A tough pill to swallow: Two cases of statin-induced necrotizing autoimmune myopathy manifesting as dysphagia and transaminitis

Chaudhry, Hunza; Lin, Joanne; Atefi, Rameen; Hagino, Jeffrey; Yuvienco, Candice; Roytman, Marina

doi:10.1177/2050313x221150583

Cited by 4 publications

(3 citation statements)

References 11 publications

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“…In most cases of statin-induced immune-mediated myopathy, the muscular symptoms resolve upon prolonged treatment, and generally, the prognosis is good. In rare instances, the muscle weakness persists beyond years of aggressive treatment [ 23 , 37 , 38 ]. One of the most feared and commonly reported complications of untreated statin-induced immune-mediated myopathy is dysphagia caused by dysfunction of muscles related to swallowing, difficulty with aspiration, and possibly death.…”

Section: Discussionmentioning

confidence: 99%

Unveiling the Rare Complication: Statin-Induced Immune-Mediated Necrotizing Myopathy

Chowdhury,

Mahneva,

Maharaj

et al. 2023

Am J Case Rep

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Patient: Female, 59-year-old Final Diagnosis: Anti-HMG-CoA reductase-induced myopathy Symptoms: Balance problems • fatigue • muscle weakness • myalgia • myopathy Clinical Procedure: Muscle biopsy Specialty: General and Internal Medicine • Neurology • Rheumatology Objective: Unknown etiology Background: Statin-induced necrotizing autoimmune myopathy is an exceptionally rare yet severe complication of statin therapy that may develop in individuals at any time during their exposure to statins. The development of proximal muscle weakness, muscle pain, and elevated creatine kinase (CK) levels in patients while taking statins should prompt clinical consideration of statin-induced myopathy. The pathophysiology arises from the production of auto-antibodies, which target the 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMG-CoA reductase) enzyme, leading to the aggressive breakdown of myofibrils. Case Report: Here, we present a case of a 59-year-old woman with a medical history of dyslipidemia who developed anti-HMGCoA reductase antibodies after taking atorvastatin. She came to the emergency department with complaints of severe proximal muscle weakness. The laboratory workup showed an elevated CK level up to 12 000 IU/L. Despite discontinuing atorvastatin, the patient’s elevated CK levels persisted. The patient underwent a muscle biopsy, demonstrating myofibril necrosis. Serological analysis showed anti-HMG-CoA reductase antibodies in the patient’s serum, which led to the diagnosis of immune-mediated necrotizing myopathy due to statins. The patient’s statin therapy was promptly discontinued, and she was treated with a high dose of IV corticosteroids. After the patient’s discharge, brief discontinuation of the corticosteroids resulted in CK elevation and a return of symptoms. This led to the second re-admission and restarting of corticosteroids until stabilization and discharge. Conclusions: This case represents an important reminder for clinicians to recognize the possibility of statin-induced immune-mediated necrotizing myopathy in patients presenting with proximal muscle weakness while taking a statin, notwithstanding the rarity of this condition.

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Section: Discussionmentioning

confidence: 99%

Unveiling the Rare Complication: Statin-Induced Immune-Mediated Necrotizing Myopathy

Chowdhury,

Mahneva,

Maharaj

et al. 2023

Am J Case Rep

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“…Diagnosis of SINM requires the detection of anti-HMGCR antibodies. One of the proposed mechanisms of SINM suggests an increased expression of HMGCR post-initiation of statins, leading to an autoimmune pathology [16]. This persists even after the discontinuation of the medication, and thus, immunosuppressive therapy is required [16].…”

Section: Discussionmentioning

confidence: 99%

“…One of the proposed mechanisms of SINM suggests an increased expression of HMGCR post-initiation of statins, leading to an autoimmune pathology [16]. This persists even after the discontinuation of the medication, and thus, immunosuppressive therapy is required [16]. The autoimmune process is suspected to be caused by anti-HMGCR antibodies cross-reacting with an antigen associated with myositis [17].…”

Section: Discussionmentioning

confidence: 99%

Necrotizing Autoimmune Myopathy: A Case Report on Statin-Induced Rhabdomyolysis

Altaf,

Bhatt,

Qasim

et al. 2023

Cureus

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Statin-induced necrotizing myopathy (SINM) is an uncommon but severe complication associated with statin medication. SINM can develop at any point after a person starts taking steroids. It is now being acknowledged as a component of the broader category of "statin-induced myopathy." Like other immunemediated necrotizing muscle diseases, statin-induced myositis is identified by weakness in proximal muscles, increased serum creatine kinase (CK) levels, and, in some cases, dysphagia and respiratory distress. In addition, there is evidence of muscle cell damage when examined under a microscope, occurring with minimal or no infiltration of inflammatory cells. Diagnosing SINM promptly is frequently challenging due to its unpredictable development over time, with symptoms sometimes emerging many years after the initial exposure to statins. One distinctive characteristic of SINM is the continued presence of muscle inflammation and elevated CK levels even after discontinuing statin treatment. Currently, no clinical trials are available to guide how to manage statin-induced immune-mediated necrotizing myopathy (IMNM). Here, we present a case of a 42-year-old woman diagnosed with SINM and was found to have persistently elevated CPK despite discontinuation of statins. Our case also suggests that intravenous (IV) immunoglobins and steroids are an effective and well-tolerated alternative to immunosuppressants.

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Atorvastatin

2023

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A tough pill to swallow: Two cases of statin-induced necrotizing autoimmune myopathy manifesting as dysphagia and transaminitis

Cited by 4 publications

References 11 publications

Unveiling the Rare Complication: Statin-Induced Immune-Mediated Necrotizing Myopathy

Unveiling the Rare Complication: Statin-Induced Immune-Mediated Necrotizing Myopathy

Necrotizing Autoimmune Myopathy: A Case Report on Statin-Induced Rhabdomyolysis

Atorvastatin

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