title: Necrotising myopathy, an unusual presentation of a steroid-responsive myopathy.
abstract: OBJECTIVE
  To evaluate the clinical features, muscle pathology and response to treatment in patients with a necrotising myopathy, without mononuclear cell infiltrates.
  
  
  BACKGROUND
  Mononuclear cell infiltrates in the muscle biopsy specimen are the diagnostic hallmark of the immune-mediated idiopathic inflammatory myopathies (IIM). In patients with the typical clinical features of IIM, absence of these infiltrates in the muscle biopsy specimen casts doubt on the diagnosis and leads to uncertainty about therapeutical strategies.
  
  
  METHODS
  A detailed description is given of the clinical, laboratory, and histopathological features of eight patients suspected of having an idiopathic inflammatory myopathy, in whom mononuclear cell infiltrates in their muscle biopsy specimens were lacking.
  
  
  RESULTS
  Eight patients (five men, three women, age range 40-69 years) had severe, symmetrical proximal weakness with a subacute onset. There were no skin abnormalities suggesting dermatomyositis. Serum creatine kinase activity was more than 10 times elevated. Repeated muscle biopsy specimens, taken from a symptomatic muscle prior to immunosuppressive treatment showed widespread necrosis, regeneration, and atrophy of muscle fibres, but no mononuclear cell infiltrates. Known causes of necrotising myopathy were excluded. Three patients had a malignancy. Adequately dosed and sustained immunosuppressive treatment eventually resulted in normal or near normal muscle strength in seven patients. One patient showed marked improvement.
  
  
  CONCLUSIONS
  Occasionally, patients who clinically present as an idiopathic inflammatory myopathy may lack mononuclear cell infiltrates in their muscle biopsy specimens. This subacute-onset progressive necrotising myopathy should not deter the clinician from timely and appropriate treatment as we consider this myopathy to be steroid-responsive with a possible immune-mediated pathogenesis.
authors.affiliation: Department of Neurology, Sint Lucas Andreas Hospital, Jan Tooropstraat 164, 1061 AE Amsterdam, The Netherlands. i.bronner@slaz.nl
authors.forename: I M
authors.initials: IM
authors.lastname: Bronner
authors.forename: J E
authors.initials: JE
authors.lastname: Hoogendijk
authors.forename: A R
authors.initials: AR
authors.lastname: Wintzen
authors.forename: M F G
authors.initials: MF
authors.lastname: van der Meulen
authors.forename: W H J P
authors.initials: WH
authors.lastname: Linssen
authors.forename: J H J
authors.initials: JH
authors.lastname: Wokke
authors.forename: M
authors.initials: M
authors.lastname: de Visser
mesh_terms: D000328:Adult; D000368:Aged; D001706:Biopsy; D003402:Creatine Kinase / Q000032:analysis / Q000494:pharmacology; D005260:Female; D006801:Humans; D007963:Leukocytes, Mononuclear; D008297:Male; D008875:Middle Aged; D009133:Muscular Atrophy; D009220:Myositis / Q000188:drug therapy* / Q000473:pathology*; D009336:Necrosis; D012720:Severity of Illness Index; D013256:Steroids / Q000627:therapeutic use*
chemical_list: D013256:Steroids; D003402:Creatine Kinase