Dermatomyositis associated with malignancy: A report of 3 cases
A 65-year-old married female, operated case of carcinoma of the right breast (in situ ductal carcinoma), presented with complaints of sudden appearance of swelling and redness over the right breast since 2 weeks. The swelling was associated with appearance of red-colored minimally itchy lesions on the forehead, cheeks, nape of neck retroauricular area and pinna since 6 days. The patient also developed generalized swelling all over the body since 2 days with difficulty in raising her arms above the head and getting up from the squatting position. Cutaneous examination of the patient revealed violaceous erythema over the periorbital area, forehead, malar area, chin ([], pre- and postauricular area [Figure and ] and both the breasts [Figure and ]. Systemic examination of the patient revealed generalized edema and musculoskeletal system examination revealed proximal muscle weakness affecting the limb girdles. Laboratory investigations of the patient revealed raised ESR and markedly elevated muscle enzymes (LDH, CPK-MM) [Tables and ]. Electromyography showed presence of myopathic denervation consistent with polymyositis, while a muscle biopsy from the quadriceps muscles revealed inflammatory myositis. Skin biopsy from the erythematous lesion revealed atrophic epidermis, focal basal cell vacuolar degeneration and dermal edema [], suggesting the diagnosis of dermatomyositis. The patient was simultaneously investigated for the recurrence of operated ductal carcinoma of the breast and metastasis. Ultrasonography of the right breast showed edema of the skin and subcutaneous tissue with fluid collection in the subcutaneous tissue without evidence of any mass. Positron emission tomography (PET) scan of the whole body did not reveal recurrence of previous malignancy or metastasis. The patient was diagnosed as dermatomyositis associated with treated ductal carcinoma of the breast and was initially started on oral prednisolone 1.5 mg/kg/day. But, in the absence of satisfactory improvement, subcutaneous injection methotrexate 15 mg/week was added. The patient showed excellent improvement in skin lesions and muscle function within 2 weeks [Figure –] with reduction in titers of muscle enzymes []. The dose of oral steroids and methotrexate was tapered slowly without recurrence of the disease, leading to complete discontinuation of the treatment at the end of 4 months.