Polymyositis and dermatomyositis physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sadaf Sharfaei M.D.[2]

Physical Examination

• Physical examination of patients with polymyositis and dermatomyositis is usually remarkable for:[finding 1], [finding 2], and [finding 3].
• The presence of gottron's papules and the heliotrope eruption on physical examination is pathognomonic of dermatomyositis.

Appearance of the Patient

• Patients with polymyositis and dermatomyositis usually appear normal. They might be weak in severe cases.

Vital Signs

• Low-grade fever

Skin

• Skin eruptions like:
  • Gottron's papules is pathognomonic of dermatomyositis.
  • Heliotrope eruption is pathognomonic of dermatomyositis.
  • Gottron's sign
  • Facial erythema
  • Photodistributed poikiloderma
  • Nailfold changes
  • Scalp involvement
  • Calcinosis cutis
  • Mechanic's hands
  • Cutaneous ulceration
• Skin manifestations of dermatomyositis can be divided into 5 categories:

Lesion	Location	Picture	Percentage	Pathognomonic
Gottron papules	Dorsal aspect of interphalangeal or metacarpophalangeal joints		80%	Pathognomonic
Heliotrope rash	Eyelids and periorbital tissue
Gottron sign	dorsal aspect of the interphalangeal or metacarpophalangeal joints, olecranon process, patella, and medial malleoli			Characteristic
Macular violaceous erythema	Symmetric distribution in classic areas			Characteristic
shawl sign	Nape of the neck, shoulders, and upper back			Characteristic
“V sign”	V-shaped region of the neck and upper chest			Characteristic
Linear extensor erythema	Extensor aspects of the legs, thighs, arms, fingers, hands, and feet			Characteristic
Mechanic’s hands	Palms and fingers			Characteristic
Nail abnormalities	nail fold telangiectasias, cuticular overgrowth, and prominent periungual erythema	30-60%		Characteristic
Pruritus
Cutaneous calcinosis	Sites of compression, such as elbows and buttocks		30-70% in JDM 10% in DM
Flagellate erythema	Trunk, back, and proximal extremities
Poikiloderma	Sun exposed areas
Pityriasis rubra pilaris–like lesions	dorsal aspect of the hands and feet, frequently over the bony prominences		Rare
nonscarring alopecia, erythroderma, vesiculobullous lesions, and livedo reticularis			Rare
Cutaneous vasculitis such as with palpable purpura, urticaria-like lesions, livedo reticularis, and digital ulcerations
Leukocytoclastic vasculitis	Underlying malignancy
Raynaud phenomenon		25%

HEENT

• Periorbital swelling

Neck

• Neck examination of patients with polymyositis and dermatomyositis is usually normal.

Lungs

• Asymmetric chest expansion
• Lungs are hypo/hyperresonant
• Fine crackles upon auscultation of the lung bilaterally
• Wheezing may be present

Heart

• Cardiovascular examination of patients with polymyositis and dermatomyositis is usually normal.

Abdomen

• Abdominal examination of patients with polymyositis and dermatomyositis is usually normal.

Back

• Back examination of patients with polymyositis and dermatomyositis is usually normal.

Genitourinary

• Genitourinary examination of patients with polymyositis and dermatomyositis is usually normal.

Neuromuscular

• Patient is usually oriented to persons, place, and time
• Symmetric proximal muscle weakness mostly in:
  • Deltoids
  • Hips
  • Neck flexors
• Mild distal muscle weakness

• Hyporeflexia / areflexia
• Muscle rigidity

Extremities

• Muscle atrophy in severe, long standing disease
• Fasciculations in the upper/lower extremity