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Case Reports

Abstract

A 62-year-old female with hyperlipidemia and type II diabetes mellitus presented with a pruritic rash on the trunk and progressive extremity weakness, which coincided with starting rosuvastatin four months prior. Creatinine kinase level was elevated to 9918 U/L on admission and continued to rise despite discontinuation of rosuvastatin, peaking at 15,436 U/L. Dermatology evaluated her for diffuse pink-red patches across the face, chest, back, and abdomen, along with widespread erosions and ulcerations involving the back, chest, and buttocks. Skin biopsy obtained from the posterior shoulder showed confluent epidermal necrosis, minimal dermal inflammatory infiltrate, and a slight increase in background dermal mucin. The patient’s auto-antibodies, including HMGCR and SRP, and malignancy screening were negative. Biopsies of the quadriceps and deltoid muscles revealed preferential type 2 atrophy (possibly due to prednisone and the inflammatory myopathy), mild mitochondrial dysfunction, mild nonspecific myopathic changes, mild neurogenic changes, and several histiocytic infiltrates suggestive of inflammatory myopathy with abundant macrophages, but immunohistochemical and ultrastructural findings favored dermatomyositis. Dermatomyositis rarely occurs with extensive epidermal necrosis, but this presentation has been previously described in the literature in association with anti-MDA-5 antibodies and malignancy.  Drug-induced dermatomyositis with epidermal necrosis is unusual, and these combined clinical features should alert clinicians and dermatopathologists to consider this entity.