Post Covid-19 Dermatomyositis: A Case Report

Here we present the case of a 40-year-old female, without any previous history of illness, including a negative family history of autoimmune diseases, who developed a COVID-19 infection in October 2022. She had been vaccinated for Covid-19; the last booster dose was received in December 2021. The symptoms of Covid-19 were relatively mild and did not require hospitalization. Two weeks later when the myalgia and fatigue did not subside, she consulted her doctor and was told that her symptoms were due to “long COVID” and would resolve with time. In December she began to develop skin rashes on her face and arms after exposure to sun on the beach and was diagnosed with Rosacea by a dermatologist. In May 2023 the rashes spread to involve the neck, upper chest, back (Shawl sign), legs, arms, and over the MCP and IP joints of hands (Gottron’s sign). Laboratory investigations revealed elevated CK level (8281U/L) and positive Antinuclear antibodies (1:2560), elevated aspartate transaminase, and alanine transaminase - around 200 U/L (normal values 3-35 U/L). However, the myositis panel workup was unremarkable. EMG studies supported the clinical diagnosis of myositis. She was diagnosed with Dermatomyositis based on current American College of Rheumatology /European League Against Rheumatism (ACR/EULAR) diagnostic criteria for idiopathic inflammatory myopathy ^[4] (score 8.2). She was started on immunosuppressant medications (Azathioprine and Prednisolone). A few days later her condition deteriorated further, and she presented to the Emergency Department with shortness of breath, difficulty in swallowing (tolerating soft food only), and muscle weakness. She was admitted to the hospital and received intravenous methylprednisolone and intravenous immunoglobulin therapy. Her symptoms improved gradually. HRCT Chest showed atelectatic band in the lung bases. Holter ECG and Echocardiography were normal. Screening tests for malignancy were negative. She was discharged with oral Prednisolone and Mycophenolate Mofetil and referred to PMR Hospital for rehabilitation.

Rehabilitation: The patient was referred to Physical Medicine and Rehabilitation Hospital in June 2023. On admission, her examination revealed motor power by MRC grading (Medical Research Council Manual Muscle Testing Scale) for proximal muscles in the upper limbs was 3/5 and in the lower limbs grade 2/5. The distal muscles for both upper and lower limbs were grade 4/5 bilaterally. The muscles were tender on palpation. Functional Assessment showed that she needed mild assistance for bed mobility, moderate assistance for getting up from a low level, and could walk only indoors for short distances with an unsteady gait. She needed moderate assistance for grooming and showering and maximum assistance to get up from the floor. Her endurance was poor, and she required multiple rest breaks during the therapy sessions. She received an intensive rehabilitation program for 8 weeks after which her strength and endurance improved. She could walk outdoors unaided at discharge and stopped using a wheelchair for long distances. She became independent in all activities of daily living and returned to sporting activities at the end of one year. Her FIM score (Functional Independence Measure) was 101 on admission and 126 on discharge.