Focal myositis with extraordinary late onset after the combined antilipidemics therapy: Risk factors management

Abstract

Introduction: Statins and other antilipidemics are frequently described medications for the treatment of hypercholesterolemia to prevent cardiovascular events like heart infarctions or strokes. Statins are, conform to the German neurological guidelines, administered often independent of initial cholesterol level after stroke to prevent new relapses. Hence, we can observe in the clinical practice in our Neurologic Rehabilitation Department permanent increase in number of patients with long-term statin therapy. Although statins have side effects like deleterious effect on skeletal muscle. The most serious complications are myositis or rhabdomyolysis with kidney failure. Case Report: We present a case report of a 51-year-old Caucasian woman with combined antilipidemics therapy who developed a focal myositis with extraordinary late onset after the cessation of drug therapy. The patient received simvastatin 40 mg per day for a couple of weeks. Due to the persistent high cholesterol level the patient received an add-on therapy with ezetimibe for 2–3 weeks. She complained about generalized muscle pains and her high level of creatine kinase 373 U/l (normal range, 0–167 U/L). The patient showed initially a good recovery with less intense pain. Nevertheless, the muscle pain did not disappear completely and six months after the cessation of statin therapy the patient revealed again an intense muscle pain and tenderness notably femoral on the right side with the very high level of CK 2694 U/l. The femoral magnetic resonance imaging (MRI) demonstrated an accentuated vascular network right and a congestion of subcutaneous and endomysial lymphatic vessels, hence this configuration implicated a focal inflammatory reaction. We diagnosed a focal myositis in view to the clinical characteristics and MRI-tests. We initiated a steroid therapy (prednisolon 1 mg/kg on total body weight). Thereby the CK level decreased dramatically. At discharge CK level decreased to 548 U/l and ESR revealed normal values 3 mm in the first hour. After three weeks of therapy with steroids we could not register any femoral induration or local tenderness any more. Conclusion: Hence, it should be a prime concern to evaluate risk factors for statin-induced myopathy or myositis by intensive rehabilitation training.