A man with fever and bilateral limb weakness
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IM - CASE RECORD
A man with fever and bilateral limb weakness Sara Bernardi1 · Giuseppe Gargiulo1 · Gabriella Gruden1 · Valentina Ponzalino2 · Sara Bortolani2 · Tiziana E. Mongini2 · Claudia Papa1 · Giovanni Rolla1 · Paolo Cavallo Perin1 Received: 7 March 2019 / Accepted: 16 May 2019 © Società Italiana di Medicina Interna (SIMI) 2019
Case presentation A 49-year-old Caucasian male was admitted to our Emergency Department complaining of bilateral upper and lower limb weakness, interfering with daily activities, and intermittent fever, and weight loss. Two months before presentation he had an acute respiratory illness. Both intermittent fever and nonproductive cough persisted thereafter, followed by muscle weakness and weight loss (5 kg in 2 months). Both family and personal history were negative for cancer, endocrinopathy, hereditary muscle disorders, connective tissue diseases, and rheumatologic disorders except for Raynaud’s disease, which was diagnosed 5 years before admission. The patient was an accountant, he regularly practiced non-competitive sports, and he had a pet dog but no other animals. The patient denied recent foreign travels, known contact with sick persons, smoking, high-risk sexual behavior, abuse of alcohol or illicit substances, and any recent traumas. His only medication was acetaminophen and there was no history of exposure to statins or non-drug sources of statins, as red yeast rice and dietary supplements. The chief complain was severe symmetrical muscle limb weakness and myalgia, affecting mostly the legs, with increasing difficulties in climbing upstairs, arising from chair, and getting in and out of a car. He denied diplopia, dysphagia and other gastrointestinal symptoms, shortness of breath on exertion, arthralgia, or night sweats. Neurological examination in the Emergency Department showed symmetrical limb girdle weakness and tenderness of lower limb muscles without axial muscle involvement. Finger flexor strength was normal as well as sensory findings,
* Sara Bernardi [email protected] 1
Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy
Department of Neuroscience “Rita Levi Montalcini”, University of Turin, Turin, Italy
2
reflexes, and the remainder of the neurological examination. General physical examination was unremarkable and there was no evidence of interstitial disease at lung auscultation or heart sound abnormalities. Joint examination did not detect signs of inflammatory arthritis. A thorough skin examination with particular attention to the scalp, face, eyelids, hands, fingers, did not reveal any abnormality. In particular, there were no heliotrope rash, Gottron’s papules, shawl sign, mechanic hands, ulcerations, calcinosis or skin thickening of the fingers. Routine blood tests (Table 1), including electrolytes, renal function, and thyroid hormones, were normal, but there was a marked rise in CK (19.112 UI/l, reference range 25–190), LDH (4.291 UI/l, reference range 250–450), AST (618 UI/l, reference range 8–40), ALT
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