Environmental Risk Factors for Myositis in Military Personnel

Myositis, an autoimmune muscle disease, likely develops as a result of environmental
exposures in genetically susceptible persons. Preliminary data suggest a trend for an
increasing incidence in myositis in military personnel over the last decade for unknown
reasons. Although a few environmental exposures have been preliminarily associated with
myositis in the civilian population, these have not been confirmed. In addition, no study has
assessed exposures that might result in the development of myositis in military personnel.
Military personnel experience a number of intense, unique exposures, often over a relatively
short interval, which include different stresses, novel vaccines, distinct occupational
exposures, battlefield injuries and unique chemicals during field deployment, that differ
from those exposures in non-military populations. Therefore, we propose a protocol that
consists of three complementary approaches to attempt to determine the environmental factors
associated with the development of myositis in active duty military personnel and an initial
understanding of the possible mechanisms involved. In the first approach, we will assess risk
factors in a case-control study of 300 patients who developed myositis while on active duty
by comparing them to 1500 active duty military personnel (randomly selected, but matched 5:1
by gender, race, and age and military service within 10 years) who have not been diagnosed
with an autoimmune disease or chronic muscle disease. For this first approach, we will
analyze existing military databases for information on medications, vaccines, infections,
co-existing medical conditions, military occupations, deployments, and worldwide active duty
locations. In the second case-control approach, we will attempt to define environmental
factors associated with the development of myositis that developed in military personnel
(n=150) by comparing them to 150 similarly matched military personnel who have not been
diagnosed with an autoimmune disease or chronic muscle disease. This second approach will
differ from the first approach, in that subjects will be prospectively enrolled and assessed
during a single clinic visit to confirm diagnoses and examine patient questionnaires on
focused environmental exposures, including those not captured in the military databases. A
third laboratory approach will identify, in an exploratory study, the global DNA methylation
epigenetic changes, microRNA and mRNA profiles in peripheral blood and muscle tissues from 18
subjects (six PM and six DM compared to six non-myositis controls enrolled in the second
approach) and assess the effects of selected environmental exposures on these parameters.
These complementary approaches should enhance the understanding of environmental factors and
possible mechanisms associated with the development of myositis in the military, and provide
insights into environmental risk factors that may also be relevant to the development of
myositis in non-military populations.

- ELIGIBILITY CRITERIA:

For Aim 1 of the study:

The inclusion criteria for myositis subjects are:

-Diagnosis of PM, DM or IBM during military service. Subjects may be active duty or no
longer active duty personnel. A matrix diagnosis of myositis will be based on ICD-9 codes,
laboratory tests and medical records in an attempt to match criteria for probable or
definite PM, DM or IBM

The inclusion criteria for matched control subjects are:

-The same gender, race, age within 10 years, and service in the military within 10 years as
the myositis subject.

The exclusion criteria for control subjects are:

-A matrix diagnosis of autoimmune or chronic muscle disease based on ICD-9 codes and
medical records.

For Aims 2 and 3 of the study:

The inclusion criteria for enrollment of myositis subjects are:

- Diagnosis of myositis during military service or service as a military contractor
based on criteria for probable or definite PM or DM, or clinically or pathologically
defined or possible IBM. Subjects may be active duty or no longer active duty
personnel. Military contractors include those with at least 1 year of collective
service on a military base or who actively deployed with military units after October
1998 and developed myositis will be eligible for this study.

- Able and willing to give informed consent, to complete the questionnaires and to
donate blood samples.

The inclusion criteria for matched controls are:

- Persons with military experience or having served as a military contractor attending
the same clinic or hospital as the myositis subject to which they are matched, or if
not available, volunteers from the general community (such as other participating
military or VA hospitals, private HCPs, or the NIH Healthy volunteer program), gender-
race- and age- (within 10 years) and military service period (within 10 years) matched
to the myositis subject. Military contractors include those with at least 1 year of
collective service on a military base or who actively deployed with military units
after October 1998.

- Controls should be without a recognized autoimmune or chronic muscle disease, able and
willing to give informed consent, to complete the questionnaires and to donate blood
samples.

The exclusion criteria for all protocol subjects are:

- Medical illness that in the judgment of the investigators does not allow safe blood
draws or other clinical evaluations needed for study participation.

- Chronic muscle diseases other than idiopathic inflammatory myopathy (i.e. infectious,
dystrophic, metabolic, toxic or drug-induced myopathies).

- Cognitive impairment.

- Not able or willing to give informed consent.

- Age <18 years.

- Current incarceration

There are no gender or ethnic restrictions to enrollment in the study.

HIV is not an exclusion for this study for the two following reasons:

- It has no impact on study procedures or tests.

- HIV may be one of the viral risk factors we are investigating.