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Muscle PathologySurgical Pathology Unknown Conference
November, 2008
Philip Boyer, M.D., Ph.D.
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Abnormal
Neoplastic Non-Neoplastic
Normal
Vascular
- Ischemic
Toxic -
MetabolicDegenerative
Traumatic
Developmental
Symptoms / Signs / Imaging / Biopsy / CSF Analysis
Other
Primary“Metastatic” /
Hematogenous
Spread /Direct extension
Infectious -
Inflammatory
(neoplastic divide)
Reactive /
Hyperplastic
Etiologic Approach to Differential Diagnosis
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Case 1
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� A 75-year-old man presented with a rapid onset and progression of generalized skeletal muscle aches and weakness over a 4-5 day period prior to hospital admission. � Difficulty raising his arms above the level of the shoulders� Difficulty getting out of chairs and off the commode
� Laboratory evaluation identified a CPK level of greater than 13,390 U/L (not titrated, normal range, adult male 40-210 U/L)
� Past history was significant for:� Atherosclerotic coronary and peripheral vascular disease
treated with three-vessel coronary vessel bypass grafting� Hypercholesterolemia treated with the statin medication
Zocor for over a year. � He recently had been diagnosed with diabetes and was begun on
Glucotrol (glipizide), a sulfonylurea class oral hypoglycemic agent, 2 weeks prior to hospitalization.
History
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Acid Phosphatase Histochemistry: Lysosomal Protein
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Case 2
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� 56 year-old woman
� 15 year history of “seronegative rheumatoid arthritis”
� Finger stiffness and swelling (PIPs and MCPs)
� Treatment:
� Plaquenil
� Methotrexate
� Recent 6 – 12 months:
� Progressive proximal weakness of arms and legs
� Dysphagia to pills and water
History
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H&E Stain
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Acid Phosphatase Histochemistry
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Acid Phosphatase Histochemistry
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Case 3
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- 6-year old male- History of difficulty walking, particularly in negotiating stairs- Neurologic Examination:
- Weakness, proximal greater than distal- “Gower sign” on arising from floor- Calf muscle hypertrophy
- Laboratory Evaluation:- Creatine Kinase = high: >10,000
History
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H&E
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H&E
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Trichrome
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DystrophinSpectrin
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Case 4
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History
- l year old girl (A.O.)
- History of congenital weakness
- Neurologic Examination:
- Weakness, proximal greater than distal
- Laboratory Evaluation:
- CK elevated (>1,000)
- MRI:
- White matter abnormality
- No evidence of malformation
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Dystrophin Laminin Alpha-2 (Merosin)
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Case 5
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H&E – Low Power
H&E
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Electron Micrograph
Electron Microscopy
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Case 6
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Histologic Findings
H&E
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Histologic Findings
H&E
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Histologic Findings
Trichrome
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Electron Microscopy
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Case 7
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History
� 21-year-old G2P2 woman with a past medical history significant only for obesity� A year prior to the current admission, during the third trimester of her second pregnancy,
developed symptoms which continued after delivery of healthy 40-week gestation infant
� Weight loss - 80-90 pounds� Night sweats which continued after term delivery of a healthy infant; total weight loss
was
� Four months prior to admission� Arthralgias of the hips and knees
� Non-pruritic hyperpigmented macular rash involving her arms and torso but sparing her face
� Working diagnosis: "lupus-like syndrome“
� Course of prednisone which resulted in resolution of the rash and cessation of weight loss
� Tapering of the prednisone, weight loss continued� Two weeks prior to admission
� Burning sensation involving the soles of both feet with extension to the ankles in a stocking distribution
� Admitted for evaluation.
� Thin habitus
� Liver palpable to 4 cm below the right costal margin
� Extreme sensitivity to light touch of the feet to the level of the ankles bilaterally
� Strength and reflexes were normal� Labs: CPK 34 U/L (normal adult female 38-176 U/L), C-reactive protein 6.0 mg/dL
(normal < or= 0.8 mg/dL), sedimentation rate 67 (normal female 0-29 mm in 1 hour), and angiotensin converting enzyme 59 U/L (normal 7.0-46.0 U/L )
� Chest X-ray: normal
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Histology - Muscle
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Histology - Nerve
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Histology - Liver
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Histology - Liver
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Case 8
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� 28-year-old woman
� Past Medical History: History of antibody negative myasthenia gravis
� Medications: None
� Presentation: Ptosis and swallowing difficulty
� Neurologic Examination:
� Ptosis
� Laboratory Evaluation:
� CPK 100
� Myasthenia panel: negative
History
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H&E
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Trichrome
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Succinate Dehydrogenase Histochemistry
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Electron Microscopy
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Case 9
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- 14-year old boy
- History of difficulty keeping up with peers during physical activity- Not running, jumping, playing like others due to “pain” after exercise
(“exercise intolerance”)- CPK 8,600
- EMG: myopathic motor units
- Biopsy at age 4 identified focal inflammation, diagnosed with “inflammatory myopathy
- Treated with corticosteroids with some symptomatic improvement- Attempts to reduce corticosteroids resulted in increased CPK levels (500
– 10,000) but without associated symptoms
- Needed wheel-chair by age 12-13- After strength testing: severe pain and stiffness for several hours but not
persistent - Re-evaluated now
- Weakness, proximal greater than distal
- Laboratory Evaluation:- Creatine Kinase = ~normal
- Re-biopsied
History
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H&E
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Trichrome
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Electron Microscopy
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Myophosphorylase – PatientMyophosphorylase – Control
2005
Biopsy
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Case 10
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� 37-year-old man
� History since childhood of proximal weakness, lower extremities greater than upper extremities.
� Family history is significant for "muscular dystrophy" in aunts and uncles
� Biopsy of one uncle was non-diagnostic with a "whorling pattern" on oxidative preparations
� The differential diagnosis included a limb-girdle muscular dystrophy and a congenital myopathy.
History
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H&E
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Trichrome
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Electron Microscopy
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Case 11
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History
� Newborn, 37 weeks gestation, with marked hypotonia
� Etiology uncertain clinically
� Muscle biopsy performed
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H&E
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Trichrome
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Case 12
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History - A
- Newborn; delivered at 36 weeks gestation due to a breech position
- Respiratory distress was noted at birth- Hypotonia - Congential bilateral hip dislocations- There is no known family history
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TrichromeATPase pH 4.3H&E
NADH
NADH
Electron Microscopy
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-- 54-year-old man-- Life-long history of exertional fatigue and muscle tightness-- With multiple episodes of rhabdomyolysis / myoglobinuria-- He has a 5-year-old son
- - Easily fatigued- - Proximal weakness
History - B
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Histology
Thick Section, T. BlueNADH NADH
Electron Microscopy
NADHTrichromeATPase 4.3H&E
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Case 13
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� 35-year-old man
� Past Medical History: Unremarkable
� Medications: None
� Presentation: Diffuse muscle pain / soreness, proximal and distal
� Neurologic Examination:
� Pain in multiple muscles; no weakness
� Laboratory Evaluation:
� CPK 600
� Social History: Hunter in the Upper Peninsula of Michigan
History
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Case 14
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History
- 56-year-old woman- Past medical history: lupus erythematosus X 5 years- Medications: Immunosuppressives including corticosteroids- Symptoms: Progressive weakness, profound
- Proximal-predominant
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ATPase pH 9.4
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Histochemical Fiber Typing
Type 1 Type 2
� Twitch sLow fast
� Turkey Meat Dark – drumstick White – Breast
analogy (weight bearing) (rapid / skilled movement)
� Metabolism Oxidative Glycolytic
� Fat More Less
� Glycogen Less More
� NADH (oxidative) Dark Light
� ATPase
� 4.3 Dark Light
� 9.4 Light Dark
“One Slow Fat Red Ox”
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Case 15
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� 56-year-old man
� Past Medical History: Unremarkable
� Medications: None
� Presentation: Slowly progressive weakness, left leg, then right leg and arms; difficulty swallowing
� Neurologic Examination:
� Weakness, distal and proximal
� Laboratory Evaluation:
� CPK 150 (normal < 220)
History
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Esterase
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Fiber type grouping – groups of type 1 and type 2 fibers (ATPase pH 9.4 – type 2 fibers dark)
Neurogenic Changes
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Case 16
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• 60 year old woman with a history of chronic obstructive pulmonary disease.
• Suffered an episode of respiratory failure that required intubation approximately 3 weeks prior to biopsy
• She has received
• Neuromuscular blocking agent
• High dose corticosteroid therapy
• She has now been extubated and is manifesting significant weakness, legs greater than arms.
History
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Electron Microscopy
Electron Microscopy, 30000 X Magnification: Evaluation of intact (left) and affected (right) myofibers.
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ANSWERS
� 1. Myofiber necrosis from statin medication� 2. Vacuolar myopathy
� 3. Duchenne muscular dystrophy� 4. Congenital muscular dystrophy, merosin
negative� 5. Dermatomyositis
� 6. Inclusion body myositis� 7. Sarcoid
� 8. Mitochondrial disease
� 9. McArdle's Disease� 10. Nemaline myopathy
� 11. Centronuclear myopathy� 12. Central core disease
� 13. Trichinella spiralis
� 14. Steroid-induced atrophy� 15. ALS
� 16. Critical Care myopathy