Tacrolimus for antisynthetase syndrome with interstitial lung disease?

To the Editors:

We read with great interest the recent case study by Guglielmi et al. 1. They described the clinical course of a 52-yr-old male admitted to hospital for life-threatening acute respiratory distress syndrome (ARDS) and diagnosed with anti-Jo-1 antibody positive polymyositis (antisynthetase syndrome). Improvement and recovery were mainly attributed to institution of immunomodulatory therapy with tacrolimus.

Polymyositis patients with anti-Jo-1 antibodies are generally responsive to corticosteroids 2. The patient’s condition improved when he was given high-dose corticosteroids. He was successfully weaned from the ventilator on day 6 after intubation (which is very good for ARDS). Given that steroids are not greatly beneficial in the treatment of ARDS 3, it is likely that the improvement of the respiratory symptoms in this patient also resulted from the prompt suppression of the inflammatory systemic response by corticosteroids. This, together with appropriate mechanical ventilation, was probably the main reason for a successful outcome. Tacrolimus may have had little or no role in the patient’s recovery as it is slow-acting and unlikely to have been playing a significant role for several weeks.

In severe interstitial lung disease associated with polymyositis/dermatomyositis that is refractory to corticosteroids, cyclophosphamide has been the treatment of choice in many centres. Tacrolimus has not been widely investigated, it is overly expensive and important adverse events (more nephrotoxicity and neurotoxicity compared with ciclosporin) are common. However, tacrolimus could be reserved for those refractory cases who respond poorly to standard combination regimen.

Finally, could any of the clinical situations be explained by drug side-effects, such as the pneumonitis and rhabdomyolysis that can occur with levofloxacin. Further details of the patient history would also be helpful. Has the pulmonary disease and myositis remained in remission and what therapy is currently being used? We would also encourage the diagnosis of myositis using electromyography and a muscle biopsy.

Statement of interest

None declared.