Muscle weakness and stiffness

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Differential Diagnosis of Muscle Weakness and Stiffness

Organ system Disease Symptoms History Physical

Examination

Diagnosis
Age of onset Muscle weakness Fever Myalgia Contractures Gait abnormality Neuropathy Atrophy Stiffness Myoglobinuria Other features Laboratory Findings Creatine Kinase Muscle Biopsy Electromyogram
Endocrine Adrenal insufficiency[1] 30−50 years Proximal + +
  • Normal
  • Normal
  • Normal
Hyperthyroidism[2] 40 Proximal + + +
  • ↑↑
  • Non specific
Hypothyroidism[3] 55 Proximal + + + + + Rhabdomyolysis
  • ↑↑
  • Nonspecific 
  • Normal
Organ system Disease Age of onset Muscle weakness Fever Myalgia Contractures Gait abnormality Neuropathy Atrophy Stiffness Myoglobinuria Other features History Physical

Examination

Laboratory Findings Creatine Kinase Muscle Biopsy Electromyogram
Inflammatory/ Rheumatologic Dermatomyositis[4] 40s−50s
Can affect children
Proximal + + +
  • ↑↑
  • Perimysial mononuclear infiltrate
Polymyositis[5] > 18 years Proximal + + +
  • N/A
  • N/A
  • ↑↑
  • Endomysial mononuclear infiltrate
  • Patchy necrosis
Polymyalgia Rheumatica[6] 50s Diffuse + + +
  • History of joints stiffness, worse in the morning
  • Restricted shoulder motion
  • Normal
  • Normal
  • Normal
Genetic Myotonic dystrophy[7] <18 years Proximal
&
distal
+ + +
  • Positive family history
  • Muscles often contract and are unable to relax
  • Mutations in the DMPK gene
  • N/A
  • N/A
Organ system Disease Age of onset Muscle weakness Fever Myalgia Contractures Gait abnormality Neuropathy Atrophy Stiffness Myoglobinuria Other features History Physical

Examination

Laboratory Findings Creatine Kinase Muscle Biopsy Electromyogram
Infectious Pyomyositis[8] Variable Proximal
&
Distal
+ + +
    • Muscles are painful, swollen, tender, and indurated.
    • Depending on the site of involvement, it may mimic appendicitis (psoas muscle), septic arthritis of the hip (iliacus muscle), or epidural abscess (piriformis muscle).
  • Leukocytosis
  • Elevated ESR
  • N/A
  • N/A
  • N/A
Neurologic ALS[9] >35 Proximal
&
Distal
  • Distal
+ + +
  • N/A
  • Clinical diagnosis
  • Normal
  • Nonspecific findings of chronic denervation with reinnervation
  • Neuropathic
GBS[10] 18 −350 Proximal + +
  • Weakness of lower extremities followed by upper extremities
  • Cytologic albumin ratio
  • Normal
  • Normal
  • Neuropathic
Organ system Disease Age of onset Muscle weakness Fever Myalgia Contractures Gait abnormality Neuropathy Atrophy Stiffness Myoglobinuria Other features History Physical

Examination

Laboratory Findings Creatine Kinase Muscle Biopsy Electromyogram
Neuromuscular Botulinum[11] Variable Distal + +
  • H/O food exposure
  • +Toxin
  • Normal
  • N/A
  • Myopathic
Lambert−Eaton syndrome[12] Variable Distal + + +
  • Weakness of the bulbar muscles
  • Ocular
  • Limb weakness
  • Weaknessa is often relieved temporarily after exertion or physical exercise.
  • Antibodies against voltage−gated calcium channels 
Myasthenia gravis[13] Variable Proximal + + +
  • Ocular
  • Bulbar 
  • Limb weakness
  • Isolated neck, limbs and respiratory weakness
  • Weakness often worsens with activity

References

  1. Ruff RL, Weissmann J (August 1988). "Endocrine myopathies". Neurol Clin. 6 (3): 575–92. PMID 3065602.
  2. Li Q, Liu Y, Zhang Q, Tian H, Li J, Li S (July 2017). "Myopathy in hyperthyroidism as a consequence of rapid reduction of thyroid hormone: A case report". Medicine (Baltimore). 96 (30): e7591. doi:10.1097/MD.0000000000007591. PMC 5627834. PMID 28746208.
  3. Khaleeli AA, Griffith DG, Edwards RH (September 1983). "The clinical presentation of hypothyroid myopathy and its relationship to abnormalities in structure and function of skeletal muscle". Clin. Endocrinol. (Oxf). 19 (3): 365–76. PMID 6627693.
  4. Dalakas MC (1991). "Polymyositis, dermatomyositis and inclusion-body myositis". N Engl J Med. 325 (21): 1487–98. doi:10.1056/NEJM199111213252107. PMID 1658649.
  5. Dalakas MC (1991). "Polymyositis, dermatomyositis and inclusion-body myositis". N Engl J Med. 325 (21): 1487–98. doi:10.1056/NEJM199111213252107. PMID 1658649.
  6. Myklebust G, Gran JT (1996). "A prospective study of 287 patients with polymyalgia rheumatica and temporal arteritis: clinical and laboratory manifestations at onset of disease and at the time of diagnosis". Br J Rheumatol. 35 (11): 1161–8. PMID 8948307.
  7. Udd B, Krahe R (October 2012). "The myotonic dystrophies: molecular, clinical, and therapeutic challenges". Lancet Neurol. 11 (10): 891–905. doi:10.1016/S1474-4422(12)70204-1. PMID 22995693.
  8. Crum NF (September 2004). "Bacterial pyomyositis in the United States". Am. J. Med. 117 (6): 420–8. doi:10.1016/j.amjmed.2004.03.031. PMID 15380499.
  9. Zarei S, Carr K, Reiley L, Diaz K, Guerra O, Altamirano PF, Pagani W, Lodin D, Orozco G, Chinea A (2015). "A comprehensive review of amyotrophic lateral sclerosis". Surg Neurol Int. 6: 171. doi:10.4103/2152-7806.169561. PMC 4653353. PMID 26629397.
  10. van Doorn PA (June 2013). "Diagnosis, treatment and prognosis of Guillain-Barré syndrome (GBS)". Presse Med. 42 (6 Pt 2): e193–201. doi:10.1016/j.lpm.2013.02.328. PMID 23628447.
  11. Cherington M (June 2004). "Botulism: update and review". Semin Neurol. 24 (2): 155–63. doi:10.1055/s-2004-830901. PMID 15257512.
  12. Titulaer MJ, Lang B, Verschuuren JJ (December 2011). "Lambert-Eaton myasthenic syndrome: from clinical characteristics to therapeutic strategies". Lancet Neurol. 10 (12): 1098–107. doi:10.1016/S1474-4422(11)70245-9. PMID 22094130.
  13. Jayam Trouth A, Dabi A, Solieman N, Kurukumbi M, Kalyanam J (2012). "Myasthenia gravis: a review". Autoimmune Dis. 2012: 874680. doi:10.1155/2012/874680. PMC 3501798. PMID 23193443.

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