DrAlex_76
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A 48 yo woman complaint of difficult walking upstair, rising from the chair for the past 3 months. No headache or scalp pain. Exam reveals bilateral weakness of her proximal legs and arms. Lab test reveals markedly elevated CK level and normal ESR. WHich of the following is themost appropriate initial step in management ?
A. IV fluid replacement
B. Plasma exchange
C. Steroids
D. Neostigmine
E. Azathiprine
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| nightflight1945
banned
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Steroids
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| treblechar
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Polymyositis–Dermatomyositis. yup. high dose steroids first
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| DrAlex_76
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If ESR normal in those 2 diseases ?
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| Eagle_303
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ESR is increased in both PM and DM but may be normal in IBM.
But in IBM proximal as well as distal muscles are affected and there is no treatment.
This scenario is very confusing :
Involvement of only Proximal muscles + age less than 50 indicates = PM or DM
Normal ESR points to IBM
A typical commercial Question dilemma
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| DrAlex_76
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ESR increase 50 % in both Derm and Poly , source from emedicine.com
so, this case most likely Poly and Rx = Steroids
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| Eagle_303
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DrAlex_76 wrote:
ESR increase 50 % in both Derm and Poly , source from emedicine.com
so, this case most likely Poly and Rx = Steroids
Dr Alex that is nice information.
I will appreciate if you can provide the link because there are many article on e-medicine and copy paste its exact wording.
At one place under Dermatomyositis : it says nothing about ESR :
Lab Studies
- Muscle enzyme levels are often abnormal during the course of dermatomyositis, except in patients with the amyopathic variant. The most sensitive/specific enzyme is an elevated creatine kinase (CK), but aldolase levels and other tests (eg, aspartate aminotransferase [AST], lactic dehydrogenase [LDH]) may also yield abnormal results. At times, the elevation of the enzymes precedes clinical evidence of myositis. Thus, if a patient who is presumably stable develops an elevation of an enzyme previously within the reference range, the clinician should assess the possibility of a flare of the muscle disease.
- Several serologic abnormalities have been identified and may be helpful in the classification of subtypes for prognosis, but they are not used for routine diagnosis. As a group, these antibodies have been termed myositis-specific antibodies (MSAs). These autoantibodies occur in about 30% of all patients with dermatomyositis or polymyositis.
- A positive ANA finding is common in patients with dermatomyositis.
- Anti–Mi-2 antibodies are highly specific for dermatomyositis but lack sensitivity because only 25% of the patients with dermatomyositis demonstrate them. They are associated with acute-onset classic dermatomyositis with the V-shaped and shawl rash (poikiloderma) and a relatively good prognosis.
- Anti–Jo-1 (antihistidyl transfer RNA [t-RNA] synthetase) is more frequent in patients with polymyositis than in patients with dermatomyositis. It is associated with pulmonary involvement (interstitial lung disease), Raynaud phenomenon, arthritis, and mechanic's hands.
- Other MSAs include antisignal recognition protein (anti-SRP), associated with severe polymyositis, and anti–PM-Scl and anti-Ku, which are associated with overlapping features of myositis and scleroderma.
Source : http://www.emedicine.com/med/TOPIC2608.HTM
At other place it says (under polymyositis ) that ESR is usually raised.
Lab Studies
- Creatine kinase, aldolase, myoglobin, lactate dehydrogenase, aspartate aminotransferase, and alanine aminotransferase levels may be elevated.
- In practice, usually only the creatine kinase and aldolase levels are determined. The creatine kinase level is the most sensitive and specific; it usually is 5-50 times above the reference level. A level greater than 100 times the reference level is rare and is a signal of other diagnoses.
- The erythrocyte sedimentation rate usually is elevated.
- Myoglobinuria may be present.
- Positive rheumatoid factor results are found in more than 50% of patients.
- Positive antinuclear antibody results are found in fewer than 50% of patients.
- Leukocytosis is present in more than 50% of patients.
Source: http://www.emedicine.com/emerg/TOPIC474.HTM
I am really grateful if you can provide proper reference because that is great information.
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| DrAlex_76
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Nonspecific markers of inflammation include the following:
CBC count may show leukocytosis or thrombocytosis.
Elevated erythrocyte sedimentation rate or C-reactive protein occurs in 50% of patients with PM
http://www.emedicine.com/med/TOPIC3441.HTM
dude, u made me work ...
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| Eagle_303
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DrAlex_76 wrote:Nonspecific markers of inflammation include the following: CBC count may show leukocytosis or thrombocytosis. Elevated erythrocyte sedimentation rate or C-reactive protein occurs in 50% of patients with PM http://www.emedicine.com/med/TOPIC3441.HTM dude, u made me work ...
And I have learnt something from you 
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