Orbital myositis and rheumatoid arthritis: case report

Abstract

-Orbital myositis implies orbital inflammation confined to one or more of the extraocular muscles. The acute form responds well to high doses of oral corticosteroids tapered gradually, but it may recur or become chronic. We describe a 38 years old female who has been suffering from rheumatoid arthritis for six years. She developed diplopia as a result of a paralysis of the right and left rectus medialis muscle. MRI showed inflammatory process and thickness of the referred muscles. The patient had a total recovery with oral use of 80 mg methylpredinisolone daily. Two months after the first episode she developed a bilateral ophthalmoplegy. The patient improved with oral use of steroids the second time, but a paresis of the left rectus lateralis muscle remained. From the 156 cases we reviewed only three have been related to rheumatic diseases and none has been previously related to rheumatoid arthritis.KEY WORDS: orbital myositis, ophthalmoplegy, rheumatoid arthritis.Miosite orbitária e artrite reumatóide: relato de caso RESUMO -Miosite orbitaria é a inflamação de um ou mais músculos extraoculares. A forma aguda responde ao tratamento com doses altas de esteróides, porém pode-se tornar recorrente ou crônica. Relatamos uma paciente de 38 anos de idade, portadora de artrite reumatoide há 6 anos, que apresentou diplopia e cefaléia de um mês de evolução. A ressonância magnética (RM) de órbitas mostrou processo inflamatório e espessamento dos músculos reto mediais. A paciente apresentou recuperação completa após o uso de 80 mg/dia de metilprednisolona. Dois meses depois, ela apresentou oftalmoplegia bilateral que acometia toda a musculatura ocular extrínseca. Desta vez, a RM foi normal. A paciente melhorou com nova série do esteroide, porém permaneceu com paresia do músculo reto lateral esquerdo como sequela. Revisamos 153 casos de miosite orbitaria publicados; apenas três estavam relacionados com doenças reumatológicas e nenhum deles com artrite reumatóide. PALAVRAS-CHAVES: miosite orbitária, artrite reumatoide,oftalmoplegia.

Orbital inflammatory disease management

“…Both cases responded well to a temporary increased dose of oral prednisone [126,127]. In another case of RA-associated OID, disease had been well controlled on regular adalimumab when the patient developed orbital involvement.…”

“…Although exceedingly rare, orbital manifestations, including myositis [126,127] and diffuse orbital inflammatory disease (OID) [128], have been reported in patients with RA.…”

Non-infectious orbital vasculitides

“…Other patients developed a myositis with enlargement of the muscles on CT. 83,84,86 Reported cases of orbital inflammation in RA mostly involve patients with limited extraocular movements secondary to a myositis. Nabili et al 92 and Panfilio et al 93 reported cases of extraocular muscle enlargement in patients with a prior history of RA. Orbital biopsy was not performed in either case, therefore it is difficult to determine the exact etiology of the myositis.…”

“…Patients in the literature have been successfully treated with oral or IV glucocorticoids. [81][82][83][84][85][86][87][88][89][90][91][92][93] Most patients had complete resolution of symptoms after initiating therapy, although there were four cases in which the patients had a recurrence of disease and needed an increase in dosage. [89][90][91] Treatment with steroids was always in addition to their ongoing treatment for SLE or RA.…”

Idiopathic Orbital Inflammation Successfully Treated Using Rituximab in a Patient with Rheumatoid Arthritis: Figure 1.

“…A common feature of many autoimmune diseases is the deposition of autoantibody in tissues at various sites around the body, leading to the fixation and activation of complement, and resulting in generation of the inflammatory response 7 . Reports describe development of localized IOI in patients with RA 8,9 , the first of which describes successful treatment of a 38-year-old woman with a 6-year history of seropositive RA, with high-dose methylprednisolone 9 . However, despite use of IV methylprednisolone and MTX in our case, symptom resolution is attributed to RTX alone.…”