Ritik Tiwari, MD*, University of Texas Health Science Center San Antonio, San Antonio, TX;Mark Edward Hall, MD, UT Health Sciences Center San Antonio, San Antonio, TX and Monica Lee, MD, South Texas Veterans Health Care Systems, San Antonio, TX

Meeting: Hospital Medicine 2017, May 1-4, 2017; Las Vegas, Nev.

Abstract number: 756

Categories: Adult, Clinical Vignette Abstracts

Case Presentation: An 18 year-old man presented with two months of progressive weakness and dysphagia. He was previously active in high school wrestling and weightlifting but is now unable to participate in either due to the weakness. He was recently treated for rhabdomyolysis at an outside facility and encouraged to continue aggressive oral hydration. Exam was notable for sinus tachycardia without chest pain, reduced strength in hip and elbow flexion without palpable tenderness, and tea-colored urine. He had an extensive non-pruritic rash involving the face, torso, and hands. Labs revealed an elevated troponin I which peaked at 0.41 ng/mL, myoglobin elevated to greater than 1,000 ng/mL, and creatine kinase at 21,825 IU/L. Both electrocardiogram and echocardiogram were unremarkable for acute pathology. While video swallow fluoroscopy revealed severe pharyngeal dysphagia, no cause could be identified by esophagogastroduodenoscopy. Rheumatology was consulted and with their assistance a muscle biopsy was performed. Findings were consistent with dermatomyositis (DM). The patient was first started on high dose steroids but due to only a modest response, intravenous immunoglobulin was initiated. This young man further improved and was discharged home to the care of his parents but required a percutaneous endoscopic gastrostomy tube due to his continued dysphagia. It is unknown if he has since recovered enough to resume his previously active lifestyle.

Discussion: DM is part of a group of rare Idiopathic Inflammatory Myopathies associated with proximal muscle weakness and is differentiated by a violaceous, photosensitive rash classically appearing on the face, chest, and hands. Though it is often considered a disease of older age with peak incidence around age 50-59, a juvenile form also exists but is notably less common (1-10 versus 1-3.2 cases per million annually). DM may present with a variety of extra-muscular symptoms such as dysphagia, pulmonary, and cardiac involvement. Swallowing may be disrupted by involvement of the striated muscles in the oropharynx causing dysphagia and possible aspiration. Cardiac involvement, though rare, includes myocarditis, conduction abnormalities, arrhythmias, and even increased risk for myocardial infarction. Before the development of extensive cutaneous involvement, early DM may be difficult to distinguish from rhabdomyolysis as both classically involve weakness and elevated creatine kinases.

Conclusions: When faced with suspected rhabdomyolysis and extra-muscular symptoms in the acute setting, It is prudent for the hospitalist to broaden their differential and include this rheumatological pathology. Awareness of these extra-muscular manifestations can heighten clinical suspicion for DM, prevent misdiagnosis, and help expedite appropriate treatment.

To cite this abstract:

Tiwari, R; Hall, ME; Lee, M . BREAKDOWN ON THE MAT: A RARE CASE OF EARLY ADULT-ONSET DERMATOMYOSITIS. Abstract published at Hospital Medicine 2017, May 1-4, 2017; Las Vegas, Nev. Abstract 756. Journal of Hospital Medicine. 2017; 12 (suppl 2). Accessed February 25, 2020.

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