Frank myositis is an uncommon manifestation of systemic vasculitides. In fact, it has been reported in different vasculitic syndromes, most notably in polyarteritis nodosa, AAV, and rheumatoid vasculitis. Granulomatosis with polyangiitis, microscopic polyangiitis, and eosinophilic granulomatosis with polyangiitis—the three subsets of AAV—have been rarely reported to present with myositis.1
When a part of AAV, myositis is usually accompanied by other systemic manifestations of the disease. Muscle enzymes tend to be normal or marginally elevated, and inflammatory markers appear high.1 While the imaging findings were traditionally considered indistinguishable from those in IIMs, a recent MRI comparison study suggested that fascial and diffuse subcutaneous fat hyperintensities are more prominent in microscopic polyangiitis than in IIMs.2
In a review of 310 muscle biopsies performed in one center, 31 (10%) patients had a final diagnosis of systemic vasculitis. Of these, AAV was present in 22 patients (~71%). In muscle biopsies of patients diagnosed with systemic vasculitis, 66.7% showed signs of small-vessel inflammation, both necrotizing and non-necrotizing; the rest were considered normal. Myalgia and elevated creatine phosphokinase (CPK) were not found to be predictive of muscle biopsy positivity. In this study, the sensitivity of muscle biopsy for detecting vasculitis was overall good (~67%); the specificity was close to 100%.3
In another retrospective study of 78 patients with AAV (all of whom underwent muscle biopsy as a part of the diagnostic work-up), 45 (58%) patients had positive biopsies. Anti-myeloperoxidase antibody, female sex, and elevated neutrophil count were predictors of biopsy positivity.4
There is scarce evidence in the literature suggesting successful control of myositis in AAV with corticosteroids, methotrexate, azathioprine, mycophenolate mofetil, intravenous immunoglobulin, and cyclophosphamide, among other drugs.1
A well-known feature of AAV is CNS involvement. While hypertrophic pachymeningitis is the most frequent CNS presentation, cerebrovascular events, hypophysitis, isolated mass lesions, and seizures may occur. Ischemic infarctions typically present as isolated or multiple lesions affecting the white matter. Peripheral neuropathy may also be a manifestation of AAV.5
The muscle biopsy performed on our patient showed no clear necrosis or inflammation, but proved the deposition of MHC-I and MAC. The latter finding signifies an immune-mediated insult.6 The absence of clear findings on hematoxylin and eosin staining does not definitely rule out the diagnosis of myositis, since a false-negative rate of more than 20% may be present in muscle biopsies.7 The impressive MRI findings further supported our patient’s diagnosis. Fraser et al. found that signal intensity scores on short tau inversion recovery (STIR) were more sensitive in detecting myositis disease activity than was the presence of pathologic changes on muscle biopsy.8
Anti-SRP antibody was positive in our patient. Although this autoantibody is considered specific for IMNM, it may also appear in otherwise healthy patients.9 It is directed against a ribonucleoprotein complex involved in the regulation of protein translocation across the endoplasmic reticulum. Patients with IMNM tend to have pure myositis with very elevated muscle enzymes; muscle histopathology usually shows scant inflammation and prominent necrosis.6
Our patient had features that supported a diagnosis of AAV, including the presence of sinusitis, peripheral neuropathy, mild eosinophilia, only slightly elevated muscle enzymes, and positive p-ANCA. He also had features suggestive of an IIM, including muscle weakness, myalgia, anti-SRP positivity, and the deposition of MAC and MHC-I on biopsy. This combination of findings compatible with AAV and IIM remains extremely rare. Taking into consideration the two diagnoses, therapy with corticosteroids and rituximab was selected.