A 61-Year-Old Woman With Progressive Weakness and Rash

Abstract

A 61-year-old female with a history of hypertension, hyperlipidemia, gastroesophageal reflux disease, and arthritis requiring several orthopedic procedures presented to her primary care physician complaining of a rash on her neck. A complete metabolic panel showed that her liver function tests were elevated, and her simvastatin was discontinued. She was referred to a dermatologist and was treated with oral antibiotics and topical cream. Eventually, she presented to the emergency department (ED) following a fall resulting in a fracture of the fifth metatarsal of her left foot. In the ED, she stated that the rash had spread to her face, upper torso, arms, and legs over the course of 3 weeks. She also complained of increasing weakness and multiple falls accompanied by myalgias and cramping in her thighs. She had difficulty arising from a chair, lifting her arms over her head, and lifting her head off the bed. She denied difficulty manipulating objects with her hands but did endorse worsening dysphagia and odynophagia. She denied any alcohol, tobacco, or other drug use aside from her prescribed omeprazole, aspirin, and lisinopril. She denied any exotic travel or flu-like symptoms. Family history was remarkable for rheumatoid arthritis in her mother and sister. On general examination, she was an obese caucasian female in no acute distress. Blood pressure was 128/68 mm Hg, heart rate was 96 beats/min, temperature was 36.7°C, and oxygen saturation was 97% on room air. A red maculopapular rash was noted over her knuckles, neck, chest, forearms, and thighs. Her eyelids were a purple hue and a malar rash was present. She had anicteric sclerae, pharyngeal erythema, regular cardiac rhythm, clear lungs, normal bowel sounds without distention, and a cast on her left foot placed by the ED physician. On neurologic examination, she was alert and fully oriented with a normal cognitive mental status examination. Her cranial nerves were intact, with full strength in her occuli, orbicularis oris, masseter, and temporalis muscles; she had no dysarthria. She had 4/5 strength in her neck flexors and extensors and 3/5 strength in her deltoids, biceps, and triceps bilaterally; wrist and hand power was 4/5. Hip flexor and quadriceps strength were symmetric at 2/5 and 4/5, respectively. Reflexes were normal and symmetric throughout. Sensory examination was normal aside from the painful rash. Serum laboratory analysis revealed increased creatine phosphokinase (CPK) and muscle related enzymes (Table 1), as well as elevated inflammatory markers (erythrocyte sedimentation rate 77; C-reactive protein 3.35). Electrocardiograph (ECG) showed normal sinus rhythm. Chest X-ray was clear without consolidation or hypoventilation. Computed tomography (CT) and magnetic resonance imaging (MRI) of head and spine were normal. Modified barium swallow confirmed dysphagia with overt aspiration. The patient was admitted and subsequently transferred to Emory University Hospital for further management. Table 1. Muscle-Related Enzyme Elevations