Recovery from severe dysphagia in polymyositis using Rituximab: a case report
Fajer Altamimi, Usman Amin, Asif Munir, Donnoca O’Gradaigh, Claire Sheehy
Rheumatology- University Hospital Waterford
Polymyositis is one of the inflammatory myopathies. It is chronic autoimmune disease that usually involves the proximal muscles. It is caused by an inflammatory infiltrate of the skeletal muscle. Notably, Dysphagia occurs in one third of the patients.
Many rehabilitation and pharmacological measures for dysphagia have been tried to reduce the risk of aspiration. However, severe dysphagia should be managed by nasopharyngeal or gastric feeding tube. Also pharmacologically with high dose corticosteroids, other steroids sparing immunosuppressive agents, or intravenous immunoglobulins. However the role of Rituximab in the treatment of dysphagia was not clearly addressed.
32 year old gentleman has known to have psoriasis and necrotizing polymyositis who suffered from severe dyshpagia requiring percutaneous gastrostomy insertion.
He was treated with intravenous methylprednisolone, methotrexate and even intravenous immunoglobulins with no improvement. He is then tried on two doses of rituximab, when he started to show signs of improvement and eventually his tube was removed. Currently he is off medications.
It is a case report.
The turn corner in our case when the patient started to tolerate full feeding after rituximab. We recommend conducting more researches using these agents in treatment of dysphagia
Dysphagia is one of the serious symptoms in patients with inflammatory myopathies and can be the presenting symptom. It was noticed that patients who required percutaneous endoscopic gastrostomy had a higher mortality rate.
In terms of management, Rehabilitation by a trained speech therapist should be tried. However, severe dysphagia should be managed by nasopharyngeal or gastric feeding tube to protect the airways and support the nutritional need.
Corticosteroids are the initial type of management in polymyositis. In case the patient required prolonged maintenance course, other steroid sparing agents should be tried. Interventional procedures such as cricopharyngeal myotomy found to be beneficial.
Having said that, reversal of dysphagia has not been clearly documented in the literatures with the use of rituximab. There is one case report mentioned the use of rituximab in systemic sclerosis – myositis. Accordingly, we suggest the need to evaluate the efficacy of rituximab in myositis-associated dysphagia.