DERMATOMYOSITIS: Childhood & Adults 2
  Dermatomyositis with Vascular Pathology (DM-VP)

    Muscle fiber pathology
      MHC Class I
      Perifascicular atrophy
        Gomori trichrome
        Alkaline phosphatase
        Toluidine blue
  Vessel pathology
    Capillaries, Endomysial
      H&E stain
      Alkaline phosphatase
      Complement deposition
      Endothelial stains
    Artery & Vein, Perimysial
    Child, Severe

Other DM syndromes

Br J Child Dis 1912;9:247

Dermatomyositis with Vascular Pathology (DM-VP)
  Muscle fiber atrophy: Perifascicular (Border zone) distribution

Original Pathologic Description of Dermatomysitis with Vascular Pathology

Batten FE Br J Child Dis 1912;9:247


Perifascicular Muscle Fiber Atrophy: Along Avascular Perimysiumn
Atrophic perifascicular muscle fibers neighbor along region of avascular perimysium (Center).
Normal sized muscle fibers neighbor vascular perimysium (Sides).
Control: Vessels & Perimysium

H&E stain
Atrophic perifascicular muscle fibers neighbor long regions of avascular perimysium.

Gomori trichrome stain

Atrophic perifascicular muscle fibers neighbor a long region of avascular perimysium.

H&E stain
Atrophic perifascicular muscle fibers have basophilic cytoplasm and large nuclei.
Some perifascicular muscle fibers have basophilic or eosinophilic aggregates

H&E stain
Perifascicular muscle fiber pathology: Cytoplasmic aggregates (dark staining) & Internal nuclei.

VvG stain

Perifascicular pathology: Other stains


NADH stain
Muscle fibers near avascular perimysium are small & stain darkly
Muscle fibers near vascular perimysium are more normal (Below, Arrow)

NADH stain

Perifascicular atrophy: Toluidine blue-stained plastic sections

Muscle fibers: Atrophic in perifascicular regions; Irregular sarcolemmal membrane
Muscle fibers
  Size: Atrophic
  Sarcolemmal membrane: Irregular
  Contain lipid droplets

The extent of the perifascicular muscle fiber pathology in active DM is often more prominent on cytochrome oxidase stain.
SDH stain is not reduced.
Reduced cytochrome oxidase staining is not typically present in IMPP syndromes which have a different pattern of perifascicular muscle fiber pathology.

Cytochrome Oxidase

COX stain
Muscle fibers near avascular perimysium are small & have pale COX staining
Succinate Dehydrogenase

SDH stain
Muscle fibers near the avascular perimysium are small & have normal or dark SDH staining

Perifascicular muscle fibers near avascular perimysium: Small; Pale COX staining, Blue (SDH) color

COX + SDH stain

Mildy reduced COX stain in perifascicular muscle fibers with normal size. (Arrow; Right)

COX stain

Perifascicular atrophy: ATPase pH 9.4 stain

ATPase pH 9.4 stain
Perifascicular atrophy is often more obvious on ATPase stains.
Small fibers are both types I & II.

ATPase pH 4.3

ATPase pH 4.3 stain

Type IIC muscle fibers (intermediate staining) are present in regions of atrophy and larger muscle fibers.
Few, or no, type 1 muscle fibers in regions of most severe atrophy at edge of fascicles (Below; Arrow).

ATPase pH 4.3 stain

Type IIC muscle fibers are large & small
Small muscle fibers are near avascular perimysium.
Fibers near intermediate-sized perimysial vessel are larger.


PAS stain
DM-VP: Increased glycogen staining in small perifascicular muscle fibers.1

Alkaline Phosphatase

Enlarged capillaries (Arrows): In regions neighboring the smallest muscle fibers: Also see
  Fewer capillaries stain among larger fibers or amid the smallest fibers at the edge of fascicles.

Alkaline phosphatase stain

Alkaline phosphatase may stain several different structures in patients with dermatomyositis.

Alkaline phosphatase stain

Alkaline phosphatase stain

Alkaline phosphatase stain
Vascular staining.
More common in children
Capillary staining, especially
in perifascicular regions.
Diffuse staining.
More common in adults
Rare in children

Perifascicular muscle fiber atrophy: Fiber pathology

Muscle fibers in regions of perifascicular pathology show several abnormalities in addition to being small.
Some muscle fibers have
  Vacuolar or reticulated cytoplasm (Below).
  Cytochrome oxidase staining reduced
  MHC-I upregulation
  Aggregates: LC3 & Caveolin-3
Muscle fiber nuclei are enlarged.
Muscle fiber necrosis is rare.

H&E stain
Vacuoles in small & intermediate-sized muscle fibers

GT stain

Congo red stain

Muscle fibers may also have
  Coarse internal architecture with basophilia (Left, Arrow), or
  Internal nuclei (Right).
The abnormal internal architecture may be better visualized on Gomori trichrome
H&E stain

Abnormal internal architecture in dermatomyositis muscle fibers is more apparent on Gomori trichrome stains.
The abnormalities may be present in both small and large muscle fibers.
Cytoplasmic bodies may occur


Cytoplasmic bodies

GT stain

Aggregates: LC-3 & Caveolin-3
Aggregates and increased cytoplasmic staining are common in perifascicular muscle fibers
with abnormal internal architecture in DM-VP.
Caveolin-3 stain

LC3 stain
LC-3 aggregates: More prominent in muscle fibers toward edge of fascicle

LC-3 aggregates: Irregular shaped in muscle fiber cytoplasm

AMPDA stain
Aggregates in the center of muscle fibers

Dermatomyositis (DM-VP): Inflammation

Vvg stain
Mononuclear cell inflammation: Foci:
  Cell type: Lymphocytic
    Around intermediate-sized vessels
    Distant from muscle fiber atrophy

H&E stain

H&E stain

Mononuclear cell inflammation:
Stains for CD4 and, in some regions, CD20 (B-cells)
Commonly perivascular.

CD4 stain

CD20 stain

Congo red stain

Childhood dermatomyositis (DM-VP): Capillary pathology

Capillaries: Ulex staining or endothelium

Stain: Ulex europaeus agglutinin I

Dermatomyositis: Capillaries
  Capillary pathology is patchy and most prominent in perifascicular regions.
  Capillary staining with Ulex lectin is often absent in regions with small perifascicular muscle fibers (Above left).
  Capillaries in regions near perifascicular atrophy are often enlarged (Above right).

Stain: Ulex europaeus agglutinin I

Stain: Ulex europaeus agglutinin I

Control: Capillaries are abundant and small


Stain: Ulex europaeus agglutinin I (UEAI)
Muscle fiber atrophy (Top)
  Few stained capillaries
  Many muscle fibers with no adjacent capillary.
Region neighboring muscle fiber atrophy (Purlieu; Middle & Below)
  Enlarged capillaries
  Increased staining for alkaline phosphatase; Also see
Region distant from muscle fiber atrophy: Capillaries have nearly normal size and number

Endomysial capillaries in region neighboring muscle fiber atrophy (Purlieu):
  Abnormal staining for alkaline phosphatase: Also see

Alkaline phosphatase stain

Capillaries: PECAM-1 & Collagen IV stains

Normal capillaries
  Enlarged capillaries
  Capillary remnants


Endothelium + Collagen IV
  Collagen IV: Stains Capillary walls (Red & Yellow) & Basal lamina around muscle fibers (Red).
  PECAM1: Stains Capillary endothelium in lumens (Green) and overlaps Collagen IV (Yellow) in walls.

  Location: Near regions of Perifascicular Atrophy

Endothelium + Collagen IV stains
  Collagen IV: Capillary walls (Red & Yellow) & Basal lamina around muscle fibers (Red).
  PECAM1: Capillary endothelium in lumens (Green) & Some overlaping Collagen IV (Yellow) in walls.

Enlarged endomysial capillaries (Arrows)
Location: Neighbor regions of perifascicular muscle fiber pathology .
H&E stain

Dermatomyositis (DM-VP): SMALL ENDOMYSIAL CAPILLARY REMNANTS in areas of Perifascicular Atrophy

Endothelium + Collagen IV
Collagen IV (Red) stains small capillary wall remnants (Arrow) without lumens.
PECAM1 stains little, or no, capillary endothelium.

Pericytes & Cells + Collagen IV
Collagen IV (Red & Yellow) stains round capillary remnants and basal lamina around muscle fibers.
PDGFRβ stains capillary pericytes (Yellow) overlapping Collagen IV & elongated endomysial cells (Green).

Dermatomyositis (DM-VP) Capillaries in area of perifascicular atrophy: Ultrastructure
Small endomysial capillary residua (Arrow)
  Basal lamina: Thick
    Differs from thin basal laminae of nearby muscle fibers (Arrowhead))
  No endothelium within basal lamina
  Neighboring Pericyte cytoplasm: Provides evidence of the pathologic vessel's microvascular origin)

Well preserved capillary amidst normal muscle fibers has normal size and morphology.
  Capillary compositon
    Endothelial cells (E): Next to lumen
    Basal lamina: Thick; Surrounds endothelial cellls
    Pericyte (processes) (P).
    Red blood cell: In capillary lumen

Childhood dermatomyositis (DM-VP): Complement (C5b-9) deposition in endomysial capillaries

Stain: C5b-9 components of complement (Membrane attack complex)
Dermatomyositis: C5b-9 deposition in endomysial capillaries
Changes are patchy and most prominent in perifascicular regions amid small muscle fibers.
C5b-9 is deposited on damaged endomysial capillaries that have often lost their endothelium.

Stain: C5b-9 components of complement (Membrane attack complex)
Normal control
No C5b-9 deposition in endomysial capillaries in control muscle

C5b-9 stain

C5b9 complement compared to PECAM1 staining of Punctate Capillary Remnants
Endomysial capillaries: C5b-9 complement deposits

C5b-9 complement (Green) with Collagen IV (Red)
Endomysial capillaries: No endothelium

PECAM1 (Green) with Collagen IV (Red)

Childhood dermatomyositis (DM-VP): Perimysial Vascular Pathology

Vessel walls: Abnormal structure
Damaged vessels: Fragments without lumens

Perimysial Arteries (a) & Veins (v)

VvG stain
  Normal vessels (Left)
  DM-VP (Right & Below)
    Loss or thinning of fibrils in walls of arteries & veins
    Endothelial cells: Enlarged

VvG stain

VvG stain

Perimysial vascular fragments with no lumen

VvG stain

Dermatomyositis (DM-VP): Vascular Perimysium
  Contains abnormal vascular fragments (Yellow)
  Has increased PECAM1 staining
  Located away from perifascicular muscle fiber atrophy
  PECAM1 (Green) + Collagen IV (Red): Overlap = Yellow

Normal: Vascular Perimysium
  Contains normal intermediate-sized vessels with lumens
  Has minimal PECAM1 staining
  PECAM1 (Green) + Collagen IV (Red): Overlap = Yellow

DM-VP (Childhood dermatomyositis): MHC Class I upregulation

Pathology degree

DM-VP, Moderately severe: MHC-I up-regulation by muscle fibers, more in small fibers at edge of fascicle

MHC Class I

MHC Class I

Normal: MHC I not present in muscle fibers.
Staining is only on capillaries
MHC Class I up regulation at the edge of fascicles
  Perifascicular muscle fibers ner avascular perimysium express MHC-I
  Central musclle fibers near vessel (Arrow; Below) express less, or no, MHC-I

MHC Class I

DM-VP, Mild: Patterns of MHC-I staining
  MHC-I up-regulation more in muscle fibers at edge of fascicle, or diffusely
  Affected muscle fibers may be normal size, or small.
MHC Class I upregulation
  More in muscle fibers in perifascicular region
  May occur in regions without myofiber atrophy
DM-VP: MHC I up on muscle fibers
  especially near perimysium
A similar pattern may occur in IMPP syndromes

Stain: MHC Class I

MHC Class I stain

MHC Class I upregulation
  Slightly more prominent in perifascicular region
  May occur in regions without severe myofiber atrophy

DM-VP: MHC I up on muscle fibers, severe
  Diffusely on the surface and within muscle fibers

Stain: MHC Class I

Dermatomyositis with Vascular Pathology (DM-VP): Severe

H&E stain
Center of Fascicle: Artery-Vein pair
Periphery of Fascicle: Atrophic muscle fibers near avascular perimysium

VvG stain

Small Muscle Fibers

Gomori trichrome stain
Purlieu Zone: Between areas with larger & very small muscle fibers
  Muscle fibers: Intermediate-sized
  Endomysial capillaries: Large

Gomori trichrome stain
Very Small Muscle fibers
  Near perimysium
  Nuclei: Often internal
  Surface: Irregular
  Cytoplasm: Dark NADH stain

NADH stain

VvG stain

VvG stain
Intermediate-sized Perimysial Vessels
  Abnormal structure: Loss of fibrils in arteries & veins
  Also see: DM-VP Vessels

VvG stain

DM-VP (Childhood): Muscle fiber Atrophy at Muscle Surface (Epimysium)

Severe atrophy of muscle fibers at edge of muscle

H&E stain

H&E stain
Muscle fibers in purlieu zone, near & beneath area of severe fiber atrophy
  Nuclei: Enlarged: Internal
  Muscle fibers: Intermediate size
  Endomysial capillaries: Large

H&E stain

Gomori trtichrome stain
Muscle Fibers: Perifascicular Atrophy

VvG stain

Congo Red stain

Internal Architecture
  Smallest muscle fibers: Very dark stained
  Intermediate-sized muscle fibers: Irregular staining & aggregates
  Endomysial capillaries: Positive staining

NADH stain

Cytochrome oxidase stain
Mitochondrial Pathology
  Muscle fibers in, & near, region of atrophy have reduced COX

  Muscle fibers in, & near, region of atrophy have inreased SDH, diffusely, or as aggregates

SDH stain

Muscle fibers in purlieu zone contain aggregated, cytoplasmic material

VvG stain

Endomysial Capillaries: Reduced staining in regions with small muscle fibers
  Some small mnuscle fibers have no adjacent capillary

VvG stain

DM-VP (Adult)

H&E stain
Muscle fibers: Perifascicular Atrophy
Lymphocyte focus: In perimysium

Congo Red stain

H&E stain
Lymphocyte Focus
  Location: Perimysium
  Contents: Lymphocytes & Small vessels

Congo Red stain

Vessels within Lymphocyte foci

Congo Red stain

H&E stain
Muscle Fibers
  Small at edge of fascicles
  Nuclei: Large; Often internal
  Internal architecture: Abnormal; Aggregates

VvG stain

H&E stain
Perifascicular Muscle Fibers
  Nuclei: Large; Often several internal

H&E stain

H&E stain
Perifascicular Muscle Fibers
  Nuclei: Large; Often several internal
  Internal architecture: Aggregates & Vacuoles

VvG stain

NADH stain
Muscle Fiber Internal Architecture
  Small Muscle fibers: Dark stained
  Larger Muscle Fibers: Sarcoplasmic reticulum aggregates

NADH stain

Myosin ATPase
  Small muscle fibers at edge of fascicles: Reduced staining

ATPase pH 9.4 stain

DM-VP: MHC Class I

MHC-I stain
  Small muscle fibers: MHC-I upregulation in cytoplasm & on surface
  Larger muscle fibers: MHC-I mostly on muscle fiober surfaces

DM-VP: Mitochondrial Pathology

COX stain
Mitochondrial stains: Small muscle fibers
  Cytochrome oxidase (COX): Reduced (Above)
  Succinate Dehydrogenase (SDH): Increased (Below)

SDH stain

DM-VP: Aggregates in Muscle Fibers

AMPDA stain
Aggregated material in muscle fiber cytoplasm stains for AMPDA & LC3

LC3 stain

LC3 stain

Acid phosphatase stain
Acid phosphatase positive granules in muscle fiber cytoplasm

Large Artery
  Abnormal structure: Patchy loss of internal fibrils

VvG stain

Large Vein
  Abnormal; Endothelial layer is widened

VvG stain

Perimysial Smaller Vessel
  Thick wall

VvG stain

DM-VP: Capillaries

Alkaline phosphatase stain
Increased numbers of enlarged, alkaline phosphatase positive, endomysial capillaries in regions near muscle fiber atrophy

UEA I stain
Reduced numbers of UEA I positive endomysial capillaries in regions of perrifasciculat muscle fiber atrophy
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1. Neuromuscul Disord 2006;16:391-393
2. Muscle Nerve 2010; Online April