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1.
Clin Exp Rheumatol ; 38(1): 1-10, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32041680

RESUMO

The idiopathic inflammatory myopathies (IIMs) are a rare group of immune, systemic diseases characterised by muscle inflammation and frequently by extramuscular involvement. IIMs are heterogeneous with generally a chronic or subacute onset, which vary from less severe to more serious manifestations, not always easy to diagnose and even less to manage. In the past year, many studies have been published in order to clarify disease pathogenesis and improve patient management and treatment.The purpose of this review article is to provide an overview of the new insights in pathogenesis, serological findings, clinical manifestations and treatment of IIMs, summarising the most relevant studies published over the last year.


Assuntos
Miosite , Humanos , Miosite/diagnóstico , Miosite/patologia , Miosite/terapia
3.
Best Pract Res Clin Rheumatol ; 33(3): 101433, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31590993

RESUMO

Myalgia is a common symptom of various neuromuscular disorders: myalgia occurs in metabolic muscle diseases, inflammatory muscle diseases, dystrophic myopathies and myotonic muscle disorders. Myalgia leads to a significantly reduced quality of life. Other muscular symptoms that are present along with myalgia often provide the clue towards a diagnosis and include weakness, cramps and myotonia as well as the type of pain. In addition, extramuscular symptoms like an erythema in dermatomyositis can lead to the correct diagnosis. Basic diagnostic workup includes a detailed medical history, full neurologic assessment, laboratory tests, EMG and nerve conduction studies. Muscle imaging, genetic testing and muscle biopsy may be required to make a diagnosis. Whenever possible, treatment should aim to improve or correct the underlying cause for myalgia such as inflammation or hypothyroidism. Symptomatic therapy includes different avenues: Myotonia can be treated with mexiletine. Carbamazepine or phenytoin can be used in myotonic syndromes, particularly with muscle cramps. Pregabalin, gabapentin, or amitriptyline can be tried in conditions with myalgic pain. This review summarizes the symptoms, diagnostic strategies, and therapeutic approach in neuromuscular disorders that present with myalgia.


Assuntos
Doenças Musculares/complicações , Doenças Musculares/diagnóstico , Mialgia/etiologia , Miosite/complicações , Miosite/diagnóstico , Humanos , Qualidade de Vida
4.
Zhonghua Jie He He Hu Xi Za Zhi ; 42(10): 765-770, 2019 Oct 12.
Artigo em Chinês | MEDLINE | ID: mdl-31594111

RESUMO

Objective: To investigate the clinical significance of detection of myositis-specific antibodies (MSAs) and myositis-associated antibodies (MAAs) in patients with connective tissue disease-associated interstitial lung diseases (CTD-ILD). Methods: Serum samples of 120 patients with CTD-ILD admitted to the Department of Respiratory, Affiliated Drum Tower Hospital of Nanjing University Medical College from December 2016 to April 2018 were collected for analysis. The patients included 45 with polymyositis/dermatomyositis (PM/DM), 36 with Sjogren's syndrome (SS) and 39 with undifferentiated connective tissue disease (UCTD). There were 37 males and 83 females with an average age of (56±11) years. Thirty-two patients with non-CTD-ILD, 10 males and 22 females with an average age of (42±17) years, were enrolled as the control group. Euroline Autoimmune Inflammatory Myopathies 16 Ag kit was used for detecting MSAs and MAAs, and the positive rates of serum MSAs and MAAs were calculated. The antibody distribution and clinical characteristics of different groups were analyzed and compared. Results: Eighty-nine of the 120 patients with CTD-ILD were positive for MSA and/or MAA (74.2%), and the detection rates of MSAs and MAAs were 52.5% (63/120) and 61.7% (74/120) respectively. No myositis antibody was detected in the non-CTD-ILD group. The detection rates of MSAs in PM/DM-ILD group, SS-ILD group and UCTD-ILD group were 75.6% (34/45), 33.3%(12/36) and 43.6%(17/39) respectively. The total detection rate of MSAs in PM/DM group was significantly higher than that in SS group and UCTD group (χ(2)=14.53, 8.95, 0.01). The anti-ARS was the most frequent (50/120, 41.7%). The positive rates of MAAs in the three groups were 64.4%(29/45), 77.8%(28/36), 43.6%(17/39) respectively, and anti-Ro-52 accounted for 60%(72/120), and were highly correlated with MSAs such as anti-Jo-1 antibodies. Conclusion: Myositis antibody profiling should be performed in patients with ILD who were negative for conventional autoimmune antibody testing and had no CTD. In patients with SS-ILD and UCTD-ILD, the myositis antibody spectrum could detect the presence of myositis-specific antibodies and myositis-related antibodies in some patients, and its role in clinical diagnosis and treatment needed further observation.


Assuntos
Autoanticorpos/sangue , Autoantígenos/imunologia , Doenças Pulmonares Intersticiais/imunologia , Miosite/imunologia , Polimiosite/imunologia , Adulto , Idoso , China/epidemiologia , Doenças do Tecido Conjuntivo/sangue , Dermatomiosite/sangue , Dermatomiosite/complicações , Dermatomiosite/epidemiologia , Dermatomiosite/imunologia , Feminino , Humanos , Doenças Pulmonares Intersticiais/sangue , Doenças Pulmonares Intersticiais/etiologia , Masculino , Pessoa de Meia-Idade , Miosite/sangue , Miosite/diagnóstico , Miosite/epidemiologia , Polimiosite/complicações , Polimiosite/epidemiologia , Testes Sorológicos
5.
Am J Case Rep ; 20: 1411-1417, 2019 Sep 25.
Artigo em Inglês | MEDLINE | ID: mdl-31551403

RESUMO

BACKGROUND Proliferative fasciitis/myositis is a benign disease that can be treated conservatively. However, some patients are mistakenly treated surgically because of a misdiagnosis of the condition as a malignant tumor. CASE REPORT A 50-year-old Japanese man developed swelling in his left cheek 12 days before admission; he developed a fever and trismus 3 days later. He was admitted to our hospital because of worsening of his condition despite treatment with sitafloxacin for 5 days and needle-aspiration drainage. On admission, he had a fever of 38.1°C, swelling in his left cheek spreading to the lower jaw, and several dental caries. Although ceftriaxone and clindamycin were administered for 7 days because an odontogenic infection was suspected, his condition did not improve. T2-weighted magnetic resonance imaging of the facial muscles on Day 5 of hospitalization showed swelling and high-intensity signals in the left masseter, temporalis, and pterygoid muscles. Macroscopic findings from a biopsy of the left temporalis muscle performed on Day 17 showed white and thickened fascia. Histopathological examination revealed fibrous hyperplasia of the fascia, increased fibrous connective tissue between muscle fibers, and infiltration of inflammatory cells, providing not a definite but a compatible diagnosis of proliferative fasciitis/myositis. Beginning on Day 18, the patient's fever lessened with gradual improvement of his facial swelling and trismus. CONCLUSIONS It is imperative to include proliferative fasciitis/myositis as a possible diagnosis when patients present with facial swelling and trismus of unknown cause.


Assuntos
Músculos Faciais , Fasciite/diagnóstico , Miosite/diagnóstico , Trismo/etiologia , Músculos Faciais/diagnóstico por imagem , Febre/etiologia , Humanos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada por Raios X
6.
J Assoc Physicians India ; 67(8): 11-12, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31562728

RESUMO

Inflammatory myositis involving the proximal muscles has been reported to occur in 5% to 11% of SLE patients and may develop at any time during the course of the disease. It can be secondary to internal malignancies also. We report one such patient who presented with generalised muscle weakness for 7 months. Erythematous hyperpigmented scaly patches were present over the scalp, face, trunk, upper limbs. We discuss the inflammatory myopathies secondary to SLE and internal malignancies. Most cases responds to low-dose corticosteroid treatment.


Assuntos
Lúpus Eritematoso Sistêmico , Miosite/diagnóstico , Corticosteroides , Humanos , Debilidade Muscular , Neoplasias , Pele
7.
Adv Respir Med ; 87(4): 243-246, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31476013

RESUMO

A young woman presented with gradually progressive breathlessness, cough and muscle weakness for one and a half year. Her chest radiograph showed multiple, bilateral thin-walled cavitary lesions. Her serum was found to be positive for anti-Jo1 antibodies on serology. Histopathology of lung lesions was suggestive of organizing pneumonia. The muscle biopsy demonstrated a myopathic pattern. On the basis of these findings she was diagnosed to be the case of idiopathic inflammatory myopathy. Her condition improved significantly after treatment with steroids.


Assuntos
Pneumonia em Organização Criptogênica/diagnóstico , Pneumonia em Organização Criptogênica/tratamento farmacológico , Glucocorticoides/administração & dosagem , Miosite/diagnóstico , Miosite/tratamento farmacológico , Tosse/etiologia , Pneumonia em Organização Criptogênica/complicações , Feminino , Humanos , Miosite/complicações , Resultado do Tratamento , Adulto Jovem
9.
J Med Case Rep ; 13(1): 241, 2019 Aug 04.
Artigo em Inglês | MEDLINE | ID: mdl-31376837

RESUMO

BACKGROUND: Antisynthetase syndrome is a relatively uncommon entity, and can be easily missed if not specifically looked for in adults whose initial presentation is with interstitial lung disease. Its presentation with interstitial lung disease alters its prognosis. CASE PRESENTATION: This case report describes a 27-year-old Pakistani, Asian man, a medical student, with no previous comorbidities or significant family history who presented with a 3 months' history of low grade fever and lower respiratory tract infections, associated with exertional dyspnea, arthralgias, and gradual weight loss. During these 3 months, he had received multiple orally administered antibiotics for suspected community-acquired pneumonia. When he presented to us, he was pale and febrile. A chest examination was significant for bi-basal end-inspiratory crackles. Preliminary investigations revealed raised erythrocyte sedimentation rate. High resolution computed tomography of his chest showed fine ground-glass attenuation in posterior basal segments of both lower lobes suggestive of interstitial lung disease. He was started on dexamethasone, to which he responded and showed improvement. However, during the course of events, he developed progressive proximal muscle weakness. Further investigations revealed raised creatinine phosphokinase and lactate dehydrogenase. A thorough autoimmune profile was carried out which showed positive anti-Jo-1 antibodies in high titers. A muscle biopsy was consistent with inflammatory myopathy. Clinical, radiological, serological, and histopathological markers aided in making the definitive diagnosis of antisynthetase syndrome. Antisynthetase syndrome is a variant of polymyositis but with visceral involvement, that is, interstitial lung disease and positive anti-Jo-1 antibodies. Our patient responded very well to glucocorticoids and azathioprine. CONCLUSION: Antisynthetase syndrome is a rare clinical entity which apart from clinical presentation requires specific serological investigations for diagnosis. Concomitant association of interstitial lung disease gives it a guarded prognosis.


Assuntos
Miosite/diagnóstico , Adulto , Anticorpos Antinucleares/sangue , Autoanticorpos/sangue , Azatioprina/administração & dosagem , Creatina Quinase/sangue , Diagnóstico Diferencial , Dispneia/etiologia , Humanos , Doenças Pulmonares Intersticiais/diagnóstico , Masculino , Debilidade Muscular/etiologia , Miosite/tratamento farmacológico , Prednisolona/administração & dosagem , Prednisolona/análogos & derivados
10.
J Dermatol ; 46(10): 886-897, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31418479

RESUMO

Patients with dermatomyositis positive for anti-aminoacyl tRNA synthetase (ARS) antibodies, also known as antisynthetase syndrome (ASS), frequently present with mechanic's hand and interstitial lung disease (ILD). We first screened the antibody profiles of 59 patients with dermatomyositis, and then examined the cutaneous, muscular and pulmonary manifestations characteristic for patients with ASS. The anti-ARS antibodies Jo-1, PL-7, PL-12, EJ and KS, along with antibodies to TIF1-γ, MDA5 and Mi-2, were examined. Among the 59 patients, 20, 21, 15 and three patients were classified into the ASS, non-ASS, myositis-specific antibody-negative and unknown groups, respectively. Five of 16 patients (31%) with ASS had six relatives with a history of collagen diseases, within the second degree of relationship, including two cases of dermatomyositis (vs the non-ASS group, P = 0.018). Patients with ASS more frequently presented with fever and arthralgia, and had elevated levels of C-reactive protein. Nine of the 11 finger lesions (82%) clinically diagnosed as mechanic's hands showed a psoriasiform tissue reaction. ILD was observed in 19 of 20 patients (95%) with ASS, and eight of 21 patients (38%) in the non-ASS group, in which six patients possessed anti-MDA5 antibody. Patients with ASS showed higher serum levels of muscle enzymes, and four of 12 patients (33%) had fasciitis-dominant myopathy, while only one of 11 patients (9%) in the non-ASS group had fasciitis-dominant myopathy. Patients with ASS often present with a psoriasiform tissue reaction in the hand lesions and fasciitis-dominant myopathy, and the relatives of those with ASS are at high risk for collagen diseases.


Assuntos
Aminoacil-tRNA Sintetases/imunologia , Autoanticorpos/sangue , Dermatomiosite/complicações , Doenças Pulmonares Intersticiais/diagnóstico , Miosite/diagnóstico , Psoríase/diagnóstico , Adulto , Idoso , Autoanticorpos/imunologia , Dermatomiosite/sangue , Dermatomiosite/imunologia , Feminino , Humanos , Pulmão/diagnóstico por imagem , Doenças Pulmonares Intersticiais/sangue , Doenças Pulmonares Intersticiais/imunologia , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Músculo Esquelético/diagnóstico por imagem , Miosite/sangue , Miosite/imunologia , Psoríase/sangue , Psoríase/imunologia , Tomografia Computadorizada por Raios X
11.
Acta Myol ; 38(1): 13-16, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-31309176

RESUMO

Scleromyxedema is a rare cutaneous mucinosis with frequent extracutaneous manifestations. Myopathy in scleromyxedema is a poorly recognized syndrome among neurologists and can mimic idiopathic and connective tissue disease-associated inflammatory myopathy. Diagnosis is suspected by the characterization of the skin lesions and clinched by skin and muscle biopsies. Here, we report a patient with scleromyxedema and myopathy with the characteristic histopathological feature of mucin deposition in skin biopsy. Her muscle biopsy showed a picture consistent with scleromyxedema myopathy with vacuolar and inflammatory changes. The association with paraproteinemia, propensity to life-threatening central nervous system disease and good response to intravenous immunoglobulin necessitate the accurate diagnosis of this condition.


Assuntos
Miosite/diagnóstico , Escleromixedema/diagnóstico , Adulto , Biópsia , Diagnóstico Diferencial , Quimioterapia Combinada , Feminino , Glucocorticoides/uso terapêutico , Humanos , Imunoglobulinas Intravenosas/uso terapêutico , Imunossupressores/uso terapêutico , Miosite/tratamento farmacológico , Prednisolona/uso terapêutico , Escleromixedema/tratamento farmacológico , Talidomida/uso terapêutico
12.
Acta Myol ; 38(2): 37-40, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31309181

RESUMO

Inflammatory myopathies comprise a group of rare autoimmune muscle diseases characterized by a variable degree of muscle weakness, elevated creatine kinase levels and necrotic fibres associated with invading inflammatory cells at histologic examination. Although there are several reports about their relationship with malignancy, association with papillary cancer of the thyroid gland is extremely rare. We present a case of a female patientdiagnosed withinflammatory myopathy and apapillary cancer of the thyroid gland, with a remarkable clinical improvement after thyroid cancer surgery and radioactive iodine treatment, supporting a correlation between the two conditions.


Assuntos
Carcinoma Papilar/complicações , Carcinoma Papilar/diagnóstico , Miosite/etiologia , Neoplasias da Glândula Tireoide/complicações , Neoplasias da Glândula Tireoide/diagnóstico , Carcinoma Papilar/terapia , Feminino , Humanos , Pessoa de Meia-Idade , Miosite/diagnóstico , Miosite/terapia , Neoplasias da Glândula Tireoide/terapia
15.
Am J Case Rep ; 20: 1094-1103, 2019 Jul 25.
Artigo em Inglês | MEDLINE | ID: mdl-31344020

RESUMO

BACKGROUND With the advent and advancement of autoantibodies, there has been progress in the diagnosis, prognosis, and treatment of rheumatologic diseases. Antisynthetase syndrome (ASS) is a great example of a disease that initially was described as arthritis, myositis, interstitial lung disease, mechanic's hands, Raynaud's phenomenon, and fever in the presence of the anti-JO-1 antibody, but nowadays it presents with a different spectrum related to new antibodies. CASE REPORT We describe 4 patients with antisynthetase syndrome who were diagnosed with antibodies specific for myositis associated with different clinical findings. All patients responded to immunosuppressive therapy, and rituximab was the most used. CONCLUSIONS It is necessary to search for specific autoantibodies related to the syndrome in suspected clinical cases and in other rheumatological diseases refractory to the usual treatment.


Assuntos
Autoanticorpos/sangue , Miosite/diagnóstico , Adulto , Feminino , Glucocorticoides/uso terapêutico , Humanos , Imunossupressores/uso terapêutico , Masculino , Metotrexato/uso terapêutico , Miosite/tratamento farmacológico , Prednisona/uso terapêutico , Doenças Raras
16.
Neurology ; 93(9): e889-e894, 2019 08 27.
Artigo em Inglês | MEDLINE | ID: mdl-31358616

RESUMO

OBJECTIVE: To determine interrater variability in diagnosing individual muscle biopsy abnormalities and diagnosis. METHODS: We developed a scoring tool to analyze consensus in muscle biopsy reading of an ad hoc workgroup of international experts. Twenty-four samples from patients with suspected idiopathic inflammatory myopathy (IIM) were randomly selected, providing sections that were stained with standard histologic and immunohistochemical methods. Sections were made available on an online platform, and experts were queried about myopathologic features within 4 pathologic domains: muscle fibers, inflammation, connective tissue, and vasculature. A short clinical presentation of cases was included, and experts were asked to give a tentative diagnosis of polymyositis, dermatomyositis, inclusion-body myositis, antisynthetase syndrome-related myositis, immune-mediated necrotizing myopathy, nonspecific myositis, or other disease. Fleiss κ values, scoring interrater variability, showed the highest agreement within the muscle fiber and connective tissue domains. RESULTS: Despite overall low κ values, moderate agreement was achieved for tentative diagnosis, supporting the idea of using holistic muscle biopsy interpretation rather than adding up individual features. CONCLUSION: The assessment of individual pathologic features needs to be standardized and harmonized and should be measured for sensitivity and specificity for subgroup classification. Standardizing the process of diagnostic muscle biopsy reading would allow identification of more homogeneous patient cohorts for upcoming treatment trials.


Assuntos
Biópsia/estatística & dados numéricos , Músculo Esquelético/patologia , Miosite/diagnóstico , Variações Dependentes do Observador , Humanos
17.
Rinsho Shinkeigaku ; 59(8): 502-508, 2019 Aug 29.
Artigo em Japonês | MEDLINE | ID: mdl-31341124

RESUMO

A 77-year-old woman with lung adenocarcinoma noticed bilateral ptosis 7 weeks after a first pembrolizumab infusion. Her symptoms rapidly progressed to generalized manifestations including limb and neck weakness, dyspnea, and dysphasia within the following two weeks. We diagnosed him with pembrolizumab-related myasthenia gravis and myositis based on clinical symptoms, elevation of muscle enzymes and anti-acetylcholine receptor antibodies, repetitive nerve stimulation and muscle biopsy. We commenced combination immunotherapy, including intravenous and oral steroid therapy, immune absorption therapy and plasma exchange therapy with noninvasive positive-pressure ventilation and tracheotomy positive pressure ventilation. She had gradual symptoms improvement and discharged after 209 days in a hospital. In this case, anti-titin antibodies, one of anti-striational antibodies, was positive and correlated with severity of myasthenia gravis. With the development of immune checkpoint inhibitors for various malignancies, clinicians should closely monitor patients for important immune-related adverse events and coordinate on early treatment.


Assuntos
Adenocarcinoma/terapia , Anticorpos Monoclonais Humanizados/efeitos adversos , Antineoplásicos Imunológicos/efeitos adversos , Neoplasias Pulmonares/terapia , Miastenia Gravis/induzido quimicamente , Miastenia Gravis/terapia , Miosite/induzido quimicamente , Miosite/terapia , Idoso , Anticorpos Monoclonais Humanizados/administração & dosagem , Antineoplásicos Imunológicos/administração & dosagem , Autoanticorpos/sangue , Biomarcadores/sangue , Terapia Combinada , Conectina/imunologia , Feminino , Humanos , Imunoterapia , Infusões Intravenosas , Miastenia Gravis/diagnóstico , Miosite/diagnóstico , Ventilação não Invasiva , Troca Plasmática , Respiração com Pressão Positiva , Prednisolona/administração & dosagem , Fatores de Tempo , Resultado do Tratamento
18.
Int J Rheum Dis ; 22(7): 1278-1282, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31124267

RESUMO

OBJECTIVES: To evaluate the ability of 2017 European League Against Rheumatism/American College of Rheumatology (EULAR/ACR) classification criteria for adult and juvenile idiopathic inflammatory myopathies (IIM) to classify IIM in comparison with the 1975 Bohan and Peter criteria in Chinese patients. METHODS: Two hundred and twenty-one inpatients with suspected IIM (including 40 children) were retrospectively included in this study. The performance of the 2017 EULAR/ACR criteria was evaluated by sensitivity, specificity, positive predictive value, negative predictive value and classification rate, in comparison to the 1975 criteria, with clinical diagnosis as the gold standard. RESULTS: The sensitivity, specificity, positive predictive value, negative predictive value of the 2017 EULAR/ACR criteria in IIM classification were 92.7%, 87.0%, 90.1% and 90.4%, respectively, in contrast to the 1975 Bohan and Peter criteria of 84.0%, 52.2%, 61.8%, and 77.9%. The classification rate of the 2017 criteria was also much better than that of the 1975 criteria (90.2% vs 67.4%). The performance of the new criteria in general, as well as the new criteria with muscle biopsy was better. Most IIM patients were correctly further sub-classified by the classification tree. The positive rate of myogenic lesions in electromyography, muscular inflammatory edema in magnetic resonance imaging and specific antibodies of myositis were significantly higher in the IIM group than those in the control group (P < 0.001, all). CONCLUSIONS: The 2017 EULAR/ACR criteria exhibited high sensitivity, specificity, classification rate in the Chinese IIM patients, which was superior to the 1975 criteria. The new criteria showed potential as clinical classification criteria in the future.


Assuntos
Técnicas de Apoio para a Decisão , Miosite/diagnóstico , Adolescente , Adulto , Idade de Início , Idoso , Grupo com Ancestrais do Continente Asiático , Autoanticorpos/sangue , Biomarcadores/sangue , Biópsia , Criança , China , Eletromiografia , Feminino , Humanos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Miosite/classificação , Miosite/etnologia , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Estudos Retrospectivos , Adulto Jovem
20.
Rinsho Shinkeigaku ; 59(6): 360-364, 2019 Jun 22.
Artigo em Japonês | MEDLINE | ID: mdl-31142711

RESUMO

An 84-year-old woman developed blepharoptosis, diplopia, weakness of extremities, and dysphagia with elevation of serum CK levels after treatment with nivolumab against renal cell carcinoma. 3 Hz repetitive stimulation showed waning in the trapezius muscle, leading to the diagnosis of myasthenia gravis. Laboratory examination showed that anti-acetylcholine receptor antibody was negative. We performed IVIg and steroid therapy. However, her symptoms did not improve, and she died of respiratory failure, although serum CK levels ameliorated to the normal range. The results of autopsy showed atrophy of muscle fibers and massive infiltration of inflammatory cells in the endomysium of the iliopsoas muscle and diaphragm, indicating occurrence of myositis. Immunohistochemical analysis showed that CD8-positive T cells mainly infiltrates in the endomysium with a small number of CD4-potive T cells. Here, we report an autopsy case of nivolumab-induced myasthenia gravis and myositis.


Assuntos
Antineoplásicos Imunológicos/efeitos adversos , Miastenia Gravis/induzido quimicamente , Miastenia Gravis/patologia , Miosite/induzido quimicamente , Miosite/patologia , Nivolumabe/efeitos adversos , Idoso de 80 Anos ou mais , Antineoplásicos Imunológicos/uso terapêutico , Autopsia , Linfócitos T CD4-Positivos/patologia , Linfócitos T CD8-Positivos/patologia , Carcinoma de Células Renais/tratamento farmacológico , Creatina Quinase/sangue , Evolução Fatal , Feminino , Humanos , Imunoglobulinas Intravenosas/administração & dosagem , Neoplasias Renais/tratamento farmacológico , Miastenia Gravis/diagnóstico , Miastenia Gravis/tratamento farmacológico , Miosite/diagnóstico , Miosite/tratamento farmacológico , Nivolumabe/uso terapêutico , Insuficiência Respiratória/induzido quimicamente
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