Utility of EDX in Autoimmune Pathology, Discoid Lupus Erythematosus: A Case Report

Case Diagnosis: This case is a 66 year-old-male who presented with 2 weeks of progressive distal limb weakness, distal limb skin ulcerations, muscle atrophy, falls, and was diagnosed while in rehab with Discoid Lupus Erythematosus.

Case Description or Program Description: Pertinent physical exam findings included distal joint rigidity and muscle atrophy, bilateral lower leg ulcerations, dark thickened plaques, and facial and scalp lesions with alopecia Areata. Significant lab results included hyponatremia, leukopenia, elevated ESR, mildly elevated CRP, and an indeterminate liver biopsy. He was admitted to Inpatient rehab without a definitive diagnosis. After extensive collaborative work-up, he was diagnosed with Discoid Lupus Erythematosus and placed on Plaquenil 200 mg BID while continuing to work with PT/OT/SLP.

Setting: Acute inpatient rehab

Assessment/Results: An extensive autoimmune workup identified several positive antibodies including: ANA, Anti-smith antibody, AMA, RF, CCP, and anti-smooth muscle antibody. Skin biopsy done of jaw and skin displayed thickened basement membrane, melanophages and periadnexal infiltrate, pathology consistent with discoid lupus erythematosus. EDX findings of the bilateral lower extremity were abnormal, displaying sensorimotor axonal polyneuropathy with active denervation, consistent with suspected autoimmune disease.

Discussion (relevance): This case report demonstrated the necessary collaboration between specialties including Internal Medicine and Physical Medicine and Rehab to make a complicated autoimmune diagnosis. Both the initial rheumatological work-up and EDX findings played a large role in this patient’s prognosis. He was started on Hydroxychloroquine 200 mg bid with positive results. The patient progressed from a functional level of supervision-min A to independent at discharge.

Conclusions: Autoimmune pathology should always be considered in the acute rehab setting with progressive weakness, acute skin ulcerations, and distal limb atrophy. Collaborative diagnostic effort between specialties is often vital for patients success, and EDX can be a powerful supplementary diagnostic tool.