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Old 09-05-2012
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Default Neurology Question

A 65-year old woman complains of periodic headaches in the temporal region,visual disturbances ,and neck stiffness.Appropriate medical therapy in initiated early, and biopsy of scalp artery is consistent with arteritis.This patient comes to the physician 6 months later because of weakness. Her headaches are gone , but she has difficulty climbing stairs and getting up form a chair.Her blood pressure is 120/70mm Hg, pulse 82/min and respiartion are 12/min.Physical examination show 4/5 muscle power in her proximal lower extremities bilaterally.Her creatine kinase level and ESR are normal.Which of the following is the most likely cause of this patients current complain?

A. Polymyalgia rheumatica
B. Mononeuritis multiplex
C. Symmetric polyneuropathy
D. Inflammatory myositis
E. Multiple sclerosis
F. Drug induced myopathy
G. Neuromuscular junction disease
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A) Polymyalgia rheumatica

Seen in association with Giant cell arteritis
Laboratory studies are normal which differentiates this disorder from other proxymal myophaties
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F. Drug induced myopathy.

While polymyalgia rheumatica is associated with temporal artery arteritis the ESR is normal! It would be elevated in case of PR.
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this is one of the bitch qs that make me think that every qs has a twist

its not A as pt has normal esr and doubtful about steriod induced myopathy as cpk is also normal

so the ans is C .......... symmetrical polyneuropathy............
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Quote:
Originally Posted by Hitman View Post
this is one of the bitch qs that make me think that every qs has a twist

its not A as pt has normal esr and doubtful about steriod induced myopathy as cpk is also normal

so the ans is C .......... symmetrical polyneuropathy............
Steroid myopathy can go with normal CPK, just saying. In fact, it's usually within the normal range. With the info given you couldn't decide I guess.
This woman has no risk factors for polyneuropathy..., I doubt they would ask a question like this.... just my opinion.
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Originally Posted by dr_mhm View Post
Steroid myopathy can go with normal CPK, just saying. In fact, it's usually within the normal range. With the info given you couldn't decide I guess.
This woman has no risk factors for polyneuropathy..., I doubt they would ask a question like this.... just my opinion.
i know , its a very strange qs , if i remember ..... but i feel every myopathy has increase in cpk and the strength of proximal muscle 4/5 is normal for a 65 yr old and so in muscles are not involved as seen by normal cpk and power the fault is in the nerves , vit def for old people unable to stand from chair is possible ....... thats what i think
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Quote:
Originally Posted by step_enhancer View Post
A 65-year old woman complains of periodic headaches in the temporal region,visual disturbances ,and neck stiffness.Appropriate medical therapy in initiated early, and biopsy of scalp artery is consistent with arteritis.This patient comes to the physician 6 months later because of weakness. Her headaches are gone , but she has difficulty climbing stairs and getting up form a chair.Her blood pressure is 120/70mm Hg, pulse 82/min and respiartion are 12/min.Physical examination show 4/5 muscle power in her proximal lower extremities bilaterally.Her creatine kinase level and ESR are normal.Which of the following is the most likely cause of this patients current complain?

A. Polymyalgia rheumatica
B. Mononeuritis multiplex
C. Symmetric polyneuropathy
D. Inflammatory myositis
E. Multiple sclerosis
F. Drug induced myopathy
G. Neuromuscular junction disease
Would go with F, as CPK typically is within normal limits as steroid down regulate muscle protein synthesis( if the pt. is on chronic use of steroid as in this case).
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Originally Posted by Hitman View Post
i know , its a very strange qs , if i remember ..... but i feel every myopathy has increase in cpk and the strength of proximal muscle 4/5 is normal for a 65 yr old and so in muscles are not involved as seen by normal cpk and power the fault is in the nerves , vit def for old people unable to stand from chair is possible ....... thats what i think
Reference http://emedicine.medscape.com/article/313842-workup
Quote:
In chronic (classic) steroid myopathy, serum levels of creatine kinase typically are within the reference range.
In acute steroid myopathy, most patients have high levels of serum creatine kinase, as well as associated myoglobinuria.
Patient here came after 6 months so he can have a chronic myopathy ,and so can have a normal creatine kinase .
I am not saying its the answer ,I am just clearing your doubt.
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F. Drug induced myopathy

This is typical of steroid induced myopathy.

Another clue in the question stem is that the writer have tried very hard not to mention the word high dose prednisone (appropriate medical therapy ).

Steroid myopathy differs from other myopathies in that there is downregulation of muscle proteins as compared to destruction of muscle (leading to a rise in CK in other myopathies) and there is no inflammation (normal ESR)

A very good question indeed!

Last edited by Novobiocin; 09-05-2012 at 12:25 PM.
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F. Drug induced myopathy.

Steroid induced myopathy...As ESR is normal he is under steroids..
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Quote:
Originally Posted by step_enhancer View Post
A 65-year old woman complains of periodic headaches in the temporal region,visual disturbances ,and neck stiffness.Appropriate medical therapy in initiated early, and biopsy of scalp artery is consistent with arteritis.This patient comes to the physician 6 months later because of weakness. Her headaches are gone , but she has difficulty climbing stairs and getting up form a chair.Her blood pressure is 120/70mm Hg, pulse 82/min and respiartion are 12/min.Physical examination show 4/5 muscle power in her proximal lower extremities bilaterally.Her creatine kinase level and ESR are normal.Which of the following is the most likely cause of this patients current complain?

A. Polymyalgia rheumatica
B. Mononeuritis multiplex
C. Symmetric polyneuropathy
D. Inflammatory myositis
E. Multiple sclerosis
F. Drug induced myopathy
G. Neuromuscular junction disease

normal ESR rules out A.), and here normal CK and ESR plus symptoms of muscle weakness after treatment of temporal arteritis, which is steroid gives the diagnosis of steroid-induced myopathy.


Please correct me if I am wrong
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Old 09-06-2012
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Originally Posted by XpaezX View Post
A) Polymyalgia rheumatica

Seen in association with Giant cell arteritis
Laboratory studies are normal which differentiates this disorder from other proxymal myophaties
The way I remember these is the presentation:

Pain>>>>>>>>>>> Polymyalgia rheumatica

Weakness>>>>>>> Myopathy
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http://emedicine.medscape.com/article/313842-overview

Quote:
Steroid myopathy is usually an insidious disease process that causes weakness mainly to the proximal muscles of the upper and lower limbs and to the neck flexors.
In chronic (classic) steroid myopathy, serum levels of creatine kinase typically are within the reference range.
glucocorticoid down-regulation of protein synthesis may lead to decreased levels of these proteins in chronic steroid myopathy.
This patient has a history of temporal arteritis(i.e giant cell arteritis), which is usually treated with high dose oral steroids tapered over a prolonged period of time.Steroid-induced myopathy is the most common cause of drug-induced myopathy and can occur weeks to months after starting steroid therapy.The mechanism of steroid myopathy is thought to be decreased protein synthesis, mitochondrial alteration, increased protein degradation, and electrolyte and carbohydrate metabolism disturbances .
Acute steroid myopathy occurs within 1 week of drug initiation (relatively uncommon) and is cahrachterized by muscle weakness and rhabdomyolysis. The chronic form is more common and has an insidious onset after prolonged steroid use. patient present with proximal muscle weakness (lower extremity before upper ) without significant pain and difficult getting up from a chair , climbing stairs or brushing their hair.For both acute and chronic forms, the Diagnosis is clinical and no difinitive diagnostic test.
Muscle power imporves after discontinuation of the steroids, but the improvement can take weeks to months.

Choice A Polymyalgia rheumatica can be seen in up to 50% of the patients with temporal arteritis. Patients typically presents with aching and morning stiffness with pain in the shoulder, hip girdle and neck. The ESR is usually elevated and symptoms usualy improve with steriods.

Choice B Mononeuritis multiplex is usually seen in vasculitis and is caused by nerve damage in two or more nerves in seperate parts of the body.Patient typically presents with peripheral nerve findings ,such as wrist or foot drop.

Choice C Symmetrical poluneuropathy involves more dista; than proximal muscles and is not consistent with the patients presentation.

Choice D Muscle enzymes are elevated

Choice G Myasthenia gravis causes more upper than lower extremity disease and typically occular symptoms.

Additional reference http://www.ncbi.nlm.nih.gov/pubmed/20471889
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