A 54-year-old woman comes to the physician with complaints of weakness and skin rash. She thinks that her symptoms could be related to medications she started on over the last 6 months. She was diagnosed with hypertension and hyperlipidemia and takes valsartan, amlodipine, chlorthalidone, and atorvastatin. It has become progressively more difficult for her to perform activities of daily living. She has no family history of skin disease.
Her vital signs are normal. BMI is 33 kg/m². Physical examination findings are shown in the pictures below. She has decreased muscle strength (4/5) in the quadriceps muscles bilaterally. Deep-tendon reflexes are 1+ and symmetrical. The remainder of the physical examination is within normal limits.

Laboratory results are as follows:

Which of the following is the most likely diagnosis?

Question

A 54-year-old woman comes to the physician with complaints of weakness and skin rash. She thinks that her symptoms could be related to medications she started on over the last 6 months. She was diagnosed with hypertension and hyperlipidemia and takes valsartan, amlodipine, chlorthalidone, and atorvastatin. It has become progressively more difficult for her to perform activities of daily living. She has no family history of skin disease.
Her vital signs are normal. BMI is 33 kg/m². Physical examination findings are shown in the pictures below. She has decreased muscle strength (4/5) in the quadriceps muscles bilaterally. Deep-tendon reflexes are 1+ and symmetrical. The remainder of the physical examination is within normal limits.

Laboratory results are as follows:

Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec193a_9929_21fe_853d_21fc3680522a_MD0002_00 This patient's cutaneous manifestations strongly suggest dermatomyositis (DM). Patients with DM usually present with symmetrical weakness that is more proximal. Classic skin findings include Gottron's papules, which are violaceous to dusky pink papules with scaling over the extensor surfaces of the MCP and IP hand joints and dorsal aspect of the wrists, elbows, and knees. Fewer than 50% of patients present with violaceous periorbital rash in the upper eyelid (heliotrope rash). Other skin findings include shawl sign (diffuse, flat erythema in a V-shaped distribution over the chest and shoulder), mechanic's hands (painful roughening and skin cracking in lateral fingers), and erythroderma. Diagnosis is suggested by these clinical findings and can be confirmed with laboratory testing, EMG, and skin/muscle biopsy. Treatment involves glucocorticoids and evaluation for possible associated malignancy. (Choice B) Statins can cause myalgias, acute rhabdomyolysis, and, rarely, inflammatory myopathy. Cutaneous manifestations are usually not present. (Choice C) Psoriasis usually presents with scaly plaques on the extensor surfaces of the arms and does not normally cause muscle weakness, as seen in this patient. (Choice D) Lupus may present with malar or discoid rash, myalgias, and arthritis. However, it does not usually cause muscle weakness, as seen in this patient. (Choice E) Systemic sclerosis can present with sclerodactyly, inflammatory myositis, and fatigue. However, it usually does not present with the skin findings seen in this patient. Educational objective: Dermatomyositis typically presents with proximal and symmetrical muscle weakness and characteristic skin findings (eg, Gottron's papules, heliotrope rash). Diagnosis is suggested by clinical findings and can be confirmed with laboratory testing, EMG, and skin/muscle biopsy. Treatment involves glucocorticoids and evaluation for possible associated malignancy. __________ References: Review: an update on inflammatory and autoimmune myopathies. (http://www.ncbi.nlm.nih.gov/pubmed/21155862) Polymyositis and dermatomyositis. (http://www.ncbi.nlm.nih.gov/pubmed/14511932)

A 54-Year-Old Woman Comes to the Physician with Complaints of Weakness