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The relevance of anti-Jo-1 autoantibodies in patients with definite dermatomyositis

Abstract

Background:

To assess the prevalence and clinical relevance of anti-Jo-1 autoantibodies in a representative sample of patients with definite dermatomyositis (DM).

Methods:

This retrospective cohort study took place from 2005 to 2020 and assessed 118 adult patients from a tertiary center who were diagnosed with definite DM. A commercial kit was used to detect anti-Jo-1 autoantibodies.

Results:

The presence of anti-Jo-1 autoantibodies was observed in 10 out of 118 (8.5%) patients with definite DM. The following variables were comparable between individuals with and without anti-Jo-1 autoantibodies: age at diagnosis, sex, ethnicity, disease duration, follow-up period, recurrence rate, complete clinical response, death rate, and cancer incidence. There was no difference in clinical features between groups, except for an increased prevalence of “mechanic's hands,” joint involvement, and lung disease, as well as a reduced occurrence of skin findings in patients positive for anti-Jo-1 autoantibodies. No anti-Jo-1-positive patients went into remission; they required greater use of glucocorticoids and immunosuppressive drugs.

Conclusions:

Anti-Jo-1 positivity was found in 8.5% of patients with definite DM. This autoantibody was associated with an antisynthetase syndrome phenotype and might predict clinical outcomes in patients with definite DM.

Keywords:
Autoantibodies; Dermatomyositis; Inflammatory myopathies; Myositis

Introduction

Dermatomyositis (DM) is a systemic autoimmune disease whose cardinal features include classical cutaneous findings and mostly proximal muscle weakness affecting the limbs [11. Bohan A, Peter JB. Polymyositis and dermatomyositis (first of two parts). N Engl J Med. 1975;292:344–7.33. Lundberg IE, Tjärnlund A, Bottai M, Werth VP, Pilkington C, de Visser M, International Myositis Classification Criteria Project Consortium, the Euromyositis Register, and the Juvenile Dermatomyositis Cohort Biomarker Study and Repository (UK and Ireland), et al. 2017 European league against rheumatism/American college of rheumatology classification criteria for adult and juvenile idiopathic inflammatory myopathies and their major subgroups. Arthritis Rheumatol. 2017;69:2271–82.].

The classical cutaneous manifestations of DM are Gottron's papules and heliotrope rash, but other findings such as digital ulcers, photosensitivity, calcinosis cutis, the “shawl” and “V-neck” signs, cuticular hypertrophy, periungueal erythema, and “mechanic's hands” might be present [44. Muro Y, Sugiura K, Akiyama M. Cutaneous manifestations in dermatomyositis: key clinical and serological features: a comprehensive review. Clinic Rev Allerg Immunol. 2016;51:293–302.]. In addition, extramuscular manifestations such cardiac, gastrointestinal, joint, and lung involvement might occur [55. Souza FH, Barros TB, Levy-Neto M, Shinjo SK. Adult dermatomyositis: experience of a Brazilian tertiary care center. Rev Bras Reumatol. 2012;37: 264–7., 66. Cruellas MG, Viana VS, Levy-Neto M, Souza FH, Shinjo SK. Myositis-specific and myositis-associated autoantibody profiles and their clinical associations in a large series of patients with polymyositis and dermatomyositis. Clinics. 2013;68:909–14.]. DM therefore has a broad spectrum of phenotypical presentations.

A variety of autoantibodies have been described in DM patients, who have myositis-associated or myositis-specific autoantibodies [66. Cruellas MG, Viana VS, Levy-Neto M, Souza FH, Shinjo SK. Myositis-specific and myositis-associated autoantibody profiles and their clinical associations in a large series of patients with polymyositis and dermatomyositis. Clinics. 2013;68:909–14.1414. Mielnik P, Wiesik-Szewczyk E, Olesinska M, Chwalinska-Sadowska H, Zabek J. Clinical features and prognosis of patients with idiopathic inflammatory myopathies and anti-Jo-1 antibodies. Autoimmunity. 2006;39:243–7.]. Myositis-specific auto-antibodies include anti-Mi-2, anti-TIF1-γ, anti-NXP-2, anti-MDA-5, anti-SAE, and anti-aminoacyl-tRNA synthetase [66. Cruellas MG, Viana VS, Levy-Neto M, Souza FH, Shinjo SK. Myositis-specific and myositis-associated autoantibody profiles and their clinical associations in a large series of patients with polymyositis and dermatomyositis. Clinics. 2013;68:909–14.1414. Mielnik P, Wiesik-Szewczyk E, Olesinska M, Chwalinska-Sadowska H, Zabek J. Clinical features and prognosis of patients with idiopathic inflammatory myopathies and anti-Jo-1 antibodies. Autoimmunity. 2006;39:243–7.]. These autoantibodies are associated with different clinical phenotypes of systemic autoimmune myopathies, making them potentially useful as prognostic markers and predictors of clinical response to drug therapy [66. Cruellas MG, Viana VS, Levy-Neto M, Souza FH, Shinjo SK. Myositis-specific and myositis-associated autoantibody profiles and their clinical associations in a large series of patients with polymyositis and dermatomyositis. Clinics. 2013;68:909–14.1414. Mielnik P, Wiesik-Szewczyk E, Olesinska M, Chwalinska-Sadowska H, Zabek J. Clinical features and prognosis of patients with idiopathic inflammatory myopathies and anti-Jo-1 antibodies. Autoimmunity. 2006;39:243–7.].

Among anti-aminoacyl-tRNA synthetase autoantibodies, anti-Jo-1 is most commonly found in systemic autoimmune myopathies [66. Cruellas MG, Viana VS, Levy-Neto M, Souza FH, Shinjo SK. Myositis-specific and myositis-associated autoantibody profiles and their clinical associations in a large series of patients with polymyositis and dermatomyositis. Clinics. 2013;68:909–14., 77. Wolstencroft PW, Fiorentino DF. Dermatomyositis clinical and pathological phenotypes associated with myositis-specific autoantibodies. Curr Rheumatol Rep. 2018;20:28., 99. Lega JC, Fabien N, Reynaud Q, Durieu I, Durupt S, Dutertre M, et al. The clinical phenotype associated with myositis-specific and associated autoantibodies: a meta-analysis revisiting the so-called antisynthetase syndrome. Autoimmun Rev. 2014;13:883–91., 1313. Betteridge Z, Tansley S, Shaddick G, Chinoy H, Cooper RG, New RP, et al. Frequency, mutual exclusivity and clinical associations of myositis autoantibodies in a combined European cohort of idiopathic inflammatory myopathy patients. J Autoimmun. 2019;101:48–55.]. Anti-Jo-1 positivity in DM ranges from 5 to 20% [66. Cruellas MG, Viana VS, Levy-Neto M, Souza FH, Shinjo SK. Myositis-specific and myositis-associated autoantibody profiles and their clinical associations in a large series of patients with polymyositis and dermatomyositis. Clinics. 2013;68:909–14., 77. Wolstencroft PW, Fiorentino DF. Dermatomyositis clinical and pathological phenotypes associated with myositis-specific autoantibodies. Curr Rheumatol Rep. 2018;20:28., 99. Lega JC, Fabien N, Reynaud Q, Durieu I, Durupt S, Dutertre M, et al. The clinical phenotype associated with myositis-specific and associated autoantibodies: a meta-analysis revisiting the so-called antisynthetase syndrome. Autoimmun Rev. 2014;13:883–91., 1313. Betteridge Z, Tansley S, Shaddick G, Chinoy H, Cooper RG, New RP, et al. Frequency, mutual exclusivity and clinical associations of myositis autoantibodies in a combined European cohort of idiopathic inflammatory myopathy patients. J Autoimmun. 2019;101:48–55.] and is linked to the occurrence of joint involvement [99. Lega JC, Fabien N, Reynaud Q, Durieu I, Durupt S, Dutertre M, et al. The clinical phenotype associated with myositis-specific and associated autoantibodies: a meta-analysis revisiting the so-called antisynthetase syndrome. Autoimmun Rev. 2014;13:883–91., 1111. Ohashi K, Sada KE, Nakai Y, Matsushima S, Asano Y, Hayashi K, et al. Cluster analysis using anti-aminoacyl-tRNA synthetases and SS-A/Ro52 antibodies in patients with polymyositis/dermatomyositis. J Clin Rheumatol. 2019;25:246–51.1414. Mielnik P, Wiesik-Szewczyk E, Olesinska M, Chwalinska-Sadowska H, Zabek J. Clinical features and prognosis of patients with idiopathic inflammatory myopathies and anti-Jo-1 antibodies. Autoimmunity. 2006;39:243–7.], interstitial lung disease [1010. Srivastava P, Dwivedi S, Misra R. Myositis-specific and myositis-associated autoantibodies in Indian patients with inflammatory myositis. Rheumatol Int. 2016;36:935–43., 1212. Yamasaki Y, Satoh M, Mizushima M, Okazaki T, Nagafuchi H, Ooka S, et al. Clinical subsets associated with different anti-aminoacyl transfer RNA synthetase antibodies and their association with coexisting anti-Ro52. Mod Rheumatol. 2016;26:403–9.1717. Li S, Ge Y, Yang H, Wang T, Zheng X, Peng Q, et al. The spectrum and clinical significance of myositis-specific autoantibodies in Chinese patients with idiopathic inflammatory myopathies. Clin Rheumatol. 2019;38:2171 –9.], Raynaud's phenomenon [1313. Betteridge Z, Tansley S, Shaddick G, Chinoy H, Cooper RG, New RP, et al. Frequency, mutual exclusivity and clinical associations of myositis autoantibodies in a combined European cohort of idiopathic inflammatory myopathy patients. J Autoimmun. 2019;101:48–55., 1414. Mielnik P, Wiesik-Szewczyk E, Olesinska M, Chwalinska-Sadowska H, Zabek J. Clinical features and prognosis of patients with idiopathic inflammatory myopathies and anti-Jo-1 antibodies. Autoimmunity. 2006;39:243–7.], myositis [99. Lega JC, Fabien N, Reynaud Q, Durieu I, Durupt S, Dutertre M, et al. The clinical phenotype associated with myositis-specific and associated autoantibodies: a meta-analysis revisiting the so-called antisynthetase syndrome. Autoimmun Rev. 2014;13:883–91., 1616. Hamaguchi Y, Fujimoto M, Matsushita T, Kaji K, Komura K, Hasegawa M, et al. Common and distinct clinical features in adult patients with anti-aminoacyl-tRNA synthetase antibodies: heterogeneity within the syndrome. PLoS One. 2013;8:e60442.], and “mechanic's hands” [66. Cruellas MG, Viana VS, Levy-Neto M, Souza FH, Shinjo SK. Myositis-specific and myositis-associated autoantibody profiles and their clinical associations in a large series of patients with polymyositis and dermatomyositis. Clinics. 2013;68:909–14., 99. Lega JC, Fabien N, Reynaud Q, Durieu I, Durupt S, Dutertre M, et al. The clinical phenotype associated with myositis-specific and associated autoantibodies: a meta-analysis revisiting the so-called antisynthetase syndrome. Autoimmun Rev. 2014;13:883–91., 1010. Srivastava P, Dwivedi S, Misra R. Myositis-specific and myositis-associated autoantibodies in Indian patients with inflammatory myositis. Rheumatol Int. 2016;36:935–43., 1313. Betteridge Z, Tansley S, Shaddick G, Chinoy H, Cooper RG, New RP, et al. Frequency, mutual exclusivity and clinical associations of myositis autoantibodies in a combined European cohort of idiopathic inflammatory myopathy patients. J Autoimmun. 2019;101:48–55.]. However, those variables were investigated in samples comprising patients with different subtypes of systemic autoimmune myopathies, including overlap syndromes [55. Souza FH, Barros TB, Levy-Neto M, Shinjo SK. Adult dermatomyositis: experience of a Brazilian tertiary care center. Rev Bras Reumatol. 2012;37: 264–7., 88. Alenzi FM. Myositis specific autoantibodies: a clinical perspective. Open Access Rheumatol. 2020;12:9–14.1616. Hamaguchi Y, Fujimoto M, Matsushita T, Kaji K, Komura K, Hasegawa M, et al. Common and distinct clinical features in adult patients with anti-aminoacyl-tRNA synthetase antibodies: heterogeneity within the syndrome. PLoS One. 2013;8:e60442.]. In addition, even when only DM cases were evaluated, samples were small [1010. Srivastava P, Dwivedi S, Misra R. Myositis-specific and myositis-associated autoantibodies in Indian patients with inflammatory myositis. Rheumatol Int. 2016;36:935–43., 1111. Ohashi K, Sada KE, Nakai Y, Matsushima S, Asano Y, Hayashi K, et al. Cluster analysis using anti-aminoacyl-tRNA synthetases and SS-A/Ro52 antibodies in patients with polymyositis/dermatomyositis. J Clin Rheumatol. 2019;25:246–51., 1414. Mielnik P, Wiesik-Szewczyk E, Olesinska M, Chwalinska-Sadowska H, Zabek J. Clinical features and prognosis of patients with idiopathic inflammatory myopathies and anti-Jo-1 antibodies. Autoimmunity. 2006;39:243–7.], or the Bohan and Peter criteria [11. Bohan A, Peter JB. Polymyositis and dermatomyositis (first of two parts). N Engl J Med. 1975;292:344–7., 22. Bohan A, Peter JB. Polymyositis and dermatomyositis (second of two parts). N Engl J Med. 1975;292:403 – 7.], which are restricted to muscle involvement and a narrow number of skin manifestations, were used for diagnosis. These limitations preclude an overall assessment of the relevance of anti-Jo-1 autoantibodies concerning the potential clinical features of DM.

Therefore, this study was aimed at describing the prevalence of anti-Jo-1 positivity in a representative sample of patients with definite DM and assessing the potential associations of anti-Jo-1 positivity with clinical, laboratory, and therapeutic characteristics, remission and relapse rates, and prognosis.

Patients and methods

This was a single-center, retrospective cohort study that took place from 2005 to 2020 and involved adult patients diagnosed with definite DM according to the Bohan and Peter classification criteria [11. Bohan A, Peter JB. Polymyositis and dermatomyositis (first of two parts). N Engl J Med. 1975;292:344–7., 22. Bohan A, Peter JB. Polymyositis and dermatomyositis (second of two parts). N Engl J Med. 1975;292:403 – 7.], as well as the European League Against Rheumatism/American College of Rheumatology (EULAR/ACR) 2017 criteria [33. Lundberg IE, Tjärnlund A, Bottai M, Werth VP, Pilkington C, de Visser M, International Myositis Classification Criteria Project Consortium, the Euromyositis Register, and the Juvenile Dermatomyositis Cohort Biomarker Study and Repository (UK and Ireland), et al. 2017 European league against rheumatism/American college of rheumatology classification criteria for adult and juvenile idiopathic inflammatory myopathies and their major subgroups. Arthritis Rheumatol. 2017;69:2271–82.]. To be included, patients had to present with pathognomonic skin rashes, as well as muscle involvement (objective muscle weakness in the upper and/or lower limbs accompanied by elevated serum creatine phosphokinase or aldolase levels). The following ancillary tests were also considered: an electromyography and nerve conduction studies suggesting an isolated myopathic process and/or a muscle biopsy suggesting an inflammatory myopathy.

Patients with clinically amyopathic DM (CADM), cancer-associated myositis, overlap syndromes as well as those with anti-OJ, anti-EJ, anti-PL-7, anti-PL-12, anti-SRP, anti-Ku, or anti-PM/Scl autoantibodies were excluded.

The following data were collected from electronic medical records containing previously parameterized and standardized information:

  • General characteristics: age at diagnosis, sex, ethnicity, disease duration, and outpatient follow-up period;

  • Initial and cumulative clinical manifestations: constitutional symptoms (weight loss and fever), Gottron's papules, Gottron's sign, heliotrope rash, facial erythema, Raynaud phenomenon, “shawl” sign, “V-neck” sign, cutaneous vasculitis, digital ulcers, calcinosis cutis, periungueal erythema, “mechanic's hands,” dysphagia, joint involvement (arthralgia or arthritis), and lung involvement (dyspnea and chest high-resolution computed tomography - CT - imaging showing incipient interstitial lung disease, ground-glass opacities, and pulmonary fibrosis). All patients with respiratory symptoms underwent chest CT scans.

  • Laboratory data: maximum serum creatine phosphokinase (reference range: 32–294 U/L) and aldolase (reference range: 1.0–7.5 U/L) levels during outpatient follow-up; blood samples collected at the beginning of the investigation of disease activity were assayed for myositis-specific (anti-Jo-1, -OJ, -EJ, -PL-7, -PL-12, -SRP, and -Mi-2) and myositis- associated (anti-Ro-52, -Ku, and -PM/Scl) autoantibodies. Myositis Profile Euroline blood test kits (Euroimmun, Germany) were used to detect the above-mentioned autoantibodies, and samples were processed as per manufacturer's instructions. The assessment of results was based on a predetermined method described elsewhere [66. Cruellas MG, Viana VS, Levy-Neto M, Souza FH, Shinjo SK. Myositis-specific and myositis-associated autoantibody profiles and their clinical associations in a large series of patients with polymyositis and dermatomyositis. Clinics. 2013;68:909–14.]. The indirect immunofluorescence assay on HEp-2 cells was used for the detection of antinuclear antibodies.

The following data were also collected at the last follow-up appointment and/or at the end of outpatient follow-up:

  • Disease in remission: no evidence of disease activity for at least 6 months with no drug therapy for DM;

  • Complete clinical response: no evidence of disease activity for at least 6 months with drug therapy for DM;

  • Disease relapse: recurrence of clinical (muscle and/ or skin manifestations) and/or laboratory findings (elevated muscle enzymes creatine phosphokinase and aldolase) with no explanation other than disease activity;

  • Drug therapy (glucocorticoids and immunosuppressants or immunomodulators);

  • Occurrence of death or diagnosis of neoplasia during the follow-up period.

Statistical analysis

The Kolmogorov-Smirnov test was used to assess the distribution of continuous variables. Results are presented as means ± standard deviations (SD) for continuous variables and as frequencies (%) for categorical variables. Medians and interquartile ranges (75th – 25th) were calculated for continuous variables with non-normal distribution. Student's t-test or Mann-Whitney U test were used for continuous variables, and the chi-square test or Fisher's exact test were used for categorical variables in order to compare patients with and without of anti-Jo-1 autoantibodies. Odds ratios (OR) and 95% confidence intervals (CI) were estimated by a logistic regression model that was used to evaluate the association between anti-Jo-1 positivity and relevant covariates with statistical significance in the univariate analysis. We adopted P values < 0.05 to indicate statistical significance. SPSS Statistics, version 15.0 (Chicago, USA), was used for all analyses performed.

Results

In the present study, 152 DM patients were evaluated. Of these, 7 patients had CADM, 12 patients had cancer-associated myositis, 2 patients had overlap syndromes, and 13 patients had anti-OJ, anti-EJ, anti-PL-7, anti-PL-12, anti-SRP, anti-Ku, or anti-PM/Scl autoantibodies. These patients were excluded and, therefore, 118 patients with definite DM were finally analyzed.

Anti-Jo-1 autoantibodies were detected in 10 out of 118 (8.5%) patients with definite DM. Table 1 shows the general characteristics of DM patients with and without anti-Jo-1 autoantibodies.

Table 1
General features of patients with dermatomyositis with versus without anti-Jo-1 autoantibodies

A significantly increased prevalence of “ mechanic ‘ s hands,” as well as joint and lung involvements, and a reduced prevalence of facial erythema, “shawl” sign, and “V-neck” sign were found among patients positive for anti-Jo-1 autoantibodies compared to anti-Jo-1-negative patients (Table 1).

No patients with anti-Jo-1 autoantibodies had vasculit- ides, digital ulcers, or calcinosis cutis (Table 1).

Regarding treatment, current use of glucocorticoids (prednisone) and immunosuppressive drugs (particularly mycophenolate mofetil) was significantly more prevalent among anti-Jo-1-positive patients compared to those without this autoantibody (Table 2).

Table 2
Current treatment, relapsing, disease status, death, neoplasia, and follow-up of patients with dermatomyositis

Relapse rates, complete clinical response, and death were also comparable between the two groups. No anti-Jo-1-positive patients achieved disease remission or had active disease at the end of follow-up (Table 2).

In addition, all patients with anti-Jo-1 autoantibodies continued to be regularly followed up, unlike anti-Jo-1-negative patients (Table 2).

All significant variables shown in Tables 1 and 2 were strongly associated with anti-Jo-1 autoantibody positivity (Table 3).

Table 3
Univariate analysis of relevant variables in anti-Jo-1-positive patients

Discussion

In the present study, anti-Jo-1 positivity was observed in 8.5% of patients with definite DM, and it was associated with “mechanic's hands,” as well as joint and lung involvement.

In contrast, anti-Jo-1-positive patients exhibited a decreased frequency of skin manifestations such as facial erythema, “shawl” sign, and “V-neck” sign compared to anti-Jo-1-negative patients.

The frequency of anti-Jo-1 positivity ranges from 5 to 20% in the literature [66. Cruellas MG, Viana VS, Levy-Neto M, Souza FH, Shinjo SK. Myositis-specific and myositis-associated autoantibody profiles and their clinical associations in a large series of patients with polymyositis and dermatomyositis. Clinics. 2013;68:909–14., 77. Wolstencroft PW, Fiorentino DF. Dermatomyositis clinical and pathological phenotypes associated with myositis-specific autoantibodies. Curr Rheumatol Rep. 2018;20:28., 99. Lega JC, Fabien N, Reynaud Q, Durieu I, Durupt S, Dutertre M, et al. The clinical phenotype associated with myositis-specific and associated autoantibodies: a meta-analysis revisiting the so-called antisynthetase syndrome. Autoimmun Rev. 2014;13:883–91., 1010. Srivastava P, Dwivedi S, Misra R. Myositis-specific and myositis-associated autoantibodies in Indian patients with inflammatory myositis. Rheumatol Int. 2016;36:935–43., 1313. Betteridge Z, Tansley S, Shaddick G, Chinoy H, Cooper RG, New RP, et al. Frequency, mutual exclusivity and clinical associations of myositis autoantibodies in a combined European cohort of idiopathic inflammatory myopathy patients. J Autoimmun. 2019;101:48–55.], and such wide variation occurs because of the different ethnic groups evaluated, which included Indians [1010. Srivastava P, Dwivedi S, Misra R. Myositis-specific and myositis-associated autoantibodies in Indian patients with inflammatory myositis. Rheumatol Int. 2016;36:935–43.], Europeans [1313. Betteridge Z, Tansley S, Shaddick G, Chinoy H, Cooper RG, New RP, et al. Frequency, mutual exclusivity and clinical associations of myositis autoantibodies in a combined European cohort of idiopathic inflammatory myopathy patients. J Autoimmun. 2019;101:48–55.], Brazilians [66. Cruellas MG, Viana VS, Levy-Neto M, Souza FH, Shinjo SK. Myositis-specific and myositis-associated autoantibody profiles and their clinical associations in a large series of patients with polymyositis and dermatomyositis. Clinics. 2013;68:909–14.], and cohorts comprising patients from multiple ethnicities [99. Lega JC, Fabien N, Reynaud Q, Durieu I, Durupt S, Dutertre M, et al. The clinical phenotype associated with myositis-specific and associated autoantibodies: a meta-analysis revisiting the so-called antisynthetase syndrome. Autoimmun Rev. 2014;13:883–91.]. In the present study, the prevalence of anti-Jo-1 positivity was 8.5% in Brazilian patients, which is within the range found in the literature. However, unlike other published research [99. Lega JC, Fabien N, Reynaud Q, Durieu I, Durupt S, Dutertre M, et al. The clinical phenotype associated with myositis-specific and associated autoantibodies: a meta-analysis revisiting the so-called antisynthetase syndrome. Autoimmun Rev. 2014;13:883–91., 1010. Srivastava P, Dwivedi S, Misra R. Myositis-specific and myositis-associated autoantibodies in Indian patients with inflammatory myositis. Rheumatol Int. 2016;36:935–43., 1212. Yamasaki Y, Satoh M, Mizushima M, Okazaki T, Nagafuchi H, Ooka S, et al. Clinical subsets associated with different anti-aminoacyl transfer RNA synthetase antibodies and their association with coexisting anti-Ro52. Mod Rheumatol. 2016;26:403–9.1414. Mielnik P, Wiesik-Szewczyk E, Olesinska M, Chwalinska-Sadowska H, Zabek J. Clinical features and prognosis of patients with idiopathic inflammatory myopathies and anti-Jo-1 antibodies. Autoimmunity. 2006;39:243–7., 1616. Hamaguchi Y, Fujimoto M, Matsushita T, Kaji K, Komura K, Hasegawa M, et al. Common and distinct clinical features in adult patients with anti-aminoacyl-tRNA synthetase antibodies: heterogeneity within the syndrome. PLoS One. 2013;8:e60442.], the presence of anti-Jo-1 autoantibodies was evaluated in a sample comprising only patients with DM in the present study. Moreover, only patients exclusively with definite DM were included, and patients with possible or probable DM, according to both the EULAR/ ACR 2017 [33. Lundberg IE, Tjärnlund A, Bottai M, Werth VP, Pilkington C, de Visser M, International Myositis Classification Criteria Project Consortium, the Euromyositis Register, and the Juvenile Dermatomyositis Cohort Biomarker Study and Repository (UK and Ireland), et al. 2017 European league against rheumatism/American college of rheumatology classification criteria for adult and juvenile idiopathic inflammatory myopathies and their major subgroups. Arthritis Rheumatol. 2017;69:2271–82.] and the Bohan and Peter criteria [11. Bohan A, Peter JB. Polymyositis and dermatomyositis (first of two parts). N Engl J Med. 1975;292:344–7., 22. Bohan A, Peter JB. Polymyositis and dermatomyositis (second of two parts). N Engl J Med. 1975;292:403 – 7.], were excluded. Patients with clinically amyopathic DM, myositis associated with neoplasia or other systemic autoimmune disorders, and patients with other myositis-specific (e.g., anti-OJ, -EJ, -PL-7, and -PL-12) or myositis-associated (e.g., anti-Ku and anti-PM/Scl) auto-antibodies were also excluded. Although this was a retrospective study, patient data were collected from records containing previously parameterized and standardized information, including that of interest to the present study.

Although the manifestations of DM are primarily cutaneous and muscular, we observed a significant prevalence of joint involvement in our cohort. We also identified a strong association between anti-Jo-1 positivity and the occurrence of joint involvement in our sample. This association has also been found in other studies. For instance, in a large European cohort [1313. Betteridge Z, Tansley S, Shaddick G, Chinoy H, Cooper RG, New RP, et al. Frequency, mutual exclusivity and clinical associations of myositis autoantibodies in a combined European cohort of idiopathic inflammatory myopathy patients. J Autoimmun. 2019;101:48–55.] comprising 1637 patients with probable or definite DM, or polymyositis (PM) according to the Bohan and Peter criteria [11. Bohan A, Peter JB. Polymyositis and dermatomyositis (first of two parts). N Engl J Med. 1975;292:344–7., 22. Bohan A, Peter JB. Polymyositis and dermatomyositis (second of two parts). N Engl J Med. 1975;292:403 – 7.], arthritis was strongly associated with anti-Jo-1 positivity. In addition, in a study by Ohashi et al. [1111. Ohashi K, Sada KE, Nakai Y, Matsushima S, Asano Y, Hayashi K, et al. Cluster analysis using anti-aminoacyl-tRNA synthetases and SS-A/Ro52 antibodies in patients with polymyositis/dermatomyositis. J Clin Rheumatol. 2019;25:246–51.], japanese patients with systemic autoimmune myopathies and anti-Jo-1 positivity frequently presented with joint symptoms. Such an association between arthralgia or arthritis and anti-Jo-1 positivity has also been observed among patients with multiple types of idiopathic inflammatory myopathies [99. Lega JC, Fabien N, Reynaud Q, Durieu I, Durupt S, Dutertre M, et al. The clinical phenotype associated with myositis-specific and associated autoantibodies: a meta-analysis revisiting the so-called antisynthetase syndrome. Autoimmun Rev. 2014;13:883–91., 1212. Yamasaki Y, Satoh M, Mizushima M, Okazaki T, Nagafuchi H, Ooka S, et al. Clinical subsets associated with different anti-aminoacyl transfer RNA synthetase antibodies and their association with coexisting anti-Ro52. Mod Rheumatol. 2016;26:403–9., 1414. Mielnik P, Wiesik-Szewczyk E, Olesinska M, Chwalinska-Sadowska H, Zabek J. Clinical features and prognosis of patients with idiopathic inflammatory myopathies and anti-Jo-1 antibodies. Autoimmunity. 2006;39:243–7.]. Thus, a marked influence of anti-Jo-1 autoantibodies on the phenotype of patients with DM and joint involvement can be inferred.

The cutaneous lesions known as “mechanic's hands,” classically associated with antisynthetase syndrome, are characterized by hyperkeratosis, scaling, and fissuring affecting the phalanges of the hands [44. Muro Y, Sugiura K, Akiyama M. Cutaneous manifestations in dermatomyositis: key clinical and serological features: a comprehensive review. Clinic Rev Allerg Immunol. 2016;51:293–302.]. The correlation between anti-Jo-1 autoantibodies and “mechanic's hands” has been described for Indian and Japanese patients with systemic autoimmune myopathies [1010. Srivastava P, Dwivedi S, Misra R. Myositis-specific and myositis-associated autoantibodies in Indian patients with inflammatory myositis. Rheumatol Int. 2016;36:935–43., 1212. Yamasaki Y, Satoh M, Mizushima M, Okazaki T, Nagafuchi H, Ooka S, et al. Clinical subsets associated with different anti-aminoacyl transfer RNA synthetase antibodies and their association with coexisting anti-Ro52. Mod Rheumatol. 2016;26:403–9.]. In a meta-analysis of 27 studies that included 3487 patients with idiopathic inflammatory myopathies, Lega et al. [99. Lega JC, Fabien N, Reynaud Q, Durieu I, Durupt S, Dutertre M, et al. The clinical phenotype associated with myositis-specific and associated autoantibodies: a meta-analysis revisiting the so-called antisynthetase syndrome. Autoimmun Rev. 2014;13:883–91.] observed that the frequency of “mechanic's hands” increased by about 50% among patients with anti-Jo-1 autoantibodies compared to patients positive for other anti-aminoacyl-tRNA synthetase autoantibodies. Anti-Jo-1 positivity was also associated with an increased frequency of “mechanic's hands” among DM patients in the present study. This finding is also corroborated by Srivastava et al. [1010. Srivastava P, Dwivedi S, Misra R. Myositis-specific and myositis-associated autoantibodies in Indian patients with inflammatory myositis. Rheumatol Int. 2016;36:935–43.], who found that patients with antisynthetase antibodies as a group and those with anti-Jo-1 antibodies alone had significantly more “mechanics’ hands,” while this association was not noted with other non-Jo-1 antisynthetase autoantibodies.

As for the other DM skin lesions, we observed a reduced prevalence of facial erythema, “shawl” sign, and “V-neck” sign, and no digital ulcers or calcinosis cutis among our anti-Jo-1-positive patients. Thus, this auto-antibody might act as a protective factor against these cutaneous manifestations; however, further research is needed to investigate this hypothesis.

Interstitial lung disease is associated with increased morbidity and mortality in patients with idiopathic inflammatory myopathies [1818. Marie I, Haltron PY, Dominique S, Cherin P, Mouthron L, Menard JF. Short term and long term outcomes of interstitial lung disease in polymyositis and dermatomyositis: a series of 107 patients. Arthritis Rheum. 2011;63:3439–47., 1919. Johnson C, Pinal-Fernandez I, Parikh R, Paik J, Albayda J, et al. Assessment of mortality in autoimmune myositis with and without associated interstitial lung disease. Lung. 2016;194:733–7.]. We observed a strong association between anti-Jo-1 autoantibodies and lung involvement, including clinical (dyspnea) and radiographic abnormalities on high-resolution CT imaging suggestive of interstitial lung disease. Anti-Jo-1 positivity is indeed associated with interstitial lung disease as defined by imaging findings alone [66. Cruellas MG, Viana VS, Levy-Neto M, Souza FH, Shinjo SK. Myositis-specific and myositis-associated autoantibody profiles and their clinical associations in a large series of patients with polymyositis and dermatomyositis. Clinics. 2013;68:909–14.] or together with abnormal pulmonary function testing [1010. Srivastava P, Dwivedi S, Misra R. Myositis-specific and myositis-associated autoantibodies in Indian patients with inflammatory myositis. Rheumatol Int. 2016;36:935–43., 1212. Yamasaki Y, Satoh M, Mizushima M, Okazaki T, Nagafuchi H, Ooka S, et al. Clinical subsets associated with different anti-aminoacyl transfer RNA synthetase antibodies and their association with coexisting anti-Ro52. Mod Rheumatol. 2016;26:403–9.1717. Li S, Ge Y, Yang H, Wang T, Zheng X, Peng Q, et al. The spectrum and clinical significance of myositis-specific autoantibodies in Chinese patients with idiopathic inflammatory myopathies. Clin Rheumatol. 2019;38:2171 –9.]. In our cohort, not all patients underwent pulmonary function testing, and therefore we did not include those data in the present study. However, previous research [66. Cruellas MG, Viana VS, Levy-Neto M, Souza FH, Shinjo SK. Myositis-specific and myositis-associated autoantibody profiles and their clinical associations in a large series of patients with polymyositis and dermatomyositis. Clinics. 2013;68:909–14., 1010. Srivastava P, Dwivedi S, Misra R. Myositis-specific and myositis-associated autoantibodies in Indian patients with inflammatory myositis. Rheumatol Int. 2016;36:935–43., 1212. Yamasaki Y, Satoh M, Mizushima M, Okazaki T, Nagafuchi H, Ooka S, et al. Clinical subsets associated with different anti-aminoacyl transfer RNA synthetase antibodies and their association with coexisting anti-Ro52. Mod Rheumatol. 2016;26:403–9.1717. Li S, Ge Y, Yang H, Wang T, Zheng X, Peng Q, et al. The spectrum and clinical significance of myositis-specific autoantibodies in Chinese patients with idiopathic inflammatory myopathies. Clin Rheumatol. 2019;38:2171 –9.] has examined heterogeneous samples of patients with systemic autoimmune myopathies, and also has included cases of probable DM or PM, defined according to the Bohan and Peter criteria [11. Bohan A, Peter JB. Polymyositis and dermatomyositis (first of two parts). N Engl J Med. 1975;292:344–7., 22. Bohan A, Peter JB. Polymyositis and dermatomyositis (second of two parts). N Engl J Med. 1975;292:403 – 7.] as well as overlap syndromes [1010. Srivastava P, Dwivedi S, Misra R. Myositis-specific and myositis-associated autoantibodies in Indian patients with inflammatory myositis. Rheumatol Int. 2016;36:935–43., 16]. Furthermore, no additional analysis to exclude potential cases of antisynthetase syndrome [1010. Srivastava P, Dwivedi S, Misra R. Myositis-specific and myositis-associated autoantibodies in Indian patients with inflammatory myositis. Rheumatol Int. 2016;36:935–43., 1212. Yamasaki Y, Satoh M, Mizushima M, Okazaki T, Nagafuchi H, Ooka S, et al. Clinical subsets associated with different anti-aminoacyl transfer RNA synthetase antibodies and their association with coexisting anti-Ro52. Mod Rheumatol. 2016;26:403–9., 1313. Betteridge Z, Tansley S, Shaddick G, Chinoy H, Cooper RG, New RP, et al. Frequency, mutual exclusivity and clinical associations of myositis autoantibodies in a combined European cohort of idiopathic inflammatory myopathy patients. J Autoimmun. 2019;101:48–55., 1515. Zhang L, Wu G, Gao D, Liu G, Pan L, Ni L, et al. Factors associated with interstitial lung disease in patients with polymyositis and dermatomyositis: a systematic review and meta-analysis. PLoS One. 2016;11:e0155381., 1717. Li S, Ge Y, Yang H, Wang T, Zheng X, Peng Q, et al. The spectrum and clinical significance of myositis-specific autoantibodies in Chinese patients with idiopathic inflammatory myopathies. Clin Rheumatol. 2019;38:2171 –9.], which might also affect the lungs [2020. Souza FH, Cruellas MG, Levy-Neto M, Shinjo SK. Anti-synthetase syndrome: anti-PL-7, anti-PL-12 and anti-EJ. Rev Bras Reumatol. 2013;53:352–7.2222. Cavagna L, Trallero-Araguás E, Meloni F, Cavazzana I, Rojas-Serrano J, Feist E, et al. Influence of antisynthetase antibodies specificities on antisynthetase syndrome clinical spectrum time course. J Clin Med. 2019;8:2013.], has been performed.

We also found that anti-Jo-1 positivity was associated with lung involvement in patients with definite DM. We excluded patients who were positive for other anti-aminoacyl-tRNA synthetase autoantibodies, anti-Ku, and anti-PM/Scl to avoid biasing the interpretation of our data, as they are also associated with lung involvement [2020. Souza FH, Cruellas MG, Levy-Neto M, Shinjo SK. Anti-synthetase syndrome: anti-PL-7, anti-PL-12 and anti-EJ. Rev Bras Reumatol. 2013;53:352–7., 2323. Alves SP, Silva MG, Borges IBP, Shinjo SK. Patients with pure dematomositis/ polymyositis and anti-PM/Scl autoantibody resembling anti-synthetase syndrome. MedicalExpress. 2018;8:mo18002., 2424. Yamasaki Y, Yamada H, Nozaki T, Akaogi J, Nichols C, Lyons R, et al. Unusually high frequency of autoantibodies to PL-7 associated with milder muscle disease in Japanese patients with polymyositis/dermatomyositis. Arthritis Rheum. 2006;54:2004–9.].

As for other autoantibodies, anti-Ro-52 is a myositis-associated antibody and is commonly related to anti-Jo-1 positivity [66. Cruellas MG, Viana VS, Levy-Neto M, Souza FH, Shinjo SK. Myositis-specific and myositis-associated autoantibody profiles and their clinical associations in a large series of patients with polymyositis and dermatomyositis. Clinics. 2013;68:909–14., 99. Lega JC, Fabien N, Reynaud Q, Durieu I, Durupt S, Dutertre M, et al. The clinical phenotype associated with myositis-specific and associated autoantibodies: a meta-analysis revisiting the so-called antisynthetase syndrome. Autoimmun Rev. 2014;13:883–91., 1616. Hamaguchi Y, Fujimoto M, Matsushita T, Kaji K, Komura K, Hasegawa M, et al. Common and distinct clinical features in adult patients with anti-aminoacyl-tRNA synthetase antibodies: heterogeneity within the syndrome. PLoS One. 2013;8:e60442., 2525. Marie I, Hatron PY, Dominique S, Cherin P, Mouthon L, Menard JF, et al. Short-term and long-term outcome of anti-Jo1-positive patients with anti-Ro52 antibody. Semin Arthritis Rheum. 2012;41:890–9.]. The co-occurrence of anti-Ro-52 and anti-Jo-1 positivity was reported by Marie et al. [2525. Marie I, Hatron PY, Dominique S, Cherin P, Mouthon L, Menard JF, et al. Short-term and long-term outcome of anti-Jo1-positive patients with anti-Ro52 antibody. Semin Arthritis Rheum. 2012;41:890–9.] to be prevalent in patients with systemic autoimmune myopathies, suggesting that the simultaneous presence of these autoantibodies is associated with an increased risk of severe interstitial lung disease, more severe myositis, joint involvement, and neoplasia in patients older than 50 years. A potential explanation for the fact that anti-Ro-52 positivity was not associated with the occurrence of anti-Jo-1 autoantibodies in the present study is the small size of our sample.

Anti-Mi-2 positivity is known to be associated with the classical DM skin findings [2525. Marie I, Hatron PY, Dominique S, Cherin P, Mouthon L, Menard JF, et al. Short-term and long-term outcome of anti-Jo1-positive patients with anti-Ro52 antibody. Semin Arthritis Rheum. 2012;41:890–9.2727. Dos Passos Carvalho MIC, Shinjo SK. Frequency and clinical relevance of anti-Mi-2 autoantibody in adult Brazilian patients with dermatomyositis. Adv Rheumatol. 2019;59:27.], to be a protective factor for lung involvement [2525. Marie I, Hatron PY, Dominique S, Cherin P, Mouthon L, Menard JF, et al. Short-term and long-term outcome of anti-Jo1-positive patients with anti-Ro52 antibody. Semin Arthritis Rheum. 2012;41:890–9., 2626. Hamaguchi Y, Kuwana M, Hoshino K, Hasegawa M, Kaji K, Matsushita T, et al. Clinical correlations with dermatomyositis-specific autoantibodies in adult Japanese patients with dermatomyositis: a multicenter cross-sectional study. Arch Dermatol. 2011;147:391–8.], and a marker of high rates of remission [2626. Hamaguchi Y, Kuwana M, Hoshino K, Hasegawa M, Kaji K, Matsushita T, et al. Clinical correlations with dermatomyositis-specific autoantibodies in adult Japanese patients with dermatomyositis: a multicenter cross-sectional study. Arch Dermatol. 2011;147:391–8.] and response to glucocorticoid therapy [2525. Marie I, Hatron PY, Dominique S, Cherin P, Mouthon L, Menard JF, et al. Short-term and long-term outcome of anti-Jo1-positive patients with anti-Ro52 antibody. Semin Arthritis Rheum. 2012;41:890–9., 2626. Hamaguchi Y, Kuwana M, Hoshino K, Hasegawa M, Kaji K, Matsushita T, et al. Clinical correlations with dermatomyositis-specific autoantibodies in adult Japanese patients with dermatomyositis: a multicenter cross-sectional study. Arch Dermatol. 2011;147:391–8.]. No anti-Jo-1-positive patients in our sample were found to be positive for anti-Mi-2 auto-antibodies, which reaffirms the reports in the literature suggesting myositis-specific antibodies are mutually exclusive [2525. Marie I, Hatron PY, Dominique S, Cherin P, Mouthon L, Menard JF, et al. Short-term and long-term outcome of anti-Jo1-positive patients with anti-Ro52 antibody. Semin Arthritis Rheum. 2012;41:890–9.].

Concerning treatment, patients with anti-Jo-1 auto-antibodies were found to be more frequently on gluco-corticoids and immunosuppressive drugs when compared to those negative for this autoantibody. Consequently, no anti-Jo-1-positive patients had achieved disease remission at the time of their last medical evaluation, whereas one third of those negative for this autoantibody had gone into clinical remission. Patients in remission are referred to follow-up at primary or secondary care facilities as per our local protocol, which is why approximately half of the anti-Jo-1-negative DM patients had not been receiving follow-up treatment at the time.

No cases of neoplasia were observed during follow-up, but 10% of patients died, with no difference between the groups. Relapse rates were also similar between groups.

As a major limitation of our study, we had a small number of patients with anti-Jo-1 autoantibodies, and so our results should be interpreted with caution. Moreover, since this is a retrospective study, we did not have complete data available, such as serum levels of creatine phosphokinase and aldolase at disease onset or diagnosis or serum levels of the other muscle enzymes (aspartate aminotransferase, alanine aminotransferase, lactic dehydrogenase).

Conclusions

Anti-Jo-1 autoantibodies were detected in 8.5% of DM patients and were correlated with an increased frequency of lung and joint involvement as well as “mechanic's hands,” resembling the clinical presentation of anti-synthetase syndrome. In contrast, anti-Jo-1 positivity was not correlated with cutaneous manifestations such as the “shawl” sign, “V-neck” sign, vasculitides, and digital ulcers. Anti-Jo-1 autoantibodies were not found to affect relapse rates, but no anti-Jo-1-positive patients went into remission, so they continued to require regular outpatient follow-up. Our study emphasizes the relevant role of anti-Jo-1 autoantibodies in the phenotypical characterization of patients with definite DM, as well as in disease progression, by excluding an important cofounder present in other research, which is the inclusion of patients with collagen diseases and different systemic autoimmune myopathies, in addition to patients with antisynthetase syndrome itself. Our data also favor the tendency to characterize DM patients into more homogenous groups according to their phenotypical presentation related to myositis-specific antibodies.

  • Funding
    Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) #2014/09079-1, Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) #303379/2018-9 and Faculdade de Medicina da USP - SP to SKS.
  • Availability of data and materials
    Not applicable.
  • Ethics approval and consent to participate
    This study was approved by the local ethics committee (no. 0114/11).
  • Consent for publication
    Not applicable.
  • Publisher's Note
    Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Abbreviations

  • ACR  American College of Rheumatology
  • CADM  Clinically amyopathic dermatomyositis
  • CT  Computed tomography
  • DM  Dermatomyositis
  • EULAR  European League Against Rheumatism

Acknowledgements

Not applicable.

References

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Publication Dates

  • Publication in this collection
    01 Mar 2021
  • Date of issue
    2021

History

  • Received
    06 Dec 2020
  • Accepted
    10 Feb 2021
  • Published
    19 Feb 2021
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