American College of Physicians: Internal Medicine — Doctors for Adults ®

Advertisement

MKSAP Quiz: Intermittent abdominal discomfort

From the November/December ACP Internist, copyright © 2013 by the American College of Physicians

A 61-year-old woman is evaluated for intermittent abdominal discomfort and a bloating sensation. Approximately 2 months before the swelling started, the patient had a pruritic, gradually progressive rash characterized by redness of the face, and a pruritic rash on her chest, upper back, shoulders, hands, and lateral hips. She has no muscle pain, weakness, or joint pain. Pertinent family history includes breast cancer in her mother and ovarian cancer in her grandmother. Mammogram, Pap test, and colonoscopy, all performed within the last year, were normal.

On physical examination, vital signs are normal. BMI is 30. There is violaceous erythema of the periorbital region. She has reticulate and poikilodermatous erythema of the V-neck of the chest with areas of cutaneous ulceration. There are small, flat-topped erythematous papules over the distal and proximal interphalangeal joints. Skin findings are shown.

MKSAP photo (c) American College of Physicians

MKSAP photo (c) American College of Physicians



Lungs are clear. There is no lymphadenopathy or hepatosplenomegaly. There is trace lower extremity edema. The patient has normal strength and no difficulty raising her arms or rising from a chair without using her arms to help. Pelvic examination is normal.

Laboratory findings reveal normal complete blood count, comprehensive metabolic profile, and serum aminotransferase, creatine kinase, and aldolase levels. Electromyogram of the right arm and leg is normal.

Which of the following is the most appropriate diagnostic study for this patient?

A: Antinuclear antibody serologic testing

B: Serum CA 19-9 and carcinoembryonic antigen measurement

C: Thigh muscle biopsy

D: Transvaginal ultrasound

Answer and critique

The correct answer is D: Transvaginal ultrasound. This question can be found in MKSAP 16 in the Dermatology section, item 40.

The most appropriate diagnostic study for this patient is a transvaginal ultrasound. It is likely that this patient has amyopathic dermatomyositis, a condition characterized by the typical rash and histologic findings of dermatomyositis but in the absence of clinical myopathy. In these patients, as well as in patients with classic dermatomyositis, ovarian cancers are overrepresented, and these patients should be evaluated with appropriate imaging. Patients with dermatomyositis and cutaneous ulcerations may be at an even higher risk of malignancy. Given this patient’s symptoms of increasing abdominal girth, along with her family history, ovarian cancer is a reasonable concern.

Antinuclear antibody (ANA) serologic testing may be useful in the diagnosis of autoimmune diseases and is frequently positive in dermatomyositis. A negative ANA, however, would not exclude a diagnosis of dermatomyositis, and ANA status would not alter the evaluation or management of this patient.

Carcinoembryonic antigen is a nonspecific tumor marker that may be elevated in the presence of colon cancer, as well as other tumors such as pancreatic, gastric, lung, and breast; it is an inadequate screening and diagnostic test. The CA 19-9 level is elevated in subsets of colon, gastric, and pancreatic tumors. Neither is likely to help identify the most likely diagnosis in this patient.

Thigh muscle biopsy is not indicated in this patient. Dermatomyositis may be diagnosed without muscle inflammation in patients with amyopathic dermatomyositis or those with minimal muscle disease, known as hypomyopathic dermatomyositis. A blind muscle biopsy is low yield. If the patient were having symptoms of muscle pain or weakness, a muscle biopsy would be indicated. The presence of a negative electromyogram, normal serum aminotransferase levels, and normal creatine kinase and aldolase levels make active muscle inflammation unlikely.

Key point
  • All patients with a new diagnosis of dermatomyositis should undergo age- and sex-appropriate cancer screening.

Top


.

Subscribe to MKSAP 16

ACP’s MKSAP helps you to:

  • Update your knowledge in all areas of internal medicine
  • Assess your medical knowledge with 1,200 all-new multiple-choice questions
  • Pass the ABIM Certification Exam or the ABIM Recertification Exam
  • Support your clinical decisions in practice

To order the most current edition, go online.

Top

This is a printer-friendly version of this page

Print this page  |  Close the preview

Share

 
 

Internist Archives Quick Links

What will you learn from your Annals Virtual Patient?

Reviews of the World's Top Medical Journals—FREE to ACP Members! Annals Virtual Patients is a unique patient care simulator that mirrors real patient care decisions and consequences. CME Credit and MOC Points are available. Start off with a FREE sample case. Start your journey now.

Products and Resources for Patients

Products and Resources for PatientsACP has developed easy- to-use materials designed to help educate your patients on self-management of a wide variety of common health conditions. Order yours today!