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Drugs & Diseases > Rheumatology
Author: Mythili Seetharaman, MD; Chief Editor: Herbert S Diamond, MD more...
Sections Polymyositis
Electromyography
Extramuscular Manifestations of Polymyositis
Deterrence and Prevention
DMARDs, TNF Inhibitors
Anti-CD20 Monoclonal Antibodies
Polymyositis is an idiopathic inflammatory myopathy characterized by the following [1] :
Symmetrical, proximal muscle weakness
Elevated skeletal muscle enzyme levels
Characteristic electromyography (EMG) and muscle biopsy findings (see the images below).
MRI of thighs showing increased signal in the quadriceps muscles bilaterally consistent with inflammatory myositis.
Histopathology of polymyositis showing endomysial mononuclear inflammatory infiltrate and muscle fiber necrosis.
Polymyositis is one of several idiopathic inflammatory myopathies. [2] Clinically similar to polymyositis, dermatomyositis is an idiopathic inflammatory myopathy associated with characteristic dermatologic manifestations. [3] Inclusion body myositis is a slowly progressive, idiopathic, inflammatory myopathy with characteristic pathologic findings that is generally found in older men. Bohan and Peter classified the idiopathic inflammatory myopathies as follows [4] :
I - Primary idiopathic polymyositis
II - Primary idiopathic dermatomyositis
III - Polymyositis or dermatomyositis associated with malignancy [5]
IV - Childhood polymyositis or dermatomyositis
V - Polymyositis or dermatomyositis associated with another connective-tissue disease
VI - Inclusion body myositis
VII - Miscellaneous (eg, eosinophilic myositis, myositis ossificans, focal myositis, giant cell myositis)
Necrotizing autoimmune myopathy (NAM) is a recently recognized form of idiopathic inflammatory myopathy that is identified by finding macrophage-predominant myocyte destruction, with few to no lymphocytes, on muscle biopsy. NAM has been associated with malignancy and statin use. [6]
See Etiology, Presentation, and Workup.
Polymyositis and dermatomyositis have many shared clinical features. Both present as symmetrical muscle weakness that develops over weeks to months. Initial treatment with corticosteroids usually produces a response; however, nonresponders require further treatment. Moreover, both conditions may be associated with malignancies. [5] Despite these similarities, muscle biopsy findings and characteristic skin findings of dermatomyositis reveal each as a distinct clinical entity.
Although classified as an inflammatory myopathy, inclusion body myositis shows minimal evidence of inflammation. This is the most common inflammatory myopathy in patients older than age 50 years. It more commonly presents as asymmetrical, distal weakness and also has distinct biopsy findings. Studies so far have yielded less favorable results than treatment for polymyositis and dermatomyositis. (See Treatment and Medication.)
Patients with polymyositis should be educated early about the disease and should be provided with realistic expectations about outcomes. Most patients show significant improvement with treatment.
Stress the need for close follow-up care, continued physical therapy, and long-term therapy with monitoring of several parameters, and warn patients regarding adverse events related to medications. Patients may visit The Myositis Association Web site for more information.
Polymyositis is an immune-mediated syndrome secondary to defective cellular immunity that is most commonly associated with other systemic autoimmune diseases. It may be due to diverse causes that occur alone or in association with viral infections, malignancies, or connective-tissue disorders.
Evidence points toward a T-cell–mediated cytotoxic process directed against unidentified muscle antigens. Supporting this conclusion is the involvement of CD8 T cells, which, along with macrophages, initially surround healthy nonnecrotic muscle fibers and eventually invade and destroy them. (See the image below.)
Close view of muscle biopsy, showing chronic inflammatory infiltrate consisting of T lymphocytes, especially CD8+ T lymphocytes.
The factors triggering a T-cell–mediated process in polymyositis are unclear. Viruses have been implicated; so far, however, the only viruses that have been etiologically connected with the disease are the human retroviruses human immunodeficiency virus (HIV) and human T-cell lymphotrophic virus type I (HTLV-I), the simian retroviruses, and coxsackievirus B. Those viruses may directly invade the muscle tissue, damaging the vascular endothelium and releasing cytokines, which then induce abnormal expression of the major histocompatibility complex (MHC) and render the muscle susceptible to destruction.
An autoimmune response to nuclear and cytoplasmic autoantigens is detected in about 60-80% of patients with polymyositis and dermatomyositis. Some serum autoantibodies are shared with other autoimmune diseases (ie, myositis-associated antibodies [MAAs]), and some are unique to myositis (ie, myositis-specific antibodies [MSAs]). The MSAs are found in approximately 40% of patients with polymyositis or dermatomyositis, whereas MAAs are found in 20-50% of these patients.
Myositis-specific antibodies
The identified MSA targets include the following 3 distinct groups of proteins:
Aminoacyl–transfer ribonucleic acid (tRNA) synthetases (anti-Jo-1)
Nuclear Mi-2 protein
Components of the signal-recognition particle (SRP)
Most of the anti-tRNA synthetase antibodies are directed toward functional and highly conserved domains of the enzyme. As many as 6 of 20 aminoacyl-tRNA synthetases have been described, but anti-histidyl-tRNA synthetase (Jo-1) is most common (20-30%). Autoantibodies directed toward the other synthetases specific for alanine (anti-PL12), glycine (anti-EJ), isoleucine (anti-OJ), threonine (anti-PL7), and asparagine (anti-KS) have been reported in only about 1% of patients.
Anti-Jo-1 autoantibodies were originally described as precipitating autoantibodies in sera of patients with polymyositis. Later, the anti-Jo-1 antibodies were recognized to be specific for patients with polymyositis. The target for the anti-Jo-1 antibodies was the aminoacyl-tRNA synthetases, a family of distinct cellular enzymes.
The Jo-1 antigen is histidyl-tRNA synthetase. This enzyme is partially responsible for attaching tRNA to their cognate ribosomal RNA (rRNA). The Jo-1 antigen migrates as a 53-kd protein on sodium dodecyl sulfate–polyacrylamide gel electrophoresis (SDS-PAGE).
The presence of autoantibodies against the Jo-1 antigen has been reported in up to 23% of polymyositis patients by immunodiffusion. Anti–Jo-1 antibodies are almost completely specific for myositis and are more common in polymyositis than in dermatomyositis; they are rare in children. The presence of anti-Jo-1 antibodies defines a distinct group of polymyositis patients with interstitial lung disease, arthritis, and fevers. The anti–Jo-1 response appears to be self-antigen driven, having a broad spectrotype over time and undergoing isotype switching. Anti–Jo-1 antibodies also inhibit the function of histidyl-tRNA synthetase in humans more than they do in other species.
Anti-Mi-2 antibodies recognize a major protein of a nuclear complex formed by at least 7 proteins that is involved in the transcription process. Autoantibodies recognizing Mi-2 are considered specific serologic markers of dermatomyositis. They are detected in about 20% of patients with myositis and are associated with relatively acute onset, a good prognosis, and a good response to therapy.
Anti-SRP antibodies are directed toward an RNA-protein complex that consists of 6 proteins and a 300-nucleotide RNA molecule (7SL RNA). Patients with anti-SRP antibodies have acute polymyositis with cardiac involvement, a poor prognosis, and a poor response to therapy.
Myositis-associated antibodies
The MAA are found in the sera of 20-50% of patients and are commonly encountered in other connective tissue diseases. The most important antigenic targets of the MAA are the following:
PM/Scl nucleolar antigen
Nuclear Ku antigen
Small nuclear ribonucleoproteins (snRNP)
Cytoplasmic ribonucleoproteins (RoRNP)
Anti-PM/Scl autoantibodies are generally found in patients affected by polymyositis overlapping with scleroderma. Anti-Ku antibodies are found in patients with myositis overlapping with other connective tissue diseases.
Antibodies directed against snRNP are frequently found in patients with myositis and in patients with connective tissue–disease overlap syndrome, whereas antibodies toward Ro/SSA 60 kD, Ro/SSA 52 kD, and La/SSB protein components of the RoRNP complex are almost exclusively found in patients with Sjögren syndrome and systemic lupus erythematosus (SLE).
An increased association of myositis has been found with human leukocyte antigen (HLA) haplotypes A1, B8, and DR3, which also increase the risk for autoimmune diseases. Environmental triggers, especially infectious agents, have been suggested as etiologic agents. These include the following:
Coxsackievirus B1
HTLV-1
Echovirus
Many drugs are known to cause myopathy. Most drugs, such as hydroxychloroquine and colchicine, cause a toxic or metabolic myopathy.
Several drugs, however, rarely induce an immune-mediated myopathy or myositis. Muscle biopsy shows chronic inflammatory changes consistent with polymyositis. Drugs such as D-penicillamine, hydralazine, procainamide, phenytoin, and angiotensin-converting enzyme (ACE) inhibitors have been associated with this type of inflammatory myopathy. Statins occasionally cause severe muscle inflammation and rhabdomyolysis.
Idiopathic inflammatory myopathies are relatively rare diseases, with an incidence in the United States that ranges from 0.5-8.4 cases per million population. Polymyositis is more common in the United States within the black population, with the estimated black-to-white incidences for polymyositis and dermatomyositis being 5:1 and 3:1, respectively. Internationally, polymyositis is less common among Japanese persons.
Sex- and age-related demographics
Polymyositis and dermatomyositis are more common in women than in men (2:1 ratio), while inclusion body myositis is twice as common in men.
Polymyositis usually affects adults older than 20 years, especially those aged 45-60 years. Polymyositis rarely affects children. The age of onset of polymyositis with another collagen vascular disease is related to the associated condition.
Although dermatomyositis is primarily a disease of adults, it also is observed in children, usually those aged 5-14 years. Eighty percent of patients with inclusion body myositis are older than 50 years at onset.
In most patients, polymyositis responds well to treatment, although residual weakness occurs in approximately 30% of patients. Osteoporosis, a common complication of long-term corticosteroid therapy, may cause significant morbidity. A study from Taiwan determined that the risk of osteoporosis was 2.99 times higher in patients with polymyositis, and that the risk was independent of corticosteroid and immunosuppressant treatment. [7]
Poor prognostic factors include the following:
Female sex
African-American race
Presence of anti-Jo-1 (lung disease) and anti-SRP antibodies (severe muscle disease, cardiac involvement)
Associated malignancy
Delayed or inadequate treatment
Dysphagia, dysphonia
Cardiac and pulmonary involvement
Morbidity and mortality
Complications of polymyositis may include the following:
Heart block
Infection [8]
Myocardial infarction [9]
Carcinoma - Especially in the breast and lung [10]
Steroid myopathy or other complications of steroid therapy
Carruthers et al reported that patients with polymyositis are at increased risk for venous thromboembolism (VTE), with hazard ratios of 7.0 for VTE, 6.16 for deep venous thrombosis, and 7.23 for pulmonary embolism. Overall, the highest calculated incidence rate ratios were observed in the first year after diagnosis of polymyositis. [11]
The incidence of lung, bladder, and non-Hodgkin lymphoma may be increased in patients with polymyositis, especially in the first year after diagnosis.
Polymyositis shares pathologic characteristics and immunologic features with amyotrophic lateral sclerosis (ALS), and a nationwide cohort study from Taiwan found that a diagnosis of polymyositis increased the likelihood of a subsequent diagnosis of ALS (P <0.001). The association was independent of sex, age, and concomitant autoimmune diseases. [12]
Five-year survival rates in polymyositis have been estimated at more than 80%. Mortality is most often related to associated malignancy or pulmonary complications; however, elderly patients with cardiac involvement or dysphagia also have a higher mortality rate. [13]
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Hematoxylin and eosin frozen section shows polymyositis. Endomysial chronic inflammation is present among intact myofibers, which are remarkable only for increased variability of fiber size. Image courtesy of Roberta J. Seidman, MD.
Hematoxylin and eosin paraffin section shows polymyositis. Patient had dense endomysial inflammation that contains an abundance of plasma cells, which can be observed in patients with chronic polymyositis. Two necrotic myofibers, characterized by dense eosinophilic staining, are observed. Focal fatty infiltration of the muscle is present in the lower left quadrant of the photomicrograph. Image courtesy of Roberta J. Seidman, MD.
Hematoxylin and eosin paraffin section shows polymyositis. Photomicrograph illustrates attack on a nonnecrotic myofiber by autoaggressive T lymphocytes. On the left, the central myofiber is intact. On the right, it is obliterated by a segmental inflammatory attack. If immunohistochemistry were performed, expected findings would include an admixture of CD8 T lymphocytes and macrophages in the inflammatory process. Image courtesy of Roberta J. Seidman, MD.
Hematoxylin and eosin paraffin shows dermatomyositis. In dermatomyositis, inflammation is characteristically perivascular and perimysial. Vessel oriented approximately vertically in the center has a mild perivascular chronic inflammatory infiltrate. The endothelium is plump. The wall is not necrotic. A few lymphocytes in the wall of the vessel are probably in transit from the lumen to the external aspect of the vessel. Some observers may interpret this finding as vasculitis, but it is certainly neither necrotizing vasculitis nor arteritis. Image courtesy of Roberta J. Seidman, MD.
Hematoxylin and eosin paraffin section shows polymyositis. Longitudinal section shows a dense, chronic, endomysial inflammatory infiltrate. Image courtesy of Roberta J. Seidman, MD.
Mythili Seetharaman, MD Consultant Rheumatologist, OAA, St Luke's University Hospital, St Christopher's Hospital for Children
Mythili Seetharaman, MD is a member of the following medical societies: American College of Rheumatology, American Medical Association
Herbert S Diamond, MD Visiting Professor of Medicine, Division of Rheumatology, State University of New York Downstate Medical Center; Chairman Emeritus, Department of Internal Medicine, Western Pennsylvania Hospital
Herbert S Diamond, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology, American Medical Association, Phi Beta Kappa
Michael S Beeson, MD, MBA, FACEP, Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine and Pharmacy; Attending Faculty, Akron General Medical Center
Michael S Beeson, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Thomas H Brannagan III, MD, Associate Professor of Clinical Neurology and Director, Peripheral Neuropathy Center, Columbia University, College of Physicians and Surgeons; Co-Director, EMG Laboratory, New York-Presbyterian Hospital, Columbia Campus, New York
Thomas H Brannagan III, MD is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and Peripheral Nerve Society
Lawrence H Brent, MD, Associate Professor of Medicine, Jefferson Medical College of Thomas Jefferson University; Chair, Program Director, Department of Medicine, Division of Rheumatology, Albert Einstein Medical Center
Lawrence H Brent, MD is a member of the following medical societies: American Association for the Advancement of Science, American Association of Immunologists, American College of Physicians, and American College of Rheumatology
Disclosure: Genentech Honoraria Speaking and teaching; Genentech Grant/research funds Other; Amgen Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching; Abbott Immunology Honoraria Speaking and teaching; Takeda Honoraria Speaking and teaching; UCB Speaking and teaching; Omnicare Consulting fee Consulting; Centocor Consulting fee Consulting
Zaineb Daud, MD, Consulting Staff, Department of Neurology, Medical College of Pennsylvania Hahnemann University
Disclosure: None
Gino A Farina, MD, FACEP, FAAEM, Associate Professor of Clinical Emergency Medicine, Albert Einstein College of Medicine; Program Director, Department of Emergency Medicine, Long Island Jewish Medical Center
Gino A Farina, MD, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Francisco de Assis Aquino Gondim, MD, MSc, PhD, Associate Professor of Neurology, Department of Neurology and Psychiatry, St Louis University School of Medicine
Francisco de Assis Aquino Gondim, MD, MSc, PhD is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and Movement Disorders Society
Aamir Hashmat, MD, Consulting Staff, Neurology and Neurodiagnostics Lab, Department of Neurology, Jeff Anderson Regional Medical Center
Aamir Hashmat, MD is a member of the following medical societies: American Academy of Neurology, American Epilepsy Society; American Medical Association, AO Foundation
Milind J Kothari, DO, Professor and Vice-Chair, Department of Neurology, Pennsylvania State University College of Medicine; Consulting Staff, Department of Neurology, Penn State Milton S Hershey Medical Center
Milind J Kothari, DO is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and American Neurological Association
Kristine M Lohr, MD, MS, Professor, Department of Internal Medicine, Center for the Advancement of Women's Health and Division of Rheumatology, Director, Rheumatology Training Program, University of Kentucky College of Medicine
Kristine M Lohr, MD, MS is a member of the following medical societies: American College of Physicians, American College of Rheumatology, and American Medical Women's Association
Glenn Lopate, MD, Associate Professor, Department of Neurology, Division of Neuromuscular Diseases, Washington University School of Medicine; Director of Neurology Clinic, St Louis ConnectCare; Consulting Staff, Department of Neurology, Barnes-Jewish Hospital
Glenn Lopate, MD is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and Phi Beta Kappa
Nicholas Lorenzo, MD, Consulting Staff, Neurology Specialists and Consultants
Nicholas Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Neurology
Henry Rosenkranz, MD, FAAEM, FACEP, Department of Emergency Medicine, Norwood Hospital
Henry Rosenkranz, MD, FAAEM, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Erik D Schraga, MD, Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates
Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
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