Letters to the Editors

Development of biopsy-proven of cutaneous lesions and muscle weakness. toid arthritis (3, 4) and systemic lupus ery- giant cell arteritis in a patient She weaned off steroids in 12 months and thematosus (5). Kennedy and Mitchinson remained in clinical remission on 10 mg (6) described histologic findings of -myo with dermatomyositis on weekly methotrexate. carditis and skeletal myositis in an autopsy methotrexate: comment on the She presented in 2018 still on methotrexate, case of a 57-year-old female with GCA, article by Monti et al. at the age of 80 years, with several months but these features were incidentally found of malaise, jaw claudication, new-onset and clinically asymptomatic prior to the Sirs, frontotemporal headaches, and stiffness of patients demise. To our knowledge, this is We read with interest the vasculitis year-in- the neck and shoulder girdle without objec- the first report of a patient with a history of review article by Monti et al. (1) highlight- tive weakness. Creatine kinase and aldolase dermatomyositis subsequently developing ing the benefit of tocilizumab in patients were normal. Erythrocyte sedimentation biopsy-proven GCA. with giant cell arteritis (GCA). Herein we rate was elevated at 48 mm/hr and C-reac- Development of GCA in a patient with der- report an illustrative case highlighting the tive protein at 13.4 mg/L. Scalp tenderness matomyositis on chronic maintenance with lack of efficacy of long-term methotrexate and prominent temporal arteries were noted methotrexate is of importance for several in preventing the development of GCA in a bilaterally. Biopsy of the temporal artery reasons. First, approximately 50% of pa- patient with dermatomyositis. revealed features consistent with GCA (Fig. tients with GCA present with polymyalgia In 1995, a 57-year old Caucasian female 1D). Angiography of the chest was negative rheumatica (PMR) symptoms. As such, it presented with heliotrope rash (Fig. 1A) as for large-vessel vasculitis or occult malig- is essential to clinically differentiate be- well as violaceous erythema of her trunk, nancy. Prednisone 60 mg daily was initiated, tween the features of an inflammatory my- upper chest (Fig. 1B), upper back and arms resulting in prompt resolution of symptoms ositis, such as dermatomyositis, and PMR, and Gottron’s papules. Clinical examina- and normalisation of inflammatory mark- with the former demonstrating weakness tion and electromyogram identified proxi- ers. Methotrexate was continued for chronic and the latter stiffness without overt weak- mal myopathy and deltoid biopsy con- maintenance of her dermatomyositis. ness. Proximal muscle stiffness with intact firmed findings consistent with dermatomy- The reports of GCA developing in patients strength and normal muscle enzymes sug- ositis. She was initiated on prednisone and with other pre-existing autoimmune dis- gested in this case that symptoms were not methotrexate with subsequent normalisa- eases are rare. Coexistent GCA has been due to active dermatomyositis. Second, re- tion of her muscle enzymes and resolution noted with systemic sclerosis (2), rheuma- ports have shown that patients with other

A B

C D

Fig. 1. A: Violaceous erythema of the eyelids (heliotrope), and (B) hyperpigmentation of the neck and upper chest (V neck) around the time of dermatomyositis diagnosis. C: Temporal artery biopsy demonstrating transmural granulomatous inflammation (H&E, x40 magnification) with presence of giant cells (H&E, x200 magnification)D ( , arrow).

Clinical and Experimental Rheumatology 2020 S-239 Letters to the Editors autoimmune diseases, such as our patient, T.D. Garvey1, MD 5. BUNKER CB, DOWD PM: Giant cell arteritis and can develop GCA despite ongoing treat- C.J. Michet, Jr.1, MD systemic lupus erythematosus. Br J Dermatol 1988; 2 ment with immunosuppressive medica- L.N. Dao , MD 119: 115-20. 1 6. KENNEDY LJ, Jr, MITCHINSON MJ: Giant cell tions such as leflunomide (4), etanercept M.J. Koster , MD 1 arteritis with myositis and myocarditis. Calif Med (3), adalimumab (4), and methotrexate (3). Department of Internal Medicine, Division 1971; 115: 84-7. of Rheumatology, 2Department of Laboratory This corroborates clinical trial data failing 7. KOSTER MJ, MATTESON EL, WARRINGTON KJ: Medicine and Pathology, Mayo Clinic, Recent advances in the clinical management of gi- to show marked benefit of these agents in Rochester, Minnesota, USA. the management of GCA (7). One should ant cell arteritis and takayasu arteritis. Curr Opin Please address correspondence to: Rheumatol 2016; 28: 211-7. not exclude GCA from their differential di- Thomas D. Garvey, 8. STONE JH, TUCKWELL K, DIMONACO S et al.: agnosis in patients with suggestive features Mayo Clinic, 200 1st St. SW, Trial of tocilizumab in giant-cell arteritis. N Engl J even if they are currently on disease modi- Rochester, MN 55905, USA. Med 2017; 377: 317-28. fying agents; especially if their clinical E-mail: [email protected] 9. NARAZAKI M, HAGIHARA K, SHIMA Y, OGATA symptoms evolve, or are atypical for their ClinicalTrials.gov Identifier NCT02043548. A, KISHIMOTO T, TANAKA T: Therapeutic effect primary autoimmune process. of tocilizumab on two patients with polymyositis. Competing interests: none declared. Rheumatology (Oxford) 2011; 50: 1344-6. Tocilizumab, a monoclonal antibody target- © Copyright Clinical and 10. KONDO M, MURAKAWA Y, MATSUMURA T et al.: ing interleukin-6, is the first medication to Experimental Rheumatology 2020. A case of overlap syndrome successfully treated exhibit definitive benefit in the treatment with tocilizumab: A hopeful treatment strategy for of both newly-diagnosed and relapsing References refractory dermatomyositis? Rheumatology (Ox- GCA(8). Tocilizumab has also shown pre- 1. MONTI S, BOND M, FELICETTI M et al.: One year ford) 2014; 53: 1907-8. liminary benefit in a small series of patients in review 2019: Vasculitis. Clin Exp Rheumatol with refractory polymyositis (9) and also a 2019; 37 (Suppl. 117): S3-19. 2. SARI-KOUZEL H, HERRICK AL, FREEMONT AJ, patient with recalcitrant dermatomyositis MARCUSON RW, JAYSON MI: Giant cell arteritis in (10) and is currently being evaluated in a a patient with limited cutaneous systemic sclerosis. phase 2 clinical trial for the treatment of Rheumatology (Oxford) 1999; 38: 479-80. these conditions (ClinicalTrials.gov Iden- 3. SETON M: Giant cell arteritis in a patient taking tifier NCT02043548). Therefore, tocili- etanercept and methotrexate. J Rheumatol 2004; 31: 1467. zumab may represent a viable monotherapy 4. LEYDET-QUILICI H, LUC M, ARMINGEAT T, for patients with GCA and inflammatory PHAM T, LAFFORGUE P: Giant cell arteritis dur- myositis and is a potential option for our ing adalimumab treatment for rheumatoid arthritis. patient if symptoms return on steroid taper. Joint Bone Spine 2007; 74: 303-4.

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