|LETTER TO EDITOR
|Ahead of print publication
Telecommunication in the COVID-19 era: As an assessment tool for patients with dermatomyositis
Prakash Gupta1, Latika Gupta2
1 MBBS Student, Saint Louis University Hospital of the Sacred Heart Baguio city, Virgen Milagrosa University Foundation-College of Medicine, San Carlos City, Pangasinan, Philippines
2 Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
|Date of Submission||13-Oct-2020|
|Date of Acceptance||15-Oct-2020|
Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
A 36-year-old female with anti-Mi-2-positive dermatomyositis reported inability to continue injectable methotrexate during the nationwide lockdown due to the coronavirus disease 2 (COVID-19) pandemic, while requesting a switch to oral drugs. Three months later, she complained of difficulty in climbing stairs, and also reported periungual skin changes and diffuse hair loss. On a teleconsultation, a relapse was confirmed by periungual changes and the V-sign, which was itchy, with areas of excoriation [Figure 1]a and [Figure 1]b. Pictures of the face suggested malar rash indoors, which could not be identified when clicked in bright sunlight [Figure 1]c and [Figure 1]d. Because an objective assessment using the manual muscle test was not feasible remotely, she was asked to record 2 min of walk distance and the time in seconds to lift the arms overhead ten times twice over a week. The corresponding values were 150 m and 40 s, much lower than the reported average for most patients in remission (180–220 and 8–18 s) in the authors' experience. Elevated muscle enzymes (creatine phosphokinase 580 U/L [25–170], lactate dehydrogenase 870 U/L [12–250], serum glutamic oxaloacetic transaminase 91 IU/L [10–50], and serum glutamate pyruvate transaminase 68 IU/L [10–50]) confirmed a relapse.
|Figure 1: Cutaneous manifestations in a patient with relapse of dermatomyositis. (a) Fingers with periungual desquamation. (b) V-sign and areas of excoriation. (c) Malar rash indoors. (d) Malar rash not identified due to bright light|
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Teleconsultation can be a challenge in patients with chronic diseases, who may suffer from poor mobility in addition to a possibly accentuated risk of contracting COVID-19. While certain distinctive rashes may be identified by the patients themselves, transformed cutaneous manifestations such as rashes in new areas or of a different phenotype may be difficult to identify. The systematic and early detection of worsening disease by the patient is fraught with confounding variables such as awareness, education level, familiarity with the usage of technology, and availability of proper lighting and conditions for useful clinical images. In patients without rashes, early identification of muscle weakness would require regular assessment using remote patient-driven outcome measures. While several tools such as SF-36 and PROMIS capture quality of life, their cost and language barrier may limit accessibility. Although the importance of a formal physical examination cannot be overemphasized, technological advances including the widespread use of smartphones may allow better remote monitoring than was feasible a few years ago.
The author is using the abovementioned two simple tools for remote assessment, which helped with an early diagnosis of relapse in this case. Because the projected pandemic duration seems rather long at this point, it is imperative for clinicians to devise measures for quick and easy remote assessment. It is also vital to identify and educate the patients regarding the possible lacunae while sharing appropriate clinical images, such as appropriate lighting, distance, focus, and clarity.
To conclude, remote monitoring can be a challenge in chronic diseases. In the present case, timely attention to a flare was brought by the rash and confirmed by two simple patient-reported outcome measures. As patients prepare for a long haul at home during the pandemic, it is prudent to develop simple tools of remote assessment for wider usage and better patient care.
The authors thank connecting researchers and Malke Asaad for their help with this work.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initial will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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