Unusual instance of a syndrome featuring multiple autoimmune disorders, featuring a case study involving myocarditis
In an unusual turn of events, a 46-year-old female patient with known autoimmune disorders - rheumatoid arthritis (RA) and secondary Sjogren's syndrome (GSJ) - was diagnosed with myocarditis, a condition that is not commonly reported in patients with the overlap of RA and SjS.
Myocarditis, an inflammation of the heart muscle, is a rare occurrence in patients with RA and even more so in those with SjS. While cardiac manifestations such as pericarditis and pericardial effusion are relatively more frequent in RA, myocarditis itself is not commonly reported, especially in patients with the combination of RA and SjS [1].
The patient's case presents an atypical combination of the three conditions. Cardiac MRI, considered the test of choice for monitoring cardiotoxicity in patients undergoing long-term treatment with disease-modifying antirheumatic drugs (DMARDs), confirmed the presence of myocarditis, likely of autoimmune origin.
The patient's troponin level was markedly elevated at 1090 ng/ml, a clear indication of myocardial damage. The uncommon occurrence of myocarditis in rheumatoid arthritis, and even more so in Sjogren's syndromes, is noteworthy in this case.
Giant cell myocarditis (GCM), a form of myocarditis assumed to have an immunological mechanism with a worse prognosis, has also been reported in the context of RA. Aggressive immunosuppressive therapy appears to improve the prognosis of affected patients with GCM.
The patient was administered 20 mg hydrocortisone daily due to a history of corticosteroid-induced adrenal insufficiency. The patient was also treated with 20 mg methotrexate weekly for rheumatoid arthritis.
Myocarditis is classified as type 3 multiple autoimmune syndrome (MAS) and typically does not present with connective tissue involvement. However, conditions such as autoimmune thyroid disease, RA, myasthenia gravis, aortitis, vitiligo vulgaris, pernicious anemia, inflammatory bowel disease, and orbital myositis have all been associated with GCM.
Interstitial and granulomatous forms of myocarditis have been the most frequently described in the course of rheumatoid arthritis (RA), with a greater specificity for the granulomatous form. These abnormalities may also be observed in other autoimmune rheumatic diseases (AIRD), such as systemic lupus erythematosus (SLE), systemic sclerosis (SSc), and inflammatory myopathies.
While the literature does not provide specific prevalence data for myocarditis in patients who have both RA and SjS, indicating that this combination with myocarditis as a complication is either very rare or underreported, further studies are needed to better understand this complex interplay of autoimmune diseases.
[1] Reference: [Insert appropriate citation here]
Ultrasonography could be useful in monitoring the patient's cardiovascular health due to her chronic diseases and previous medical-conditions. The science of sports-analysis may find interest in this case, as it sheds light on the potential impact of autoimmune disorders on athletes' health. Neurological disorders, while not immediately apparent in this case, need to be monitored closely given the patient's autoimmune history. Cancer and other life-threatening conditions, although not currently evident, should also be considered in future assessments due to the patient's autoimmune disorders.
