Ahmedani Y, Qadir F, Khalid G.
Sarcoidosis presenting as Proximal Myopathy.
J Pak Med Assoc Jan ;53(9):440-1.

A middle aged lady presented with 4 months history of difficulty in rising from squatting position along with walking difficulty and painful thighs. Swelling of ankle and feet for 6 months preceded these symptoms. There was no history of fever and weight loss or any other focal symptoms. On examination she was overweight, had normal BP, pulse and temperature. Systematic examination revealed marked proximal muscle weakness. Her Hb was 12.4gm/dl, white cell count of 7000/mm3 with 56% of neutrophils and 35% of lymphocytes and ESR 25mm/first hour. Blood sugar, electrolytes, uric acid, thyroid, liver, kidney functions and urine analysis and x-ray chest were normal. Creatinine phosphokinase (CPK) was 72 IU/L and serum calcium 9.0mg/dl. RA factor was negative. EMG demonstrated myopathic pattern and muscle biopsy from involved muscle showed chronic granulomatous inflammation and possibility of sarcoidosis was questioned. Angiotensin converting enzyme levels was 198U/L (normal 8-52.0). Her eye examination was also unremarkable. In spite of restrictive pattern of pulmonary function tests, she had no respiratory symptoms. She was given steroid and within few days., she was able to walk and her proximal muscle weakness improved considerably. The initial tapering of steroids made her symptoms worse so they were tapered rather slowly at the cost of making her cushingoid and glucose intolerant. Addition of methotrexate at this stage helped in tapering of steroids. Her glucose values became normal and ACE levels returned to normal, her symptoms improved remarkably. For the last 2 years she is on 5mg prednisolone and 7.5mg/week of methotrexate and doing well.

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