Clinical information: 

    The patient was a pleasant 56 year-old, right handed white man who presented with chronic insidious weakness of the turncal muscles and proximal muscles of extremities. His problem started about a year ago when he experienced soreness and progressive weakness in the upper arms and thighs. The pain was not associated with exercise or triggered by any known events or activities. He also complained of soreness involving multiple muscle groups along the trunk and torso that extends to the extremities. The patient also described muscle loss in his extremities. His creatine kinase (CPK) in serum was chronically elevated with a highest record of 2380 U/L (normal is 20-140 U/L). There was no numbness or tingling in his hands and feet.

    The patient had a history of hyperlipidemia and was treated with antihyperlipidemic drug including Lipitor and Lescol for 10 years but the treatment has been stopped 6 months ago.  The patient also had a history of hypothyroidism and was treated by Synthroid but the treatment has been discontinued. At the time of the biopsy, a thyroid function evaluation was within normal limits. There was a history of hypertension and his blood pressure at the time of biopsy was 140/94 mmHg.. There was no history of low exercise tolerance or clauditation. There was no know family history of multiple sclerosis, muscular diseases, or other collagen vascular diseases. The patient  was married. He smoked about three cigars per night. He chewed tobacco. He never used any illicit drugs. His father had high cholesterol and coronary artery disease. 

    On physical examination, his muscle strength and deep tendon reflexes were within normal limits. The rest of the physical examination was within normal limits.  Findings on electromyogram (EMG) and nerve conduction studies were within normal limits. 

     A muscle biopsy was performed as a diagnostic procedure.

                  Click thumbnails to see pictures.

A.	B. Trichrome	C. ATPase pH 9.4	D. NADH-TR	E. SDH	F. COX
G. Esterase	H. PAS	I. PASD	J. Phos	K. AD	L. AD-Control

What is your diagnosis? Discussion