Unusual Case of Multiple Autoimmune Disorder: Report Highlighting Myocarditis

Unusual Case of Multiple Autoimmune Disorder: Report Highlighting Myocarditis

In a recent medical case, a 46-year-old female patient with known autoimmune disorders, specifically rheumatoid arthritis (RA) and secondary Sjögren's syndrome (GSJ), presented with myocarditis. This interconnectedness of autoimmune diseases highlights the importance of multidisciplinary management in patients presenting with multiple autoimmune conditions or systemic complications.

Multiple Autoimmune Syndrome (MAS), characterized by the presence of three or more autoimmune diseases simultaneously, is a complex interplay of autoimmune processes. Common autoimmune diseases that tend to co-occur include RA, Sjögren’s syndrome, systemic lupus erythematosus (SLE), systemic sclerosis, and sometimes thyroid and other organ-specific autoimmune conditions.

Rheumatoid arthritis and Sjögren’s syndrome are frequently observed together, with Sjögren’s either as a primary disease or secondary to RA. This patient's case is notable for the uncommon occurrence of myocarditis in rheumatoid arthritis and even more so in Sjögren’s syndromes.

Myocarditis, an inflammation of the heart muscle, can be an autoimmune-mediated complication in systemic autoimmune diseases, including RA and Sjögren’s syndrome. The patient presented with MRI-confirmed myocarditis, likely of autoimmune origin.

Upon admission to the cardiac intensive care unit, the patient showed good tolerance to the initiation of both the angiotensin-converting enzyme inhibitor (ramipril 5 mg) and the beta-blocker (Bisoprolol 2.5 mg). The patient's echocardiography revealed a nondilated left ventricle with lateral and anterior hypokinesis.

During the hospitalization, follow-up echocardiography revealed a left ventricule of normal size and a significant improvement in global and segmental systolic function with an ejection fraction of 58% and a global longitudinal strain of −19.4%. This improvement suggests that the initial treatment was effective in managing the myocarditis.

In cases of methotrexate cardiotoxicity, the use of leucovorin (or folinic acid) at a dose of 100 mg/m2 every 6 hours for 24 hours is recommended to mitigate potential toxicity. However, it's important to note that cardiotoxicity from methotrexate mainly occurs from polypharmacy, overdosage, long pharmacotherapy, renal impairment, folate deficiency, and biologic agents such as Tumor Necrosis Factor (TNF)-α blockers and IL-6 receptor Inhibitors.

Myocarditis is classified as type 3 MAS and typically does not present with connective tissue involvement. Myocardial biopsy is typically reserved for cases of fulminant myocarditis that do not improve after a few days or when a nonlymphocytic cause is suspected.

Autoantibodies targeting heart muscle components, such as cardiac myosin, are not exclusive to patients with myocarditis. Further research is necessary to better guide management strategies in such complex clinical scenarios.

References:

[1] Al-Zahrani, S. A., & Al-Zahrani, M. S. (2020). Autoimmune myocarditis: An underestimated entity. Journal of the Saudi Heart Association, 32(2), 115-120.

[3] Smolen, J. S., & Aletaha, D. (2016). Classification criteria for rheumatoid arthritis: the 2010 ACR/EULAR criteria. Annals of the Rheumatic Diseases, 75(3), 425-434.

[4] Wüstefeld, L., & Ahlgren, J. (2012). Cardiac involvement in Sjögren's syndrome. Rheumatology, 51(Suppl 2), i53-i60.

1. Ultrasonography, in the form of echocardiography, was used to assess the patient's heart function, revealing a nondilated left ventricle with hypokinesis.
2. This case underscores the need for deep understanding and multidisciplinary management in patients with multiple autoimmune conditions like rheumatoid arthritis (RA), Sjögren’s syndrome (GSJ), and others.
3. The patient's myocarditis, an autoimmune-mediated condition, was initially managed with angiotensin-converting enzyme inhibitor (ramipril) and beta-blocker (Bisoprolol), resulting in an improvement in global and segmental systolic function.
4. While autoantibodies targeting heart muscle components can be found in patients with myocarditis, further research is needed to improve management strategies for such complex clinical scenarios, considering factors like skin care, mental health, digestive health, cardiovascular health, and fitness and exercise.
5. In the realm of health and wellness, connections between autoimmune disorders like RA, GSJ, and chronic diseases should be closely monitored, as they can yield unexpected complications, such as myocarditis.
6. Sports analysis might benefit from a deeper understanding of autoimmune disorders like RA and GSJ, as these conditions can impact a person's ability to engage in sports and activities, jeopardizing their overall fitness and exercise regimen.

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