JEADV

LETTER TO THE EDITOR

Anti-transcription intermediary factor 1-c antibody-positive clinically amyopathic dermatomyositis complicated by interstitial lung disease and breast cancer Editor A 63-year-old Japanese woman noted facial erythema, and, around the same time, a mass in her left breast (Fig. 1), which was diagnosed as breast cancer. Subsequently, she underwent partial excision of the left breast and sentinel lymph node biopsy, which confirmed early-stage breast cancer. A therapeutic regimen of two courses of adriamycin and cyclophosphamide chemotherapy, in addition to trastuzumab therapy was conducted. Thereafter, radiation therapy at 50 Gy was administered to the left axilla. The patient remained disease-free at the 3-year follow-up. One year after the onset of facial erythema, the patient began to experience general fatigue that continued for 1.5 years. She was then referred to our clinic. At the first visit, she showed Gottron’s sign and facial erythema (Fig. 2). No muscle weakness was detected by manual muscle testing. She had no significant medical history or a family history of rheumatic disease. Laboratory parameters were as follows: white blood cells, 3300/lL; platelets, 157 000/mm; C-reactive protein (CRP), 0.1 mg/dL; creatine kinase (CK), 47 IU/L; aldolase, 3.9 IU/L;

serum myoglobin, 32 ng/mL; KL-6, 304 U/mL. Serum antinuclear antibody test results were positive (940; speckled pattern). Using an enzyme-linked immunosorbent assay (ELISA) that we developed, serum anti-TIF1-c antibodies, but not anti-melanoma differentiation-associated gene 5 (MDA5) antibodies, were detected.1 No serum anti-aminoacyl transfer RNA synthetase (ARS) antibodies were detected using a commercial ELISA kit (MBL, Nagoya, Japan). Based on these findings, the patient was diagnosed with clinically amyopathic dermatomyositis (CADM). She was prescribed topical tacrolimus for the skin lesions. At a follow-up visit 3 months after her first visit, her serum KL-6 level had increased to 2326 U/mL (Fig. 2). High-resolution computed tomography (CT) of the chest showed a slight ground glass pattern bilaterally at the lung bases, which was suspected to be an early sign of interstitial lung disease (ILD). However, she had no respiratory symptoms and the CT findings were not pathognomonic. Thus, follow-up periodic blood tests and chest CT scans were conducted for 1 year without administering any treatment. The serum KL-6 levels gradually decreased, although they were still above the normal limit (>1000 U/mL). Serum surfactant protein-D levels were persistently high. Serum CK, aldolase and CRP levels were within the normal ranges. Restricted areas showing ground glass patterns were detected at various sites on all follow-up chest CT images (Fig. 1). Overall, the ILD remained stable. The patient’s cutaneous symptoms were exacerbated by sunlight exposure. Nearly half of all dermatomyositis (DM) cases are complicated by ILD, which is one of the most important prognostic factors despite appropriate

Figure 1 Clinical course of the patient and associated computed tomography (CT) imaging. Three months after her first visit to our hospital, the KL-6 level had increased to 2326 U/mL and a chest CT image showed ILD, although she had no respiratory symptoms. The serum KL-6 level was persistently high, but no remarkable change was observed on CT. Areas showing ground glass patterns are indicated by red circles. Creatine kinase, aldolase and C-reactive protein levels remained low.

JEADV 2014

© 2014 European Academy of Dermatology and Venereology

Letter to the Editor

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(b)

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Figure 2 The patient’s clinical features. The patient showed facial erythema (a), Gottron’s sign (b) and periungual capillary dilation (c).

treatment, making it difficult to predict the prognosis of each patient. Accumulation of data on the correlations between patient prognosis and myositis-specific autoantibody positivity, such as anti-ARS and anti-MDA5 antibodies, may to some extent allow us to predict the course of ILD in DM patients.2 The presence of anti-ARS and anti-MDA5 antibodies is often associated with recurrent ILD and acute refractory ILD respectively. Anti-TIF1-c antibodies are associated with cancer or juvenile DM. However, a few reports on the clinical features of antiTIF1-c-positive DM including ILD have been published.3 The prognosis of ILD in anti-TIF1-c-positive DM patients should be clarified in the near future. Drug-induced ILD can be induced by trastuzumab or other anti-neoplastic agents.4 Therefore, we cannot deny the possibility of drug-induced ILD in the patient. To our knowledge, this is the first detailed report of the clinical course of a patient with anti-TIF1-c autoantibody-positive CADM, complicated by ILD and breast cancer. The findings of this case suggest that ILD in a patient with anti-TIF1-c autoantibody-positive CADM can be managed without aggressive immunosuppressive treatment.

JEADV 2014

M. Ogawa, K. Sugiura,* K. Yokota, Y. Muro, M. Akiyama Department of Dermatology, Nagoya University Graduate School of Medicine, Nagoya, Japan *Correspondence: K. Sugiura. E-mail: [email protected]

References 1 Muro Y, Sugiura K, Akiyama M. Limitations of a single-point evaluation of anti-MDA5 antibody, ferritin, and IL-18 in predicting the prognosis of interstitial lung disease with anti-MDA5 antibody-positive dermatomyositis. Clin Rheumatol 2013; 32: 395–398. 2 Mimori T, Nakashima R, Hosono Y. Interstitial lung disease in myositis: clinical subsets, biomarkers, and treatment. Curr Rheumatol Rep 2012; 14: 264–274. 3 Fujimoto M, Hamaguchi Y, Kaji K et al. Myositis-specific anti-155/140 autoantibodies target transcription intermediary factor 1 family proteins. Arthritis Rheum 2012; 64: 513–522. 4 Kang HJ, Park JS, Kim DW et al. Adverse pulmonary reactions associated with the use of monoclonal antibodies in cancer patients. Resp Med 2012; 106: 443–450. DOI: 10.1111/jdv.12797

© 2014 European Academy of Dermatology and Venereology

Anti-transcription intermediary factor 1-γ antibody-positive clinically amyopathic dermatomyositis complicated by interstitial lung disease and breast cancer.

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