Skeletal muscle vasculitis exclusive of inflammatory myopathic conditions: a clinicopathologic study of 40 patients

Vasculitis is an infrequently encountered pathology in skeletal muscle biopsy specimens, the diagnosis of which has significant therapeutic implications. This study retrospectively reviewed the clinicopathologic features of 40 patients with vasculitis (infiltration of vessel walls by inflammatory cells) diagnosed via skeletal muscle biopsy during a 27-year period of time. Cases of vasculitis associated with inflammatory myopathic conditions, such as polymyositis or dermatomyositis, were excluded from study. Forty patients, including 21 women and 19 men ranging in age from 19 to 83 years (mean of 52 years), formed the study group. The most common clinical presentations included muscle pain (n = 22, 55%), paresthesias (n = 16, 40%), and weight loss (n = 15, 38%). Westergren erythrocyte sedimentation rate was known in 31 patients and ranged from 12 to >150 mm/h (mean, 61 mm/h). Necrotizing vasculitis was identified in 35 patients (88%). The vasculitic process involved multiple vessels in 30 cases (75%). Vessel wall scarring and/or fibrosis were identified in 11 patients (28%), thrombi in 3 patients (8%), eosinophils in 2 patients (5%), and granulomas in 1 patient (3%). Neurogenic changes were observed in the majority of biopsy specimens as follows: angular atrophic esterase-positive muscle fibers (n = 35, 88%), grouped atrophy (n = 14, 35%), fiber type grouping (n = 17, 43%), and target fibers (n = 6, 15%). Other commonly identified pathologies included scattered degenerating muscle fibers (n = 15, 38%), regenerating muscle fibers (n = 17, 43%), and type II muscle fiber atrophy (n = 10, 25%). Thirty-three patients also underwent sural nerve biopsy. Vasculitis was identified in the nerve in 26 of 33 of these patients (79%). Peripheral nerve vasculitis was classified as necrotizing in 15 cases (57.7%) and as nonnecrotizing in 11 cases (42.5%). Seventeen of 33 patients (52%) with known follow-up showed clinical improvement with steroid/immunosuppressive therapy. The following 2 conclusions were made: the majority of vasculitis cases arising outside the setting of inflammatory myopathy in skeletal muscle are necrotizing, and the predominant muscle pathology in the setting of vasculitis is neurogenic atrophy, likely caused by concomitant involvement of the peripheral nervous system.     

Skeletal muscle expression of class II histocompatibility antigens (HLA-DR) in polymyositis and other muscle disorders with an inflammatory infiltrate.

Muscle biopsy specimens with a pronounced inflammatory component were evaluated for myocyte expression of class II histocompatibility antigens (HLA-DR) by immunohistochemical techniques. All 15 cases of polymyositis were positive; six cases of muscular dystrophy (two Duchenne, four facio-scapulo-humeral), and one case of acute denervation (motor neurone disease) were negative, despite having a comparably intense mononuclear infiltrate. Twelve entirely normal biopsy specimens were also negative for HLA-DR expression. Expression of this membrane glycoprotein may have a clinically important aetiological role in polymyositis, and demonstration of its presence may prove useful as a marker for this disorder in selected problematic biopsy specimens.     

Skeletal muscle in polymyositis. Immunohistochemical study.

Thirty-two patients with adult-onset polymyositis uncomplicated by cancer or systemic connective tissue disease were studied. Muscle biopsy specimens were examined with direct immunofluorescence microscopy and results were compared with those in 94 control subjects. Sarcolemmal and sarcoplasmic staining were observed in both groups and considered to be nonspecific. Immune deposits in the muscle microvasculature were present in some cases of systemic lupus erythematosus and dermatomyositis but were not present in polymyositis. Our data suggest that the finding of vascular immunofluorescence excludes the diagnosis of adult polymyositis and implies that the pathogenesis of this disease and other idiopathic inflammatory myopathies may differ.     

Role of inositol starvation on ecto-5'-nucleotidase activity during mitogen-induced lymphocyte activation

Cell-surface 5'-nucleotidase was assayed by incubating intact cells with 5' [3H]AMP in iso-osmotic buffer and measuring [3H]adenosine production. The activity of cell surface 5'-nucleotidase in small resting lymphocytes and in cells of the B cell line BCL1 was 5.7 and 1.1 nmol/min/mg protein respectively at 37 degrees C. The 5'-nucleotidase was inhibited by Concanavalin A and anti-IgM, the inhibition by anti-IgM being reversible. Incubating the lymphocytes in the presence and absence of mitogens in inositol-free medium for 15 min, 60 min, and 24 h had no effect on 5'-nucleotidase activity. The reaction product adenosine as well as adenine nucleotides were shown to inhibit mitogen-induced proliferation.     

Can tissue transglutaminase be a marker of idiopathic inflammatory myopathies?

In the normal striated muscle, tissue transglutaminase (TG2) content is vestigial. However, this protein's presence has been reported to occur in myoblasts and myotubes during the fetal period. Its increased expression has been also found in the muscle tissue in the course of sporadic inclusion body myositis, as well as in polymyositis (PM) and dermatomyositis (DM), which are considered to be diseases of immunological origin. Based on in vitro studies, a substantial TG2 role in the infiltration of some T cell subsets into inflamed tissues has been suggested lately. In this study, the immunohistochemical reactions in the guinea pig experimental myositis specimens and in the ones from PM/DM patients were compared. The guinea pig tissue specimens were taken from muscles affected by experimental myositis induced by intramuscular injections of: 1/sera from 30 neoplasm patients with no metastases; 2/sera from 10 healthy people; 3/sera from 2 DM patients; 4/neuropeptides (SP, NPY or VIP) and from 5/the muscles affected by the reversed passive Arthus reaction (RPAR). The immunostaining for TG2 revealed substantial presence of this protein in single, damaged muscle fibers and a weak reaction in regenerating fibers appearing in PM/DM patients' specimens. From among experimental myositis specimens, a very intensive reaction appeared only in the damaged and regenerating muscle fibers present in the slides from guinea pig muscles injected with DM patients' sera. Such results suggest some presence of a specific factor(s) (the one(s) responsible for TG2 expression in the damaged muscle fibers) in DM patients' sera. The results suggest that transglutaminase can be a marker of inflammatory myopathies. A probable correlation between TG2 expression in muscles and organismal immunological factors, including the complement activation status, requires additional studies.     

Local T-Cell Proliferation and Differentiation in Inflammatory Myopathies

Our objective was to investigate the patterns of proliferation and differentiation of infiltrating cells in inflammatory myopathies. Immunohistochemical staining was performed on muscle biopsy specimens from 18 patients with inclusion body myositis, polymyositis and dermatomyositis using monoclonal and polyclonal antibodies.
An abundance of cells were TNF-α⁺ (4–8%), ICAM-1⁺ (7–65%). IFN-γ⁺ (3–6%), and Ki-67⁺ (4–8%). It was shown that 70% of the Ki-67⁺ cells were Ki-67⁺CD3⁺ cells. Very few mononuclear cells were IL-2R⁺. MHC-I expression was found on nearly all muscle fibres in all cases, while MHC-II expression was found on occasional muscle fibres in 1/3 of cases. Analysis of repeated biopsies from four IBM patients after prednisolone treatment showed no change in the proportions of TNF-α, ICAM-1, IFN-γ or Ki-67 positive cells. In inflammatory myopathies there is an intense proliferation and differentiation of inflammatory cells in situ , indicating a local stimulation of the inflammatory process.     

Hepatocellular carcinoma,polymyositis,rhabdomyolysis,and acute renal failure

A 55 yr-old man presented with progressive muscle weakness and oliguria for 5 days. Laboratory findings suggested rhabdomyolysis complicated with acute renal failure. A diagnosis of polymyositis was based upon the proximal muscle weakness on both upper and lower limbs, elevated muscle enzyme levels, muscle biopsy findings and the needle electromyography findings. The muscle biopsy showed extensive muscle necrosis and calcification. Investigations for underlying malignancy demonstrated hepatocellular carcinoma. The patient was managed with hemodialysis and high dose prednisolone. His renal function was fully recovered and his muscle power did improve slightly, but he died of a rupture of the hepatic tumor. In our view, this is an interesting case in that the hepatocellular carcinoma was associated with polymyositis and fulminant rhabdomyolysis-induced acute renal failure requiring hemodialysis.     

Skeletal muscle fibers express major histocompatibility complex class II antigens independently of inflammatory infiltrates in inflammatory myopathies

The aim of our study was to address the question of whether muscle fibers express major histocompatibility complex (MHC) class II in inflammatory myopathies. For this purpose we performed a systematic study of MHC class II antigen expression on muscle fiber membranes in muscle tissue from polymyositis and dermatomyositis patients in various stages of disease activity. Thirty-two patients with classical clinical signs of myositis were divided into subgroups depending on duration of clinical signs of myositis and presence or absence of inflammatory infiltrates in muscle tissue. Immunohistochemistry as well as double-immunofluorescence stainings were used to identify the presence of MHC class II in muscle tissue. MHC class I was included for comparison. Quantification of positive staining was performed using an image analysis system in addition to evaluation by manual microscopic scoring and laser confocal microscopy. It was demonstrated that a significant proportion of skeletal muscle fibers in inflammatory myopathies express MHC class II as well as MHC class I and that MHC antigen expression is independent of the inflammatory cell infiltration. Furthermore, there were no differences in staining pattern between polymyositis and dermatomyositis patients. Our results indicate that MHC class II and MHC class I molecules may be involved in initiating and maintaining the pathological condition in myositis rather than only being a consequence of a preceding local inflammation.     

The importance of B-cells and ecto-5'nucleotidase in Mycoplasma fermentans infection and the relevance to rheumatoid arthritis

The aim of this work was to discover if Mycoplasma fermentans, which is known to infect B cells, could be the cause of the raised ecto-5'-nucleotidase observed in the synovial fluid of rheumatoid arthritis patients. The ecto-5'-nucleotidase activity in the patients' serum has been shown to correlate with the erythrocyte sedimentation rate and DNA from the mycoplasma has been found in the synovial fluid. B lymphoblastoid cell lines were exposed to 16 strains of Mycoplasma fermentans and their ecto-5'-nucleotidase, CD73, was measured both biochemically and by mouse antibodies to human ecto 5'-nucleotidase using the fluorescence activated cell sorter. The type strain, PG 18, did not grow with the B cells. Some of the mycoplasma strains (9/15) increased the cellular ecto-5'-nucleotidase activity from twice to 17 fold, and usually showed 5'-nucleotidase activity themselves. At least one strain, M106, induced human 5'-nucleotidase on the normally 5'-nucleotidase negative Daudi and Raji Burkitt's lymphoma cell lines, and increased sevenfold the 5'-nucleotidase on the monocyte/macrophage cell line THP-1. Growing the cells in aged medium increased the level of mycoplasma infection. This mycoplasma-induced enzyme showed a conformational change and an increase in activity with a glycosylation change involving mannose groups. The other group of strains, mostly of respiratory or cell culture origin, usually did not have any 5'-nucleotidase of their own and decreased the B-cell enzyme activity by about half. Electron microscopy and flow cytometry showed that the strain M106 was filamentous and could be found inside the B-cells. The 5'-nucleotidase-inducing strains of M. fermentans may be important in the aetiology of rheumatoid arthritis.     

Chronic interstitial nephritis and mixed cryoglobulinemia associated with drug abuse

Two cases of chronic interstitial nephritis with renal insufficiency were associated with mixed cryoglobulinemia and parenteral drug abuse. Previously recognized causes of interstitial nephritis were not present in either case. Despite extensive interstitial inflammatory infiltrates, no substantial glomerular abnormalities or immune deposits were present in either patient. One patient had a history of intravenous injection of suspended methadone tablets containing talc crystals, and there was evidence of talc embolization in biopsy specimens of liver, spleen, and kidney. Interstitial nephritis associated with drug abuse has not been previously described to our knowledge, but the association in these cases seems not to have been fortuitous and warrants consideration in the evaluation of both parenteral drug abusers and patients with unexplained interstitial nephritis.     

Histochemical and biochemical study on adenylate cyclase and 5'-nucleotidase activity in thyroid glands with normal and various thyroid diseases

The adenylate cyclase and 5'-nucleotidase activity was measured biochemically in the thyroid glands from patients with various thyroid diseases in comparison with normal thyroid. The basal adenylate cyclase activity in normal thyroid was 159.3 p-moles cAMP/min./g tissue. The activity was elevated to 230% of basal with 20 mM NaF and 190% of basal with 100 mU/ml TSH. These values in chronic thyroiditis and Graves' disease were not significantly different from the values of normal thyroid. In adenomatous goiter, adenoma and carcinoma, the basal adenylate cyclase activity was significantly higher than that of normal thyroid. Parallel to the biochemical determination of both enzyme activities, the distribution of histochemically demonstrable adenylate cyclase and 5'-nucleotidase activity was described in the follicular cells with normal and various thyroid diseases. The reaction product of adenylate cyclase and 5'-nucleotidase activity was restricted to the plasma membrane of the follicular cells. However, the distribution and intensity of the adenylate cyclase reaction varied in each thyroid disease, except for the absence of reaction product in the basal plasma membrane. The lack of demonstrable adenylate cyclase activity in the basal plasma membrane suggests the possibility that the basal plasma membrane may not play an important role of TSH-reception.     

CD4+ cells,macrophages, MHC-I and C5b-9 involve the pathogenesis of dysferlinopathy

Objective: Dysferlin is a sarcolemmal protein that plays an important role in membrane repair by regulating vesicle fusion with the sarcolemma. Mutations in the dysferlin gene (DYSF) lead to multiple clinical phenotypes, including Miyoshi myopathy (MM), limb girdle muscular dystrophy type 2B (LGMD 2B), and distal myopathy with anterior tibial onset (DMAT). Patients with dysferlinopathy also show muscle inflammation, which often leads to a misdiagnosis as inflammatory myopathy. In this study, we examined and analyzed the dyferlinopathy-associated immunological features. Methods: Comparative immunohistochemical analysis of inflammatory cell infiltration, and muscle expression of MHC-I and C5b-9 was performed using muscle biopsy samples from 14 patients with dysferlinopathy, 7 patients with polymyositis, and 8 patients with either Duchenne muscular dystrophy or Becker muscular dystrophy (DMD/BMD). Results: Immunohistochemical analysis revealed positive staining for immune response-related CD4⁺ cells, macrophages, MHC-I and C5b-9 in dysferlinopathy, which is in a different mode of polymyositis and DMD/BMD. Conclusion: These results demonstrated the involvement of immune factors in the pathogenesis of dysferlinopathy.     

HISTOCHEMICAL AND BIOCHEMICAL STUDY ON ADENYLATE CYCLASE AND 5'-NUCLEOTIDASE ACTIVITY IN THYROID GLANDS WITH NORMAL AND VARIOUS THYROID DISEASES

The adenylate cyclase and 5'-nucleotidase activity was measured biochemically in the thyroid glands from patients with various thyroid diseases in comparison with normal thyroid. The basal adenylate cyclase activity in normal thyroid was 159.3 p-moles cAMP/min./g tissue. The activity was elevated to 230% of basal with 20 mM NaF and 190% of basal with 100 mU/ml TSH. These values in chronic thyroiditis and Graves'disease were not significantly different from the values of normal thyroid. In adenomatous goiter, adenoma and carcinoma, the basal adenylate cyclase activity was significantly higher than that of normal thyroid. Parallel to the biochemical determination of both enzyme activities, the distribution of histochemically demonstrable adenylate cyclase and 5'-nucleotidase activity was described in the follicular cells with normal and various thyroid diseases. The reaction product of adenylate cyclase and 5'-nucleotidase activity was restricted to the plasma membrane of the follicular cells. However, the distribution and intensity of the adenylate cyclase reaction varied in each thyroid disease, except for the absence of reaction product in the basal plasma membrane. The lack of demonstrable adenylate cyclase activity in the basal plasma membrane suggests the possibility that the basal plasma membrane may not play an important role of TSH-reception.     

皮肌炎／多发性肌炎16例患者死亡原因分析

目的：分析皮肌炎／多发性肌炎16例患者（DM／PM）的死亡原因,从而提高对皮肌炎和多发性肌炎主要死因的认识。方法：对16例皮肌炎／多发性肌炎患者死亡原因进行回顾性分析。结果：①16例皮肌炎／多发性肌炎患者的平均死亡年龄为（45±9）岁,平均病程（4±2）y。②死亡原因依次为：各种感染作为直接死因占75％（12／16例,其中伴肺间质病变的有8例,占50％）;消化道出血并穿孔占6．25％（1／16例）;心脑血管意外占6．25％（1／16例）;纵隔（皮下）气肿／气胸占6．25％（1／16例）;恶性肿瘤占6．25％（1／16例）。结论：DM／PM患者平均寿命缩短近15y;死亡主要原因为肺间质病变及其并发症,其次为与ILD（肺间质病变）无益接相关的各种感染。     

Monoclonal antibodies to human leucocyte antigens in polymyositis and muscular dystrophy

Biopsy specimens from patients with treated or untreated polymyositis and muscular dystrophy controls were examined by indirect immunoperoxidase staining with a panel of monoclonal antibodies to human leucocyte antigens. In untreated polymyositis, helper/inducer T cells were the predominant T cell subset. In treated cases few T cells were seen. Overall, few T cells were seen in dystrophic cases, most infiltrating cells being dendritic and lacking T cell antigens. Staining of sarcolemma with anti-HLA class 1 antibody is weak or negative except in areas adjacent to infiltrating leucocytes or where muscle fibre damage is apparent.     

Myopathology of non-infectious inflammatory myopathies - the current status

Besides the classical inflammatory myopathies (IM), dermatomyositis (DM), polymyositis, and inclusion body myositis, the much larger spectrum of IM includes focal and nodular myositis, granulomatous myositis, macrophagic myofasciitis, graft vs. host myositis, eosinophilic myositis, and other immune-associated conditions, some of them only recently described. In addition, paraneoplastic, statin-induced and critical illness myopathies have been considered immune-associated IM. Infectious, i.e., bacterial, viral, and parasitic IM are much less frequent in the northern hemisphere. In IM, muscle biopsy is an essential diagnostic procedure to initiate therapy. The myopathological spectrum encompasses disease-specific histopathological features, such as perifascicular atrophy in DM, non-necrotizing granulomas in sarcoid myopathy, autophagic vacuoles with tubulofilamentous inclusions in inclusion body myositis, rarely electron microscopic criteria, such as undulating tubules in endothelial cells of DM specimens, and, foremost, immunohistochemical findings. These latter features concern inflammatory infiltrates, the muscle parenchyma, the interstitial compartment, and the vasculature with varying involvement of each component in the different IM. Differences in immunohistochemical parameters among the IM, such as major histocompatibility complexes I and II, cytokines, cell adhesion molecules, different types of inflammatory cells, metalloproteinases, and complement factors procure a large gamut of data, the individual patterns of which characterize the myopathology of individual IM.     

Enzyme histochemistry in plastic-embedded sections of normal and diseased kidneys

Interest in the role of mononuclear phagocytes in glomerulonephritis (GN) and in defining markers of renal neoplasms led the authors to study alpha-naphthyl acetate/butyrate esterase (ANAE/ANBE), alkaline phosphatase (AlkP), acid phosphatase (AcP), 5'-nucleotidase (5'N), and ATPase (ATP) activity in paraformaldehyde-fixed, plastic-embedded renal tissue from patients with a variety of pathologic conditions. These conditions included GN, renal tumors, and transplant rejection. Enzymatic staining for ANAE, ANBE, AcP, AlkP, and ATP was generally confined to tubules and collecting ducts in normal kidney. Nine of 10 cases of renal carcinoma had weakly to strongly positive reactions with AlkP, AcP, and ANAE; 9 of 10 cases of Wilms' tumor showed weakly positive reactions with AcP and ANAE, particularly in tubular structures. Severely damaged kidney allografts showed surprising retention of normal histochemical features. In all cases 5'N stained both glomerular capillaries and interstitial vasculature; ATPase and AlkP stained interstitial vessels only. Plastic embedding provides superb preservation of both microscopic anatomy and enzymatic activity, which may allow utilization of enzyme histochemistry for diagnostic and research purposes.     

小鼠胸腺皮质5′-核苷酸酶的细胞化学定位

用Robinson和Kamovsky法,以腺苷-5′-单磷酸或紐?5′-单磷酸为底物,铈为捕获剂,显示BALB/c小鼠胸腺皮质的5′-核苷酸酶。同时使用左旋咪唑抑制非特异性碱性磷酸酶活性。腺苷-5-单磷酸酶和紐?5′-单磷酸酶活性反应产物的细胞化学定位基本相似。此酶活性定位于上皮性网状细胞和某些胸腺细胞的质膜外层,特别是两者的相邻面。5′-核苷酸酶活性也见于巨噬细胞溶酶体和上皮性网状细胞的囊泡、靠近质膜的小泡及一些溶酶体内。本研究就胸腺皮质内5′-核苷酸酶的生物学意义进行了讨论。