Dermatomyositis associated with malignancy: A report of 3 cases
A 58-year-old married male presented with complaints of swelling and redness of the periorbital area, face, trunk and upper extremities since 2 months, difficulty in raising limbs and getting up from squatting position since 15 days and nasal twang of voice and nasal regurgitation of the food since 1 day. The patient was apparently alright 3 months ago, when he developed increased frequency of micturition, urgency and reddish discoloration of urine lasting for 3-4 days. The patient was investigated and diagnosed to have high-grade transitional cell carcinoma of the urinary bladder with extension to prostate on biopsy of the prostate. Cutaneous examination of the patient revealed confluent macular violaceous erythema and edema of the periorbital area, forehead and malar area [] with erythematous rash on the neck, chest [] and back. Systemic examination of the patient revealed generalized edema and musculoskeletal system examination revealed weakness of the muscles of limb girdles.\nLaboratory investigations of the patient revealed raised ESR, positive antinuclear antibody test (ANA 4+) and markedly elevated muscle enzymes (LDH, CPK-MM). Electromyography showed presence of myopathic denervation consistent with polymyositis, while a muscle biopsy from the quadriceps muscles revealed inflammatory myositis. Urine examination of the patient showed 30-40 RBCs/hpf, 8 to 15 transitional epithelial cells and 3-5 pus cells/hpf [Tables and ]. Skin biopsy from the violaceous erythematous lesion reveled atrophic epidermis, basal cell vacuolar degeneration, dermal edema and perivascular inflammatory infiltrate with abundant mucin in the dermis [Figure and ]. Ultrasonography of the abdomen and pelvis revealed 1 cm × 3.2 cm-sized mass at the bladder base, involving the prostate and suspected to be transitional cell carcinoma of the bladder. CT scan of the abdomen reveled ill-defined, mildly enhancing lesion at the bladder base extending into the prostate which on biopsy and immunohistochemistry confirmed the diagnosis of high grade transitional cell carcinoma. Rhinolaryngoscopy of the patient showed bulbar palsy. The patient was diagnosed as DMS associated with transitional cell carcinoma of the bladder and received oral prednisolone 1.5 mg/kg/day and subcutaneous injection methotrexate 15 mg/week in view of severity of skin and muscle involvement. Skin lesions of the patient showed complete resolution after 2 weeks of the treatment [Figure –], but muscle function recovery was monitored by fall in titers of muscle enzymes []. Unfortunately, the patient died of sudden cardiac arrest while awaiting the surgery.