific to fast-twitch fibers in SBMA subjects. The mRNA levels of peroxisome proliferator-activated receptor gamma coactivator 1-alpha and peroxisome proliferator-activated receptor delta were up-regulated in SBMA compared with ALS and controls. In conclusion, %PEF is a disease-specific respiratory marker for the severity and progression of SBMA. Explosive muscle strength, including %PEF, was selectively affected in subjects with SBMA and was associated with activation of the mitochondrial biogenesis-related molecular pathway in skeletal muscles.

[67Ga scintigraphy as a therapeutic marker for spinal cord and muscular sarcoidosis: A case report].

A 70-year-old woman was admitted to our hospital because of the right limb pain and gait disturbance. (67)Ga scintigraphy showed an increased uptake in the spinal cord, mediastinal lymph node and right tibialis anterior muscle. Based on the histopathological findings of epithelioid cell granuloma in endobronchial ultrasound-guided transbronchial needle aspiration of lymph node, she was diagnosed as having probable spinal cord/muscular sarcoidosis. After she was treated with oral prednisolone, her limb pain and gait disturbance improved. Furthermore, uptake in (67)Ga scintigraphy was reduced after the treatment. In conclusion, (67)Ga scintigraphy is useful not only for diagnosis, but also for estimating the efficiency of the treatment for sarcoidosis involving multiple organs such as the spinal cord and skeletal muscle.

Genetic profile for suspected dysferlinopathy identified by targeted next-generation sequencing.

OBJECTIVE: To investigate the genetic causes of suspected dysferlinopathy and to reveal the genetic profile for myopathies with dysferlin deficiency. METHODS: Using next-generation sequencing, we analyzed 42 myopathy-associated genes, including DYSF, in 64 patients who were clinically or pathologically suspected of having dysferlinopathy. Putative pathogenic mutations were confirmed by Sanger sequencing. In addition, copy-number variations in DYSF were investigated using multiplex ligation-dependent probe amplification. We also analyzed the genetic profile for 90 patients with myopathy with dysferlin deficiency, as indicated by muscle specimen immunohistochemistry, including patients from a previous cohort. RESULTS: We identified putative pathogenic mutations in 38 patients (59% of all investigated patients). Twenty-three patients had DYSF mutations, including 6 novel mutations. The remaining 16 patients, including a single patient who also carried the DYSF mutation, harbored putative pathogenic mutations in other genes. The genetic profile for 90 patients with dysferlin deficiency revealed that 70% had DYSF mutations (n = 63), 10% had CAPN3 mutations (n = 9), 2% had CAV3 mutations (n = 2), 3% had mutations in other genes (in single patients), and 16% did not have any identified mutations (n = 14). CONCLUSIONS: This study clarified the heterogeneous genetic profile for myopathies with dysferlin deficiency. Our results demonstrate the importance of a comprehensive analysis of related genes in improving the genetic diagnosis of dysferlinopathy as one of the most common subtypes of limb-girdle muscular dystrophy. Unresolved diagnoses should be investigated using whole-genome or whole-exome sequencing.

Myotonia-like symptoms in a patient with spinal and bulbar muscular atrophy.

We describe the case of a 33-year-old man with a 4-year history of worsening muscle stiffness and weakness in his right hand. He showed elevated serum creatine kinase levels at the onset of muscle stiffness that was characterized by delayed muscle relaxation after voluntary contraction. This symptom often occurred during cold exposure, and was partially attenuated by sodium channel blockade. Electrodiagnostic findings in repetitive nerve stimulation, short-exercise, and cooling tests were normal. Electromyography showed chronic denervation potentials in his cranial, cervical, thoracic, and lumbosacral myotomes without myotonic discharge. He exhibited facial and tongue fasciculations, hypernasality, gynecomastia, neurogenic changes in muscle biopsy, and increased serum testosterone levels. Spinal and bulbar muscular atrophy (SBMA) was diagnosed on the basis of the CAG trinucleotide expansion in the gene coding androgen receptor. A myotonia-like symptom without myotonic discharge may present as an early neurological sign of SBMA, which possibly reflects a sodium channel dysfunction in skeletal muscles.

Clinicopathological features of sarcoidosis manifesting as generalized chronic myopathy.

Although chronic myopathy has been reported to affect skeletal muscle in sarcoidosis, its clinicopathological features have not been fully elucidated. We characterized the clinical, histopathological, and prognostic features of eleven patients with sarcoidosis manifesting with chronically progressive, generalized myopathy that was confirmed with muscle biopsy. Generalized muscle weakness extending to the four extremities and trunk was the cardinal feature of these cases. Muscle atrophy was evident in nine patients, particularly in the lower limbs, whereas myalgia was reported in only two patients. Myopathy was the first manifestation of sarcoidosis in five patients. Only six patients showed elevated plasma creatine kinase levels. Using skeletal muscle computed tomography, the distribution of muscle atrophy was predominant in the hip adductors, knee flexors and ankle plantarflexors. Radiological assessments, including magnetic resonance imaging, gallium scintigraphy, and fluorodeoxyglucose positron emission tomography-computed tomography imaging, revealed findings suggestive of skeletal muscle inflammation in only half of the patients examined. However, in all patients, muscle biopsy specimens revealed an active inflammatory process, as observed by focal non-caseating epithelioid granuloma with predominant CD4-positive lymphocytic infiltration. Sarcolemmas were diffusely stained with HLA-ABC, HLA-DR and intercellular adhesion molecule-1 antibodies, suggesting diffuse and active antigen presentation. Functional improvement after immunomodulatory treatment was significantly better in patients with short disease durations (p < 0.05). The therapeutic response was poor in patients with long disease durations; thus, early diagnosis and early initiation of treatment are important.

[A case of pulmonary actinomycosis with recurrent hemoptysis].

A 68-year-old man was admitted to our hospital because of hemoptysis in September 1999. Chest CT scans showed a nodular shadow with infiltration in the right S 7. Bronchial arteriography showed vascularization in the right S 7, and bronchial artery embolization was performed. However, in April and October 2000 hemoptysis recurred, and bronchial arteriography showed recurrence of vascularization in the same area, so embolization was performed again. Then, the patient was admitted in March 2001 because of recurrent hemoptysis. CT scans showed growth of the nodular shadow. Right lower lobectomy was performed, and the microscopic findings in the tissue from the resected lobe showed branching filamentous bacteria, and pulmonary actinomycosis was diagnosed. We concluded that pulmonary actinomycosis should be considered in the differential diagnosis of nodular shadows with recurrent hemoptysis.

Demographic features of Japanese patients with sporadic inclusion body myositis: a single-center referral experience.

OBJECTIVE: The incidence of sporadic inclusion body myositis (sIBM) in the Japanese population has increased, and some researchers have suggested that race and genetic background may influence the clinical features of the disease. The aim of this study was to clarify the demographic features of Japanese patients with sIBM. METHODS: We retrospectively evaluated the demographic features of consecutive patients who were referred to our institution between 1995 and 2011 for diagnostic muscle biopsies and who subsequently were diagnosed to have sIBM. RESULTS: Seventy-three patients comprising 54 men and 19 women received a diagnosis of sIBM during the study period. The patients were divided into two groups based on the date of diagnosis (before and including 2002, and after 2002). The annual number of patients who received a diagnosis of sIBM increased significantly from 3.6±1.6 (mean ± SD) before and including 2002 to 4.9±3.1 (mean ± SD) after 2002 (p<0.05), whereas the annual number of patients who received a diagnosis of polymyositis (PM) or dermatomyositis (DM) remained consistent from 1995 to 2011. The ratio of PM and DM to sIBM was 7.6 during the period from 1995 to 2002 and 5.5 during the period from 2003 to 2011. However, the age-adjusted annual number of patients newly diagnosed with sIBM did not increase significantly after 2002. CONCLUSION: The number of Japanese patients with sIBM appears to have increased in recent years; however, the characteristics of the patients have not changed. Considering the increased size of the elderly population, prolonged lifespans could explain the demographic movement of sIBM in Japan.

[Case of NMO (neuromyelitis optica) spectum disorder triggered by interferon alpha, which involved extensive pyramidal tract lesion of the brain].

A 65-year-old woman developed left optic neuritis during the course of peg-interferon alpha (PEG-IFN-α) and ribavirin combination therapy for chronic hepatitis C. Brain T(2)W-MRI disclosed hyperintense lesions in the corpus callosum and white matter. We diagnosed neuromyelitis optica spectrum disorder (NMOSD) on the basis of anti-aquaporin-4 antibody seropositivity. PEG-IFN-α was discontinued, and she received steroid pulse therapy (intravenous high dose methylprednisolone). Two weeks later she also developed right optic neuritis. Repetitive steroid pulse therapy improved the left optic neuritis, but the upper half of the visual field of the right eye remained impaired. One month later she presented with mild dysarthria and mild left hemiparesis. Brain MRI disclosed an extensive pyramidal tract lesion from the right corona radiata to the pedunculus cerebri. This cerebral pyramidal tract lesion is associated with NMOSD. Our case corresponds to the past reports of optic neuritis or multiple sclerosis-like disease triggered by IFN-α. IFN-α may trigger NMOSD via a biological effect characteristic of Type I IFNs, a group that includes IFN-α and IFN-ß.