Polymyositis and dermatomyositis pathophysiology: Difference between revisions

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Latest revision as of 23:47, 29 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sadaf Sharfaei M.D.[2]

Overview

The exact pathogenesis of polymyositis and dermatomyositis is not fully understood. However, it is understood that polymyositis and dermatomyositis are the result of autoimmune attack but triggering factors are not well-known. Polymyositis is caused by inflammation and degeneration of the muscles. In polymyositis, CD8-positive cytotoxic T cells invade muscle fibers that express MHC class I antigens which may leads to fiber necrosis via the perforin pathway. Hypoxia may reduce creatine phosphate and adenosine triphosphate (ATP) levels in muscle and lead to fatigue and muscle weakness. Dermatomyositis is caused by skin inflammation. In dermatomyositis, activation and deposition of complements may lead to lysis of endomysial capillaries and muscle ischemia. Genes including HLA DRB1*0301 and HLA DQA1*0501 alleles, and tumour necrosis factor 308A might be associated with development of polymyositis and dermatomyositis, especially in familial cases. Different conditions associated with polymyositis and dermatomyositis include respiratory and cardiac diseases, other connective tissue diseases, and malignancies. On microscopic histopathological analysis, partial invasion of lymphocytes within the muscle fibers and regenerating fibers with enlarged nuclei are characteristic findings of polymyositis.

Pathophysiology

Pathogenesis

The exact pathogenesis of polymyositis and dermatomyositis is not fully understood. However, it is understood that polymyositis and dermatomyositis are the result of autoimmune attack but triggering factors are not well-known.^[1]^[2]^[3]^[4]^[5]

Polymyositis

Polymyositis is caused by inflammation and degeneration of the muscles.
In polymyositis, CD8-positive cytotoxic T cells invade muscle fibers that express MHC class I antigens which may lead to fiber necrosis via the perforin pathway.
Hypoxia may reduce creatine phosphate and adenosine triphosphate (ATP) levels in muscle and lead to fatigue and muscle weakness.
Interleukin (IL) 21, tumor growth factor-b (TGF-b), and high-mobility group protein 1 (HMG-1) induce muscle fatigue by decreasing Ca release.

Dermatomyositis

Dermatomyositis is caused by skin inflammation.^[6]^[7]^[8]^[9]
In dermatomyositis, activation and deposition of complements may lead to lysis of endomysial capillaries and muscle ischemia.^[4]

Genetics

Genes might be associated with development of polymyositis and dermatomyositis, especially in familial cases, which include:^[10]
- HLA DRB1*0301 alleles for polymyositis and inclusion-body myositis
- HLA DQA1*0501 for juvenile dermatomyositis,
- Tumour necrosis factor 308A polymorphism for photosensitivity in dermatomyositis

Associated Conditions

Different conditions associated with polymyositis and dermatomyositis include:

Association	Polymyositis	Dermatomyositis
Malignancy	Lung Kidney Breast Bladder Endometrial Cervical Thyroid Lymphoma Myeloma Brain	5-7 fold more risks than the general population Lung Ovarian Breast Colorectal Cervical Bladder Nasopharyngeal Esophageal Pancreatic Kidney

Microscopic Pathology

On microscopic histopathological analysis of polymyositis, partial invasion of lymphocytes within the muscle fibers and regenerating fibers with enlarged nuclei are characteristic findings.
On microscopic histopathological analysis of dermatomyositis, perifascicular inflammation with perifascicular atrophy and loss of vessels around muscle fibers are characteristic findings.

Muscle biopsy frozen section specimen - Myositis (HE stain)-Partial invasion of lymphocytes within the muscle fibers via librepathology.org^[11]	Muscle biopsy frozen section specimen - Myositis (CD45 stain) Partial invasion of lymphocytes within the muscle fibers via librepathology.org^[12]
Immunostain in a case of dermatomyositis displaying complement complex depositis of C5b9 Via librepathology.org^[13]	Histopathology specimen - muscle biopsy with perifascicular atrophy of myofibers as seen in dermatomyositis via librepathology.org^[14]

References

↑ Khan, Sabiha; Christopher-Stine, Lisa (2011). "Polymyositis, Dermatomyositis, and Autoimmune Necrotizing Myopathy: Clinical Features". Rheumatic Disease Clinics of North America. 37 (2): 143–158. doi:10.1016/j.rdc.2011.01.001. ISSN 0889-857X.
↑ Dobloug, Cecilie; Garen, Torhild; Bitter, Helle; Stjärne, Johan; Stenseth, Guri; Grøvle, Lars; Sem, Marthe; Gran, Jan Tore; Molberg, Øyvind (2015). "Prevalence and clinical characteristics of adult polymyositis and dermatomyositis; data from a large and unselected Norwegian cohort". Annals of the Rheumatic Diseases. 74 (8): 1551–1556. doi:10.1136/annrheumdis-2013-205127. ISSN 0003-4967.
↑ Chinoy, H.; Fertig, N.; Oddis, C. V; Ollier, W. E R; Cooper, R. G (2007). "The diagnostic utility of myositis autoantibody testing for predicting the risk of cancer-associated myositis". Annals of the Rheumatic Diseases. 66 (10): 1345–1349. doi:10.1136/ard.2006.068502. ISSN 0003-4967.
↑ ^4.0 ^4.1 Dalakas, Marinos C; Hohlfeld, Reinhard (2003). "Polymyositis and dermatomyositis". The Lancet. 362 (9388): 971–982. doi:10.1016/S0140-6736(03)14368-1. ISSN 0140-6736.
↑ Douglas, William W.; Tazelaar, Henry D.; Hartman, Thomas E.; Hartman, Robert P.; Decker, Paul A.; Schroeder, Darrell R.; Ryu, Jay H. (2001). "Polymyositis–Dermatomyositis-associated Interstitial Lung Disease". American Journal of Respiratory and Critical Care Medicine. 164 (7): 1182–1185. doi:10.1164/ajrccm.164.7.2103110. ISSN 1073-449X.
↑ Bodoki L, Nagy-Vincze M, Griger Z, Betteridge Z, Szöllősi L, Dankó K (December 2014). "Four dermatomyositis-specific autoantibodies-anti-TIF1γ, anti-NXP2, anti-SAE and anti-MDA5-in adult and juvenile patients with idiopathic inflammatory myopathies in a Hungarian cohort". Autoimmun Rev. 13 (12): 1211–9. doi:10.1016/j.autrev.2014.08.011. PMID 25182203.
↑ Tiniakou E, Mammen AL (February 2017). "Idiopathic Inflammatory Myopathies and Malignancy: a Comprehensive Review". Clin Rev Allergy Immunol. 52 (1): 20–33. doi:10.1007/s12016-015-8511-x. PMID 26429706.
↑ Bohan, Anthony; Peter, James B. (1975). "Polymyositis and Dermatomyositis". New England Journal of Medicine. 292 (8): 403–407. doi:10.1056/NEJM197502202920807. ISSN 0028-4793.
↑ Adler BL, Christopher-Stine L (February 2018). "Triggers of inflammatory myopathy: insights into pathogenesis". Discov Med. 25 (136): 75–83. PMID 29579414.
↑ Dalakas, Marinos C; Hohlfeld, Reinhard (2003). "Polymyositis and dermatomyositis". The Lancet. 362 (9388): 971–982. doi:10.1016/S0140-6736(03)14368-1. ISSN 0140-6736.
↑ "File:Neuropathology case XII 01.jpg - Libre Pathology".
↑ "File:Neuropathology case XII 03.jpg - Libre Pathology".
↑ "File:Dermatomyositis c5b9.jpg - Libre Pathology".
↑ "File:NP MGMT 0252.jpg - Libre Pathology".

[KhanChristopher-Stine2011-1] Khan, Sabiha; Christopher-Stine, Lisa (2011). "Polymyositis, Dermatomyositis, and Autoimmune Necrotizing Myopathy: Clinical Features". Rheumatic Disease Clinics of North America. 37 (2): 143–158. doi:10.1016/j.rdc.2011.01.001. ISSN 0889-857X.

[DoblougGaren2015-2] Dobloug, Cecilie; Garen, Torhild; Bitter, Helle; Stjärne, Johan; Stenseth, Guri; Grøvle, Lars; Sem, Marthe; Gran, Jan Tore; Molberg, Øyvind (2015). "Prevalence and clinical characteristics of adult polymyositis and dermatomyositis; data from a large and unselected Norwegian cohort". Annals of the Rheumatic Diseases. 74 (8): 1551–1556. doi:10.1136/annrheumdis-2013-205127. ISSN 0003-4967.

[ChinoyFertig2007-3] Chinoy, H.; Fertig, N.; Oddis, C. V; Ollier, W. E R; Cooper, R. G (2007). "The diagnostic utility of myositis autoantibody testing for predicting the risk of cancer-associated myositis". Annals of the Rheumatic Diseases. 66 (10): 1345–1349. doi:10.1136/ard.2006.068502. ISSN 0003-4967.

[DalakasHohlfeld2003-4] 4.0 ^4.1 Dalakas, Marinos C; Hohlfeld, Reinhard (2003). "Polymyositis and dermatomyositis". The Lancet. 362 (9388): 971–982. doi:10.1016/S0140-6736(03)14368-1. ISSN 0140-6736.

[DouglasTazelaar2001-5] Douglas, William W.; Tazelaar, Henry D.; Hartman, Thomas E.; Hartman, Robert P.; Decker, Paul A.; Schroeder, Darrell R.; Ryu, Jay H. (2001). "Polymyositis–Dermatomyositis-associated Interstitial Lung Disease". American Journal of Respiratory and Critical Care Medicine. 164 (7): 1182–1185. doi:10.1164/ajrccm.164.7.2103110. ISSN 1073-449X.

[pmid25182203-6] Bodoki L, Nagy-Vincze M, Griger Z, Betteridge Z, Szöllősi L, Dankó K (December 2014). "Four dermatomyositis-specific autoantibodies-anti-TIF1γ, anti-NXP2, anti-SAE and anti-MDA5-in adult and juvenile patients with idiopathic inflammatory myopathies in a Hungarian cohort". Autoimmun Rev. 13 (12): 1211–9. doi:10.1016/j.autrev.2014.08.011. PMID 25182203.

[pmid26429706-7] Tiniakou E, Mammen AL (February 2017). "Idiopathic Inflammatory Myopathies and Malignancy: a Comprehensive Review". Clin Rev Allergy Immunol. 52 (1): 20–33. doi:10.1007/s12016-015-8511-x. PMID 26429706.

[BohanPeter1975-8] Bohan, Anthony; Peter, James B. (1975). "Polymyositis and Dermatomyositis". New England Journal of Medicine. 292 (8): 403–407. doi:10.1056/NEJM197502202920807. ISSN 0028-4793.

[pmid29579414-9] Adler BL, Christopher-Stine L (February 2018). "Triggers of inflammatory myopathy: insights into pathogenesis". Discov Med. 25 (136): 75–83. PMID 29579414.

[DalakasHohlfeld20032-10] Dalakas, Marinos C; Hohlfeld, Reinhard (2003). "Polymyositis and dermatomyositis". The Lancet. 362 (9388): 971–982. doi:10.1016/S0140-6736(03)14368-1. ISSN 0140-6736.

[urlFile:Neuropathology_case_XII_01.jpg_-_Libre_Pathology-11] "File:Neuropathology case XII 01.jpg - Libre Pathology".

[urlFile:Neuropathology_case_XII_03.jpg_-_Libre_Pathology-12] "File:Neuropathology case XII 03.jpg - Libre Pathology".

[urlFile:Dermatomyositis_c5b9.jpg_-_Libre_Pathology-13] "File:Dermatomyositis c5b9.jpg - Libre Pathology".

[urlFile:NP_MGMT_0252.jpg_-_Libre_Pathology-14] "File:NP MGMT 0252.jpg - Libre Pathology".

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@@ Line 4: / Line 4: @@
 {{CMG}}; {{AE}} {{SSH}}
 ==Overview==
-The exact pathogenesis of polymyositis and dermatomyositis is not fully understood.
+The exact pathogenesis of polymyositis and dermatomyositis is not fully understood. However, it is understood that polymyositis and dermatomyositis are the result of [[Autoimmunity|autoimmune]] attack but triggering factors are not well-known. Polymyositis is caused by [[inflammation]] and [[degeneration]] of the [[Muscle|muscles]]. In polymyositis, [[CD8-positive cytotoxic T cells]] invade [[Skeletal muscle|muscle fibers]] that express [[MHC class I]] antigens which may leads to fiber [[necrosis]] via the [[perforin]] pathway. [[Hypoxemia|Hypoxia]] may reduce [[Phosphocreatine|creatine phosphate]] and [[adenosine triphosphate]] ([[Adenosine triphosphate|ATP]]) levels in [[muscle]] and lead to [[fatigue]] and [[muscle weakness]]. Dermatomyositis is caused by skin [[inflammation]]. In dermatomyositis, activation and deposition of [[complements]] may lead to lysis of endomysial [[Capillary|capillaries]] and muscle [[ischemia]]. [[Gene|Genes]] including [[HLA-DRB1|HLA DRB1*0301]] and [[HLA-DQ|HLA DQA1*0501]] alleles, and [[tumour necrosis factor]] 308A might be associated with development of polymyositis and dermatomyositis, especially in familial cases. Different conditions associated with polymyositis and dermatomyositis include [[Respiratory system|respiratory]] and [[Heart|cardiac]] diseases, other [[Connective tissue disease|connective tissue diseases]], and [[Cancer|malignancies]]. On microscopic histopathological analysis, partial invasion of [[Lymphocyte|lymphocytes]] within the [[Skeletal muscle|muscle fibers]] and regenerating fibers with enlarged [[Cell nucleus|nuclei]] are characteristic findings of polymyositis.
 ==Pathophysiology==
 ===Pathogenesis===
-The exact pathogenesis of polymyositis and dermatomyositis is not fully understood. However, it is understood that polymyositis and dermatomyositis are the result of autoimmune attack but triggering factors of are not well-known.
+The exact pathogenesis of polymyositis and dermatomyositis is not fully understood. However, it is understood that polymyositis and dermatomyositis are the result of autoimmune attack but triggering factors are not well-known.<ref name="KhanChristopher-Stine2011">{{cite journal|last1=Khan|first1=Sabiha|last2=Christopher-Stine|first2=Lisa|title=Polymyositis, Dermatomyositis, and Autoimmune Necrotizing Myopathy: Clinical Features|journal=Rheumatic Disease Clinics of North America|volume=37|issue=2|year=2011|pages=143–158|issn=0889857X|doi=10.1016/j.rdc.2011.01.001}}</ref><ref name="DoblougGaren2015">{{cite journal|last1=Dobloug|first1=Cecilie|last2=Garen|first2=Torhild|last3=Bitter|first3=Helle|last4=Stjärne|first4=Johan|last5=Stenseth|first5=Guri|last6=Grøvle|first6=Lars|last7=Sem|first7=Marthe|last8=Gran|first8=Jan Tore|last9=Molberg|first9=Øyvind|title=Prevalence and clinical characteristics of adult polymyositis and dermatomyositis; data from a large and unselected Norwegian cohort|journal=Annals of the Rheumatic Diseases|volume=74|issue=8|year=2015|pages=1551–1556|issn=0003-4967|doi=10.1136/annrheumdis-2013-205127}}</ref><ref name="ChinoyFertig2007">{{cite journal|last1=Chinoy|first1=H.|last2=Fertig|first2=N.|last3=Oddis|first3=C. V|last4=Ollier|first4=W. E R|last5=Cooper|first5=R. G|title=The diagnostic utility of myositis autoantibody testing for predicting the risk of cancer-associated myositis|journal=Annals of the Rheumatic Diseases|volume=66|issue=10|year=2007|pages=1345–1349|issn=0003-4967|doi=10.1136/ard.2006.068502}}</ref><ref name="DalakasHohlfeld2003">{{cite journal|last1=Dalakas|first1=Marinos C|last2=Hohlfeld|first2=Reinhard|title=Polymyositis and dermatomyositis|journal=The Lancet|volume=362|issue=9388|year=2003|pages=971–982|issn=01406736|doi=10.1016/S0140-6736(03)14368-1}}</ref><ref name="DouglasTazelaar2001">{{cite journal|last1=Douglas|first1=William W.|last2=Tazelaar|first2=Henry D.|last3=Hartman|first3=Thomas E.|last4=Hartman|first4=Robert P.|last5=Decker|first5=Paul A.|last6=Schroeder|first6=Darrell R.|last7=Ryu|first7=Jay H.|title=Polymyositis–Dermatomyositis-associated Interstitial Lung Disease|journal=American Journal of Respiratory and Critical Care Medicine|volume=164|issue=7|year=2001|pages=1182–1185|issn=1073-449X|doi=10.1164/ajrccm.164.7.2103110}}</ref>
 ==== Polymyositis ====
 *Polymyositis is caused by [[inflammation]] and [[degeneration]] of the [[Muscle|muscles]].
-*In polymyositis, CD8-positive cytotoxic T cells invade muscle fibres that express MHC class I antigens which may leads to fibre necrosis via the perforin pathway.
+*In polymyositis, CD8-positive cytotoxic T cells invade muscle fibers that express MHC class I antigens which may lead to fiber necrosis via the perforin pathway.
+*Hypoxia may reduce creatine phosphate and adenosine triphosphate (ATP) levels in muscle and lead to fatigue and muscle weakness.
+*Interleukin (IL) 21, tumor growth factor-b (TGF-b), and high-mobility group protein 1 (HMG-1) induce muscle fatigue by decreasing Ca release.
 ==== Dermatomyositis ====
 *Dermatomyositis is caused by skin [[inflammation]].<ref name="pmid25182203">{{cite journal |vauthors=Bodoki L, Nagy-Vincze M, Griger Z, Betteridge Z, Szöllősi L, Dankó K |title=Four dermatomyositis-specific autoantibodies-anti-TIF1γ, anti-NXP2, anti-SAE and anti-MDA5-in adult and juvenile patients with idiopathic inflammatory myopathies in a Hungarian cohort |journal=Autoimmun Rev |volume=13 |issue=12 |pages=1211–9 |date=December 2014 |pmid=25182203 |doi=10.1016/j.autrev.2014.08.011 |url=}}</ref><ref name="pmid26429706">{{cite journal |vauthors=Tiniakou E, Mammen AL |title=Idiopathic Inflammatory Myopathies and Malignancy: a Comprehensive Review |journal=Clin Rev Allergy Immunol |volume=52 |issue=1 |pages=20–33 |date=February 2017 |pmid=26429706 |doi=10.1007/s12016-015-8511-x |url=}}</ref><ref name="BohanPeter1975">{{cite journal|last1=Bohan|first1=Anthony|last2=Peter|first2=James B.|title=Polymyositis and Dermatomyositis|journal=New England Journal of Medicine|volume=292|issue=8|year=1975|pages=403–407|issn=0028-4793|doi=10.1056/NEJM197502202920807}}</ref><ref name="pmid29579414">{{cite journal |vauthors=Adler BL, Christopher-Stine L |title=Triggers of inflammatory myopathy: insights into pathogenesis |journal=Discov Med |volume=25 |issue=136 |pages=75–83 |date=February 2018 |pmid=29579414 |doi= |url=}}</ref>
 *In dermatomyositis, activation and deposition of complements may lead to lysis of endomysial capillaries and muscle ischemia.<ref name="DalakasHohlfeld2003">{{cite journal|last1=Dalakas|first1=Marinos C|last2=Hohlfeld|first2=Reinhard|title=Polymyositis and dermatomyositis|journal=The Lancet|volume=362|issue=9388|year=2003|pages=971–982|issn=01406736|doi=10.1016/S0140-6736(03)14368-1}}</ref>
-====Antisynthetase syndrome====
-*
-====Amyopathic dermatomyositis====
-*
 ==Genetics==
-*[Disease name] is transmitted in [mode of genetic transmission] pattern.
-*Genes involved in the pathogenesis of [disease name] include [gene1], [gene2], and [gene3].
-*The development of [disease name] is the result of multiple genetic mutations.
 *Genes might be associated with development of polymyositis and dermatomyositis, especially in familial cases, which include:<ref name="DalakasHohlfeld20032">{{cite journal|last1=Dalakas|first1=Marinos C|last2=Hohlfeld|first2=Reinhard|title=Polymyositis and dermatomyositis|journal=The Lancet|volume=362|issue=9388|year=2003|pages=971–982|issn=01406736|doi=10.1016/S0140-6736(03)14368-1}}</ref>
 **HLA DRB1*0301 alleles for polymyositis and inclusion-body myositis
@@ Line 38: / Line 32: @@
 *[[Conduction disorders|Conduction abnormalities]] and [[Cardiac arrhythmia|arrhythmia]]
 *[[Myocardial infarction]]
-*Malignancy in patients with dermatomyositis (5-7 fold more risks than the general population) include:<ref name="TiniakouMammen2015">{{cite journal|last1=Tiniakou|first1=Eleni|last2=Mammen|first2=Andrew L.|title=Idiopathic Inflammatory Myopathies and Malignancy: a Comprehensive Review|journal=Clinical Reviews in Allergy & Immunology|volume=52|issue=1|year=2015|pages=20–33|issn=1080-0549|doi=10.1007/s12016-015-8511-x}}</ref>
-**Lung
-**Ovarian
-**Breast
-**Colorectal
-**Cervical
-**Bladder
-**Nasopharyngeal
-**Esophageal
-**Pancreatic
-**Kidney
-*Malignancy in patients with polymyositis include:
-**Lung
-**Kidney
-**Breast
-**Bladder
-**Endometrial
-**Cervical
-**Thyroid
-**Lymphoma
-**Myeloma
-**Brain
 *Other [[Connective tissue disease|connective tissue diseases]] like
 **[[Scleroderma]]
@@ Line 66: / Line 38: @@
 **[[Rheumatoid arthritis]]
 **[[Sjögren's syndrome]]
+*[[Cancer|Malignancies]] are as follows:
-==Gross Pathology==
+{|
-*On gross pathology, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].
+! align="center" style="background:#4479BA; color: #FFFFFF;" + |Association
+! align="center" style="background:#4479BA; color: #FFFFFF;" + |Polymyositis
+! align="center" style="background:#4479BA; color: #FFFFFF;" + |Dermatomyositis
+|-
+! align="center" style="background:#DCDCDC;" + |[[Cancer|Malignancy]]
+| align="left" style="background:#F5F5F5;" + |
+*[[Lung]]
+*[[Kidney]]
+*[[Breast]]
+*[[Urinary bladder|Bladder]]
+*[[Endometrium|Endometrial]]
+*[[Cervical]]
+*[[Thyroid]]
+*[[Lymphoma]]
+*[[Multiple myeloma|Myeloma]]
+*[[Brain]]
+| align="left" style="background:#F5F5F5;" + |5-7 fold more risks than the general population
+*[[Lung]]
+*[[Ovary|Ovarian]]
+*[[Breast]]
+*[[Colon (anatomy)|Colorectal]]
+*[[Cervical]]
+*[[Urinary bladder|Bladder]]
+*[[Nasopharynx|Nasopharyngeal]]
+*[[Esophageal]]
+*[[Pancreas|Pancreatic]]
+*[[Kidney]]
+|}
 ==Microscopic Pathology==
-*On microscopic histopathological analysis, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].
+*On microscopic histopathological analysis of polymyositis, partial invasion of [[Lymphocyte|lymphocytes]] within the [[Skeletal muscle|muscle fibers]] and regenerating fibers with enlarged [[Cell nucleus|nuclei]] are characteristic findings.
+*On microscopic histopathological analysis of dermatomyositis, perifascicular [[inflammation]] with perifascicular [[atrophy]] and loss of [[Blood vessel|vessels]] around [[Skeletal muscle|muscle fibers]] are characteristic findings.
+{|
+|[[image:Neuropathology case XII 01.jpg|thumb|500px|left|Muscle [[biopsy]] frozen section specimen - [[Myositis]] (HE stain)-Partial invasion of [[lymphocytes]] within the muscle fibers via librepathology.org<ref name="urlFile:Neuropathology case XII 01.jpg - Libre Pathology">{{cite web |url=https://librepathology.org/wiki/File:Neuropathology_case_XII_01.jpg |title=File:Neuropathology case XII 01.jpg - Libre Pathology |format= |work= |accessdate=}}</ref>]]
+|[[image:800px-Neuropathology case XII 03.jpg|thumb|500px|left|Muscle [[biopsy]] frozen section specimen - [[Myositis]] (CD45 stain) Partial invasion of [[lymphocytes]] within the muscle fibers via librepathology.org<ref name="urlFile:Neuropathology case XII 03.jpg - Libre Pathology">{{cite web |url=https://librepathology.org/wiki/File:Neuropathology_case_XII_03.jpg |title=File:Neuropathology case XII 03.jpg - Libre Pathology |format= |work= |accessdate=}}</ref>]]
+|-
+|[[image:800px-Dermatomyositis c5b9.jpg|thumb|500px|left|Immunostain in a case of dermatomyositis displaying [[complement]] complex depositis of C5b9 Via librepathology.org<ref name="urlFile:Dermatomyositis c5b9.jpg - Libre Pathology">{{cite web |url=https://librepathology.org/wiki/File:Dermatomyositis_c5b9.jpg |title=File:Dermatomyositis c5b9.jpg - Libre Pathology |format= |work= |accessdate=}}</ref>]]
+|[[image:800px-NP MGMT 0252.jpg|thumb|500px|left|Histopathology specimen - muscle biopsy with perifascicular atrophy of myofibers as seen in dermatomyositis via librepathology.org<ref name="urlFile:NP MGMT 0252.jpg - Libre Pathology">{{cite web |url=https://librepathology.org/wiki/File:NP_MGMT_0252.jpg |title=File:NP MGMT 0252.jpg - Libre Pathology |format= |work= |accessdate=}}</ref>]]
+|}
+<br style="clear:left" />
 ==References==
 {{Reflist|2}}
 [[Category:Medicine]]
 [[Category:Rheumatology]]
 [[Category:Dermatology]]
 [[Category:Up-To-Date]]
-[[Category:Primary care]]