Title : Dermatomyositis presenting with progressive tetraparesis: A rare case report highlighting diagnostic challenges

Background: Dermatomyositis is an idiopathic inflammatory myopathy characterized by proximal muscle weakness and distinctive skin manifestations. When weakness progresses rapidly, neurological disorders may initially be considered, making careful examination of the skin and targeted muscle investigations important.

Case Presentation: A 50-year-old woman was admitted with progressive weakness of all four limbs, eventually becoming unable to stand or raise her arms to shoulder level. Symptoms had evolved over approximately one year, beginning with bilateral leg pain and skin discoloration, followed by worsening proximal weakness and photosensitive eruptions. Examination revealed a violaceous periorbital rash consistent with heliotrope rash, Gottron papules/sign over the finger joints, an eruption over the upper chest, neck, shoulders, and back, periungual erythema, scalp scaling, and alopecia. Proximal muscle weakness was more prominent than distal weakness. She denied dysphagia, choking, and dyspnea. The initial differential diagnosis included neurological conditions, particularly Guillain–Barré syndrome. Serum creatine kinase was markedly elevated at 4,181 U/L (laboratory reference: less than 145 U/L). Needle electromyography showed increased insertional activity, fibrillation potentials, positive sharp waves, and short-duration, low-amplitude, polyphasic motor unit potentials with early recruitment, consistent with an irritable myopathic pattern. The characteristic cutaneous findings, proximal weakness, elevated creatine kinase, and electromyographic findings supported a clinical diagnosis of dermatomyositis.

Outcome: During hospitalization, the patient received intravenous immunoglobulin and intravenous methylprednisolone, together with supportive care and active physiotherapy. Clinical notes documented some improvement in muscle strength and reduced paresthesia

Conclusion: This case highlights the diagnostic value of recognizing characteristic cutaneous manifestations in patients presenting with progressive tetraparesis. Correlating skin findings with muscle enzyme levels and electromyography can help distinguish an inflammatory myopathy from a primary neurogenic process and support timely clinical management. Persistent weakness at discharge emphasizes the need for rehabilitation and continued follow-up.

Shabrina Maharani is a medical resident affiliated with Universitas Jenderal Soedirman, Indonesia, and a master's student in Hospital Management. Her academic interests include clinical medicine, healthcare management, neurology, and the management of complex medical cases. She received first place in a scientific poster competition at PIR Joglosemarmas for a case involving neurointervention, demonstrating her interest in clinical research and scientific communication. She aspires to integrate clinical expertise with healthcare management knowledge to support evidence-based practice and improve the quality of healthcare services.