Question (EMQ) of the day – a history of weakness and fatigue
July 22nd, 2009
A 64 year old man presents with a history of weakness and fatigue. He has lost 3 stone in weight. On systemic enquiry, he has no other clinical symptoms, other than a mild dry cough which he has had for 3 days and some occasional dysuria, present intermittently for 6 months. His examination findings are as follows:
- No Jaundice , anaemia, cyanosis, jaundice or lymphadenopathy
- noted rash under both eyelids.
- BP 134/66
- Pulse 78 regular
- Sats 98% air
- BM 4.5 mmol/l RR 16
- Normal Cardiovascular Respiratory Gastrointestinal examination.
Neurology as follows:
- Grade 4 power upper and lower limbs symmetrically.
- Normal sensory examination.
- Normal reflexes.
- No clonus
- No fatigability
Where is the likely pathology?
Central Brain Lesion
Brainstem Lesion
Cord Lesion
Peripheral Nerve
Neuromuscular Junction
Acetylcholimesterase enzyme problem
Muscle lesion
None of the above
Let us know what you think, answer to follow soon. Remember: more questions like these can be found in the free trial area.
Could this be dermatomyositis with underlying malignancy?
This was my first thought on reading this question.
i agree,polymyositis(dermatomyositis)
as clinically,,heliotrope rash
interst. pneumonitis(dry cough)
in addition to muscular complaint
all neurological exams are normal ,in fact the intermittente dysuria is related to the acetylcholimesterase enzym problem
Wouldn’t a heliotrope rash be on the upper eyelids as opposed to under the eyelids. It does sound like a malignancy that may be invading the nervous system/renal system – possibly respiratory in origin??
it is a renal problem possibly responsible for Acetylcholimesterase enzyme acumlation i do not think there is aneurological disease
It’s heliotrope rash so the diagnosis is Dermatomyositis. Dry cough may be due to Interstitial lung disease as it is frequently associated with Polymyositis/ Dermatomyositis. So, the likely pathology is muscle lesion. Muscle biopsy is diagnostic for dermatomyosiits. On the muscle biopsy, there are two classic microscopic findings of dermatomyositis. They are:
-A mixed B- and T-cell perivascular inflammatory infiltrate
-Perifascicular muscle fiber atrophy
I agree with muscle lesion(Dermatomyositis):1,muscular involvment.2,lung involvment(interstitial pneumonitis). 3,skin involvment(helitrope rash).
[...] for all of your great responses to our question of the day – some good analyses and [...]
Thanks for all of your responses
The answer can be found here…
i think all these symptome due to renal causes