892 M.-J. Kim, J.-A. Kim, M.-S. Sung, et al. Fig. 1. The histologic findings of liver showing hepatocellular car- cinoma (H&E, ×200). Fig. 2. The histologic findings of skeletal muscle showing muscle necrosis with calcification (arrow head) (H&E, ×400). mg/dL, phosphorus 7.6 mg/dL, ionized calcium 0.7 mmol/L (normal 1.05-1.35 mmol/L), intact parathyroid hormone 201.87 pg/mL (normal 12-72 pg/mL). erythrocyte sedimen- tation rate 55 mm/hr, C-reactive protein 200 mg/dL, creatine kinase 40,000 U/L, LDH 3,286 U/L, serum aldolase 66 sigma U/mL, serum myoglobin 1,140 ng/mL, and urine myoglobin 948 ng/mL. Urinalysis revealed 10-20 RBC per high power field. Urine myoglobin was positive and urine hemoglobin was negative. Tests for anti-HBs, anti-HCV, anti-HAV, anti- HIV, rheumatoid factor, anti-nuclear antibody, anti-dsDNA antibody, anti-neutrophil cytoplasmic antibody, anti-Jo-1 antibody were all negative. Serum levels of complements and alpha-fetoprotein were normal. Hypercalcemia appeared on day 14 and lasted for 28 days. The serum level of intact PTH measured on the 37th hospital day was 5.81 pg/mL. A chest radiograph showed bilateral pleural effusion. Computed tomo- graphy of the abdomen demonstrated a 6 cm sized-exophytic bulging mass in the hepatic angle. Two smaller satellite nod- ules near the main hepatic mass and several enlarged intraperi- toneal lymph nodes were also detected. A radionuclear bone scan image showed increased uptake of radioisotope in the most of the skeletal muscles including the both lower limbs, indicative of inflammatory myopathy or rhabdomyolysis. Fat suppressed T2-weighted MR imaging of the thigh showed high signal intensity and gadolinium enhancement along the whole length of vastus muscle group, biceps femoralis and adductor longus. Needle electromyography showed spon- taneous activity of fibrillations, sharp positive waves, polypha- sic motor unit potentials of low amplitude, and short dura- tion in all muscle fibers during voluntary contraction. The muscle biopsy was obtained from the left thigh and showed extensive myofiber necrosis with heavy infiltration of macro- phages within necrotic fibers, multifocal calcifications in myo- fibers, and multifocal lymphocytic infiltrations in endomy- sium (Fig. 1). The emergent hemodialysis was initiated with a tentative diagnosis of ARF. After 15 days with hemodialytic support, his renal function was gradually restored to allow withdrawal of dialysis. The liver biopsy was performed on the 20th day of hospitalization under ultrasonographic guidance. Immunohistochemical stain of biopsied tissue showed posi- tive for AFP and negative for CEA, and poorly differentiated HCC was diagnosed (Fig. 2). Under the diagnosis of PM, our patient was put on methylprednisolone (1 mg/kg/day) con- currently with hemodialysis. Treatment was switched to oral prednisolone and persisted for following 5 weeks. However, muscle power did not improve significantly. Chemotherapy for HCC was considered, but the patient had an episode of hemorrhagic shock from a sudden rupture of hepatic mass on the 44th day of hospitalization. He progressively deteriorated and remained in an unstable condition until he passed away on the 54th day. DISCUSSION On the matter about the association of malignancy and myositis, major excess risk was attributable to DM. PM is generally considered that there is much weaker relation with malignancy than DM. However, we concluded that it is more reasonable to diagnose for our patient as PM based on the fol- lowings. First of all, our patient presented no apparent skin lesion for DM. Typical skin lesions are essential components