Background <p>Anti-melanoma differentiation-associated protein 5 antibody positive dermatomyositis (MDA5⁺ DM) is an autoimmune disease related to rapidly progressive interstitial lung disease (RPILD) with high mortality. However, the pathogenesis of MDA5⁺ DM with RPILD remains unclear. We aimed to explore the peripheral immune landscape of MDA5⁺ DM with RPILD using single-cell RNA sequencing (scRNA-seq).</p> Methods <p>We performed scRNA-seq of peripheral blood mononuclear cells (PBMCs) from MDA5⁺ DM with RPILD (<i>n</i> = 4), MDA5⁺ DM with ILD (non-RPILD, <i>n</i> = 3), and healthy controls (HCs, <i>n</i> = 3).</p> Results <p>The proportion of CD14⁺ monocytes increased, but the proportion of natural killer cells, CD4⁺ T cells and CD8⁺ T cells decreased in MDA5⁺ DM with RPILD compared with HCs. Obvious antiviral response was the main feature of MDA5⁺ DM with RPILD, and the expression of several interferon-stimulated genes (ISGs) related to RIG-I pathway increased, including IRF7, DDX60, IFI27 and IFI6. However, this antiviral response was not significant in MDA5⁺ DM with ILD. In addition, multiple immune pathways were downregulated in MDA5⁺ DM with RPILD, including antigen processing and presentation, translation initiation, mRNA splicing, and activation of T and B cells. Cell communication analysis revealed that multiple signaling pathways, including MHC-I and MHC-II, were attenuated in MDA5⁺ DM with RPILD. Notably, MHC-II signaling was absent in CD4⁺ naïve T cells from MDA5⁺ DM with RPILD.</p> Conclusions <p>This study demonstrates that antiviral response plays an important role in the pathogenesis of MDA5⁺ DM with RPILD, as well as changes in downstream immune pathways, providing potential therapeutic targets for future treatment.</p>