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| LETTER TO EDITOR |
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| Year : 2022 | Volume
: 17
| Issue : 1 | Page : 89-90 |
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Hyperpigmentation heralding relapse of active dermatomyositis in an indian patient
Mahathi Kunduru1, Latika Gupta2
1 MBBS Student, Osmania Medical College, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
2 Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| Date of Submission | 12-May-2021 |
| Date of Acceptance | 31-Aug-2021 |
| Date of Web Publication | 27-Jan-2022 |
Correspondence Address:
Dr. Latika Gupta
Assistant Professor, Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/injr.injr_92_21
How to cite this article:
Kunduru M, Gupta L. Hyperpigmentation heralding relapse of active dermatomyositis in an indian patient. Indian J Rheumatol 2022;17:89-90 |
Dear Editor
A 23-year-old female diagnosed with dermatomyositis (DM) since 2016 sought teleconsultation for skin pigmentation over the face and upper limbs in March 2021. Hyperpigmentation was limited to the sun-exposed areas for the past 3 months. She could perform activities of daily living without difficulty suggesting normal muscle strength. However, timed remote tests for assessment indicated muscle weakness of the lower limbs on teleconsultation. The 2-min walk distance was 98 m (normal 167–225), and ten times arm lift time was 15 s (normal 10.5–14 s).
She was asked to report to the clinic, wherein hyperpigmented skin was noted in areas of direct sun exposure, including the face, neck, bilateral upper limbs (arms and forearms), and feet with areas of faint erythema [Figure 1]a, [Figure 1]b, [Figure 1]c. Muscle power on manual muscle testing was 59 of 80 (neck flexors – 5/10, deltoid – 7/10, biceps – 7/10, wrist extensor – 9/10, hip extensor – 7/10, hip abductors – 7/10, knee extension – 8/10, ankle dorsiflexion – 9/10) while the rest of the systemic examination was unremarkable. | Figure 1: (a-c) Hyperpigmentation of face, outer ear, chest, and forearm (arrows) with faint erythema, residual hyperpigmentation. (d) Residual hyperpigmentation
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Laboratory investigations were notable for raised muscle enzymes, specifically lactate dehydrogenase and transaminases, with a normal creatine kinase. The patient had a relapsing disease which had flared previously as well, following an episode of acute gastroenteritis in 2018 while on methotrexate. She had responded to Mycophenolate mofetil, though the current episode was diagnosed as a second flare of DM. The patient was treated with rituximab and tapering doses of 1 mg/kg prednisolone for 6 weeks, following which she improved, although with partial residual pigmentation [Figure 1d].
DM may manifest with varied cutaneous involvement, ranging from classic rashes such as a heliotrope appearance on the eyelids, gottron's signs on the knuckles to less specific extensor erythema, and poikiloderma. The cutaneous spectrum continues to evolve with greater recognition of different forms such as unilateral eyelid edema, lip edema, psoriasiform rashes, and flagellate erythema in recent times.[1],[2],[3] Our patient reported hyperpigmentation, and careful examination revealed areas of mild skin erythema in areas of sun exposure along with increased muscle weakness, as a sign of a flare which was missed over teleconsultation. A similar finding has been discussed in a retrospective, descriptive study of 37 hispanic individuals who exhibited similar facial hyperpigmentation as a part of disease relapse.[4] Notably, this observation finding is particularly important in dark-skinned individuals since it may be difficult to detect as a flare.[3] Besides, hyperpigmentation may be the first cutaneous manifestation of relapse, preceding frank muscle weakness by days to weeks.
It is noteworthy that none of the current classification criteria recognize this form of cutaneous involvement as a specific marker of DM. It is worthwhile exploring the entire range of cutaneous involvement in various ethnic groups and revising the current classification systems to make them more ethnically inclusive.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Rathore U, Haldule S, Gupta L. Psoriasiform rashes as the first manifestation of anti-MDA5 associated myositis. Rheumatology 2021;60:3483.  |
| 2. | Mehta P, Machado PM, Gupta L. Understanding and managing anti-MDA 5 dermatomyositis, including potential COVID-19 mimicry. Rheumatol Int 2021;41:1021-36. |
| 3. | Gupta L, Naveen R, Gaur P, Agarwal V, Aggarwal R. Myositis-specific and myositis-associated autoantibodies in a large Indian cohort of inflammatory myositis. Semin Arthritis Rheum 2021;51:113-20. |
| 4. | Chavez-Alvarez S, Suro-Santos Y, Villarreal-Martinez A, Herz-Ruelas ME. The sunburn sign and the suntan sign- two novel findings in Hispanic patients with dermatomyositis. J Eur Acad Dermatol Venereol 2021;35:e88-9. |
[Figure 1]
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