Acute Onset Significant Muscle Weakness in a Patient Awaiting Liver Transplantation: Look for Statins

Abstract

Statins are commonly used drugs in patients with liver and cardiac disease. Statin-induced severe myopathy is a very uncommon presentation and rhabdomyolysis may occur in extreme cases which leads to renal failure. Patients with comorbidities like diabetes, hypothyroidism, and liver disease have higher chances of development of statin-induced myopathy. We describe a case of Child's C cirrhosis wherein the patient had acute onset significant muscle weakness and improved on statin discontinuation. ( J CLIN EXP HEPATOL 2017;7:66-67) A 57-year-old male presented with history of generalized weakness and inability to walk for 4 days. He also felt fatigue of jaw muscles on chewing. There was no history of fever or sensory symptoms. He was diagnosed as a case of cryptogenic (possibly NASH related) cirrhosis with decompensation three and half years back when he developed jaundice and ascites. His co-morbidities included diabetes mellitus and hypothyroidism for 4 years. In addition, he also had morbid obesity (body mass index 34.08 kg/m 2 ). He was worked up for deceased donor liver transplantation. His child's score was 11 and MELD score was 20. He had normal electrolytes, 25(OH)D 34 ng/ ml (<20 taken as deficient) and thyroid function test (TSH 3.9 mu/ml, T3 2.6 pg/ml, T4 1.6 ng/dl). His lipid profile revealed low values of total cholesterol (51 mg/dl), lowdensity lipoprotein (30 mg/dl), high-density lipoprotein (8 mg/dl), and triglycerides 67 (mg/dl). During his pretransplant workup, he was diagnosed to have 95% stenosis of left anterior descending coronary artery during cardiac evaluation. He underwent coronary stent placement for the same and was started on low dose Atorvastatin as per post-coronary stenting cardiac protocol 19 days before the current admission. He presented with marked generalized weakness and inability to walk for 4 days. His other medications at the time of admission included Aspirin 75 mg, Clopidogrel 75 mg, Furosemide 20 mg, Spironolactone 50 mg, L-ornithine and L-aspartate, Rifaximine, Calcium, Norfloxacin 400 mg once a day (as primary prophylaxis for spontaneous bacterial peritonitis), and Injection Albumin 20% 100 ml intravenous twice a week. At admission, his investigations were as follows: hemoglobin 10.5 g/dl, total leukocyte count 6420/cmm (neutrophils 47%, lymphocytes 27%, monocytes 21%), platelet count 110,000/cmm, serum bilirubin 5.8 (direct 2.8) mg/dl, aspartate aminotransferase 214 IU/L (195 IU/L one month back), alanine aminotransferase 62 IU/L (28 IU/L one month back), normal Alkaline Phosphatase and Gamma-glutamyl Transpeptidase, albumin 2 g/dl, globulins 3.6 g/dl, INR 1.82, creatinine 0.6 mg/ dl, magnesium 1.9 (1.6-2.3 mg/dl), calcium 8.2 (8.4-10.2) mg/dl, potassium 4.6 mmol/l, and phosphate 3.7 (2.5-4.5) mg/dl; these levels remained within normal values at the time of symptom improvement also. A thorough neurology evaluation was done which revealed muscle power of 3/ 5 in lower limbs and 4/5 in upper limbs. He had normal sensory examination and plantar reflex was normal. His ...