|
|
LETTER TO THE EDITOR |
|
Year : 2015 | Volume
: 8
| Issue : 1 | Page : 118-119 |
|
|
A persistent facial rash turned out to be dermatomyositis
Milind A Patvekar, Urvi N Panchal, Kedarnath Dash, Manasi K Visana
Department of Dermatology, Dr. D.Y. Patil Medical College and Hospital, Chinchwad, Pune, Maharashtra, India
Date of Web Publication | 8-Jan-2015 |
Correspondence Address: Milind A Patvekar Department of Dermatology, Dr. D.Y. Patil Medical College and Hospital, B-204, Queens Town Society, Udyog Nagar, Opp. Lokmanya Hospital, Chinchwad, Pune - 411 033, Maharashtra India
Source of Support: None, Conflict of Interest: None | Check |
DOI: 10.4103/0975-2870.148874
How to cite this article: Patvekar MA, Panchal UN, Dash K, Visana MK. A persistent facial rash turned out to be dermatomyositis. Med J DY Patil Univ 2015;8:118-9 |
Sir,
We report a case of persistent facial hyperpigmentation, which turned out to be dermatomyositis on proper history and examination. A 30-year-old male presented with a malar rash associated with pruritus and burning sensation on sun exposure. The patient gave a history of difficulty in performing routine daily activities like rising from a chair, climbing stairs, raising arms above the head and lifting heavy objects associated with pain and tenderness over the bilateral upper limbs and lower limbs. There was no associated dysphagia or dyspnea.
On clinical examination, well-defined, bilaterally symmetrical hyperpigmented patches were seen over the malar region of the face with few poikilodermatous lesions [Figure 1]. | Figure 1: Hyperpigmented, well-defined bilaterally symmetrical changes — patches over the malar area
Click here to view |
On investigation, complete blood count, erythrocyte sedimentation rate, blood sugar levels, ultrasonography of the abdomen, shoulder/thigh were normal. Chest X-ray, urine (routine and microscopy), anti-Streptolysin-O titer, rheumatoid factor, electrocardiomyogram and 2-D echo were within normal limits.
The following results were observed: Serum lactate dehydrogenase −1308 IU/L (normal range: 40-250), serum aldolase −11.50 U/L (normal range <7.60), serum. Jo1 antibody −0.07 U/mL (normal range <3.00), serum creatinine phosphokinase −6459 IU/L (normal range: 24-190) and C-reactive protein-positive.
The electromyogram and nerve conduction study were suggestive of myopathic process. Skin biopsy revealed epidermal atrophy, focal mild non-specific inflammatory infiltrate in the superficial dermis and foci of calcification in the deeper dermis consistent with dermatomyositis [Figure 2] and [Figure 3]. | Figure 2: Photomicrograph of skin biopsy showing focal, mild, non-specific infl ammatory infi ltrate in the superfi cial dermis and foci of calcifi cation in the deeper dermis (hematoxylin and eosin stain, x100)
Click here to view |
| Figure 3: Photomicrograph of the skin biopsy showing mucin deposition in the dermis (alcian blue stain, x100)
Click here to view |
Muscle biopsy revealed skeletal muscle fibers in scattered degenerative changes, some being intensely eosinophilic while others showing granularity. There was internalization of the nuclei and areas of nuclear fragmentation. The dermal vessels showed perivascular collections of lymphocyte and endothelial cell swelling consistent with dermatomyositis [Figure 4]. | Figure 4: Photomicrograph of the muscle biopsy section showing lymphocytic interstitial infl ammatory cells and focal necrotic muscle fibers (hematoxylin and eosin stain, x400)
Click here to view |
Direct immunofluoroscence using an anti-IgG antibody showed band-like deposits along the epidermal basement membrane[Figure 5]. | Figure 5: Photomicrograph of direct immunofl uoroscence using an anti-IgG antibody showing band-like deposits along the epidermal basement membrane
Click here to view |
Based on clinico-pathological correlation, a final diagnosis of dermatomyositis was made. Partial improvement was observed with topical and oral corticosteroids. Corticosteroids were continued considering their importance in dermatomyositis.
Dermatomyositis is a chronic inflammatory disorder of the skin and muscles. Skin involvement in dermatomyositis usually manifests with characteristic papules over the digits, erythema over the elbows and knees, a heliotrope rash around the eyes, periungual telangiectasias and cuticular overgrowth. [1] Muscle involvement usually manifest as proximal muscle weakness initially, with or without myalgias or tenderness. [2] In 1975, Bohan and Peter introduced the diagnostic criteria for the diagnosis of dermatomyositis. Four out of the five criteria involve the muscles:
- Gradually exacerbated, symmetrical, proximal muscle weakness,
- increased enzymes related to the muscles,
- abnormal electromyogram,
- histological confirmation of myositis in muscle biopsy and
- skin manifestations. [3],[4]
All the above mentioned criteria were positive in this case.
Usually, what appears as a simple rash may turn out to be a serious ailment if a high index of suspicion is kept, which helps in the early diagnosis of grave conditions for better and efficient management.
References | | |
1. | Callen JP, Wortmann RL. Dermatomyositis. Clin Dermatol 2006;24:363-73. |
2. | Sontheimer RD. Would a new name hasten the acceptance of amyopathic dermatomyositis (dermatomyositis sine myositis) as a disctinctive subset within the idiopathic inflammatory dermatomyopathies spectrum of clinical illness? J Am Acad Dermatol 2002;46:626-36. |
3. | Bohan A, Peter JB. Polymyositis and dermatomyositis (first of two parts). N Engl J Med 1975;292:344-7. |
4. | Bohan A, Peter JB. Polymyositis and dermatomyositis (second of two parts). N Engl J Med 1975;292:403-7. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
|