A 52-year-old woman was admitted to the hospital with "weak limbs and body pain for 1 week". The main manifestations of the onset were weakness of limbs, weakness of hands twisting towel when washing face, symptoms gradually progress, and difficulty standing up when squatting, accompanied by general pain, discomfort and fever. After the onset of illness, the patient was treated in the local hospital, but the symptoms did not alleviate. Then the patient came to our hospital for further diagnosis and treatment. Past history: the patient had a history of diabetes for 2 years, usually had good blood sugar control, no history of other diseases, and had lived in Inner Mongolia in the past six months.
Physical examination and outpatient information
Physical examination: T37.5℃, P 120 beats/min, R 26 beats/min, BP 130/94mmHg, conscious, weak state, wheelchair pushed into the ward, medium nutrition, pale complexion, no yellowing and bleeding spots on the skin and mucous membranes , The superficial lymph nodes were not palpable and enlarged, polycardia, and polypnea. There were no obvious positive signs in the rest of the examination. Nervous system examination: both upper limbs muscle strength was grade 4, tendon reflex was normal; both lower limbs muscle strength was grade 2 and tendon reflex was weakened,obvious lumbar tenderness, urine retention. No other obvious positive signs were seen. Outpatient information, August 28, 2020, blood routine: white blood cells 8.43G/L, hemoglobin 55g/L, platelets 55mmol/L; urine microalbumin positive; lactate delase 1869U/L; CK-MB 335U /L; a-hydroxylase 1278 U/L; anti-"O" 27.6IU/mL, rheumatoid factor 20U/mL, C-reactive protein 339.1mg/L, complement C4 44mg/dl, complement C3 157mg/dl. HLA-B27 101 U/ml, anti-cyclic citrullinate antibody <0.5U/ML, electromyography(EMG): multiple peripheral nerve damage, electromyography changes, mainly motor and sensory nerve myelin damage, accompanied by axonal damage (both lower limbs severe), mainly proximal demyelination; Rose Bengal Plate Agglutination Test (RBPT): negative.
The process of treatment
According to the patient's medical history, physical examination and examination data, the diagnosis considered polymyositis. Completion of relevant inspection results showed: blood analysis: WBC 6.74G/L, NE% 84.9%, RBC 3.98T/L, HGB 118g/L, PLT 45G/L, ESR 24mm/h, muscle enzymes: AST 130U/L, CK 190IU/L, CK-MB 383IU/L, LDH 2450IU/L, HBDH 1754IU/L; blood glucose 23.22mmol/L, renal function: BUN 10.24mmol/L, Cr 45.5umol/L, urine protein: weakly positive. NT-proBNP 813.1ng/L; Chest CT: pneumonia, pericardial effusion and a small amount of pleural effusion. Electrocardiogram(ECG): sinus tachycardia, ST-T changed (STⅠⅡⅢ aVF V3 V4 V5 horizontal shift down 0.05mV, T wave low and flat inverted). Echocardiogram: Moderate tricuspid regurgitation (estimated pulmonary artery systolic pressure was about 57mmHg), EF: 63%. There was no obvious thrombus in the veins of the lower limbs. For patient with lumbar pain, MRI showed that the thoracic and lumbar spine bone signals were abnormal, and the blood system disease was waiting to be discharged. The patient was planning to use hormone therapy, and CT of the hip joint showed that the femoral skull mass density was slightly increased (Figure 1).
The patient's condition involved the respiratory, circulatory, blood, nervous and urinary system (Table 1 and Figure 3). In treatment, anti-inflammatory, supplementation of gamma globulin, immune regulation, prevention of thrombosis, blood sugar control, pain relief, and myocardial nutrition were given. During the course of the disease, white blood cells, red blood cells, and platelets decreased significantly, among which white blood cells gradually decreased to 0.88G/L; red blood cells gradually decreased to 2.28T/L, and slightly recovered after infusion of 4U red blood cells; hemoglobin gradually decreased to 68g/L, after infusion red blood cells could rise to 106g/L, but rapidly dropped; platelets quickly dropped to 7G/L, and platelet transfusion could rise to 45G/L, but quickly dropped to 6G/L. During the treatment, the patient's muscle pain was relieved, but the muscle enzymes changed less than before. In addition, the patient's blood pressure was difficult to maintain, and NT-proBNP and BUN were also on the rise. After symptomatic treatment, the patient's symptoms could not be improved. In addition, the patient was extremely weak, poor food intake, albumin gradually decreased, but blood glucose remained at a high level, considering the possibility of gluconeogenesis, indicating a poor prognosis. (Table 2)
The patient's condition progressed rapidly, critically ill, extremely weak and drowsy. On September 7, 2020, the patient developed dyspnea, tachycardia, hyperpyrexia, blood pressure showed 70/40mmHg, blood oxygen saturation decreased, and the patient was urgently transferred to the central ICU for treatment. Dynamic examination: blood routine, myocardial enzyme spectrum, NT-proBNP, renal function, blood sugar, albumin. (Table 2)
The patient's condition involved multiple systems, and the treatment effect was poor. On September 8, 2020, a general hospital consultation was conducted, and the opinions of experts from various departments were combined. The diagnosis considered the possibility of systemic metastasis of malignant tumors. The relevant examinations were improved. Bone marrow biopsy: hematopoietic tissue 47%, adipose tissue 53%. Megakaryocyte 1%, M/E ratio + +. The diagnosis was consistent with bone marrow necrosis; tumor markers: cytokeratin 19 fragment 611ng/ml, serum CA19-9 37.4kU/L, carbohydrate antigen (CA724) >500.000kU/L, alpha-fetoprotein (AFP) 15.1μg /L, carcinoembryonic antigen (CEA) 12ug/L, squamous cell careinoma antigen(SCCA) 1.8ng/ml; abdominal ultrasound: multiple solid space-occupying lesions in the liver; whole abdomen enhanced CT: gastric cancer with liver, hilar and retroperitoneal lymph node metastasis, and a small amount of fluid in the abdominal cavity (Figure 2). Combined with the examination results, it was diagnosed as gastric cancer with extensive metastasis.
The treatment results
For gastric cancer with extensive metastasis and severe hemocytopenia, gastrointestinal surgery, oncology, and gastroenterology were invited for consultation. The results showed that there were no indications for surgery. When the family members of the patient were informed of the consultation opinion and prognosis, they asked to abandon the treatment (Figure 3). The telephone follow-up found that the patient died, considering the possibility of cerebral hemorrhage or circulatory failure.
Literature review and differential diagnosis
Because the first clinical symptom of this case is polymyositis, and there are many similar diseases of this disease, all of which are of unknown etiology, clinical manifestations are diverse, involving multiple systems, diagnosis is difficult, and easy to miss and misdiagnose. This article compares this case with polymyositis (PM), systemic lupus erythematosus (SLE), multiple myeloma (MM), Brucellosis, Hemorrhagic fever with renal Syndrome (HFRS), Polymyalgia Rheumatica (PMR), Eosinophilia-myalgia syndrome (EMS) and other diseases, review and summarize the literature in order to identify each other (Table 1) .