Musculoskeletal
Matthew S. Wang, MS
UNC School of Medicine
Cary, North Carolina, United States
Sidney Tucker, MD
Resident Physician
UNC School of Medicine
Chapel Hill, North Carolina, United States
Sierra McLean, MD
Fellow Physician
Mayo Clinic
Rochester, Minnesota, United States
William Filer, MD
Associate Professor | Residency Director | Vice Chair of Education
University of North Carolina at Chapel Hill
Chapel Hill, North Carolina, United States
Matthew S. Wang, MS
UNC School of Medicine
Cary, North Carolina, United States
An 89-year-old woman with history of ischemic stroke without residual deficits was admitted to inpatient rehabilitation following hospitalization for small bowel obstruction requiring exploratory laparotomy. She developed worsening transaminitis (AST 357, ALT 130, ALP 177) without gastrointestinal symptoms. Gastrointestinal work-up, including right upper quadrant ultrasound, was unremarkable.
Concurrently, therapy noted functional decline with onset of proximal muscle weakness and bilateral shoulder pain. Reflexes and sensation were preserved. Serum creatine kinase was elevated at 5432. MRI showed diffuse muscular and subcutaneous edema. EMG demonstrated myopathy with muscle membrane irritability. However, antibody panels – including anti-SRP and anti-HMG-CoA-reductase – were negative. Muscle biopsy showed only a single necrotic muscle fiber.
Atorvastatin, initiated 8 months prior, was discontinued. She was transferred to Neurology, where she received five days of intravenous methylprednisolone and immunoglobulin, which improved her pain and transaminitis. She was transferred back to inpatient rehabilitation and progressed to walker-assisted household mobility.
Discussions:
Early recognition of worsening transaminitis and acute muscle symptoms enabled timely transfer to Neurology where she could receive appropriate treatment for her condition and undergo evaluation to rule out of other serious diagnoses such as immune-mediated necrotizing myopathy. Her clinical presentation, negative autoimmune serologies, and equivocal muscle biopsy support statin-induced rhabdomyolysis as the most likely etiology. While statin-associated myopathies occur more commonly during initiation, they may occur at any point, as seen in this case.
Conclusions:
This case highlights the importance of a broad differential diagnosis and timely work-up for acute problems in inpatient rehabilitation. Myopathy can present with transaminitis, and serum creatine kinase is helpful in distinguishing muscle from hepatic etiologies.
