Pruritic rash with proximal muscle weakness

Presenter: Duggan C., Jajou P.
Dermatology Program: Beaumont Hospital Trenton
Program Director: Steven Grekin DO
Submitted on: Apr 29, 2016

CHIEF COMPLAINT:  Patient is a 64-year-old female who presented to the clinic with a pruritic rash that started on her left wrist and then spread to her right arm, chest, scalp, and posterior neck.

CLINICAL HISTORY:

Signs and symptoms:  She denied any recent sun exposure. Patient admits to some difficulty arising from a seated position as well as fatigue while combing her hair.

Previous Treatment:  Patient had been given multiple topical steroids with only minimal relief of the rash and the associated pruritus. Lab work, muscle, and skin biopsy were ordered, as well as follow up with rheumatology in regards to a muscle biopsy.

Other information:  Patient had been to multiple physicians prior to coming to our clinic including an internal medicine physician, dermatologist, allergist, rheumatologist, as well as her primary care physician. Patient admits having all normal screening exams such as a mammogram/colonoscopy/pelvic examination as well as a recent CT of her chest, abdomen, and pelvis which didn’t reveal any abnormalities.

Past medical history: hypertension, hyperlipidemia, hypercholesterolemia, hypothyroid, depression
Medications: amlopdipine, aspirin, clopidogrel, enalapril, hydralazine, hydrochlorothiazide, metoprolol, nitroglycerin prn, duloxetine, atorvastatin

PHYSICAL EXAM:

Well nourished, healthy appearing female with scaly pink erythematous patches on bilateral upper extremities, post-auricular bilaterally, central chest and anteiror/posterior neck. Patient also had scaly erythema along frontal forehead near her hairline, and violaceous poikiloderma especially of the lateral neck, superior back/neck and chest. She stated previously on her hands she had erythematous papules overlying the metacarpophalangeal joints but this has since resolved.

 

 

 

 

LABORATORY TESTS:

ALT-53, AST- 46, Aldolase-10.4, CPK-297.1, WBC-2.8, Platelets-122

DERMATOHISTOPATHOLOGY:

Skin biopsy demonstrated epidermal atrophy, vacuolar interface change, mucin deposition, and a heavy lymphocytic infiltrate.

Muscle biopsy showed perifascicular atrophy of myofibers as well as capillary depletion. Also the biopsy demonstrated a CD4+ lymphocytic infiltrate.

DIFFERENTIAL DIAGNOSIS:

1.   Mixed Connective Tissue Disease
2.   Dermatomyositis
3.   Systemic Lupus Erythematosus
4.   Photoallergic Drug
5.   Polymorphus Light Eruption


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