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Dermatomyositis: A Rare Presentation of Metastatic Prostate Cancer

Authors:

Iman Makki ,

Mount Sinai Morningside-West Hospital Center, Icahn School of Medicine at Mount Sinai, New York, US
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Binbin Zheng-Lin,

Mount Sinai Morningside-West Hospital Center, Icahn School of Medicine at Mount Sinai, New York, US
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Clare Bryce,

Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, US
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Sadhna Ahuja,

Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, US
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Sridevi Rajeeve,

Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, US
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Vaibhav Patel

Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, US
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Abstract

Background: Dermatomyositis (DM) is an idiopathic inflammatory myopathy with various cutaneous manifestations. There is a strong association between DM and malignancy with an estimated 5–7 fold increase in cancer incidence in DM patients compared to the general population. Dermatomyositis as a paraneoplastic manifestation has been reported in several malignancies notably ovarian, gastric, colon, cervical, pancreatic, and lung cancer but rarely in prostate cancer (Table 1).

Case Presentation: A 64-year-old male with a past medical history of hypertension, gout, and type II diabetes was admitted to the hospital following a mechanical fall after which he sustained shoulder and facial trauma. On further evaluation, the patient was found to have dysphagia, dysphonia, proximal upper extremity and lower extremity weakness, and rashes. The dysphagia began one month prior to presentation and the rashes appeared two months prior. Physical exam was notable for erythematous and scaly-dry skin in V-neck pattern, gottron papules, facial and periorbital erythema with scaly skin, periungual erythema, oropharyngeal salivary pooling, proximal bilateral upper and lower extremity weakness with intact distal extremity strength, and wasting of the bilateral quadriceps and hamstrings. Labs were notable for elevated creatine kinase (CPK) 296, positive Anti-p155/140 antibodies which are directed against transcription intermediate family-1 (TIF-1). Further workup with a computed tomography scan (CT) of the abdomen and pelvis revealed extensive pelvic and abdominal lymphadenopathy, centered in the pelvis, and therefore suspicious for either nodal metastasis from prostate adenocarcinoma versus lymphoma. A right inguinal lymph node biopsy was done and confirmed the diagnosis of metastatic adenocarcinoma of the prostatic primary. Staging workup via bone scan and MRI showed diffuse osseous metastases in the thoracolumbar spine (Figure 1). Consequently, the patient was started on Bicalutamide and Leuprolide as therapy for the underlying prostate cancer by the inpatient oncology team. The neurology service was consulted for the muscle weakness and were immediately concerned for dermatomyositis. Hence, they recommended empiric treatment with steroids whish were initiated and a biopsy of the left deltoid muscle was obtained. Biopsy results revealed skeletal muscle with perifascicular atrophy and mild mixed inflammatory infiltrate, suggestive of DM (Figure 2). Hence, in the setting of the patient’s clinical presentation confirmed the diagnosis of DM likely paraneoplastic. The patient was started on intravenous immunoglobulins (IVIG) in addition to steroids for treatment of DM. The patient’s hospital course was complicated by worsening dysphagia necessitating percutaneous gastric tube placement (PEG), worsening dysphonia, as well as hypoxic respiratory failure requiring a brief intensive care unit admission and non-invasive positive pressure ventilation. The patient slowly regained his speech and his respiratory status improved. He was able to be discharged to a subacute rehab after 37 days of inpatient stay. The patient is still requiring a PEG tube for feeding but his dysphagia has significantly improved, and his rashes have almost resolved. His muscle strength is slowly recovering. He continues to get IVIG sessions and steroids as well as Leuprolide injections every three months for treatment of his metastatic prostate cancer. His prostate-specific antigen (PSA) a marker that is usually elevated in prostate cancer and was markedly elevated in this patient began to downtrend significantly which usually indicates a positive response to therapy.

Conclusion: This case illustrates the importance of screening for an underlying malignancy in any patient presenting with DM. Because of the rarity of DM physicians should maintain a high index of suspicion and screen for more cancers than only those reported to be commonly associated with DM. Cases have shown that systemic manifestations of paraneoplastic DM tend to improve following treatment of the underlying malignancy.

How to Cite: Makki, I., Zheng-Lin, B., Bryce, C., Ahuja, S., Rajeeve, S. and Patel, V., 2021. Dermatomyositis: A Rare Presentation of Metastatic Prostate Cancer. Journal of Scientific Innovation in Medicine, 4(2), p.31. DOI: http://doi.org/10.29024/jsim.131
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  Published on 11 Jun 2021
 Accepted on 20 May 2021            Submitted on 20 May 2021

Table 1

Reported cases of dermatomyositis associated with prostate cancer diagnosis worldwide.


AUTHORS YEAR AGE SYMPTOMS AT PRESENTATION CANCER DIAGNOSIS TREATMENT SYNDROME ONSET COUNTRY CLINICAL STATUS

Hideyuki Minagawa et al. 2021 63 erythema on the skin, and muscle weakness with severe dysphagia appeared Metastatic prostate adenocarcinoma with neuroendocrine differentiation. High dose steroids and chemotherapy and androgen deprivation therapy After prostate cancer diagnosis Japan improved

Hee Yeon Kim at al. 2009 73 cutaneous lesions and progressive symmetric proximal muscle weakness systemic steroid, intravenous immunoglobulin and methotrexate. After prostate cancer diagnosis Korea improved

Béla Tállai et al. 2006 57 Total immobility developed in a short period of time; Purple-coloured rashes developed on his hand and face. These were the so-called heliotrope rash, Gottron’s papule Prostate cancer High-dose methylprednisolone; and prostatectomy Preceded prostate cancer diagnosis Hungary improved

Charalampos Papagoras at al. 2018 59 recurrent facial swelling and redness, accompanied by worsening fatigue during the previous 3 months Metastatic neuroendocrine prostate cancer prececded cancer diagnosis Greece deceased

Paula Renaux Caratta at al. 2011 72 only classic skin findings, which progressed to vesiculobullous lesions, and, months later, to myopathy Prostate adenoca Systemic steroids and chemotherapy Preceded can cer diagnosis Brazil improved

SHIN-ICHI ANSAI M.D. at al. 1996 74 Severe edema of the face and periorbital region, myalgias or extremities and dysphagia Prostate adenoca Systemic steroids Preceded can cer diagnosis Japan deceased

J. V. JOSEPH e al. 2002 63 erythematous rash on the scalp, neck, upper chest, back, extensor aspect of the elbow and gluteal region. The patient also had purple plaques over the back of his hand Metastatic prostate Ca Hormonal ablative therapy and steroids Preceded cancer diagnosis Scotland improved

Sekine Y at al. 2004 69 general fatigue, appetite loss and facial anthems Metastatic prostate Ca diethylstilbestrol phosphate and prednisolone Preceded cancer diagnosis Japan deceased

COLIN J MOONEY at al. 2006 72 1-month history of weakness and dull aches in his shoulders and thighs bilaterally Metastatic prostate Ca androgen-deprivation therapy and steroids Preceded cancer diagnosis USA improved

Figure 1 

Multifocal enhancing osseous metastases involving the thoracolumbar. Spine without spinal cord compression.

Figure 2 

This H and E stained skeletal muscle with perifascicular atrophy and mild mixed inflammatory infiltrate, suggestive of dermatomyositis(40X).

Competing Interests

The authors have no competing interests to declare.

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