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Statin-associated focal myositis
International Journal of Cardiology 133 (2009) e33 – e34 www.elsevier.com/locate/ijcard
Letter to the Editor
Statin-associated focal myositis Patrick Asbach a,b,⁎, Ingo Paetsch c , Philipp Stawowy c , Bernhard Sander a , Eckart Fleck c a
MRI Practice Dr. Sander, Luisenstrasse 12, 10117 Berlin, Germany Department of Radiology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany Department of Medicine/Cardiology, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353 Berlin, Germany b
c
Received 30 July 2007; accepted 10 August 2007 Available online 26 December 2007
Abstract Myositis is an infrequent side effect of statin therapy, usually presenting as diffuse myositis with muscle weakness and cramping involving multiple body parts. We report a case of focal myositis of a hip muscle diagnosed on magnetic resonance imaging, as the underlying pathology was suspected to be related to an orthopaedic disease due to isolated hip symptoms, and which was finally attributed to statin intake. Awareness to this rare cause of musculoskeletal symptoms is indicated in case a patient presents with probable orthopaedic disease and is on statin therapy. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Focal myositis; Statin therapy
1. Case description A 63 year old male presented with acute onset of leftsided hip pain. Detailed clinical history revealed long-term statin intake (atorvastatin, 40 mg) for treatment of dyslipidemia. Routine laboratory results and C-reactive protein were normal. Conventional X-ray imaging of the hip revealed a normally contourized femoral head and acetabulum with only slight narrowing of the joint space. The patient was referred to magnetic resonance imaging (MRI) of the left hip. On MR imaging the left gluteus minimus muscle showed an abnormally high and diffuse signal intensity increase on short-tau-inversion recovery (STIR) and T2weighted turbo-spin-echo (TSE) sequences (Fig. 1A) proving a pathologic increase of extracellular fluid being suggestive of focal myositis with diffuse edema. In addition, the contralateral gluteus minimus muscle and adjacent left sided hip muscles and joint structures showed no abnormalities. The patient was advised to withdraw the statin ⁎ Corresponding author. Department of Radiology, Charité - Universitätsmedizin Berlin, MRI Practice Dr. Sander, Luisenstrasse 12, 10117 Berlin, Germany. Tel.: +49 30 450 627417; fax: +49 30 450 578903. E-mail address: [email protected] (P. Asbach). 0167-5273/$ - see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2007.08.109
medication and two weeks later hip pain resolved completely without any other pharmacologic or physiotherapeutic intervention. Repeat MR imaging of the hip was performed four weeks later and the signal intensity pattern of the gluteus minimus muscle was now found to be normal (Fig. 1B). 2. Discussion Statins are the most prescribed drugs in the United States for cardiovascular risk reduction in secondary prevention [1]. Statin- induced rhabdomyolysis is rare and occurs in less than 0.15% [2]. However, more frequent adverse effects include headache, nausea and sleep disturbance with the incidence of muscle pain and weakness estimated to be in the range of 1% to 5% [1]. Factors predisposing to statin related myopathy are age, renal and hepatic dysfunction, hypertriglyceridemia and vigorous physical exercise. It has been suggested that as many as 25% of statin users who exercise may experience muscle fatigue, weakness and cramping [3]. The pathophysiologic mechanisms of statin-related myotoxicity are not fully understood but impaired production of small regulatory muscle proteins has been suggested [3]. Statin myotoxicity has been classified into four categories
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P. Asbach et al. / International Journal of Cardiology 133 (2009) e33–e34
Fig. 1. A) Coronal T2-weighted STIR image of the pelvis. Diffuse edema of the left gluteus minimus muscle (arrows) is demonstrated. B) Coronal T2-weighted STIR image of the pelvis 4 weeks after cessation of statin intake. The signal intensity of the left gluteus minimus muscle has normalized.
ranging from statin myopathy (any muscle complaints), myalgia (muscle complaints without a CPK rise), myositis (CPK rise b 10 times the upper level of normal) to rhabdomyolysis (severe muscle damage, creatinin kinase N 10 times the upper level of normal) [1]. However, myopathic symptoms without any biochemical correlate are not rare [4]. The involvement of multiple muscle sites usually determines the clinical presentation of statin-associated myositis which is highly variable with patient complaints reaching from generalized muscle weakness to minor myalgic symptoms or fulminant muscle pain and reduced general condition. Focal manifestation with structural damage to a single muscle, however, occurs rarely [5,6]: in the present case the isolated edematous affection of the gluteus minimus muscle was the reason for hip pain since other possible orthopaedic diseases could be ruled out. In addition, after cessation of statin medication the patient was free of symptoms within six weeks and MR signal intensity behaviour of the respective muscle region had normalized. MR imaging is ideally suited to non-invasively prove the presence of edematous muscle and can be used to monitor the
inflammation process. Furthermore other potential and far more common pathologies such as cartilage and ligamentous injury or degeneration can be diagnosed during the same imaging procedure. In our case, muscle edema was clearly seen on MR imaging and had completely resolved on the rescan 4 weeks after cessation of statin intake, correlating with absence of hip pain and normal CK laboratory findings. References [1] Thompson PD, Clarkson P, Karas RH. Statin-associated myopathy. JAMA 2003;289:1681–90. [2] Mukhtar RY, Reckless JP. Statin-induced myositis: a commonly encountered or rare side effect? Curr Opin Lipidol 2005;16:640–7. [3] Dirks AJ, Jones KM. Statin-induced apoptosis and skeletal myopathy. Am J Physiol Cell Physiol 2006;291:C1208–12. [4] Sinzinger H, Wolfram R, Peskar BA. Muscular side effects of statins. J Cardiovasc Pharmacol 2002;40:163–71. [5] Biggs MJ, Bonser RS, Cram R. Localized rhabdomyolysis after exertion in a cardiac transplant recipient on statin therapy. J Heart Lung Transplant 2006;25:356–7. [6] Ertas FS, Ertas NM, Gulec S, et al. Unrecognized side effect of statin treatment: unilateral blepharoptosis. Ophthalmic Plastic Reconstr Surg 2006;22:222–4.
Letter to the Editor
Statin-associated focal myositis Patrick Asbach a,b,⁎, Ingo Paetsch c , Philipp Stawowy c , Bernhard Sander a , Eckart Fleck c a
MRI Practice Dr. Sander, Luisenstrasse 12, 10117 Berlin, Germany Department of Radiology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany Department of Medicine/Cardiology, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353 Berlin, Germany b
c
Received 30 July 2007; accepted 10 August 2007 Available online 26 December 2007
Abstract Myositis is an infrequent side effect of statin therapy, usually presenting as diffuse myositis with muscle weakness and cramping involving multiple body parts. We report a case of focal myositis of a hip muscle diagnosed on magnetic resonance imaging, as the underlying pathology was suspected to be related to an orthopaedic disease due to isolated hip symptoms, and which was finally attributed to statin intake. Awareness to this rare cause of musculoskeletal symptoms is indicated in case a patient presents with probable orthopaedic disease and is on statin therapy. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Focal myositis; Statin therapy
1. Case description A 63 year old male presented with acute onset of leftsided hip pain. Detailed clinical history revealed long-term statin intake (atorvastatin, 40 mg) for treatment of dyslipidemia. Routine laboratory results and C-reactive protein were normal. Conventional X-ray imaging of the hip revealed a normally contourized femoral head and acetabulum with only slight narrowing of the joint space. The patient was referred to magnetic resonance imaging (MRI) of the left hip. On MR imaging the left gluteus minimus muscle showed an abnormally high and diffuse signal intensity increase on short-tau-inversion recovery (STIR) and T2weighted turbo-spin-echo (TSE) sequences (Fig. 1A) proving a pathologic increase of extracellular fluid being suggestive of focal myositis with diffuse edema. In addition, the contralateral gluteus minimus muscle and adjacent left sided hip muscles and joint structures showed no abnormalities. The patient was advised to withdraw the statin ⁎ Corresponding author. Department of Radiology, Charité - Universitätsmedizin Berlin, MRI Practice Dr. Sander, Luisenstrasse 12, 10117 Berlin, Germany. Tel.: +49 30 450 627417; fax: +49 30 450 578903. E-mail address: [email protected] (P. Asbach). 0167-5273/$ - see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2007.08.109
medication and two weeks later hip pain resolved completely without any other pharmacologic or physiotherapeutic intervention. Repeat MR imaging of the hip was performed four weeks later and the signal intensity pattern of the gluteus minimus muscle was now found to be normal (Fig. 1B). 2. Discussion Statins are the most prescribed drugs in the United States for cardiovascular risk reduction in secondary prevention [1]. Statin- induced rhabdomyolysis is rare and occurs in less than 0.15% [2]. However, more frequent adverse effects include headache, nausea and sleep disturbance with the incidence of muscle pain and weakness estimated to be in the range of 1% to 5% [1]. Factors predisposing to statin related myopathy are age, renal and hepatic dysfunction, hypertriglyceridemia and vigorous physical exercise. It has been suggested that as many as 25% of statin users who exercise may experience muscle fatigue, weakness and cramping [3]. The pathophysiologic mechanisms of statin-related myotoxicity are not fully understood but impaired production of small regulatory muscle proteins has been suggested [3]. Statin myotoxicity has been classified into four categories
e34
P. Asbach et al. / International Journal of Cardiology 133 (2009) e33–e34
Fig. 1. A) Coronal T2-weighted STIR image of the pelvis. Diffuse edema of the left gluteus minimus muscle (arrows) is demonstrated. B) Coronal T2-weighted STIR image of the pelvis 4 weeks after cessation of statin intake. The signal intensity of the left gluteus minimus muscle has normalized.
ranging from statin myopathy (any muscle complaints), myalgia (muscle complaints without a CPK rise), myositis (CPK rise b 10 times the upper level of normal) to rhabdomyolysis (severe muscle damage, creatinin kinase N 10 times the upper level of normal) [1]. However, myopathic symptoms without any biochemical correlate are not rare [4]. The involvement of multiple muscle sites usually determines the clinical presentation of statin-associated myositis which is highly variable with patient complaints reaching from generalized muscle weakness to minor myalgic symptoms or fulminant muscle pain and reduced general condition. Focal manifestation with structural damage to a single muscle, however, occurs rarely [5,6]: in the present case the isolated edematous affection of the gluteus minimus muscle was the reason for hip pain since other possible orthopaedic diseases could be ruled out. In addition, after cessation of statin medication the patient was free of symptoms within six weeks and MR signal intensity behaviour of the respective muscle region had normalized. MR imaging is ideally suited to non-invasively prove the presence of edematous muscle and can be used to monitor the
inflammation process. Furthermore other potential and far more common pathologies such as cartilage and ligamentous injury or degeneration can be diagnosed during the same imaging procedure. In our case, muscle edema was clearly seen on MR imaging and had completely resolved on the rescan 4 weeks after cessation of statin intake, correlating with absence of hip pain and normal CK laboratory findings. References [1] Thompson PD, Clarkson P, Karas RH. Statin-associated myopathy. JAMA 2003;289:1681–90. [2] Mukhtar RY, Reckless JP. Statin-induced myositis: a commonly encountered or rare side effect? Curr Opin Lipidol 2005;16:640–7. [3] Dirks AJ, Jones KM. Statin-induced apoptosis and skeletal myopathy. Am J Physiol Cell Physiol 2006;291:C1208–12. [4] Sinzinger H, Wolfram R, Peskar BA. Muscular side effects of statins. J Cardiovasc Pharmacol 2002;40:163–71. [5] Biggs MJ, Bonser RS, Cram R. Localized rhabdomyolysis after exertion in a cardiac transplant recipient on statin therapy. J Heart Lung Transplant 2006;25:356–7. [6] Ertas FS, Ertas NM, Gulec S, et al. Unrecognized side effect of statin treatment: unilateral blepharoptosis. Ophthalmic Plastic Reconstr Surg 2006;22:222–4.