title: [A case with myositis as a manifestation of chronic graft-versus-host-disease (GVHD) with severe muscle swelling developed after aggressive muscular exercise].
abstract: We report a 21-year-old-man, with myositis as a manifestation of chronic graft-versus-host-disease (GVHD). He was diagnosed as having acute myelogenous leukemia at the age of 18 years, and had bone marrow transplantation (BMT) two years after the onset of the disease. Cutaneous manifestation of acute GVHD appeared on the twelfth day following BMT, which responded to prednisolone. Thereafter, GVHD has been well-controlled except for mild liver dysfunction which was thought to be a sign of chronic GVHD. Eleven months after BMT, he enjoyed snowboarding for two days from morning till night. Two days later, he experienced muscle swelling with pain and fever, which gradually worsened for which he was admitted to our hospital. Neurological examination revealed severe proximal and distal muscle swelling with fever and tenderness in all extremities. Mild, symmetrical, proximal weakness was observed in all four limbs. Severity of muscle swelling and its generalized nature restricted the movements of shoulder-, elbow- and ankle-joints and he was unable to walk. Laboratory investigations revealed creatine kinase (CK) of 7,860 IU/L, C-reactive protein (CRP) of 21.5 mg/dL and raised biliary enzymes. MRI generated high intensity signals from the swollen muscles. Muscle biopsy examination of involved areas showed severe interstitial edema and mononuclear cells infiltration. Macrophages were scattered through out the perimysium and endomysium. On the other hand, T cells and B cells were localized to the endomysium. Although a lot of CD8 positive T cells were seen adjacent to non-necrotic fibers, none of them was obviously invading the non-necrotic fibers. Perifascicular atrophy was not seen. Symptoms gradually worsened over two weeks or so when prednisolone was started to which he responded rapidly. While tapering steroids, the symptoms relapsed on resuming aggressive exercise. Resumption of the treatment regime promptly controlled the symptoms. The cause of myositis as a manifestation of chronic GVHD is unclear. T-cell or B-cell dysfunction, collagen-vascular-like processes, viral infection and direct damage by radiation or chemotherapy have been supposed to involve in the disease process. Our case suggests that aggressive muscular exercise could play as a initiator of myositis as a manifestation of chronic GVHD.
authors.affiliation: Department of Neurology, School of Medicine, University of Tokyo.
authors.forename: Satoko
authors.initials: S
authors.lastname: Kano
authors.forename: Jun
authors.initials: J
authors.lastname: Shimizu
authors.forename: Takashi
authors.initials: T
authors.lastname: Mikata
authors.forename: Takashi
authors.initials: T
authors.lastname: Shinoe
authors.forename: Hidetaka
authors.initials: H
authors.lastname: Ota
authors.forename: Yukiko
authors.initials: Y
authors.lastname: Komeno
authors.forename: Seishi
authors.initials: S
authors.lastname: Ogawa
authors.forename: Hisamaru
authors.initials: H
authors.lastname: Hirai
authors.forename: Ichiro
authors.initials: I
authors.lastname: Kanazawa
mesh_terms: D000328:Adult; D016026:Bone Marrow Transplantation; D002908:Chronic Disease; D006086:Graft vs Host Disease / Q000150:complications*; D006801:Humans; D015464:Leukemia, Myelogenous, Chronic, BCR-ABL Positive / Q000628:therapy; D008279:Magnetic Resonance Imaging; D008297:Male; D009220:Myositis / Q000175:diagnosis / Q000209:etiology* / Q000473:pathology