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and anti-MDA-5 positivity &#40;by immunoblotting&#41;&#46; Lung function tests showed restriction with a bilateral interstitial pattern in the lower lobes&#46; Treatment with prednisone &#40;1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d&#41;&#44; cyclophosphamide in bolus form&#44; and hydroxychloroquine &#40;200<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#41; was ordered&#46; The patient did not improve on that regimen&#44; so mycophenolate mofetil &#40;2<span class="elsevierStyleHsp" style=""></span>g&#47;d&#41; was substituted for cyclophosphamide&#46; Slow improvement was noted&#44; and the patient remained stable when the prednisone dosage was reduced to 10<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Anti-MDA-5 antibodies have been reported in up to 80&#37; of amyopathic DM cases&#44; and in 60&#37; to 100&#37; of cases of progressive interstitial lung disease in different series&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#8211;5</span></a> The possible presence of skin signs has been noted in this clinical variant in recent years&#46; Radiologic findings different from those usually described for DM have also been noted&#46; Fiorentino<span class="elsevierStyleHsp" style=""></span>et<span class="elsevierStyleHsp" style=""></span>al<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> found that 10 in a series of 77 patients with DM showed anti-MDA-5 positivity and that this finding was significantly associated with hand edema&#44; arthritis&#44; skin ulcers&#44; palmar macules and papules&#44; mechanic&#39;s hands&#44; alopecia&#44; panniculitis&#44; elbow erythema&#44; and oral ulcers&#46; However&#44; Labrador-Horrillo<span class="elsevierStyleHsp" style=""></span>et<span class="elsevierStyleHsp" style=""></span>al<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> were unable to confirm those findings in a Mediterranean series&#44; possibly because both studies were retrospective and done in different populations&#46; The discrepancies might also be due to small sample size&#44; since this condition is uncommon and conclusions are difficult to draw&#46; In our series of Caucasian patients&#44; we saw several of the signs Fiorentino<span class="elsevierStyleHsp" style=""></span>et<span class="elsevierStyleHsp" style=""></span>al reported &#40;eg&#44; arthritis&#44; joint pain&#44; hand edema&#44; ulcers&#44; and palmar papules&#41;&#46; The lesions in our first patient &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; were severe&#44; and the maculopapular lesions both patients had between their fingers were very similar &#40;<a class="elsevierStyleCrossRefs" href="#fig0010">Figs&#46; 2 and 3</a>&#41;&#46; Our second patient&#39;s skin signs were milder&#44; but we note that lesions as subtle as palmar macules were key to this diagnosis&#46; The skin signs described by Fiorentino<span class="elsevierStyleHsp" style=""></span>et<span class="elsevierStyleHsp" style=""></span>al have been reported in other cases along with skin ulcers&#44; especially around the nail&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;7</span></a> Narang<span class="elsevierStyleHsp" style=""></span>et<span class="elsevierStyleHsp" style=""></span>al<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> concluded that skin ulcers in DM might be related to anti-MDA-5 antibodies&#44; predict lung involvement&#44; and tend to be caused by vascular compromise&#46; Finding these signs in the context of DM&#44; therefore&#44; can suggest a clinical strategy and call for anti-MDA-5 testing&#44; which is not routinely ordered in most centers&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">A noteworthy laboratory result is that the creatine kinase level tends to be normal whereas the components of liver function tests and ferritin tend to be very high&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> as we observed in our patients&#46; High ferritin levels in DM suggest the likelihood of anti-MDA5 positivity and rapid progression of lung disease&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Radiologic findings also vary&#46; The most common pattern in anti-MDA-5&#8211;positive cases is a subpleural ground-glass opacity in lower lung fields&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In summary&#44; we have described 2 cases of anti-MDA-5 positivity in 2 patients with amyopathic DM and characteristic skin signs such as ulcerations around the nails and palmar papules&#46; We have attempted to describe this rare condition&#44; which has certain clinical features that differ from classical DM&#46; Understanding this phenotype will contribute to improved diagnosis and better follow-up of patients with a condition that requires us to watch for possible lung involvement&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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Case and Research Letters
Anti-MDA5–Positive Dermatomyositis: A Description of the Cutaneous and Systemic Manifestations in 2 Cases
Dermatomiositis anti-MDA-5 positivas. Descripción de clínica cutánea y sistémica a propósito de dos casos
N. Barrientosa,
Autor para correspondencia
nuriabarr@yahoo.com

Corresponding author.
, J.J. Siciliab, M.J. Moreno de Vegaa, J.D. Domingueza
a Departamento de Dermatología, Hospital Universitario del Henares, Coslada, Madrid, España
b Servicio de Medicina Interna, Hospital Universitario del Henares, Coslada, Madrid, España
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1</a>&#41; in the context of edema&#44; eyelid erythema&#44; and arthritis&#46; Laboratory findings included an erythrocyte sedimentation rate of 64 mm&#47;h&#44; a ferritin level of 609<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#44; and aspartate transaminase and alanine transaminase levels both of 107<span class="elsevierStyleHsp" style=""></span>U&#47;L&#46; On diagnosis of amyopathic DM&#44; we started treatment with oral prednisone &#40;1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d&#41; plus weekly doses of methotrexate &#40;10<span class="elsevierStyleHsp" style=""></span>mg&#41;&#46; When painful ulcers developed on the palmar surfaces of the fingers &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; plantar surfaces of the feet&#44; and the trunk&#44; bosentan &#40;62&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h&#41; and cyclophosphamide &#40;1000<span class="elsevierStyleHsp" style=""></span>mg&#47;cycle&#41; 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The patient died from respiratory failure in spite of all measures&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The second patient was a 31-year-old woman admitted with fever&#44; dyspnea&#44; and arthritic joint pain in her hands as well as lesions on her palms &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41; and elbows&#46; An extensive test battery revealed vacuolar dermatitis at the dermal&#8211;epidermal junction&#44; an aspartate transaminase level of 172<span class="elsevierStyleHsp" style=""></span>U&#47;L&#44; an alanine transaminase level of 109<span class="elsevierStyleHsp" style=""></span>U&#47;L&#44; elevated ferritin level of 1185<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#44; an erythrocyte sedimentation rate of 64 mm&#47;h&#44; an anti-Sj&#246;gren&#39;s-syndrome-related antigen A antibody level of 103&#46;80<span class="elsevierStyleHsp" style=""></span>U&#47;mL&#41;&#44; and anti-MDA-5 positivity &#40;by immunoblotting&#41;&#46; Lung function tests showed restriction with a bilateral interstitial pattern in the lower lobes&#46; Treatment with prednisone &#40;1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d&#41;&#44; cyclophosphamide in bolus form&#44; and hydroxychloroquine &#40;200<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#41; was ordered&#46; The patient did not improve on that regimen&#44; so mycophenolate mofetil &#40;2<span class="elsevierStyleHsp" style=""></span>g&#47;d&#41; was substituted for cyclophosphamide&#46; Slow improvement was noted&#44; and the patient remained stable when the prednisone dosage was reduced to 10<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Anti-MDA-5 antibodies have been reported in up to 80&#37; of amyopathic DM cases&#44; and in 60&#37; to 100&#37; of cases of progressive interstitial lung disease in different series&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#8211;5</span></a> The possible presence of skin signs has been noted in this clinical variant in recent years&#46; 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since this condition is uncommon and conclusions are difficult to draw&#46; In our series of Caucasian patients&#44; we saw several of the signs Fiorentino<span class="elsevierStyleHsp" style=""></span>et<span class="elsevierStyleHsp" style=""></span>al reported &#40;eg&#44; arthritis&#44; joint pain&#44; hand edema&#44; ulcers&#44; and palmar papules&#41;&#46; The lesions in our first patient &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; were severe&#44; and the maculopapular lesions both patients had between their fingers were very similar &#40;<a class="elsevierStyleCrossRefs" href="#fig0010">Figs&#46; 2 and 3</a>&#41;&#46; Our second patient&#39;s skin signs were milder&#44; but we note that lesions as subtle as palmar macules were key to this diagnosis&#46; The skin signs described by Fiorentino<span class="elsevierStyleHsp" style=""></span>et<span class="elsevierStyleHsp" style=""></span>al have been reported in other cases along with skin ulcers&#44; especially around the nail&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;7</span></a> Narang<span class="elsevierStyleHsp" style=""></span>et<span class="elsevierStyleHsp" style=""></span>al<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> concluded that skin ulcers in DM might be related to anti-MDA-5 antibodies&#44; predict lung involvement&#44; and tend to be caused by vascular compromise&#46; Finding these signs in the context of DM&#44; therefore&#44; can suggest a clinical strategy and call for anti-MDA-5 testing&#44; which is not routinely ordered in most centers&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">A noteworthy laboratory result is that the creatine kinase level tends to be normal whereas the components of liver function tests and ferritin tend to be very high&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> as we observed in our patients&#46; High ferritin levels in DM suggest the likelihood of anti-MDA5 positivity and rapid progression of lung disease&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Radiologic findings also vary&#46; The most common pattern in anti-MDA-5&#8211;positive cases is a subpleural ground-glass opacity in lower lung fields&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In summary&#44; we have described 2 cases of anti-MDA-5 positivity in 2 patients with amyopathic DM and characteristic skin signs such as ulcerations around the nails and palmar papules&#46; We have attempted to describe this rare condition&#44; which has certain clinical features that differ from classical DM&#46; Understanding this phenotype will contribute to improved diagnosis and better follow-up of patients with a condition that requires us to watch for possible lung involvement&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Barrientos N&#44; Sicilia JJ&#44; Vega MJMd&#44; Dominguez JD&#46; Dermatomiositis anti-MDA-5 positivas&#46; Descripci&#243;n de cl&#237;nica cut&#225;nea y sist&#233;mica a prop&#243;sito de dos casos&#46; Actas Dermosifiliogr&#46; 2018&#59;109&#58;188&#8211;190&#46;</p>"
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