A diagnostic dilemma: A case of respiratory failure due to statininduced myonecrosis

Document Type

Conference Proceeding

Publication Date

1-1-2022

Publication Title

Crit Care Med

Abstract

INTRODUCTION: Statin-induced myopathies are best described on a continuum, as patients can range widely in presentation. The most extreme of cases displaying respiratory distress, quadriparesis, dysphagia, and rhabdomyolysis. Cases on the severe end of the spectrum with myonecrosis leading to eventual respiratory failure and death are rare and remain a diagnostic dilemma with subsequent delays in treatment. DESCRIPTION: A 79-year-old male presented in March 2020 with progressively worsening quadriparesis, dysarthria, and dyspnea over 3 months. He started Atorvastatin 20 mg after his CVA 18 months prior and began to manifest weakness 14 months later. He discontinued Atorvastatin a month prior to presentation due to suspicion for statin induced weakness, however, was never diagnostically confirmed or treated. Physical exam revealed muscle weakness of 3/5 in upper extremities, 4/5 in lower extremities, inability to abduct arms above a 45-degree angle, diffuse hyporeflexia, intact sensation, and normal cranial nerves. Labs revealed CPK >4,600, aldolase of 55 with negative ANA, anti-RNP, anti-PL12, paraneoplastic panel, anti-MuSK/AcHR, and myositis antibodies. EMG revealed chronic myopathy with significant membrane irritability. MRI revealed extensive diffuse muscular edema consistent with myositis, and muscle biopsy confirmed severe necrotizing myopathy. On day 7 he was found to have anti-HMGCr IgG positive > 200 and was started on IV solumedrol and IVIG for a 5-day course with transition to 60 mg prednisone. Despite treatment, he had increasing oxygen demands from 4 L on presentation to HFNC 60% FiO2 on 50 L. NIF was -40 cm H2O on presentation with slight conversational dyspnea, however on day 13 declined to -12 cm H2O with significant lethargy and required ventilator support. Given lack of improvement and overall poor prognosis he was terminally weaned per family request and expired. DISCUSSION: Statin induced myonecrosis causing respiratory failure can be a challenging diagnosis as it is a rare condition. This should be considered as a differential in any patient with new onset myopathies with past or current use of statins and diagnostic work up with appropriate treatment should not be delayed in any patient with severe features such as respiratory failure.

Volume

50

Issue

1 SUPPL

First Page

545

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