Case Report: Refractory Immune-Mediated Necrotizing Myositis and Limited English Proficiency

Abstract

Statement of Significance: We report the case of a 76-year-old Spanish-speaking patient with a three-year history of statin induced immune-mediated necrotizing myositis (IMNM) who presented with worsening symptoms and increasing creatinine kinase levels despite escalating treatment strategies. IMNM is a rare and challenging diagnosis. This case report details a myositis flare refractory to first and second-line therapies. Our report also examines limited English proficiency as a structural barrier to care in the United States, particularly in the setting of visits conducted via telehealth modalities. Purpose: To report a rare presentation of statin-induced IMNM and the clinical impacts of language barriers and telehealth. Methods: Case report. Results: A 76-year-old male with a three-year history of statin-induced IMNM presented for follow-up to the rheumatology clinic. He reported worsening weakness after beginning leucovorin to mitigate side effects ascribed to methotrexate therapy. He had previously achieved baseline strength and normal creatinine kinase (CK) levels with a regimen of weekly methotrexate and monthly infusion of intravenous immunoglobulin (IVIG). His decline in condition appeared to result from inappropriate medication scheduling due to a language barrier. The patient was taking weekly leucovorin on the day before his weekly dose of methotrexate, thus mitigating the efficacy of methotrexate. However, his condition continued to decline with three months of the recommended treatment schedule. The patient was then switched to mycophenolate mofetil as an alternative immunosuppressant. This therapy has demonstrated benefit thus far and provided the patient with symptomatic relief.