On a daily basis, I have many individuals who present to my office not only complaining of muscle pain but also progressive muscle weakness which can be more serious. I’ll never forget the time a middle age female slowly walked into my office complaining of profound muscle weakness and fatigue. She described this feeling of not being able to get herself up from her chair and had profound difficulty walking.
She described the sensation of her “legs feeling like lead or dead weight”. What caught my interest when she walked in was her erythematous diffuse facial rash and rash on her chest. She had this area around her eyelids which was a purplish color. She just couldn’t believe how weak she felt. She was diagnosed with inflammatory myositis which is an autoimmune disease where there is inflammation of the muscle.
The exact cause for myositis is unknown but there are theories that genetics, viral illnesses may play a role. Individuals who are diagnosed with other autoimmune diseases like lupus, rheumatoid arthritis, mixed connective tissue disease, Scleroderma, Raynaud disease may have a higher risk of myositis.
DIFFERENT CATEGORIES OF INFLAMMATORY MYOPATHIES
- Dermatomyositis (DM)- with skin manifestations
- Myositis Associated with Cancer
- Inclusion Body Myositis
- Juvenile Dermatomyositis
- Difficulty with getting up from a chair, or washing hair or brushing teeth, climbing stairs, lifting objects
- Muscle pain or reduced ability to perform a repetitive task
- Fatigue, sleepiness, difficulty concentrating
Polymyositis can affect adults in middle age (30s to 50s), more often females. The weakness is progressive and can occur gradually over weeks and months. Affected muscle groups may affect both sides of the body and occur in the thighs, shoulders, hips, neck, upper torso.
Dermatomyositis usually occurs in older adults (40s to 60s) and also young children. This condition is characterized my muscle weakness and specific skin rash. Rash may be painful or itchy.
- Heliotrope rash-violaceous rash on the face and eyelids
- Shawl sign- reddish rash in V shape on the chest or back
- Gottron’s papules Reddish rash on knuckles, elbows, chest, back, knees
- Mechanic hands- cracked appearance on hands
One distinct feature of this myositis is the invovlement of specific cells causing inflammation surrounding small blood vessels in the muscle. Continuous inflammation may result in muscle fiber destruction.
The important thing for the physician or rheumatologist to determine is whether the patient has only muscle pain or muscle weakness.
NOTE: Remember, there may be other causes for muscle pain, inflammation or weakness to look out for!!!
- Thyroid Disorders (Hypo or Hyperthyroidism)
- Parathyroid abnormalities
- Abnormalities with cortisol or growth hormone
- Infections or Viruses (HIV, EBV, hepatitis B), staphylococcus or streptococcus infection
- Drugs or toxic substances ( statins for high cholesterol, colchicine for gout, AZT for HIV, cocaine, heroin, ethanol)
- Disorders of lipid metabolism or defects in DNA
- Muscular dystrophies or genetic disorders where there are genetic mutations in the muscle proteins
- Severe trauma or vigorous exercise
- Chronic steroid use
EVALUATION FOR MYOSITIS
A) Blood Tests
- Elevation in muscle test,
kinase or CPK suggesting muscle trauma or damage. creatnine
- Elevation in liver function tests or abnormal thyroid tests
- There may be other abnormal tests or autoantibodies such as aldolase, myoglobin, Jo1 antibody, Mi-2 autoantibod
- There may be elevated inflammation markers ( C reactive protein/CRP or sedimentation rate/ESR)
- Test for the muscle using electrical activity to determine if there is muscle disease when there
isrelaxation and contraction of muscles.
- This is important to measure objective muscle weakness
C) MRI can detect muscle inflammation
D) Muscle biopsy or sampling of muscle tissue is the best test to see if inflammation, muscle
Skinbiopsy may also be useful for diagnosing dermatomyositis.
E) Chest radiograph may be obtained to detect lung disease that may occur with muscle inflammation in DM
- A physical exam by the physician is very important to assess muscle strength and skin disease that may be associated.
- Immunosuppressants like azathioprine (Imuran) and methotrexate to help decrease steroid dose.
- Hydroxychloroquine (Plaquenil) –
antimalarial drug for skin manifestation
- Other therapies such as intravenous immunoglobulin and Rituximab that help the immune system have been used.
NOTE: Don’t forget to wear sunscreen with UVA and UVB protection!
Complications Of Myositis
- Difficulty swallowing and aspiration pneumonia
- Lung problems (shortness of breath or scarring of lungs)
- Heart Disease (inflammation of heart muscle wall called myocarditis), congestive heart failure, irregular
- Elevated risk of cancer (lung and bladder cancer, lymphoma, breast, colorectal and others)
Your physician should do an age-appropriate cancer screen and imaging looking for cancer if you are diagnosed with PM or DM.
Always pay attention to your muscle strength and seek an evaluation if you feel any weakness.
Luckily, my patient with Dermatomyositis did not have a malignancy. It was a long road trying to find the right medications to suppress muscle inflammation. Physical therapy was need for several months to help regain muscle strength.
- Engage in swimming, yoga, walking to maintain muscle tone
Keep up on your cancer screening!
- Wear sun protection
- Maintain healthy eating habits for heart disease prevention!
- Find a support group!
REFERENCES: American College of Rheumatology Mayo Clinic Arthritis Foundation
Disclaimer: This blog contains my personal opinion based on personal and clinical experience, tips from trainers, health coaches and lastly research. This blog does not endorse specific treatments, procedures, products. You should always consult with a doctor, nutritionist, or other healthcare professional to discuss your own health and lifestyle goals and regimen based on your medical history. Thank you for reading!