Refractory rosuvastatin-associated necrotizing autoimmune myopathy: A case report and review of literature

Table 1 Laboratory and autoimmune testing results on admission and during hospital stay

Laboratory test	Result	Reference range
White blood cell count (cells/µL)	12.92 × 10³	4.8-10.8 × 10³
Hemoglobin (g/dL)	8.1	12-16
Hematocrit	25.8%	37%-47%
Mean corpuscular volume (fL)	105.7	80-100
Platelet count (cells/µL)	348 × 10³	130-400 × 10³
Sodium (mmol/L)	138	136-145
Potassium (mmol/L)	3.7	3.5-5.1
Chloride (mmol/L)	107	98-107
Bicarbonate (mEq/L)	15	22-29
Blood urea nitrogen (mg/dL)	56	8-22
Creatinine (mg/dL)	4.0	0.7-1.2
Glucose (mg/dL)	91	70-104
Calcium (mg/dL)	8.3	8.8-10.2
Total bilirubin (mg/dL)	0.24	0.20-1.0
Aspartate transaminase (U/L)	365	10-30
Alanine transaminase (U/L)	280	10-36
Alkaline phosphatase (U/L)	74	32-104
Creatine kinase (U/L)	9012	24-173
Erythrocyte sedimentation rate (mm/hour)	23	0-20
Urinalysis	Heme-positive urine with absent erythrocytes on microscopy; leukocytes present; 4+ bacteria
Jo-1 antibody (U)	Negative	< 1.0
SSA/Ro antibody (U)	Negative	< 1.0
SSB/La antibody (U)	Negative	< 1.0
Smith antibody (U)	Negative	< 1.0
RNP antibody (U)	Negative	< 1.0
Scl-70 antibody (U)	Negative	< 1.0
Antinuclear antibody (U)	Negative	≤ 1.0
Cyclic citrullinated peptide antibody (U)	Negative	< 20.0
HMG-CoA reductase antibody (CU)	Positive (348.8)	< 20.0

SSA: Sjögren syndrome-related antigen A; SSB: Sjögren syndrome–related antigen B; RNP: Ribonucleoprotein; Scl-70: Topoisomerase I; HMG-CoA: 3-hydroxy-3-methylglutaryl-coenzyme A.

Table 2 Comparison of previously reported cases of statin-associated necrotizing autoimmune myopathy

Ref.	Age/sex	Statin used	Diagnostic criteria	Therapy used	Outcome
Grable-Esposito et al[3]	74/female	Atorvastatin	Elevated CK, muscle biopsy	Prednisone, methotrexate, mycophenolate, IVIG	Improved
Fink et al[20]	65/female	Rosuvastatin	Elevated CK, MRI, anti-HMGCR antibodies	Prednisone, IVIG	Improved weakness and CK levels; required SNF
Gupta et al[24]	61/female	Pravastatin	Elevated CK, anti-HMGCR antibodies, MRI, muscle biopsy	Prednisone, azathioprine, rituximab	Improved
Srinivasan et al[25]	64/male	Atorvastatin, rosuvastatin	Elevated CK, EMG, muscle biopsy, anti-HMGCR antibodies	Prednisone, IVIG	Improved
Luong et al[27]	55/male	Rosuvastatin	Elevated CK, anti-HMGCR antibodies, MRI, muscle biopsy	Prednisone, mycophenolate, IVIG	Improved
Yamamura et al[28]	59/female	Rosuvastatin	Anti-HMGCR antibodies, elevated CK, MRI, muscle biopsy	Methylprednisolone pulse therapy, prednisolone	Improved
Chitralli et al[29]	63/male	Atorvastatin, rosuvastatin	Elevated CK, EMG	Hemodialysis	Improved
Petreski et al[30]	59/female	Rosuvastatin	EMG, muscle biopsy	Hemodialysis	Improved
Merlant et al[32]	61/female	Rosuvastatin	Elevated CK, muscle biopsy, anti-HMGCR antibodies	Immunosuppressive therapy	Improved
Mirlesse et al[35]	77/male	Atorvastatin	Elevated CK, MRI, anti-HMGCR antibodies	Methylprednisolone, IVIG	Died
Abusharar et al[36]	73/male	Simvastatin	Elevated CK, muscle biopsy, anti-HMGCR antibodies	Prednisone, methylprednisolone, IVIG, methotrexate, azathioprine	Died

HMGCR: 3-hydroxy-3-methylglutaryl–coenzyme A reductase; MRI: Magnetic resonance imaging; CK: Creatine kinase; HMG-CoA: 3-hydroxy-3-methylglutaryl-coenzyme A; EMG: Electromyography; IVIG: Intravenous immunoglobulin; SNF: Skilled nursing facility; AKI: Acute kidney injury.