case_images: PMC7427040_01
case_images: Computed tomography thorax revealing left lung opacity attributed to lung collapse due to diaphragmatic weakness.
case_images: 10.1177_2324709620950113-fig1.jpg
case_images: PMC7427040_01_10.1177_2324709620950113-fig1.jpg
case_images: fig1-2324709620950113
case_images: The opacification was suspected to be due to lung collapse secondary to left-sided diaphragmatic weakness (Figure 1).
case_images: Histological analysis of right quadriceps muscle biopsy. Hematoxylin and eosin-stained images demonstrate (A) significant fiber size variation with increased granularity and vacuoles (arrow heads) and (B) perifascicular mononuclear inflammatory cells. Gomori trichrome sections demonstrate significant fiber size variation with increased granularity and vacuoles (arrow heads) (C). Perifascicular inflammatory cells highlighted by esterase (D), CD3, demonstrating infiltrating T-lymphocytes, primarily in the perifascicular compartment, with infiltration into the endomysium (E), and CD68, demonstrating histiocytes, also primarily in the perifascicular compartment (F). ATPase pH 9.4 demonstrating selective type II fiber atrophy (atrophy of darker stained fibers) (G). Electron microscopy images demonstrating abnormal autophagosomes (red arrow) (H) and curvilinear bodies corresponding to the vacuoles seen on light microscopy (arrowheads) (I).
case_images: 10.1177_2324709620950113-fig2.jpg
case_images: PMC7427040_01_10.1177_2324709620950113-fig2.jpg
case_images: fig2-2324709620950113
case_images: TIF1 gamma, Anti-PM/Scl-100, U2 snRNP, anti-U1-RNP, Ku, and Anti-SSA. Muscle biopsy was performed on the right quadriceps muscle. Muscle biopsy light microscopy reported a granular myopathy with rimmed vacuoles and type II fiber atrophy with scattered inflammation (Figure 2A-C and G). The initial findings were relatively nonspecific but have been identified in critical illness myopathy and myopathy related to chronic corticosteroid or chronic chloroquine use. Electron microscopy (EM) as well as the addition of immunohistochemical stains; CD3, CD20, and CD68 were ordered to further evaluate the inflammatory cells found in the endomysial and perimysial regions on light microscopy (Figure 2D-F). Electron microscopy showed granular material identified by the hematoxylin and eosin stains contained a number of abnormal autophagosomes (Figure 2H) and vacuoles contained characteristic curvilinear bodies (Figure 2), consistent with hydroxychloroquine-induced myopathy. T lymphocytes and histiocytes in the perimysium and endomysium with less frequent B lymphocytes in the perimysium (Figure 2E and F). These findings were thought to be consistent with an inflammatory response to muscle injury.