Herpes Zoster in Patients with Polymyositis and - J-Stage

1394
Herpes
Zoster
in Patients
with
Polymyositis
and
Dermatomyositis
Shohei NAGAOKA, Kenji TANI, Yoshiaki ISHIGATSUBO, Jun CHIBA
Kiyoshi KATO, Keiichiro MATSUNAGA, Masahiro NARITA,
Toshihisa IGARASHI and Takao OKUBO
The First Departmentof Internal Medicine,YokohamaCity University,Schoolof Medicine
Key words:
Herpes zoster, Dermatomyositis,
Polymyositis
Abstract
Twenty-two patients with polymyositis and dermatomyositis (PM-DM)were retrospectively studied
with regard to development of herpes zoster.
Herpes zoster occurred with high frequency in patients with PM-DM. The clinical courses of zoster
infections were uneventful; no severe complications nor deaths occurred, and only one patient had
postherapeutic neuralgia. No specific therapy for this infection was necessary. Zoster tended to occur in the
inactive stage of PM-DM. PM-DM patients with herpes zoster had a significantly higher incidence of
antinuclear antibody. There seemed to be no relationship between steroid therapy and herpes zoster
infection.
Introduction
PM-DMare diffuse inflammatory diseases of the striated muscle wich may lead to muscle atrophy and
proximal muscle weakness involving the limb, pharynx, face and neck. The etiology of PM-DM is an
autoimmune disease mediated lymphocytes' and that some patiets have humoral immuodeficiency2).Such
patients have a susceptibility to infections, and corticosteroid therapy may lead to further reduction in host
defence to infection3).
Herpes zoster, an inflammatory human disease by the varicella-zoster virus, is characterized by
papulovesicular along several dermatomes. The varicella-zoster virus may produce varicella as a primary
infection and herpes zoster as a secondary infection. Zoster represents reactivation of latent varicellazoster virus that has remained dormant in the dorsal root ganglia, the activation being caused by aging,
radiation, immunosuppressive agents and so on4).In addition, this infection appears to be more frequent in
certain immunocompromised patients5).
In the present study, the clinical characteristics of herpes zoster infections in patients with PM-DM
are retrospectively analyzed. In addition, we examined possible predisposing factors of zoster infections in
these patients.
Materials and Method
Subjects
The clinical records of all patients with a diagnosis of polymyositis or dermatomyositis from the First
Department of Internal Medicine, Yokohama City University Hospital during the interval 1973 through
1983 were reviewed retrospectively and certain features were critically evaluated: Twenty-two patients
別刷請求先:
(〒232)横浜市南区浦舟町3-46
横浜市立大学医学部第1内科
谷
賢治
感染症学雑誌
第64巻
第11号
Herpes
Zoster
and PM-DM
1395
who had no family history of myopathy and who fulfilled the Bohan's criteria were selected6).Twenty cases
of non Hodgkin's lymphoma and twenty-two cases of SLE in whom age of patients was matched to it of
PM-DM patients, were studied as a disease control (Table 1). The American Rheumatism Association
criteria were used for selecting patients with SLE7).All patiens with these diagnosis were seen by authors.
The diagnosis of herpes zoster was accepted if varicella-zoster virus was isolated from skin lesions. In
those ptients with absence of viral cultures, seologic tests, i.e. herpes zoster titer in the serum increasing
more than 4 times, were done on these patients to support the conclusion of the diagnosis.
Laboratory testsAntinuclear antibody was measured using an indirect immunofluorescent technique') and
rat liver as substrate. A reaction was considered positive at a titre of 1:20 or greater.
Anti-DNAantibodies were measured using a DNA binding technique.
Herpes zoster titer in the serum was measured using the method described elsewhere1°).
Statistical analysis Correlation between herpes zoster and other features in patients with PM-DM studied
retrospectively were evaluated using t test.
Results
Incidence of Herpes Zoster in Patients with Polymyositisand Dermatomyositis
Five of the 22 patients with PM-DM (22.7%)had a history of herpes zoster infection during 180.4
observation years. On the other hand, 40.9%of the patients with SLE during 171.6 observation years, 10.0%
of those with non Hodgkin's lymphoma developedzoster during observation 56 years (Table 1).
The duration of PM-DMin these patients prior to the time of development of herpes zoster varied from
eleven to 93 months. All cases tended to have an inactive stage of PM-DM when they had an attack of
herpes zoster: 4 patients were an inactive stage of PM-DM at the time of herpes zoster infection and only
Table
*The
two
patients
Table
平成 2年11月20日
of PM
2
1
Incidence
overlapped
Clinical
with
of Herpes
classical
Manifestations
Zoster
in Patients
RA or SLE
of Herpers
with
PM-DM
.
Zoster
in 5 Patients
with
PM-DM
1396
Shohei
NAGAOKA
et al
one had a slight elevation of serum aldolase without clinical muscle manifestations when zoster developed.
Clinical Manifestations of Herpes Zoster in Five Patients with PM-DM (Table 2)
The dermatomal distributions of herpes zoster were thoracic (3 cases) and lumbosacral area (2 cases).
The duration from onset to disappearing of all symptoms of herpes zoster ranged from 10 to 30 days with
an average duration of 17.6 days. No patients had multiple episodes. In clinical courses of herpes zoster,
there were no severe complications such as disseminated zoster and death. Only one of the five patients had
persistent neuralgia of the left Th-10 area at the age 69. Interval to the attack of herpes zoster from the
onset to PM-DMranged from 1 to 93 months with an average duration of 38.6 months. Activity changes of
myositis by herpes zoster infection were as follows: four patients were inactive and one patient had a slight
increase of serum muscular enzyme.
These patients did not receive specific therapy for herpes zoster.
Relationship between Herpes Zoster Infection and Clinical and Laboratory Manifestations of PM-DM
(Table 3)
The five patients with herpes zoster infection were compared with the seventeen patients without
zoster infection, with regard to difference in sex, age at onset of PM-DM,and frequencies of manifestations
of PM-DM(both clinical and laboratory).
The sex distribution and mean age at onset of PM-DMwere not significantly different between the two
groups.
As noted in the Table 3, there was a highly significant difference in the frequencies of antinuclear
antibody among the two groups (80.0%versus 17.6%).The patterns of antinuclear antibody in PM-DM
patients with herpes zoster were various, speckled and/or homogenous, but its tendency as similar in those
patients without zoster.
Two of the five PM-DM patients with zoster infection overlapped other collagen disorders. One was
overlap RA" and the other with SLE.
The two groups showed no significant difference in the frequencies of lung fibrosis, cardiac damage,
Table 3 ClinicalFeatures in 22 patients with PM-DM
* Statiatically
significant
difference
1) Herpes zoster infected patients
, p<0.01
with PM-DM
2) Herpes zoster no infected patients
with PM-DM
感染症学雑誌
第64巻
第11号
Herpes
Table
Raynaud's
phenomenon,
Relationship
All
patients
suppressive
The
The
with
mg
initial
was
mg
29.0
of Prednisolone
malignancy
Infection
received
(range
ranged
and
and
lung
Treatment
steroid
tuberculosis.
of PM-DM
therapy
steroid
no
therapy.
In
alone
and
(Table
none
4)
was
treated
with
immuno-
patient
(7.8
shorter
(31
at
mg/day),
interval
patients
to the
31).
with
difference
PM-DM
38 .6),
(mean
compared
was
patients
of
duration
herpes
herpes
the
an
groups
infection
from
therapy
taking
zoster
two
zoster
zoster
steroid
were
without
among
herpes
of
patients
or
fond
with
development
the
These
between
in either
patient
the
than
in
(mean
months
was
the
months)
the
PM-DM
statistical
prednisolone
months
differences
one
of dose
of
in
No
the
onset
prior
average
.
was
to
dose
of
zoster
of 6 .5 mg
0-12.5).
therapy
addition,
average
93
1 to 59
(range
significant
prednisolone
respectively.
Though
to
from
daily
of
mg
dose
11
ranged
was
dose
34.4
4.2-20).
from
of prednisolone
When
daily
and
maintenance
daily
development
the
test,
Zoster
PM-DM
average
average
PM-DM
there
RA
Herpes
Administration
1397
agents.
infection
13.1
arthritis,
between
4
Zoster and PM-DM
the
developed
time
zoster
of zoster
duration
that
68
infection
of
(60
the
steroid
in
with
dose,
SLE
and
without
maintenance
months
after
in PM-DM
therepy
months)
groups
initial
steroid
patient
prior
dose
zoster
duration
therapy
(6.5
to zoster
herpes
or
was
mg/day)
development
infection
of prednisolone
terminated
was
similar
in
PM-DM
. Though
that
in SLE
patient
was
patients.
Discussion
No
detalied
Increased
studies
frequency
leukemia
and
were
most
herpes
zoster
was
of
herpes
month)11),
in those
The
the
in
with
was
this
necessary.
ranged
study
in
of 22
patients
reported
to be 0.26%
patients
with
73%13)14).
population
PM-DM,
Among
during
22.8%
of
hospitalized
to
zoster,
been
48
the
per
in
the
. Though
be
reported.
lymphoma)
zoster
patients
period13)
reported
developed
have
Hodgkin's
. Incidences
a 4-year
was
knowledge,
(particularly
studies5)11•`15)
patients
general
, to our
lymphoma
several
8 to
179
infections
with
in
from
of 55,
the
zoster
the
frequency
of
frequency
thousand
incidence
,
Hodgkin's
per
(0.04%
is less
than
per
that
SLE.
of zoster
zoster
zoster
with
SLE
was
uneventful,
within
3-4
has
been
observed
by
2) multiple
years
after
the
several
episodes
onset
of
authors16•`18)
were
SLE,
often
and
observed,
4) zoster
occurred
showed
3) the
as follows:
majority
when
1)
of SLE
lupus
activity
minimal.
study
complications
zoster
and
with
in
been
infection
of herpes
relatively
patients
zoster
has
frequent
zoster
developed
Our
herpes
found
association
course
patients
of
malignancy
disease
year
of PM-DM
showed
nor
tended
deaths
to occur
On
the
平成2年11月20日
that
other
the
occurred
in the
hand,
inactive
it was
clinical
and
courses
only
stage
different
one
of PM-DM.
from
of
patient
In
SLE
zoster
infections
developed
addition
that
were
posttherapeutic
, no specific
there
were
no
therapy
multiple
uneventful;
no
neuralgia,
for
this
infections
severe
and
infection
in
that
was
patients
1398
with
Shohei
PM-DM
The
and
patients
the
this
that
activity
macrophage
that
such
as
virus
and
for
compared
to
of
But
to
to
patients
be
and
our
the
more
PM-DM
of
predisposing
PM-DM.
herpes
zoster
in
in
immune
PM-DM
PM-DM
Johnson
and
destroys
muscle
cells
complex,
abnormality
patients19•`20).
by
effects
example,
which
of
induced
systemic
For
factor
detection
reported
infection,
the
may
has
infection
It
has
been
immunosuppressive
depress
in
been
other
host
in
Yasuko
Fujimura
by
agents
resistance
to
the
treated
with
in
assay
our
It
antigens
in
antinuclear
occurrence
patients
years,
investigators12•`22).
of
is
our
antibody.
zoster
corticosteroids,
zoster
PM-DM
a significantly
recent
nuclear
a positive
the
had
In
to
and
of
our
zoster
clear.
several
showing
therapy
development
zoster
not
autoantibodies
diseases
were
predisposed
herpes
is
reported
for
steroid
infection
herpes
with
correlation
study
between
which
this
detailed
zoster
patients
of
extract
a more
with
of
of
of
PM-DM.
produced
and
etiology
nuclear
factors
been
zoster
correlation
development
PM
addition,
These
A
examine
patients
unknown
the
have
without
no
onset
virus.
of zoster
was
with
In
patients.
thymus
incidences
in
spontaneously
antibody.
to
the
incidence
observations.
patients
found
latent
group
calf
there
overall
Thus,
the
necessary
series,
possibility
PM-DM
after
increased
immunopathogenesis
factor
is
antinuclear
autoantibodies
considered
In
inhibitory
of
an
corticosteroids1).
immunity
reactivation
incidence
of
et al
durations
with
from
by
in
permit
varius
and
variety
lymphocytes
corticosteroids,
When
higher
a
is blocked
defective
in
associated
speculations
migration
speculated
occurred
factors
supports
showed
that
infection
following
evidence
co-workers
of
this
predisposig
showed
Recent
and
that
possible
NAGAOKA
infection.
and
there
is
the
patients.
might
be
related
to
several
factors.
Acknowledgement
We
thank
Miss
for
preparation
of
this
manuscript.
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多発性筋炎患者および皮膚筋炎患者における帯状包疹
横浜市立大学第1内科
長岡
章平
千場
純
成田
雅弘
谷
賢治
石ヶ坪良明
清
松永敬一郎
五十嵐俊久
大久保隆男
加藤
(平成63年6月22日受付)
(平成2年5月1日
多発性筋炎(皮膚筋炎)患者における帯状包疹
症の臨床的特徴を解析する目的で,22名
者,20名
のポジキンリンパ腫症患者,22名
の本症患
の全身
受理)
多発筋炎(皮
膚筋炎)患
神経痛が1例
あったが,重
性エリテマトーデス患者を対象として,病歴を検
亡例もなかった.(2)本
討し,その臨床像を分析した.
はなかった.(3)多
健常人における帯状包疹の発症率は0.003%/年
であるが,多発筋炎(皮
膚筋炎)患
者のそれは
0.13%/年,ポ
ジキンリンパ腫症患者のそれは
0.18%/年,全
身性エリテマトーデス患者のそれは
0.24%/年
であった.
平成2年11月20日
者における帯状包疹症
の臨床的特徴は以下の通りである.(1)治
療後の
篤な合併症はなく,死
症に特殊な治療法の必要
発筋炎(皮
膚筋炎)の
期に本症が発症する傾向があった.(4)本
非活動
症が発
症した患者では,抗核抗体が高値を示した.
本症の発症と,ステロイド剤の初期投与量,維
持量,投与期間との間の相関は認められなかった.

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