resonance imaging (MRI) of the left
thigh showed muscle atrophy and
diminished left subcutaneous fat. A
more extensive evaluation was ordered, but the patient did not follow
up and was not seen for about 1 year.
Then, he presented with myalgia in
There were no other pertinent past
medical, surgical, or family histories.
The patient worked as a pest control
technician, drank alcohol occasionally, and did not report tobacco or illicit drug use. He took tramadol as
needed and reported no allergies.
The patient did not report fever,
weight loss, or fatigue. There was no
Raynaud’s phenomenon or sclerodactyly present—no chest pain,
shortness of breath, dry eyes or dry
mouth, oral or genital ulcers, and no
gastrointestinal, urinary, or neuro-logic symptoms.
On physical examination, the patient’s vital signs were normal. He
had no oral mucositis or ulcers. The
heart, lung, and abdominal examinations were normal.
The patient’s musculoskeletal examination showed significant muscle
atrophy in the quadriceps and calf
of the LLE (Figure 1). There were
no synovitis or joint effusions. No
sclerodactyly was appreciated. The
patient was able to lift his arms over
his shoulders and make a complete
fist. His overall range of motion and
strength were within normal limits.
The skin of the patient’s anterior
chest wall showed a small area of ice
pick sprinkling of hypopigmentation
without evidence of skin tightness
(Figure 2). Areas of shiny skin with
depigmentation were seen, most pro-
nounced in the distal aspect below
the knee, with some sprinkling of hy-
popigmentation on the upper thigh.
There was no involvement of the but-
tocks. There were no nailfold capil-
lary changes. There were no signs of
genital lesions or abnormalities.
The complete blood count, com-
plete metabolic panel, thyroid
stimulating hormone, and C-reac-
tive protein laboratory results were
within normal limits. Urine analy-
sis was negative for any abnormali-
ties. The patient tested negative for
hepatitis B, hepatitis C, and enzyme-
linked immunosorbent assay for
human immunodeficiency virus.
The serum antinuclear antibody was
positive with a titer of 1:320 (normal
range, 1: 40). Serum antibodies for
scleroderma, anticentromere, ribonu-
cleoprotein, double-stranded DNA,
anti-Ro, and anti-La were negative.
A high-resolution computed to-
mography chest scan, echocardio-
gram, and pulmonary function tests
showed no abnormalities.
Regarding the lesion on the ante-
rior chest, the patient underwent a
punch biopsy that showed focal atro-
phic epidermal changes, dense der-
mal collagen, few pigmented dermal
macrophages, and mild chronic in-
flammation; the changes were com-
patible with morphea. Clinically, the
lesion had no evidence of induration.
The patient was started on topical
treatment with tacrolimus twice daily
with occlusion for 12 weeks.
Due to advanced atrophy and inactivity of disease with no functional
impairment in the LLE, the patient
was referred for physical therapy. He
was counseled about the importance
of the therapy to avoid contracture.
The differential diagnosis included
systemic sclerosis, lipodermato-sclerosis, and morphea. In systemic
sclerosis, sclerodactyly, Raynaud’s
phenomenon, nailfold capillary
changes, and internal organ involvement are frequently seen. Lipoder-matosclerosis can be excluded, as the
patient did not show signs and symptoms suggestive of chronic venous
This case illustrates the classic
presentation of a rare disease: linear
morphea. An estimated 50% of cases
undergo spontaneous remission or
skin softening on average 2. 7 years
after onset. 2 The etiology of morphea
is a multifactorial process involving
environmental factors and host sus-
Figure 2. Anterior chest wall with ice pick sprinkling of hypopigmentation.