A young man with persistent myalgia and fatigue: an off-label therapeutic approach

A 34-year-old man reported a 16-year history of progressive chronic fatigue, neuromuscular pain in the region of the left shoulder and both knees. The patient presented difficulty in movement especially in the morning with myalgia and fatigue. Moreover, he reported constant headache localized to the parietal region, metallic taste and diarrhea. Central nervous system (CNS) involvement was diagnosed by the presence of cognitive dysfunction, attention and mood disturbances. Physical examination showed numerous flesh-colored to red-brown follicular papules and pustules, 1–3 mm in size all over the face (Fig. 1). Skin biopsy was not performed. The patient had been vaccinated for hepatitis B and tetanus toxoid in 1994 and 1995. No pathological conditions were reported in his clinical history. In 2003 because of the persistence of the symptoms, muscle biopsy was prescribed and autoimmune Macrophagic Myofasciitis (MMF) was finally diagnosed. Further investigations, management and treatment