Medical Grand Round 류마티스내과 R2 김승민

M/47 이 O 창 adm Chief Complaint 전신부종 및 근육 당김 o/s) 내원 1 년전 Present illness M/43 내원 1 년전부터 점차적으로 몸이 붓고 both leg, both arm 의 근육 뭉침이 있어 본원 신장내과 방문함. 검사 후 이뇨제 및 statin 처방 받았으며 이후 추적 검사에서 근육효소 상승이 관찰되어 (LD/CK 2013/6568) statin 을 중단함. Statin 중단 후에도 근육 효소 상승이 지속되어 류마티스 내과로 의뢰됨

Past Medical History DM / HTN / Pul.TB / hepatitis (- / - / - / +): HBV carrier OPHx (+) 1999 년 Rt 1-3th toe amputation Drug Hx(+) Lipitor 10mg qd, Dichlozid 12.5mg bid Personal History Alcohol (-): none Smoking (+): 10 pack yrs Family History none

Review of System General General Fatigue(+) Edema(+) Chill(-) Weight gain(+): 10kg/1yr Skin Skin Rash(-) Pigmentation(-) Itching(-) H&N H&N Headache(+) Sore throat(-) Hearing disturbance(-) Rhinorrhea(-) Nasal Obx.(-) Post. neck pain(-) Respiratory Respiratory Cough(-) Sputum(-) Tachypnea(-) Dyspnea(-) Hemoptysis(-) Cardiac Cardiac Chest pain(-) DOE(+): NYHA II Palpitation(-)

Review of System G-I G-I A/N/V/D/C (-/-/-/-/-) Melena(-) Renal Hematuria(-) dysuria(-) frequency(-) Musculoskeletal myalgia(+): both leg, both arm muscle weakness (+): 계단 오르기가 힘들다 muscle Cramp: intermittent both leg & both arm Neurology syncope (-) Dizziness (-)

Physical Examination V/S 120 / 80 mmHg – 90/min – 20/min – 36.0 °C height : 176 cm weight : 96 kg BMI : kg/m 2 General Appearance Alert consciousness Chronic ill-looking appearance Puffy face (+) Head & Neck No LN enlargement No neck vein engorgement Macroglossia (+) Voice change (+) Eye & ENT Isocoric pupil with PLR(++/++) Pinkish conjunctiva with clear sclera

Physical Examination Chest Clear breathing sound without crackle or wheezing Regular heart beat without murmur Abdomen Obese & distended abdomen Normoactive bowel sound Tenderness(-) Rebound tenderness(-) Back & Ext. motor power sensory IV intact

Physical Examination Back & Ext. Non pitting edema (+): Both upper arm & lower leg muscle Muscle stiffness & hypertrophy : calf muscle, forearm

Initial Lab. Findings CBC/DC 7210/mm 3 – 13.5 g/dL – 39.6% - 169,000/mm 3 (Seg %) INR / aPTT 1.09 / 43.7 (sec) Chemistry TB/ DB 0.96 / 0.12 mg/dL Prot/ Alb 7.5 / 4.7 g/dL AST/ ALT 177 / 85 U/L ALP/ GGT 55 / 32 U/L BUN/ Cr 17 / 1.6 mg/dL Na/K/ Cl 139 / 3.6 / 100 mmol/L Ca/ P / Mg 8.7 / 3.4 / 2.6 mg/dL CRP 0.7 mg/dL LD/CK 1674/5320 U/L glucose 92 mg/dL

CXR

EKG

Problemlist #1. Sustained elevation of muscle enzyme #2. Generalized non pitting edema

Initial Assesment & Plan Myopathy 1. Inflammatory myopathy 2. Endocrine myopathy 3. Metabolic myopathy 4. Drug induced myopathy Muscle enzyme, EMG&NCS, Muscle Biopsy, MRI (if needed) Muscle enzyme, EMG&NCS, Muscle Biopsy, MRI (if needed) ANA, anti Jo-1, anti Mi-2, ENA profile, C3/C4,ESR, CRP ANA, anti Jo-1, anti Mi-2, ENA profile, C3/C4,ESR, CRP TFT Forearm ischemic exercise test Medication Hx

Muscle enzyme myoglobin ng/mL 17.4~105.7 Aldolase 13.5 U/L ~ 7.6 U/L 입원

Serology ANA ( 정성 ) Negative Ig G Ig A Ig M Ig E mg/dL IU/ml 694 ~ ~ ~ 263 ~ 100 C3 C4 RA Factor <9.50 mg/dL IU/mL 88 ~ ~ 47 ~ 20 P-ANCA L-ANCA Negative Anti-Jo1 Negative Anti-RNP Negative

EMG

NCS

Muscle Biopsy

TFT T3 104 ng/dl 78~182 ng/dl Free T ng/dl 0.89~1.78 ng/dl TSH >80 mIU/L 0.17~4.05 mIU/L Thyroid auto Ab Thyroglobulin Ab 619 IU/ml 0-30 U/ml TPO(s) 2076 IU/ml 0-8 U/ml TBII(S) % Hypothyroid Myopathy Hashimoto thyroiditis

Thyroid US & Scan

Final diagnosis  Hypothyroid myopathy  Hypothyroidism d/t Hashimoto thyroiditis

Synthiroxine100 ㎍ Synthiroxine 200 ㎍ Synthiroxine 250 ㎍ Synthiroxine 200 ㎍ Clinical course

2007 년 2009 년

Case II 류마티스내과 R2 김승민

F/48 홍 O 아 adm Chief Complaint Diffuse muscular pain o/s) 내원 한달전 Present illness F/47 고혈압 이외 특이병력 없는 자로 4 년전부터 시작된 전신 근육통을 동반한 퇴행성 관절염으로 local 정형외과에서 치료 받았으나 이후 호전 없고 내원 1 달전 부터 전신 근육통 증가되어 Evaluation 위해 내원함

Past Medical History DM / HTN / Pul.TB / hepatitis (- / + / - / - ) HTN: Amlodipine 5mg qd OPHx (+) 2008 년 oophorectomy, Rt d/t ovarian rupture Drug Hx(+) Airtal 1t bid, Gasmotin 1t tid, Pantoprazole 1t qd, Gaslon N 1t qd, Personal History Alcohol (-): none Smoking (-): none Family History none History

Review of System General General Fatigue(-) Edema(+) Chill(-) Wt. change(+): 3kg/ 1yr Skin Skin Rash(-) Pigmentation(-) Itching(-) H&N H&N Headache(-) Sore throat(-) Hearing disturbance(-) Rhinorrhea(-) Nasal Obx.(-) Post. neck pain(-) Respiratory Respiratory Cough(-) Sputum(-) Tachypnea(-) Cardiac Cardiac Chest pain(-) Orthopnea(-) Palpitation(-) G-I G-I A/N/V/D/C (-/-/-/-/-) Renal Hematuria(-) dysuria(-) frequency(-) Musculoskeletal myalgia(+): both Arm, both leg, Lt Neck & shoulder, back pain muscle weakness (+): 무거운 것을 들기 힘들다 Neurology syncope (-) Dizziness (-)

Physical Examination V/S 130 / 80 mmHg – 72/min – 20/min – 36.0 °C height : 145 cm weight : 67.3 kg BMI : 31.8 kg/m General Appearance Chronic ill-looking appearance Puffy face (+) Eye & ENT Isocoric pupil with PLR(++/++) Chest Clear breathing sound without crackle or wheezing Abdomen Obese & distended abdomen Td(-) Rebound td(-) Back & Ext. Muscle stiffness & hypertrophy: calf muscle Non pitting edema (+/+) motor power sensory IV intact

Initial Assesment & Plan Myopathy 1.inflammatory myopathy 2.endocrine myopathy 3.metabolic myopathy 4.Drug induced myopathy Muscle enzyme, EMG&NCS, Muscle Biopsy, MRI (if needed) Muscle enzyme, EMG&NCS, Muscle Biopsy, MRI (if needed) ANA, anti Jo-1, anti Mi-2, ENA profile, C3/C4,ESR, CRP ANA, anti Jo-1, anti Mi-2, ENA profile, C3/C4,ESR, CRP TFT Forearm ischemic exercise test Medication Hx

Initial Lab. Findings CBC/DC 8,070/mm 3 – 13.1 g/dL – 37.6% - 218,000/mm 3 (Seg %) INR / aPTT 0.94 / 39.4 (sec) Chemistry TB/ DB 0.62 / 0.06 mg/dL Prot/ Alb 8.6 / 4.5 g/dL AST/ ALT 57 / 42 U/L ALP/ GGT 67 / 31 U/L BUN/ Cr 12 / 0.7 mg/dL Na/K/ Cl 141 / 3.6 / 103 mmol/L Ca/ P / Mg 8.4 / 2.1 / 2.0 mg/dL CRP 0.87 mg/dL LD/CK 863/1169 U/L glucose 92 mg/dL

Serology ANA ( 정성 ) Negativ e Ig G Ig A Ig M Ig E mg/dL IU/ml 694 ~ ~ ~ 263 ~ 100 C3 C4 RA Factor mg/dL IU/mL 88 ~ ~ 47 ~ 20 P-ANCA L-ANCA Aldolase Myoglobin Negativ e U/L ng/mL ~ ~ 105.7

TFT T3 107 ng/dl 78~182 ng/dl Free T ng/dl 0.89~1.78 ng/dl TSH mIU/L 0.17~4.05 mIU/L Thyroid auto Ab Thyroglobulin Ab >2000 IU/ml 0-30 U/ml TPO(s) >7500 IU/ml 0-8 U/ml TBII(S) % Hypothyroid Myopathy Hashimoto thyroiditis

CXR

EKG

Final diagnosis  Hypothyroid myopathy  Hypothyroidism d/t Hashimoto thyroiditis

Clinical course ADM Synthiroxine 50mcg Eperisone 50mg bid Acetaminophen 650mg bid Hypothyroid Myopathy LD,CK TFT LD,CK TFT Synthiroxine 100mcg Eperisone 50mg bid Ultracet 37,5mg/325mg bid Discharge Myalgia, Both hand pain Back pain Myalgia, Both hand pain Back pain Sx: improved Bone Scan Thyroid sono Bone Scan Thyroid sono

Clinical course Synthiroxine 50 ㎍ Synthiroxine 100 ㎍