Muscle weakness and Atrophy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:  Iqra Qamar M.D.[2]

## Differential Diagnosis of Muscle weakness and Atrophy

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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
Medication−induced  | Corticosteroids[1] | Variable  | Proximal  | −  | \+  | −  | −  | −  | \+  | −  | −  |

* Central obesity
* Excessive sweating
* Insomnia
* Reduced libido
* Amenorrhea
* Infertility
* Psychological disturbances

* Positive h/o medications

* Facial and sphincter muscles are usually spared

* Positive ACTH stimulation test
* 24-hour urine cortisol
* Low dose dexamethasone suppression test

* Normal

* Normal

* Normal

Endocrine  | Cushing's disease[2] | 25 −45  | Proximal  | −  | −  | −  | −  | −  | \+  | −  | −  |

* Decreased libido
* Obesity/weight gain
* Plethora
* Round face
* Menstrual changes
* Hirsutism
* Hypertension
* Ecchymoses
* Lethargy
* Depression
* Dorsal fat pad
* Abnormal glucose tolerance

* N/A

* Facial and sphincter muscles are usually spared
* Overweight
* Straie
* Moon face
* HTN
* Hyperpigmentation

* Positive ACTH stimulation test
* 24-hour urine cortisol
* Low dose dexamethasone suppression test

* Normal

* Atrophy of type 2 muscle fibers, especially type 2B

| Normal
Hyperthyroidism[3] | 40  | Proximal  | −  | −  | −  | −  | −  | \+  | \+  | \+  |

* Signs of hyperthyroidism

* H/o of weight loss

* Sweating
* Tremor
* Neck swelling

* Decreased TSH

* ↑↑

* Non specific

* Myotonic

Hypothyroidism[4] | 55  | Proximal  | −  | \+  | \+  | −  | −  | \+  | \+  | \+ Rhabdomyolysis |

* Signs of hypothyroidism

* H/o weight gain

* Myxoedema
* Muscle pseudohypertrophy

* Increased TSH

* ↑↑

* Nonspecific

* Normal

Diabetic infraction[5] | 45 | Proximal  | \+  | \+  | −  | −  | \+  | \+  | −  | −  |

* Cramps
* Sudden onset of pain
* Anterior thigh muscles are most commonly involved

* H/O long standing diabetes

* Swelling
* Tenderness

* Elevated ESR
* Leukocytosis

* Normal

* Necrosis
* Edema

* 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
Genetic  | Becker muscular dystrophy[6] | <13yrs  | Proximal  | −  | −  | \+  | \+  | −  | \+  | −  | −  |

* Milder form of Duchenne

* Growth delay
* Age of onset of symptoms is much delayed than duchenne

* Positive Grower sign

* Decreased amount of dystrophin.

* ↑↑

*     * Muscle fibril degeneration, regeneration
* Isolated fiber hypertrophy
* Muscle replacement with fat and connective tissue

* Myopathic

Duchenne muscular dystrophy[7] | <13 yrs  | Proximal  | −  | −  | \+  | \+  | −  | \+  | −  | −  |

* Calf psedohypertrophy
* Cardiomyopathy
* Kyphoscoliosis
* Cognitive impairment

* Early onset

* Positive Grower sign

* Errors in the Xp21 gene.
* Absence of dystrophin.

* ↑↑

Limb−girdle muscular dystrophies[8] | <15 yrs  | Proximal  | −  | \+  | \+  | \+  | −  | \+  | −  | −  |

* Calf hypertrophy
* Scapular winging
* Cardiomyopathy
* Cardiac arrhythmias
* Respiratory muscle weakness

* Autosomal dominant
* Deterioration of ability to run/walk

* Muscle weakness is generally symmetric

* LMNA gene
* CAV3 gene

* ↑↑

* N/A

* Myopathic

Glycogen storage disease[9] | Variable  | Proximal  | −  | −  | −  | −  | −  | \+  | −  | −  |

* AR
* Faituge
* Hypoglycemia

* Exercise intolerance

* Hypotonia
* Hepatomegaly

* Lactic acidosis
* Elevated liver enzymes
* Ketosis

* ↑↑

* Normal

* Normal

Infectious  | Polio[10] | <5 yrs  | Proximal  | −  | −  | −  | \+  | \+  | \+  | −  | −  |

* Asymmetrical paralysis
* Muscle atrophy
* Tremors
* Skeletal deformities

* History of skipped immunization.

* Normal
* Meningeal signs
* Asymmetrical flaccid paralysis
* Pharyngeal paralysis

* Isolation from pharyngealsecretions, CSF
* Positive serology

* N/A

* N/A

* Neurological pattern

Neurologic  | ALS[11] | >35  | Proximal

Distal

* Distal

| −  | −  | −  | −  | \+  | \+  | \+  | −  |

* Dysphagia
* Spasticity
* Hyperreflexia
* Babinski's +

* N/A

* Both upper and lower motor neuron signs

* Clinical diagnosis

* Normal

* Nonspecific findings of chronic denervation with reinnervation

* Neuropathic

Stroke[12] | >65  | Proximal

distal  | −  | −  | −  | \+  | \+  | \+  | −  | −  |

* Dysphagia
* Unilateral/Bilateral weakness

* H/o HTN, dyslipidaemia DM

* Weakness of the involved arm

* Head CT

* Normal

* Normal

* Neuropathic

## References

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1. ↑ Gupta A, Gupta Y (September 2013). "Glucocorticoid-induced myopathy: Pathophysiology, diagnosis, and treatment". Indian J Endocrinol Metab. 17 (5): 913–6. doi:10.4103/2230-8210.117215. PMC 3784879. PMID 24083177.
2. ↑ Sharma V, Borah P, Basumatary LJ, Das M, Goswami M, Kayal AK (July 2014). "Myopathies of endocrine disorders: A prospective clinical and biochemical study". Ann Indian Acad Neurol. 17 (3): 298–302. doi:10.4103/0972-2327.138505. PMC 4162016. PMID 25221399.
3. ↑ 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.
4. ↑ 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.
5. ↑ Horton WB, Taylor JS, Ragland TJ, Subauste AR (2015). "Diabetic muscle infarction: a systematic review". BMJ Open Diabetes Res Care. 3 (1): e000082. doi:10.1136/bmjdrc-2015-000082. PMC 4410119. PMID 25932331.
6. ↑ Flanigan KM (August 2014). "Duchenne and Becker muscular dystrophies". Neurol Clin. 32 (3): 671–88, viii. doi:10.1016/j.ncl.2014.05.002. PMID 25037084.
7. ↑ Flanigan KM (August 2014). "Duchenne and Becker muscular dystrophies". Neurol Clin. 32 (3): 671–88, viii. doi:10.1016/j.ncl.2014.05.002. PMID 25037084.
8. ↑ Guglieri M, Straub V, Bushby K, Lochmüller H (October 2008). "Limb-girdle muscular dystrophies". Curr. Opin. Neurol. 21 (5): 576–84. doi:10.1097/WCO.0b013e32830efdc2. PMID 18769252.
9. ↑ Kannourakis G (April 2002). "Glycogen storage disease". Semin. Hematol. 39 (2): 103–6. PMID 11957192.
10. ↑ Howard RS (June 2005). "Poliomyelitis and the postpolio syndrome". BMJ. 330 (7503): 1314–8. doi:10.1136/bmj.330.7503.1314. PMC 558211. PMID 15933355.
11. ↑ 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.
12. ↑ Baldwin K, Orr S, Briand M, Piazza C, Veydt A, McCoy S (May 2010). "Acute ischemic stroke update". Pharmacotherapy. 30 (5): 493–514. doi:10.1592/phco.30.5.493. PMID 20412000.