A 60-year-old female with a history of hypertension presents for evaluation of several months of a painless non-pruritic rash as well as of the bilateral upper and lower extremities but no pain. (see Figures).
She notes no fevers, chills, night sweats or weight loss. No recent tick bites or recent respiratory/gastrointestinal infections or travel. She currently takes hydrochlorothiazide. She does not use tobacco products, alcohol or illicit drugs.
Blood pressure is 130/80, Pulse 75, respirations 14, oxygen saturation 99% on room air, Temperature 99F. General physical examination is within normal limits.
A picture of the rash is shown. Neurologic examination is remarkable for bilateral symmetric upper and lower extremity proximal muscle weakness and no distal muscle weakness. Sensation and reflexes are intact in all extremities.
Complete blood count, serum chemistries, and liver enzymes are within normal limits. CK is 4500 U/L, aldolase is elevated. TSH is normal. Erythrocyte sedimentation rate and C reactive protein are within normal limits.
What is the most likely diagnosis?
This question appears in Med-Challenger Internal Medicine Review with CME
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