A Rare Case of Anti-TIF-1γ Antibody Positive Dermatomyositis in Adulthood: Case Report

A Rare Case of Anti-TIF-1γ Antibody Positive Dermatomyositis in Adulthood: Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report A Rare Case of Anti-TIF-1γ Antibody Positive Dermatomyositis in Adulthood: Case Report Upasana Agrawal, Manush Sondhi, Alexandra Zamora Smith, Syeda Sara Nida, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4189638/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 3 You are reading this latest preprint version Abstract Background Dermatomyositis (DM) is characterized by inflammatory myopathy and distinct skin manifestations. It comprises a diverse clinical spectrum often associated with specific autoantibodies. Notably, the presence of anti-transcriptional intermediary factor 1-gamma (TIF-1γ) antibodies in association with DM is typically seen in older patients and is linked to malignancy in about 15% to 40% of the cases. Case Presentation A 24-year-old female with proximal weakness, periorbital edema, heliotrope rash, erosions on oral mucosa, and painful scaly rash on bilateral lower extremities presented after a syncopal episode and fall. Myomarker panel was positive for TIF-1γ antibodies. Imaging and biopsy confirmed findings consistent with inflammatory myopathy. Treatment with steroid pulse therapy and intravenous immunoglobulin led to symptomatic improvement in muscle strength and resolution of the rash. Due to positive TIF-1γ antibody results, the patient underwent evaluation for solid organ malignancy, yielding unremarkable results. Conclusion This case highlights a unique case of a young female who was diagnosed with anti-TIF-1γ Ab positive DM, deviating from the typical age pattern associated with this condition. Our goal in presenting this case is to reinforce the importance of recognizing and managing anti-TIF-1γ Ab positive DM, even in atypical demographics. Moreover, the association with malignancy necessitates a comprehensive evaluation to exclude underlying neoplasms, emphasizing the importance of multidisciplinary management involving different specialists. Dermatomyositis anti-transcriptional intermediary factor 1-gamma (TIF-1γ) antibodies malignancy Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Dermatomyositis (DM) is a rare autoimmune disease characterized by inflammatory myopathy and distinctive skin manifestations. While DM typically presents with proximal muscle weakness and skin rash, it encompasses a spectrum of clinical phenotypes, often associated with specific autoantibodies. Among these autoantibodies, anti-transcriptional intermediary factor 1-gamma (TIF-1γ) antibodies have emerged as markers for a distinct subset of DM, known for its association with malignancy and unique clinical features. Anti-TIF-1γ Ab positive DM represents a subset of dermatomyositis characterized by the presence of antibodies targeting transcriptional intermediary factor 1-gamma, a regulator of gene transcription and cellular differentiation [1]. This subtype is particularly notable for its association with cancer, especially among adult patients, with a reported incidence ranging from 15–40% [2]. The presence of TIF-1γ antibodies has been linked to a higher risk of malignancy, particularly in older patients and those with specific clinical features such as extensive cutaneous involvement and severe muscle weakness [3]. We report the intriguing case of a 24-year-old female who sought medical attention following a syncopal episode and was subsequently diagnosed with anti-TIF-1γ Ab positive DM. What distinguishes this case is the patient's age, given that this condition is usually encountered in older individuals. This case underscores the importance of recognizing anti-TIF-1γ Ab positive DM as a distinct clinical entity within the spectrum of dermatomyositis, especially in young patients presenting with characteristic clinical features. The association with malignancy necessitates a comprehensive evaluation to exclude underlying neoplasms, emphasizing the importance of multidisciplinary management involving different specialists. Case Presentation A 24-year-old female with no significant medical history presented to the hospital after experiencing a syncopal episode followed by a fall. She denied any previous episodes of syncope. Her symptoms began two months ago with intermittent episodes of vomiting and dizziness lasting about 10 days, leading to hospitalization at another facility. During this time, she also experienced proximal muscle weakness, rendering her unable to lift herself from a chair or shower independently. Additionally, she developed a scaly, non-pruritic but painful rash several months before admission, which initially appeared on her trunk and later progressed to involve her proximal bilateral upper and lower extremities. At the previous facility, she received treatment with topical emollients and steroids for the rash and was advised to undergo outpatient physical therapy, which temporarily improved her muscle weakness. However, two weeks before admission, she experienced a decline in muscle strength. Her family history was unremarkable except for cervical cancer in her grandmother. Physical examination revealed periorbital edema, proximal muscle weakness in bilateral upper and lower extremities, heliotrope rash [Figure 1 ], erosions on oral mucosa [Figure 2 ] and rashes on bilateral lower extremities [Figure 3 ]. Laboratory findings showed a hemoglobin level of 11.5 g/dL [normal 10 − 9–14.3 g/dL], platelets 61k/uL [normal 150–450 K/uL], haptoglobin < 8 mg/dL [normal 30–250 mg/dL], LDH 752 U/L [normal 110–260 U/L], immature platelet fraction 23.2% [normal 0.8–7.0%], reticulocyte count antibodies 0.186 M/uL [normal 0.023–0.094 M/uL], fibrinogen 466 mg/dL [normal 214–454 mg/dL], D-dimer 2086 ng/mL [normal < 500 ng/mL], PT 11.9 sec [normal 9.4–12.5 sec], INR 1.03, and aPTT < 21.0 sec [normal 25.1–36.5 sec]. The direct antiglobulin test was negative, and a peripheral smear revealed schistocytes. Creatinine kinase and aldolase levels were elevated to 604 U/L [normal 20–180 U/L] and 10.2 U/L [normal < 7.7 U/L], respectively. Complement C3 and C4 levels were within normal range. The anti-nuclear antibody panel and vasculitis panel were negative. The myomarker panel was positive for TIF1 gamma antibody with a level of 25 units [normal < 20 units]. An MRI of the femur with STIR sequence revealed diffuse myositis involving the bilateral thighs [Figure 4 ], prompting a muscle biopsy from the vastus lateralis, which confirmed findings consistent with inflammatory myopathy. A CT chest ruled out interstitial lung disease (ILD) but identified pulmonary nodules in the right upper and right middle lobes, with the largest measuring 6mm. The patient underwent three days of steroid pulse therapy and received two doses of intravenous immunoglobulin treatment, resulting in symptomatic improvement, progressive enhancement in muscle strength, and resolution of the rash. She was started on prednisone 60 mg daily for maintenance therapy with a plan for tapering and subcutaneous methotrexate 10 mg weekly with folic acid supplementation. Given anti-TIF-1γ Ab positive DM, the patient underwent evaluation for evidence of solid organ malignancy. A biopsy of the gastric mucosa during esophagogastroduodenoscopy (EGD) yielded unremarkable results, and an ultrasound of bilateral breasts showed no signs of malignancy. She continues to follow up with Rheumatology as an outpatient. Discussion and Conclusion Dermatomyositis is a chronic, inflammatory condition that affects the skin and muscles. Adults between the ages of 50 and 60 are usually affected, and most patients are female. Cases of juvenile dermatomyositis with the highest incidence between the ages of 5 and 15 years have also been reported [4]. Clinically, the disease is characterized by skeletal muscle weakness, mainly affecting the proximal upper and lower extremity skeletal muscles along with cutaneous manifestations. Despite the fact that dermatomyositis is known to be an autoimmune condition, a number of new, targeted autoantibodies have recently been identified [5]. Antibodies involved in the pathogenesis of DM can be classified into myositis-specific antibodies and myositis-associated antibodies [4]. Myositis-specific autoantibodies have recently been used to classify inflammatory myopathy since each group has distinct features [6]. They include antibodies against melanoma differentiation-associated gene 5 (MDA-5), anti-aminoacyl tRNA synthetase (ARS) such as anti-Jo-1 and anti-Mi-2, anti-transcriptional intermediary factor 1-gamma (TIF-1γ), anti-nuclear matrix protein 2 antibodies, and anti-small ubiquitin-like modifier-1 activating enzyme antibody [5,7,8]. MDA-5 antibody is commonly linked to clinically amyopathic DM. This condition can cause clinical deterioration due to the quick progression of interstitial lung disease (ILD) and has a poor prognosis [9]. Autoantibodies against one of the many aminoacyl transfer RNA (tRNA) synthetases are the hallmark of anti-synthetase syndrome, an autoimmune disease whose clinical manifestations can include myositis, non-erosive arthritis, Raynaud's phenomenon, unexplained fever, and/or mechanic's hands. The most widely recognized anti-synthetase antibody is anti-Jo-1, an anti-histidyl-tRNA synthetase [10]. On the other hand, patients with dermatomyositis positive for anti-TIF-1γ antibody, similar to our patient, commonly present with proximal muscle weakness, skin rashes, and dysphagia. This form of DM is usually not complicated by interstitial lung disease (ILD) [5]. Moreover, anti-TIF-1γ Ab positive DM has shown an association with malignancy [11]. In patients with dermatomyositis, the risk of malignancy is 4.66 times higher than in the general population, and it is much higher in males and individuals older than 44 years. Within the first 12 months following the disease's diagnosis, there was a documented considerably higher risk of malignancy (SIR 17) [12]. Patients with anti-TIF-1γ Ab positive DM have been reported to have a 19–100% incidence of cancer [13]. A meta-analysis involving 1962 patients with dermatomyositis was conducted by Best et al., out of which 22.2% of patients were positive for anti-TIF1-γ antibodies. Moreover, the risk of cancer in patients with anti-TIF1-γ antibodies was 9.37 times higher than in other patients. In terms of identifying malignancy in dermatomyositis, the combined sensitivity and specificity of anti-TIF1-γ antibodies was shown to be 52% and 92%, respectively. In individuals with anti-TIF1-γ antibodies, solid tumors like ovarian, breast, lung, gastric, and colorectal cancers were also found to be more prevalent than hematological malignancies [14,15]. Cancers are usually diagnosed within 3 years after the diagnosis of DM, with most of them being diagnosed in the first 12 months [14]. When it comes to treatment of anti-TIF-1γ Ab positive DM, treatment of malignancies takes precedence [5]. Immunoglobulins, rituximab, and tumor necrosis factor-α inhibitors have been shown to be effective for patients with multiple drug resistance. Corticosteroids are effective for anti-TIF-1γ Ab positive DM, but some cases show steroid resistance. In these cases, a variety of non-steroid drugs, including methotrexate, antimalarial drugs, mycophenolate, azathioprine, and cyclosporine A, might be useful. Our patient required treatment with corticosteroids, intravenous immunoglobulins and was later started on subcutaneous methotrexate [16,17]. Our case is unique since the patient is a young female with anti-TIF-1γ antibody- positive dermatomyositis. According to studies, the mean age demonstrating positivity for anti-TIF-1γ antibody is 68.6 ± 10.7 years [5]. This is of clinical significance in 15 to 30% of adult cases who are diagnosed with DM, since it can be the initial symptom of an underlying malignancy. In the case of breast cancer, TIF-1γ expression is linked to younger age, tumors bigger than 2 cm, higher malignant grade and more estrogen receptor (ER) negativity. Moreover, TIF1γ expression indicated a propensity for unfavorable outcomes. Early anti-TIF-1γ autoantibody detection can help facilitate a quicker diagnosis of tumor-associated dermatomyositis and allow for prompt anticancer treatment [18]. Abbreviations DM: Dermatomyositis EGD: Esophagogastroduodenoscopy ER: Estrogen receptor ILD: Interstitial lung disease MDA-5: Melanoma differentiation-associated gene 5 TIF-1γ: Transcriptional intermediary factor-1-gamma tRNA: Transfer ribonucleic acid Declarations Ethics approval and consent to participate Not applicable Consent for publication Written informed consent was obtained from the patient for publication of the case report and any accompanying images. A copy of the written consent is available for review by the Editor of this Journal. Availability of data and materials Not applicable Competing interests The authors declare that they have no competing interests. Funding Nil funding received Acknowledgments Not applicable Authors and Affiliations Department of Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA Upasana Agrawal, Manush Sondhi, Alexandra Zamora Smith Center of Excellence for Arthritis and Rheumatology Louisiana State University Health Sciences Center, Shreveport, Louisiana Syeda Sara Nida, Sarwat Umer, Samina Hayat, Kinza Muzaffar Authors’ contributions Idea development and case report writing: UA, MS, SSN, KM. Drafting the manuscript: UA, MS, AZS, KM. Final writing up and critical revision of paper: KM, SU SH. Submission of the manuscript: UA. All authors read and approved the final manuscript. Corresponding author Correspondence to Upasana Agrawal References Betteridge ZE, Gunawardena H, McHugh NJ. Novel autoantibodies and clinical phenotypes in adult and juvenile myositis. Arthritis Res Ther. 2011;13(2):209. doi:10.1186/ar3257 Fiorentino D, Chung L, Zwerner J, Rosen A, Casciola-Rosen L. The mucocutaneous and systemic phenotype of dermatomyositis patients with antibodies to MDA5 (CADM-140): a retrospective study. J Am Acad Dermatol. 2011;65(1):25-34. doi:10.1016/j.jaad.2010.09.016 Tansley SL, Betteridge ZE, Gunawardena H, et al. Anti-MDA5 autoantibodies in juvenile dermatomyositis identify a distinct clinical phenotype: a prospective cohort study. Arthritis Res Ther. 2014;16(4):R138. doi:10.1186/ar4579 Marzęcka, M., Niemczyk, A. & Rudnicka, L. Autoantibody Markers of Increased Risk of Malignancy in Patients with Dermatomyositis. Clinic Rev Allerg Immunol 63, 289–296 (2022). https://doi.org/10.1007/s12016-022-08922-4 Harada Y, Tominaga M, Iitoh E, Kaieda S, Koga T, Fujimoto K, Chikasue T, Obara H, Kakuma T, Ida H, Kawayama T, Hoshino T. Clinical Characteristics of Anti-TIF-1γ Antibody-Positive Dermatomyositis Associated with Malignancy. J Clin Med. 2022 Mar 30;11(7):1925. doi: 10.3390/jcm11071925. PMID: 35407533; PMCID: PMC8999723. Fujimoto M, Watanabe R, Ishitsuka Y, Okiyama N. Recent advances in dermatomyositis-specific autoantibodies. Curr Opin Rheumatol. 2016 Nov;28(6):636-44. doi: 10.1097/BOR.0000000000000329. PMID: 27533321. Hodgkinson LM, Wu TT, Fiorentino DF. Dermatomyositis autoantibodies: how can we maximize utility? Ann Transl Med. 2021 Mar;9(5):433. doi: 10.21037/atm-20-5175. PMID: 33842654; PMCID: PMC8033377. Targoff IN, Mamyrova G, Trieu EP, Perurena O, Koneru B, O'Hanlon TP, Miller FW, Rider LG; Childhood Myositis Heterogeneity Study Group; International Myositis Collaborative Study Group. A novel autoantibody to a 155-kd protein is associated with dermatomyositis. Arthritis Rheum. 2006 Nov;54(11):3682-9. doi: 10.1002/art.22164. PMID: 17075819. Hozumi H, Fujisawa T, Nakashima R, Johkoh T, Sumikawa H, Murakami A, Enomoto N, Inui N, Nakamura Y, Hosono Y, Imura Y, Mimori T, Suda T. Comprehensive assessment of myositis-specific autoantibodies in polymyositis/dermatomyositis-associated interstitial lung disease. Respir Med. 2016 Dec;121:91-99. doi: 10.1016/j.rmed.2016.10.019. Epub 2016 Nov 2. PMID: 27888997. Witt LJ, Curran JJ, Strek ME. The Diagnosis and Treatment of Antisynthetase Syndrome. Clin Pulm Med. 2016 Sep;23(5):218-226. doi: 10.1097/CPM.0000000000000171. PMID: 27594777; PMCID: PMC5006392. Hu T, Vinik O. Dermatomyositis and malignancy. Can Fam Physician. 2019 Jun;65(6):409-411. PMID: 31189628; PMCID: PMC6738379. Qiang JK, Kim WB, Baibergenova A, Alhusayen R (2017) Risk of malignancy in dermatomyositis and polymyositis. J Cutan Med Surg 21:131–136. https://doi.org/10.1177/1203475416665601 Fiorentino DF, Chung LS, Christopher-Stine L, Zaba L, Li S, Mammen AL, Rosen A, Casciola-Rosen L (2013) Most patients with cancer-associated dermatomyositis have antibodies to nuclear matrix protein NXP-2 or transcription intermediary factor 1γ. Arthritis Rheum 65:2954–2962. https://doi.org/10.1002/art.38093 Lauinger J, Ghoreschi K, Volc S. Characteristics of dermatomyositis patients with and without associated malignancy. J Dtsch Dermatol Ges. 2021 Nov;19(11):1601-1611. doi: 10.1111/ddg.14566. Epub 2021 Nov 5. PMID: 34738719. Best M, Molinari N, Chasset F, Vincent T, Cordel N, Bessis D (2019) Use of anti-transcriptional intermediary factor-1 gamma autoantibody in identifying adult dermatomyositis patients with cancer: a systematic review and meta-analysis. Acta Derm Venereol 99:256–262. https://doi.org/10.2340/00015555-3091 Iorizzo LJ 3rd, Jorizzo JL. The treatment and prognosis of dermatomyositis: an updated review. J Am Acad Dermatol. 2008 Jul;59(1):99-112. doi: 10.1016/j.jaad.2008.02.043. Epub 2008 Apr 18. PMID: 18423790. Kovacs SO, Kovacs SC. Dermatomyositis. J Am Acad Dermatol. 1998 Dec;39(6):899-920; quiz 921-2. doi: 10.1016/s0190-9622(98)70263-4. PMID: 9843002. Kubeček, O., Soukup, T., Paulík, A., & Kopecký, J. (2016). Dermatomyositis with anti-TIF-1γ antibodies as a presenting symptom of underlying triple-negative breast cancer: a case report. BMC cancer, 16(1), 684. https://doi.org/10.1186/s12885-016-2715-1 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Submission checks completed at journal 01 Apr, 2024 Editor assigned by journal 01 Apr, 2024 First submitted to journal 29 Mar, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4189638","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":286070298,"identity":"46e31a10-e2b1-4b5c-b72b-c59beecf22ca","order_by":0,"name":"Upasana 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20:29:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4189638/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4189638/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":54397984,"identity":"346e1b51-7310-407d-92fb-be96ab26c55a","added_by":"auto","created_at":"2024-04-10 00:20:22","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":165806,"visible":true,"origin":"","legend":"\u003cp\u003eViolet rash seen on upper eyelids bilaterally, \u003cbr\u003e\nindicating heliotrope rash\u003c/p\u003e","description":"","filename":"TIF1.png","url":"https://assets-eu.researchsquare.com/files/rs-4189638/v1/f032c67690d6693564fa0d64.png"},{"id":54397696,"identity":"b1127e28-42bd-439e-89ee-f3644954c5fc","added_by":"auto","created_at":"2024-04-10 00:12:22","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":152384,"visible":true,"origin":"","legend":"\u003cp\u003eUlceration noted on oral mucosa\u003c/p\u003e","description":"","filename":"TIF2.png","url":"https://assets-eu.researchsquare.com/files/rs-4189638/v1/6af70287382fb24965e641e0.png"},{"id":54397698,"identity":"3857c9ea-ac1c-4a98-b079-d71b5b2b3ed3","added_by":"auto","created_at":"2024-04-10 00:12:22","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":77277,"visible":true,"origin":"","legend":"\u003cp\u003eReddish-purple rash noted on the lower extremity\u003c/p\u003e","description":"","filename":"TIF3.png","url":"https://assets-eu.researchsquare.com/files/rs-4189638/v1/860d6d0d4a430fb4a9f4e6fa.png"},{"id":54397699,"identity":"e08610d6-a855-4b01-b576-63da07e998ae","added_by":"auto","created_at":"2024-04-10 00:12:22","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":128982,"visible":true,"origin":"","legend":"\u003cp\u003eMRI of the femur with STIR sequence (axial view) revealing diffuse myositis in bilateral thighs\u003c/p\u003e","description":"","filename":"TIF4.png","url":"https://assets-eu.researchsquare.com/files/rs-4189638/v1/8eb487c044ca615a5adac534.png"},{"id":54398089,"identity":"c56fb37e-cc75-4d6f-8914-ef31cd28332d","added_by":"auto","created_at":"2024-04-10 00:28:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":696237,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4189638/v1/8fa0e43c-d67a-48f1-a36e-cd0012c8da35.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Rare Case of Anti-TIF-1γ Antibody Positive Dermatomyositis in Adulthood: Case Report","fulltext":[{"header":"Background","content":"\u003cp\u003eDermatomyositis (DM) is a rare autoimmune disease characterized by inflammatory myopathy and distinctive skin manifestations. While DM typically presents with proximal muscle weakness and skin rash, it encompasses a spectrum of clinical phenotypes, often associated with specific autoantibodies. Among these autoantibodies, anti-transcriptional intermediary factor 1-gamma (TIF-1γ) antibodies have emerged as markers for a distinct subset of DM, known for its association with malignancy and unique clinical features.\u003c/p\u003e \u003cp\u003eAnti-TIF-1γ Ab positive DM represents a subset of dermatomyositis characterized by the presence of antibodies targeting transcriptional intermediary factor 1-gamma, a regulator of gene transcription and cellular differentiation [1]. This subtype is particularly notable for its association with cancer, especially among adult patients, with a reported incidence ranging from 15\u0026ndash;40% [2]. The presence of TIF-1γ antibodies has been linked to a higher risk of malignancy, particularly in older patients and those with specific clinical features such as extensive cutaneous involvement and severe muscle weakness [3].\u003c/p\u003e \u003cp\u003eWe report the intriguing case of a 24-year-old female who sought medical attention following a syncopal episode and was subsequently diagnosed with anti-TIF-1γ Ab positive DM. What distinguishes this case is the patient's age, given that this condition is usually encountered in older individuals. This case underscores the importance of recognizing anti-TIF-1γ Ab positive DM as a distinct clinical entity within the spectrum of dermatomyositis, especially in young patients presenting with characteristic clinical features. The association with malignancy necessitates a comprehensive evaluation to exclude underlying neoplasms, emphasizing the importance of multidisciplinary management involving different specialists.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 24-year-old female with no significant medical history presented to the hospital after experiencing a syncopal episode followed by a fall. She denied any previous episodes of syncope. Her symptoms began two months ago with intermittent episodes of vomiting and dizziness lasting about 10 days, leading to hospitalization at another facility. During this time, she also experienced proximal muscle weakness, rendering her unable to lift herself from a chair or shower independently. Additionally, she developed a scaly, non-pruritic but painful rash several months before admission, which initially appeared on her trunk and later progressed to involve her proximal bilateral upper and lower extremities. At the previous facility, she received treatment with topical emollients and steroids for the rash and was advised to undergo outpatient physical therapy, which temporarily improved her muscle weakness. However, two weeks before admission, she experienced a decline in muscle strength. Her family history was unremarkable except for cervical cancer in her grandmother.\u003c/p\u003e \u003cp\u003ePhysical examination revealed periorbital edema, proximal muscle weakness in bilateral upper and lower extremities, heliotrope rash [Figure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e], erosions on oral mucosa [Figure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e] and rashes on bilateral lower extremities [Figure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e]. Laboratory findings showed a hemoglobin level of 11.5 g/dL [normal 10\u0026thinsp;\u0026minus;\u0026thinsp;9\u0026ndash;14.3 g/dL], platelets 61k/uL [normal 150\u0026ndash;450 K/uL], haptoglobin\u0026thinsp;\u0026lt;\u0026thinsp;8 mg/dL [normal 30\u0026ndash;250 mg/dL], LDH 752 U/L [normal 110\u0026ndash;260 U/L], immature platelet fraction 23.2% [normal 0.8\u0026ndash;7.0%], reticulocyte count antibodies 0.186 M/uL [normal 0.023\u0026ndash;0.094 M/uL], fibrinogen 466 mg/dL [normal 214\u0026ndash;454 mg/dL], D-dimer 2086 ng/mL [normal\u0026thinsp;\u0026lt;\u0026thinsp;500 ng/mL], PT 11.9 sec [normal 9.4\u0026ndash;12.5 sec], INR 1.03, and aPTT\u0026thinsp;\u0026lt;\u0026thinsp;21.0 sec [normal 25.1\u0026ndash;36.5 sec]. The direct antiglobulin test was negative, and a peripheral smear revealed schistocytes. Creatinine kinase and aldolase levels were elevated to 604 U/L [normal 20\u0026ndash;180 U/L] and 10.2 U/L [normal\u0026thinsp;\u0026lt;\u0026thinsp;7.7 U/L], respectively. Complement C3 and C4 levels were within normal range. The anti-nuclear antibody panel and vasculitis panel were negative. The myomarker panel was positive for TIF1 gamma antibody with a level of 25 units [normal\u0026thinsp;\u0026lt;\u0026thinsp;20 units].\u003c/p\u003e \u003cp\u003eAn MRI of the femur with STIR sequence revealed diffuse myositis involving the bilateral thighs [Figure \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e], prompting a muscle biopsy from the vastus lateralis, which confirmed findings consistent with inflammatory myopathy. A CT chest ruled out interstitial lung disease (ILD) but identified pulmonary nodules in the right upper and right middle lobes, with the largest measuring 6mm.\u003c/p\u003e \u003cp\u003eThe patient underwent three days of steroid pulse therapy and received two doses of intravenous immunoglobulin treatment, resulting in symptomatic improvement, progressive enhancement in muscle strength, and resolution of the rash. She was started on prednisone 60 mg daily for maintenance therapy with a plan for tapering and subcutaneous methotrexate 10 mg weekly with folic acid supplementation.\u003c/p\u003e \u003cp\u003eGiven anti-TIF-1γ Ab positive DM, the patient underwent evaluation for evidence of solid organ malignancy. A biopsy of the gastric mucosa during esophagogastroduodenoscopy (EGD) yielded unremarkable results, and an ultrasound of bilateral breasts showed no signs of malignancy. She continues to follow up with Rheumatology as an outpatient.\u003c/p\u003e"},{"header":"Discussion and Conclusion","content":"\u003cp\u003eDermatomyositis is a chronic, inflammatory condition that affects the skin and muscles. Adults between the ages of 50 and 60 are usually affected, and most patients are female. Cases of juvenile dermatomyositis with the highest incidence between the ages of 5 and 15 years have also been reported [4]. Clinically, the disease is characterized by skeletal muscle weakness, mainly affecting the proximal upper and lower extremity skeletal muscles along with cutaneous manifestations.\u003c/p\u003e \u003cp\u003eDespite the fact that dermatomyositis is known to be an autoimmune condition, a number of new, targeted autoantibodies have recently been identified [5]. Antibodies involved in the pathogenesis of DM can be classified into myositis-specific antibodies and myositis-associated antibodies [4]. Myositis-specific autoantibodies have recently been used to classify inflammatory myopathy since each group has distinct features [6]. They include antibodies against melanoma differentiation-associated gene 5 (MDA-5), anti-aminoacyl tRNA synthetase (ARS) such as anti-Jo-1 and anti-Mi-2, anti-transcriptional intermediary factor 1-gamma (TIF-1γ), anti-nuclear matrix protein 2 antibodies, and anti-small ubiquitin-like modifier-1 activating enzyme antibody [5,7,8]. MDA-5 antibody is commonly linked to clinically amyopathic DM. This condition can cause clinical deterioration due to the quick progression of interstitial lung disease (ILD) and has a poor prognosis [9].\u003c/p\u003e \u003cp\u003eAutoantibodies against one of the many aminoacyl transfer RNA (tRNA) synthetases are the hallmark of anti-synthetase syndrome, an autoimmune disease whose clinical manifestations can include myositis, non-erosive arthritis, Raynaud's phenomenon, unexplained fever, and/or mechanic's hands. The most widely recognized anti-synthetase antibody is anti-Jo-1, an anti-histidyl-tRNA synthetase [10]. On the other hand, patients with dermatomyositis positive for anti-TIF-1γ antibody, similar to our patient, commonly present with proximal muscle weakness, skin rashes, and dysphagia. This form of DM is usually not complicated by interstitial lung disease (ILD) [5]. Moreover, anti-TIF-1γ Ab positive DM has shown an association with malignancy [11].\u003c/p\u003e \u003cp\u003eIn patients with dermatomyositis, the risk of malignancy is 4.66 times higher than in the general population, and it is much higher in males and individuals older than 44 years. Within the first 12 months following the disease's diagnosis, there was a documented considerably higher risk of malignancy (SIR 17) [12]. Patients with anti-TIF-1γ Ab positive DM have been reported to have a 19\u0026ndash;100% incidence of cancer [13]. A meta-analysis involving 1962 patients with dermatomyositis was conducted by Best et al., out of which 22.2% of patients were positive for anti-TIF1-γ antibodies. Moreover, the risk of cancer in patients with anti-TIF1-γ antibodies was 9.37 times higher than in other patients. In terms of identifying malignancy in dermatomyositis, the combined sensitivity and specificity of anti-TIF1-γ antibodies was shown to be 52% and 92%, respectively. In individuals with anti-TIF1-γ antibodies, solid tumors like ovarian, breast, lung, gastric, and colorectal cancers were also found to be more prevalent than hematological malignancies [14,15]. Cancers are usually diagnosed within 3 years after the diagnosis of DM, with most of them being diagnosed in the first 12 months [14].\u003c/p\u003e \u003cp\u003eWhen it comes to treatment of anti-TIF-1γ Ab positive DM, treatment of malignancies takes precedence [5]. Immunoglobulins, rituximab, and tumor necrosis factor-α inhibitors have been shown to be effective for patients with multiple drug resistance. Corticosteroids are effective for anti-TIF-1γ Ab positive DM, but some cases show steroid resistance. In these cases, a variety of non-steroid drugs, including methotrexate, antimalarial drugs, mycophenolate, azathioprine, and cyclosporine A, might be useful. Our patient required treatment with corticosteroids, intravenous immunoglobulins and was later started on subcutaneous methotrexate [16,17].\u003c/p\u003e \u003cp\u003eOur case is unique since the patient is a young female with anti-TIF-1γ antibody- positive dermatomyositis. According to studies, the mean age demonstrating positivity for anti-TIF-1γ antibody is 68.6\u0026thinsp;\u0026plusmn;\u0026thinsp;10.7 years [5]. This is of clinical significance in 15 to 30% of adult cases who are diagnosed with DM, since it can be the initial symptom of an underlying malignancy. In the case of breast cancer, TIF-1γ expression is linked to younger age, tumors bigger than 2 cm, higher malignant grade and more estrogen receptor (ER) negativity. Moreover, TIF1γ expression indicated a propensity for unfavorable outcomes. Early anti-TIF-1γ autoantibody detection can help facilitate a quicker diagnosis of tumor-associated dermatomyositis and allow for prompt anticancer treatment [18].\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eDM: Dermatomyositis\u003c/p\u003e\n\u003cp\u003eEGD: Esophagogastroduodenoscopy\u003c/p\u003e\n\u003cp\u003eER: Estrogen receptor\u003c/p\u003e\n\u003cp\u003eILD: Interstitial lung disease\u003c/p\u003e\n\u003cp\u003eMDA-5: Melanoma differentiation-associated gene 5\u003c/p\u003e\n\u003cp\u003eTIF-1\u0026gamma;: Transcriptional intermediary factor-1-gamma\u0026nbsp;\u003c/p\u003e\n\u003cp\u003etRNA: Transfer ribonucleic acid\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eWritten informed consent was obtained from the patient for publication of the case report and any accompanying images. A copy of the written consent is available for review by the Editor of this Journal.\u003cbr\u003e \u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors declare that they have no competing interests.\u003cbr\u003e \u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNil funding received\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAuthors and Affiliations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDepartment of Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA\u003c/p\u003e\n\u003cp\u003eUpasana Agrawal, Manush Sondhi, Alexandra Zamora Smith\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Center of Excellence for Arthritis and Rheumatology\u003c/p\u003e\n\u003cp\u003eLouisiana State University Health Sciences Center, Shreveport, Louisiana\u003c/p\u003e\n\u003cp\u003eSyeda Sara Nida, Sarwat Umer, Samina Hayat, Kinza Muzaffar\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIdea development and case report writing: UA, MS, SSN, KM. Drafting the manuscript: UA, MS, AZS, KM. Final writing up and critical revision of paper: KM, SU SH. Submission of the manuscript: UA. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eCorresponding author\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCorrespondence to Upasana Agrawal\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBetteridge ZE, Gunawardena H, McHugh NJ. Novel autoantibodies and clinical phenotypes in adult and juvenile myositis. Arthritis Res Ther. 2011;13(2):209. doi:10.1186/ar3257\u003c/li\u003e\n \u003cli\u003eFiorentino D, Chung L, Zwerner J, Rosen A, Casciola-Rosen L. The mucocutaneous and systemic phenotype of dermatomyositis patients with antibodies to MDA5 (CADM-140): a retrospective study. J Am Acad Dermatol. 2011;65(1):25-34. doi:10.1016/j.jaad.2010.09.016\u003c/li\u003e\n \u003cli\u003eTansley SL, Betteridge ZE, Gunawardena H, et al. Anti-MDA5 autoantibodies in juvenile dermatomyositis identify a distinct clinical phenotype: a prospective cohort study. Arthritis Res Ther. 2014;16(4):R138. doi:10.1186/ar4579\u003c/li\u003e\n \u003cli\u003eMarzęcka, M., Niemczyk, A. \u0026amp; Rudnicka, L. Autoantibody Markers of Increased Risk of Malignancy in Patients with Dermatomyositis. Clinic Rev Allerg Immunol 63, 289\u0026ndash;296 (2022). https://doi.org/10.1007/s12016-022-08922-4\u003c/li\u003e\n \u003cli\u003eHarada Y, Tominaga M, Iitoh E, Kaieda S, Koga T, Fujimoto K, Chikasue T, Obara H, Kakuma T, Ida H, Kawayama T, Hoshino T. Clinical Characteristics of Anti-TIF-1\u0026gamma; Antibody-Positive Dermatomyositis Associated with Malignancy. J Clin Med. 2022 Mar 30;11(7):1925. doi: 10.3390/jcm11071925. PMID: 35407533; PMCID: PMC8999723.\u003c/li\u003e\n \u003cli\u003eFujimoto M, Watanabe R, Ishitsuka Y, Okiyama N. Recent advances in dermatomyositis-specific autoantibodies. Curr Opin Rheumatol. 2016 Nov;28(6):636-44. doi: 10.1097/BOR.0000000000000329. PMID: 27533321.\u003c/li\u003e\n \u003cli\u003eHodgkinson LM, Wu TT, Fiorentino DF. Dermatomyositis autoantibodies: how can we maximize utility? Ann Transl Med. 2021 Mar;9(5):433. doi: 10.21037/atm-20-5175. PMID: 33842654; PMCID: PMC8033377.\u003c/li\u003e\n \u003cli\u003eTargoff IN, Mamyrova G, Trieu EP, Perurena O, Koneru B, O\u0026apos;Hanlon TP, Miller FW, Rider LG; Childhood Myositis Heterogeneity Study Group; International Myositis Collaborative Study Group. A novel autoantibody to a 155-kd protein is associated with dermatomyositis. Arthritis Rheum. 2006 Nov;54(11):3682-9. doi: 10.1002/art.22164. PMID: 17075819.\u003c/li\u003e\n \u003cli\u003eHozumi H, Fujisawa T, Nakashima R, Johkoh T, Sumikawa H, Murakami A, Enomoto N, Inui N, Nakamura Y, Hosono Y, Imura Y, Mimori T, Suda T. Comprehensive assessment of myositis-specific autoantibodies in polymyositis/dermatomyositis-associated interstitial lung disease. Respir Med. 2016 Dec;121:91-99. doi: 10.1016/j.rmed.2016.10.019. Epub 2016 Nov 2. PMID: 27888997.\u003c/li\u003e\n \u003cli\u003eWitt LJ, Curran JJ, Strek ME. The Diagnosis and Treatment of Antisynthetase Syndrome. Clin Pulm Med. 2016 Sep;23(5):218-226. doi: 10.1097/CPM.0000000000000171. PMID: 27594777; PMCID: PMC5006392.\u003c/li\u003e\n \u003cli\u003eHu T, Vinik O. Dermatomyositis and malignancy. Can Fam Physician. 2019 Jun;65(6):409-411. PMID: 31189628; PMCID: PMC6738379.\u003c/li\u003e\n \u003cli\u003eQiang JK, Kim WB, Baibergenova A, Alhusayen R (2017) Risk of malignancy in dermatomyositis and polymyositis. J Cutan Med Surg 21:131\u0026ndash;136. https://doi.org/10.1177/1203475416665601\u003c/li\u003e\n \u003cli\u003eFiorentino DF, Chung LS, Christopher-Stine L, Zaba L, Li S, Mammen AL, Rosen A, Casciola-Rosen L (2013) Most patients with cancer-associated dermatomyositis have antibodies to nuclear matrix protein NXP-2 or transcription intermediary factor 1\u0026gamma;. Arthritis Rheum 65:2954\u0026ndash;2962. https://doi.org/10.1002/art.38093\u003c/li\u003e\n \u003cli\u003eLauinger J, Ghoreschi K, Volc S. Characteristics of dermatomyositis patients with and without associated malignancy. J Dtsch Dermatol Ges. 2021 Nov;19(11):1601-1611. doi: 10.1111/ddg.14566. Epub 2021 Nov 5. PMID: 34738719.\u003c/li\u003e\n \u003cli\u003eBest M, Molinari N, Chasset F, Vincent T, Cordel N, Bessis D (2019) Use of anti-transcriptional intermediary factor-1 gamma autoantibody in identifying adult dermatomyositis patients with cancer: a systematic review and meta-analysis. Acta Derm Venereol 99:256\u0026ndash;262. https://doi.org/10.2340/00015555-3091\u003c/li\u003e\n \u003cli\u003eIorizzo LJ 3rd, Jorizzo JL. The treatment and prognosis of dermatomyositis: an updated review. J Am Acad Dermatol. 2008 Jul;59(1):99-112. doi: 10.1016/j.jaad.2008.02.043. Epub 2008 Apr 18. PMID: 18423790.\u003c/li\u003e\n \u003cli\u003eKovacs SO, Kovacs SC. Dermatomyositis. J Am Acad Dermatol. 1998 Dec;39(6):899-920; quiz 921-2. doi: 10.1016/s0190-9622(98)70263-4. PMID: 9843002.\u003c/li\u003e\n \u003cli\u003eKubeček, O., Soukup, T., Paul\u0026iacute;k, A., \u0026amp;amp; Kopeck\u0026yacute;, J. (2016). Dermatomyositis with anti-TIF-1\u0026gamma; antibodies as a presenting symptom of underlying triple-negative breast cancer: a case report. BMC cancer, 16(1), 684. https://doi.org/10.1186/s12885-016-2715-1\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-rheumatology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"brhm","sideBox":"Learn more about [BMC Rheumatology](http://bmcrheumatol.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/brhm/default.aspx","title":"BMC Rheumatology","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Dermatomyositis, anti-transcriptional intermediary factor 1-gamma (TIF-1γ) antibodies, malignancy","lastPublishedDoi":"10.21203/rs.3.rs-4189638/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4189638/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground\u003c/p\u003e\n\u003cp\u003eDermatomyositis (DM) is characterized by inflammatory myopathy and distinct skin manifestations. It comprises a diverse clinical spectrum often associated with specific autoantibodies. Notably, the presence of anti-transcriptional intermediary factor 1-gamma (TIF-1γ) antibodies in association with DM is typically seen in older patients and is linked to malignancy in about 15% to 40% of the cases.\u003c/p\u003e\n\u003cp\u003eCase Presentation\u003c/p\u003e\n\u003cp\u003eA 24-year-old female with proximal weakness, periorbital edema, heliotrope rash, erosions on oral mucosa, and painful scaly rash on bilateral lower extremities presented after a syncopal episode and fall. Myomarker panel was positive for TIF-1γ antibodies. Imaging and biopsy confirmed findings consistent with inflammatory myopathy. Treatment with steroid pulse therapy and intravenous immunoglobulin led to symptomatic improvement in muscle strength and resolution of the rash. Due to positive TIF-1γ antibody results, the patient underwent evaluation for solid organ malignancy, yielding unremarkable results.\u003c/p\u003e\n\u003cp\u003eConclusion\u003c/p\u003e\n\u003cp\u003eThis case highlights a unique case of a young female who was diagnosed with anti-TIF-1γ Ab positive DM, deviating from the typical age pattern associated with this condition. Our goal in presenting this case is to reinforce the importance of recognizing and managing anti-TIF-1γ Ab positive DM, even in atypical demographics. Moreover, the association with malignancy necessitates a comprehensive evaluation to exclude underlying neoplasms, emphasizing the importance of multidisciplinary management involving different specialists.\u003c/p\u003e","manuscriptTitle":"A Rare Case of Anti-TIF-1γ Antibody Positive Dermatomyositis in Adulthood: Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-10 00:12:17","doi":"10.21203/rs.3.rs-4189638/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"checksComplete","content":"","date":"2024-04-01T08:24:31+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-01T08:24:31+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Rheumatology","date":"2024-03-29T20:25:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-rheumatology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"brhm","sideBox":"Learn more about [BMC Rheumatology](http://bmcrheumatol.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/brhm/default.aspx","title":"BMC Rheumatology","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"85918bc2-05a9-452d-9b3b-5415a695eae7","owner":[],"postedDate":"April 10th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-04-10T00:12:17+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-10 00:12:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4189638","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4189638","identity":"rs-4189638","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}