Methotrexate in management of dermatomyositis in a child with insulin-dependant diabetes with chronic hepatitis

We present our experience with a four-year (2004–2008) follow-up of a child with multiple autoimmune syndromes.

SB, now 13 years old, was symptomatic since 2.5 years with relapsing hepatitis, eventually diagnosed at age 6 years, as chronic lobular hepatitis (ANA positive, AntiLKM/Antimicrosomal/AntiSmoothMuscle Antibodies negative).

At 4 years, she was detected to have Type 1 Diabetes Mellitus (Islet Cell Antibodies positive) and she presented to us at 9 years, with Dermatomyositis (Gottrons papules, CPK 12,310 units, CMAS 2/52).

She was started on steroids and azathioprine. Her insulin requirements increased from 20 units/day to 120–140 units/day and she needed a dose of 0.5 mg/kg/day of prednisolone to keep a near normal CMAS and muscle enzymes within normal limits.

In October 2007, azathioprine was substituted by subcutaneous methotrexate (10 mg/m²). This led to reduction of daily prednisolone to 0.1 mg/kg/day, improved glycemic control, halving the insulin requirements, improved growth, with no worsening of liver function. She was started on Growth Hormone in 2008 for short stature and this has not altered her glycemic control till the time of reporting. She has hyperlipidemia controlled with diet and statins but has not developed candidiasis or other endocrinopathies during follow up.

In conclusion, despite her previous auto-immune liver disease, methotrexate has proven thus far to be a safe and effective steroid sparer in the management of her dermatomyositis