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Abstract

Objective:

To evaluate the diagnostic value of myxovirus resistance A (MxA) expression in the cytoplasm of myofibers in the diagnosis of dermatomyositis (DM).

Methods:

We assessed the sensitivity and specificity of the sarcoplasmic expression of MxA in muscles with DM by immunohistochemistry in consecutive cases of DM (n = 34) and other idiopathic inflammatory myopathies (n = 120: 8 with polymyositis, 16 with anti–tRNA-synthetase antibody–associated myositis, 46 with immune-mediated necrotizing myopathy, and 50 with inclusion body myositis) and compared them with conventional pathologic hallmarks of DM, including perifascicular atrophy (PFA) and membrane attack complex (MAC) deposition on endomysial capillaries.

Results:

The sensitivity and specificity of sarcoplasmic MxA expression were 71% and 98%, respectively. While the specificity was almost comparable to that of PFA and capillary MAC deposition, the sensitivity was higher, with PFA showing 47% sensitivity and 98% specificity and capillary MAC deposition showing 35% sensitivity and 93% specificity. Of note, in patients with DM with typical skin rash but no PFA, 44% of the samples showed sarcoplasmic MxA expression, which was higher than the 17% sensitivity of capillary MAC deposition in the population.

Conclusions:

Sarcoplasmic MxA expression detected by immunohistochemistry is a more sensitive marker of DM than the conventional hallmarks, indicating its practical utility in the diagnosis of DM. It may well be included in the routine immunohistochemistry panel for myositis.

Classification of evidence:

This study provides Class II evidence that immunohistochemistry-detected sarcoplasmic MxA expression accurately identifies patients with dermatomyositis.

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Supplementary Material

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Letters to the Editor
31 January 2017
Monoclonal antibody alternate for MxA
Ichizo Nishino, Director
Akinori Uruha, Shigeaki Suzuki, Tokyo, Japan

Soon after our article published, [1] we found that the sale of the myxovirus resistance A (MxA) polyclonal antibodies used in the study (Mx1/2/3 [H-285], sc-50509, Santa Cruz Biotechnology, Dallas, TX) had been discontinued. Furthermore, we received inquiries from several physicians concerning alternate MxA antibodies. We tested the company's monoclonal antibody alternate (Mx1/2/3 [C-1], sc-166412) on frozen muscle sections at various dilutions in 2% bovine serum albumin in phosphate-buffered saline using the Ventana immunohistochemistry detection system (Ventana Medical Systems, Tucson, AZ) with or without the enhancement mode. Muscle samples tested included MxA-positive dermatomyositis (n=3, including 1 juvenile participant), MxA-negative dermatomyositis (n=3), anti-Jo-1 myopathy (n=3, MxA-negative), and immune-mediated necrotizing myopathy (n=3, comprising 1 with anti-signal recognition particle antibodies [MxA-negative], 1 with anti-3-hydroxy-3-methylglutaryl-CoA reductase antibodies [MxA-negative], and 1 without those antibodies [MxA-positive]). We observed essentially the same staining pattern at comparable signal intensity as the original polyclonal antibodies at 1:10 dilution with the enhancement mode although the signal was barely detected at the manufacturer's recommended dilution (starting dilution: 1:50), indicating that the monoclonal antibody alternate can be similarly used to detect sarcoplasmic MxA expression on frozen muscle sections for the diagnosis of dermatomyositis (albeit higher concentration is necessary).

1. Uruha A, Nishikawa A, Tsuburaya RS, et al. Sarcoplasmic MxA expression: A valuable marker of dermatomyositis. Neurology Epub 2016 Dec 30.

For disclosures, please contact the editorial office at [email protected].

Information & Authors

Information

Published In

Neurology®
Volume 88Number 5January 31, 2017
Pages: 493-500
PubMed: 28039312

Publication History

Received: July 12, 2016
Accepted: October 27, 2016
Published online: December 30, 2016
Published in print: January 31, 2017

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Disclosure

A. Uruha, A. Nishikawa, R.S. Tsuburaya, and K. Hamanaka report no disclosures relevant to the manuscript. M. Kuwana holds a patent on anti-MDA5 antibody–measuring kits. Y. Watanabe, S. Suzuki, and N. Suzuki report no disclosures relevant to the manuscript. I. Nishino reports an Intramural Research Grant (26-8) for Neurologic and Psychiatric Disorders from NCNP. Go to Neurology.org for full disclosures.

Study Funding

This study was supported partly by an Intramural Research Grant (26-8) for Neurologic and Psychiatric Disorders of NCNP; a grant from the Japanese Ministry of Education, Science, Sports and Culture (26461298); a Health and Labor Sciences Research Grant on Intractable Diseases (Neuroimmunologic Diseases) from the Ministry of Health, Labor and Welfare of Japan; a Grant-in-Aid for Scientific Research (B) from the Japanese Ministry of Education, Science, Sports and Culture (24390227); and a Grant-in-Aid for Challenging Exploratory Research (24659437).

Authors

Affiliations & Disclosures

Akinori Uruha, MD, PhD*
From the Department of Genome Medicine Development (A.U., A.N., K.H., I.N.), Medical Genome Center, and Department of Neuromuscular Research (A.U., A.N., R.S.T., K.H., I.N.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Education (A.N.), Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi; Department of Pediatric Neurology (R.S.T.), National Hospital Organization, Utano National Hospital; Department of Neurology (K.H.), Graduate School of Medicine, Kyoto University; Department of Allergy and Rheumatology (M.K.), Nippon Medical School Graduate School of Medicine; and Division of Rheumatology (M.K.), Department of Internal Medicine, and Department of Neurology (Y.W., S.S., N.S.), Keio University School of Medicine, Tokyo, Japan.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
(1) Marker for differentiating inflammatory myopathy and method for distinguishing between inflammatory and non-inflammatory myopathies using the same (pending)
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
(1) JSPS KAKENHI Grant, 26860679, Principal Investigator, April 2014 to March 2016
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
(1) The Uehara Memorial Foundation, Research fellowship 2016 (2) Japan Foundation for Neuroscience and Mental Health
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Atsuko Nishikawa, MD*
From the Department of Genome Medicine Development (A.U., A.N., K.H., I.N.), Medical Genome Center, and Department of Neuromuscular Research (A.U., A.N., R.S.T., K.H., I.N.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Education (A.N.), Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi; Department of Pediatric Neurology (R.S.T.), National Hospital Organization, Utano National Hospital; Department of Neurology (K.H.), Graduate School of Medicine, Kyoto University; Department of Allergy and Rheumatology (M.K.), Nippon Medical School Graduate School of Medicine; and Division of Rheumatology (M.K.), Department of Internal Medicine, and Department of Neurology (Y.W., S.S., N.S.), Keio University School of Medicine, Tokyo, Japan.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Rie S. Tsuburaya, MD, PhD
From the Department of Genome Medicine Development (A.U., A.N., K.H., I.N.), Medical Genome Center, and Department of Neuromuscular Research (A.U., A.N., R.S.T., K.H., I.N.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Education (A.N.), Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi; Department of Pediatric Neurology (R.S.T.), National Hospital Organization, Utano National Hospital; Department of Neurology (K.H.), Graduate School of Medicine, Kyoto University; Department of Allergy and Rheumatology (M.K.), Nippon Medical School Graduate School of Medicine; and Division of Rheumatology (M.K.), Department of Internal Medicine, and Department of Neurology (Y.W., S.S., N.S.), Keio University School of Medicine, Tokyo, Japan.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Kohei Hamanaka, MD, PhD
From the Department of Genome Medicine Development (A.U., A.N., K.H., I.N.), Medical Genome Center, and Department of Neuromuscular Research (A.U., A.N., R.S.T., K.H., I.N.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Education (A.N.), Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi; Department of Pediatric Neurology (R.S.T.), National Hospital Organization, Utano National Hospital; Department of Neurology (K.H.), Graduate School of Medicine, Kyoto University; Department of Allergy and Rheumatology (M.K.), Nippon Medical School Graduate School of Medicine; and Division of Rheumatology (M.K.), Department of Internal Medicine, and Department of Neurology (Y.W., S.S., N.S.), Keio University School of Medicine, Tokyo, Japan.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Masataka Kuwana, MD, PhD
From the Department of Genome Medicine Development (A.U., A.N., K.H., I.N.), Medical Genome Center, and Department of Neuromuscular Research (A.U., A.N., R.S.T., K.H., I.N.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Education (A.N.), Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi; Department of Pediatric Neurology (R.S.T.), National Hospital Organization, Utano National Hospital; Department of Neurology (K.H.), Graduate School of Medicine, Kyoto University; Department of Allergy and Rheumatology (M.K.), Nippon Medical School Graduate School of Medicine; and Division of Rheumatology (M.K.), Department of Internal Medicine, and Department of Neurology (Y.W., S.S., N.S.), Keio University School of Medicine, Tokyo, Japan.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
(1) Arthritis and Rheumatology, Advisory editor, 4 years, (2) PLoS ONE, Academic editor, 4 years, (3) Journal of Rheumatology, Editorial board, 2 years, (4) Modern Rheumatology, Associate editor, 6 years, (5) Journal of Scleroderma and Related Disorders, Editor-in-Chief, 1 years, (6) Journal of Infectious Diseases, editor, 7 years, (7) Drugs, Editorial board, 10 years
Patents:
1.
Anti-MDA5 antibody-measuring kit
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Yurika Watanabe, MS
From the Department of Genome Medicine Development (A.U., A.N., K.H., I.N.), Medical Genome Center, and Department of Neuromuscular Research (A.U., A.N., R.S.T., K.H., I.N.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Education (A.N.), Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi; Department of Pediatric Neurology (R.S.T.), National Hospital Organization, Utano National Hospital; Department of Neurology (K.H.), Graduate School of Medicine, Kyoto University; Department of Allergy and Rheumatology (M.K.), Nippon Medical School Graduate School of Medicine; and Division of Rheumatology (M.K.), Department of Internal Medicine, and Department of Neurology (Y.W., S.S., N.S.), Keio University School of Medicine, Tokyo, Japan.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Shigeaki Suzuki, MD, PhD
From the Department of Genome Medicine Development (A.U., A.N., K.H., I.N.), Medical Genome Center, and Department of Neuromuscular Research (A.U., A.N., R.S.T., K.H., I.N.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Education (A.N.), Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi; Department of Pediatric Neurology (R.S.T.), National Hospital Organization, Utano National Hospital; Department of Neurology (K.H.), Graduate School of Medicine, Kyoto University; Department of Allergy and Rheumatology (M.K.), Nippon Medical School Graduate School of Medicine; and Division of Rheumatology (M.K.), Department of Internal Medicine, and Department of Neurology (Y.W., S.S., N.S.), Keio University School of Medicine, Tokyo, Japan.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
Grants from Japanese Ministry of Education, Science, Sports and Culture (no. 26461298) and Health and Labour Sciences Research Grant on Rare and Intractable Diseases (Evidence-based Early Diagnosis and Treatment Strategies for Neuroimmunological Diseases) from the Ministry of Health, Labour and Welfare of Japan
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Norihiro Suzuki, MD, PhD
From the Department of Genome Medicine Development (A.U., A.N., K.H., I.N.), Medical Genome Center, and Department of Neuromuscular Research (A.U., A.N., R.S.T., K.H., I.N.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Education (A.N.), Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi; Department of Pediatric Neurology (R.S.T.), National Hospital Organization, Utano National Hospital; Department of Neurology (K.H.), Graduate School of Medicine, Kyoto University; Department of Allergy and Rheumatology (M.K.), Nippon Medical School Graduate School of Medicine; and Division of Rheumatology (M.K.), Department of Internal Medicine, and Department of Neurology (Y.W., S.S., N.S.), Keio University School of Medicine, Tokyo, Japan.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Ichizo Nishino, MD, PhD
From the Department of Genome Medicine Development (A.U., A.N., K.H., I.N.), Medical Genome Center, and Department of Neuromuscular Research (A.U., A.N., R.S.T., K.H., I.N.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Education (A.N.), Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi; Department of Pediatric Neurology (R.S.T.), National Hospital Organization, Utano National Hospital; Department of Neurology (K.H.), Graduate School of Medicine, Kyoto University; Department of Allergy and Rheumatology (M.K.), Nippon Medical School Graduate School of Medicine; and Division of Rheumatology (M.K.), Department of Internal Medicine, and Department of Neurology (Y.W., S.S., N.S.), Keio University School of Medicine, Tokyo, Japan.
Disclosure
Scientific Advisory Boards:
1.
(1) Sanofi (Genzyme) (2) Ultragenyx (3) Novartis
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
(1) Sanofi (Genzyme), Speaker honoraria
Editorial Boards:
1.
(1) Neuromuscular Disorders, Associate Editor, 7 years (2) Neurology and Clinical Neuroscience, Associate Editor, 3 years (3) Therapeutic Advances in Neurological Disorders, Editorial Board, 8 years (4) Journal of the Neurological Sciences, Editorial Board, 3 years (5) Skeletal Muscle, Editorial Board, 2 years (6) Journal of Neuromuscular Diseases, Editorial Board, 2 years
Patents:
1.
(1) Efficacious agents to pathologic condition due to GNE protein dysfunction
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
(1) Intramural Research Grant for Neurological and Psychiatric Disorders of NCNP, 26-8, PI, 2014-2017 (2) JSPS KAKENHI Grant, 26293214, PI, 2014-2017 (3) Practical Research Project for Rare / Intractable Diseases from from Japan Agency for Medical Research and Development (AMED); H26-Itaku(Nan)-Ippan-081; PI; 2014-2017
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE

Notes

Correspondence to Dr. Nishino: [email protected]
*
These authors contributed equally to this work.
Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

Author Contributions

A.U. and A.N.: equally contributed to this study in terms of conceptualization and design of the study, data analysis and interpretation, literature review, and drafting the manuscript. R.S.T.: conceptualization of the study, preparation of the analyses, and manuscript revision for intellectual content. K.H.: data analysis and manuscript revision for intellectual content. M.K., Y.W., S.S., and N.S.: evaluation of autoantibodies and manuscript revision for intellectual content. I.N.: supervision of all aspects, including study design, data analysis and interpretation, and manuscript revision for intellectual content. A.U., A.N., and I.N. had full access to all of the data in the study and take responsibility for the integrity of the data and accuracy of the analysis.

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