Red fist and muscle weakness with a rare complication

A 64-year-old man was referred to our hospital, for a second opinion, with fever, skin lesions and general muscle pain. He has been treated in another hospital with antibiotics on suspicion of erysipelas. A week later skin lesions developed on the metacarpophalangeal and proximal carpophalangeal joints of the hands and nose. His mobility was impaired due to muscle pain and muscle weakness. He also showed proximal muscle atrophy and most importantly a typical heliotrope rash in the eyes. Based on these clinical observations, the most likely diagnosis was dermatomyositis. The diagnosis was confirmed by the presence of increased serum creatine kinase levels and abnormalities in skin and muscle biopsy. Prednisone (70 mg/kg) was initiated, but after 19 days the patient developed a Pneumocystis jiroveci pneumonia. He died of respiratory failure a few days later.