The correct answer is B. Malignancy.

This question presents a case of dermatomyositis with the image demonstrating Gottron’s papules, which are violaceous papules found on the metacarpophalangeal, proximal and distal interphalangeal joints. In adults, dermatomyositis is associated with a greater risk of malignancy, seen in up to 40% of patients. Associated cancers include colon, ovarian, breast, pancreatic, lung, gastric, and hematologic malignancies.

Hypothyroidism can cause muscle weakness. However, this is not likely as the patient lacks other signs of hypothyroidism and his skin findings and proximal symmetric weakness are more suggestive of dermatomyositis. Giant cell arteritis (GCA) is an autoimmune condition that that is generally diagnosed in women older than 50 years of age. It is associated with vision loss and jaw claudication. The patient is a 45-year-old male and he does not have these typical findings. Furthermore, his migraine-type headache is not concerning for GCA. Acute renal failure is a complication of systemic lupus erythematosus which is associated with malar erythema. Instead, the patient has violaceous papules overlying the joints of the hand (Gottron’s papules) which are associated with dermatomyositis. Renal involvement is rare in dermatomyositis. The patient takes a cholesterol lowering medication which could be a statin. Statins are known to cause muscle pain or rhabdomyolysis and fatigue. However, this patient has progressive, proximal muscle weakness and a rash suggestive of dermatomyositis.

References: Dalakas MC, Hohlfeld R. Polymyositis and dermatomyositis. Lancet. 2003;362(9388):971-982. doi:10.1016/S0140-6736(03)14368-1

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