They noted that there were exceptions, and also that diagnosis depended upon exclusion of all other myopathies that might mimic the IIM–in itself a challenging task. Future research would show fundamental differences in the immunopathogenic mechanisms in DM and PM, that the muscle pathology of DM could be seen in patients without a rash, and that almost certainly many patients diagnosed as having PM on Bohan and Peter criteria actually had sIBM. At this point in the chronology it is appropriate to comment upon the emergence

of sIBM and development of its diagnostic criteria. From its first CT99021 recognition as a separate disorder in the late 1960s [10] we now realise that sIBM is the most prevalent of the IIM (ignoring for the moment the question of whether it is truly a primary inflammatory myopathy). As with the seminal papers of Bohan and Peter for DM and PM, a single paper stands out concerning diagnostic criteria for sIBM [11]. And as with Bohan and Peter, rigid adherence to these initial criteria may to some extent have clouded further thought. A slightly unusual feature NLG919 molecular weight of the Griggs’ criteria is that a diagnosis of definite

sIBM can be made on histological grounds alone, without the need to fulfill any clinical criteria. In practice, there is little evidence that this approach might lead to erroneous diagnosis–that is, the pathological criteria as defined appear to be 100% specific for sIBM. The problem, some have

argued, is that there are many patients who indubitably Metalloexopeptidase have sIBM who do not, at the time of their first diagnostic biopsy, show the canonical pathological features insisted upon by Griggs [12], [13] and [14]. The evidence that they “indubitably have sIBM” is three-fold. Firstly, they have the highly distinctive, some would say essentially pathognomonic, clinical features of sIBM in terms of distribution of weakness, and follow the typical natural history of the condition in terms of rate of progression. Secondly, if a second biopsy is taken from another muscle shortly after the first biopsy, the canonical features may be seen. Thirdly, if the biopsy is repeated some time later then again the characteristic features may be seen. These latter two observations suggest two possibilities. Firstly, as is seen in DM, the pathological changes throughout the body may be patchy–whether the characteristic changes are seen is something of a lottery. The second, and more concerning possibility, is that the canonical pathological features may represent a late stage of the disease, and are indeed absent early on. sIBM is recognised as being highly resistant to immunomodulatory therapies (an argument against it being primarily an immune-mediated disorder) but maybe such treatments initiated at an earlier stage in the disease process would be more successful.