A 55-year-old woman comes to the physician due to a 2-month history of malaise, mild fever, and difficulty climbing stairs and rising from a chair. She has unintentionally lost 9.1 kg (20.1 lb) over this period. The patient has hypertension and asthma. Medications include amlodipine, as-needed albuterol, and inhaled glucocorticoids during winter. The patient does not smoke or use illicit drugs. She worked for 20 years supervising cotton processing in a textile factory but has been working as a secretary for the past 10 years. Temperature is 37.8 C (100 F), blood pressure is 120/70 mm Hg, pulse is 82/min, and respirations are 12/min. Chest examination reveals clear lung fields and normal S1 and S2. The patient has bilateral proximal upper and lower extremity weakness with normal reflexes. Plantar reflexes are down-going bilaterally. Violaceous papules and plaques are seen on the dorsum of both hands, as shown in the image below:
Kidney and liver function are within normal limits. Creatine kinase level is 1,200 IU/L.
Which of the following conditions is most likely associated with this patient's disease?

Question

A 55-year-old woman comes to the physician due to a 2-month history of malaise, mild fever, and difficulty climbing stairs and rising from a chair.  She has unintentionally lost 9.1 kg (20.1 lb) over this period.  The patient has hypertension and asthma.  Medications include amlodipine, as-needed albuterol, and inhaled glucocorticoids during winter.  The patient does not smoke or use illicit drugs.  She worked for 20 years supervising cotton processing in a textile factory but has been working as a secretary for the past 10 years.  Temperature is 37.8 C (100 F), blood pressure is 120/70 mm Hg, pulse is 82/min, and respirations are 12/min.  Chest examination reveals clear lung fields and normal S1 and S2.  The patient has bilateral proximal upper and lower extremity weakness with normal reflexes.  Plantar reflexes are down-going bilaterally.  Violaceous papules and plaques are seen on the dorsum of both hands, as shown in the image below:
 Kidney and liver function are within normal limits.  Creatine kinase level is 1,200 IU/L.
Which of the following conditions is most likely associated with this patient's disease?

Quizplus · Accepted Answer

Explanation: Dermatomyositis may occur alone but is often seen as a paraneoplastic syndrome of malignancy, which may be detected before, after, or with the skin and muscle symptoms. This patient's malaise, weight loss, and low-grade fever should raise suspicion further. All patients with newly diagnosed dermatomyositis should undergo age-appropriate cancer screening. The most common associated cancers include adenocarcinoma of the cervix, ovaries, lung, pancreas, bladder, and stomach. Dermatomyositis secondary to cancer may resolve completely once the malignancy has been successfully treated. (Choices A and E) Bacterial and viral infections can cause malaise and low-grade fever. However, the signs of dermatomyositis with unintentional weight loss make malignancy a more likely diagnosis. (Choice B) This patient has no features of degenerative disease (eg, osteoarthritis causing hip pain) that could explain her symptoms. (Choice D) This patient's history of working in the textile industry suggests asbestos or cotton dust exposure. Asbestosis can increase the risk of lung cancer, but it does not directly cause dermatomyositis. Cotton dust can cause byssinosis (a type of obstructive lung disease), not dermatomyositis. Educational objective: Dermatomyositis is associated with an increased risk of malignancy, and all patients should undergo age-appropriate cancer screening. Symptoms of dermatomyositis may resolve if the cancer is treated successfully. References: Polymyositis and dermatomyositis-challenges in diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/32743506)

A 55-Year-Old Woman Comes to the Physician Due to a 2-Month