Distal muscle weakness

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Differential diagnosis of distal muscle weaknes

Organ system	Disease	Symptoms												History	Physical Examination	Diagnosis
Organ system	Disease	Age of onset	Muscle weakness	Fever	Myalgia	Contractures	Gait abnormality	Neuropathy	Atrophy	Stiffness	Myoglobinuria	Other features	Laboratory Findings	History	Physical Examination	Creatine Kinase	Muscle Biopsy	Electromyogram
Endocrine	Hyperaldosteronism with myopathy^[1]	50	Proximal & distal	−	−	−	−	−	−	−	+ Rhabdomyolysis	Palpitations Hypertension	Episodes of increased heart beats	Hyperpigmentation	Hypokalemia	Normal	Normal	Normal
Inflammatory/ Rheumatologic	Inclusion body myositis^[2]	50s	Proximal & distal	−	−	−	−	−	−	−	−	Dysphagia Asymmetric weakness	Retrovirus (most common)	N/A	Antibodies to cytoplasmic 5'−nucleotidase	↑↑	Inflammatory cells Invading muscle cells Vacuolar degeneration Inclusions or plaques	Neurogenic
	Fibromyalgia^[3]	40−50s	Generalized	−	−	−	−	+	−	−	−	Anxiety or depression features Fatigue Sleep disturbance Numbness Muscle spasms	History of depression	Tenderness in the soft tissue anatomical location	Normal	Normal	Normal	Normal
	Polymyalgia Rheumatica^[4]	50s	Diffuse	+	+	−	−	−	−	+	−	Weight loss	History of joints stiffness, worse in the morning	Restricted shoulder motion	↑↑ ESR ↑↑ CRP	Normal	Normal	Normal
Genetic	Myotonic dystrophy^[5]	<18 years	Proximal & distal	−	−	+	+	−	−	+	−	Myotonia Cataracts Diabetes mellitus Frontal balding Cardiac arrhythmias Cholecystitis Pregnancy Eyelid ptosis	Positive family history	Muscles often contract and are unable to relax	Mutations in the DMPK gene	N/A	N/A	Myopathic
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
Infectious	Influenza^[6]	Variable	Proximal and Distal	+	+	−	+	−	−	−	+	Fever Malaise Rhinorrhea Muscle pain worse with movement	Cold weather H/o Ill contacts	Muscle weakness, tenderness, and swelling.	↑↑ Liver enzymes Positive PCR	↑↑	N/A	N/A
Infectious	Pyomyositis^[7]	Variable	Proximal & Distal	+	+	−	−	−	−	+	−	Fever Malaise Psoas abscess	Immunocompromised	Muscles are painful, swollen, tender, and indurated. Depending on the site of involvement, it may mimic appendicitis (psoas muscle), septic arthritis of the hip (iliacus muscle), or epidural abscess (piriformis muscle).	Leukocytosis Elevated ESR	N/A	N/A	N/A
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
Neurologic	ALS^[8]	>35	Proximal & 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^[9]	>65	Proximal & distal	−	−	−	+	+	+	−	−	Dysphagia Unilateral/Bilateral weakness	H/o HTN, dyslipidaemia DM	Weakness of the involved arm	Head CT	Normal	Normal	Neuropathic
	Multiple Sclerosis^[10]	30's	Proximal & distal	−	−	−	+	+	−	−	−	Ocular findings Urinary incontinence Problems with speech or swallowing	Attacks or exacerbation	Localized weakness Focal sensory disturbances Hyper reactive reflexes Increased tone or stiffness	Head CT ologo−clonal bands	Normal	N/A	Neuropathic
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
Neuromuscular	Botulinum^[11]	Variable	Distal	−	−	−	+	−	−	+	−	Double vision Blurred vision Drooping eyelids Slurred speech Difficulty swallowing	H/O food exposure	Hyporeflexia Decreased strength	+Toxin	Normal	N/A	Myopathic
Neuromuscular	Lambert−Eaton syndrome^[12]	Variable	Distal	−	−	+	+	−	−	+	−	Weakness of the bulbar muscles Ocular Limb weakness	Weaknessa is often relieved temporarily after exertion or physical exercise.	Hyporeflexia Decreased strength	Antibodies against voltage−gated calcium channels	Normal	N/A	Myopathic

References

↑ Sambrook MA, Heron JR, Aber GM (April 1972). "Myopathy in association with primary hyperaldosteronism". J. Neurol. Neurosurg. Psychiatry. 35 (2): 202–7. PMC 494037. PMID 5037033.
↑ Dalakas MC (1991). "Polymyositis, dermatomyositis and inclusion-body myositis". N Engl J Med. 325 (21): 1487–98. doi:10.1056/NEJM199111213252107. PMID 1658649.
↑ Ohara N, Katada S, Yamada T, Mezaki N, Suzuki H, Suzuki A, Hanyu O, Yoneoka Y, Kawachi I, Shimohata T, Kakita A, Nishizawa M, Sone H (2016). "Fibromyalgia in a Patient with Cushing's Disease Accompanied by Central Hypothyroidism". Intern. Med. 55 (21): 3185–3190. doi:10.2169/internalmedicine.55.5926. PMC 5140872. PMID 27803417.
↑ Myklebust G, Gran JT (1996). "A prospective study of 287 patients with polymyalgia rheumatica and temporal arteritis: clinical and laboratory manifestations at onset of disease and at the time of diagnosis". Br J Rheumatol. 35 (11): 1161–8. PMID 8948307.
↑ Udd B, Krahe R (October 2012). "The myotonic dystrophies: molecular, clinical, and therapeutic challenges". Lancet Neurol. 11 (10): 891–905. doi:10.1016/S1474-4422(12)70204-1. PMID 22995693.
↑ Bove KE, Hilton PK, Partin J, Farrell MK (1983). "Morphology of acute myopathy associated with influenza B infection". Pediatr Pathol. 1 (1): 51–66. PMID 6687269.
↑ Crum NF (September 2004). "Bacterial pyomyositis in the United States". Am. J. Med. 117 (6): 420–8. doi:10.1016/j.amjmed.2004.03.031. PMID 15380499.
↑ 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.
↑ 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.
↑ Goldenberg MM (March 2012). "Multiple sclerosis review". P T. 37 (3): 175–84. PMC 3351877. PMID 22605909.
↑ Cherington M (June 2004). "Botulism: update and review". Semin Neurol. 24 (2): 155–63. doi:10.1055/s-2004-830901. PMID 15257512.
↑ Titulaer MJ, Lang B, Verschuuren JJ (December 2011). "Lambert-Eaton myasthenic syndrome: from clinical characteristics to therapeutic strategies". Lancet Neurol. 10 (12): 1098–107. doi:10.1016/S1474-4422(11)70245-9. PMID 22094130.

[pmid5037033-1] Sambrook MA, Heron JR, Aber GM (April 1972). "Myopathy in association with primary hyperaldosteronism". J. Neurol. Neurosurg. Psychiatry. 35 (2): 202–7. PMC 494037. PMID 5037033.

[pmid16586493-2] Dalakas MC (1991). "Polymyositis, dermatomyositis and inclusion-body myositis". N Engl J Med. 325 (21): 1487–98. doi:10.1056/NEJM199111213252107. PMID 1658649.

[pmid27803417-3] Ohara N, Katada S, Yamada T, Mezaki N, Suzuki H, Suzuki A, Hanyu O, Yoneoka Y, Kawachi I, Shimohata T, Kakita A, Nishizawa M, Sone H (2016). "Fibromyalgia in a Patient with Cushing's Disease Accompanied by Central Hypothyroidism". Intern. Med. 55 (21): 3185–3190. doi:10.2169/internalmedicine.55.5926. PMC 5140872. PMID 27803417.

[pmid8948307-4] Myklebust G, Gran JT (1996). "A prospective study of 287 patients with polymyalgia rheumatica and temporal arteritis: clinical and laboratory manifestations at onset of disease and at the time of diagnosis". Br J Rheumatol. 35 (11): 1161–8. PMID 8948307.

[pmid22995693-5] Udd B, Krahe R (October 2012). "The myotonic dystrophies: molecular, clinical, and therapeutic challenges". Lancet Neurol. 11 (10): 891–905. doi:10.1016/S1474-4422(12)70204-1. PMID 22995693.

[pmid6687269-6] Bove KE, Hilton PK, Partin J, Farrell MK (1983). "Morphology of acute myopathy associated with influenza B infection". Pediatr Pathol. 1 (1): 51–66. PMID 6687269.

[pmid15380499-7] Crum NF (September 2004). "Bacterial pyomyositis in the United States". Am. J. Med. 117 (6): 420–8. doi:10.1016/j.amjmed.2004.03.031. PMID 15380499.

[pmid26629397-8] 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.

[pmid20412000-9] 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.

[pmid22605909-10] Goldenberg MM (March 2012). "Multiple sclerosis review". P T. 37 (3): 175–84. PMC 3351877. PMID 22605909.

[pmid15257512-11] Cherington M (June 2004). "Botulism: update and review". Semin Neurol. 24 (2): 155–63. doi:10.1055/s-2004-830901. PMID 15257512.

[pmid22094130-12] Titulaer MJ, Lang B, Verschuuren JJ (December 2011). "Lambert-Eaton myasthenic syndrome: from clinical characteristics to therapeutic strategies". Lancet Neurol. 10 (12): 1098–107. doi:10.1016/S1474-4422(11)70245-9. PMID 22094130.

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Distal muscle weakness

Differential diagnosis of distal muscle weaknes

References

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