Polymyositis Presenting as Rhabdomyolysis After the Initiation of Omeprazole

Jonathan K Jakubowski,Venkata Buddharaju,Rosemina Patel

doi:10.7759/cureus.8125

Jonathan K Jakubowski, Venkata Buddharaju + Show 1 more

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https://doi.org/10.7759/cureus.8125

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Abstract

Rhabdomyolysis is a clinical syndrome with a wide range of presentations; it results in muscle necrosis and release of intracellular muscle contents into the circulation. Inflammatory myopathies are a rare cause of rhabdomyolysis. We present a case of a 46-year-old male with a two-week history of progressively worsening diffuse muscle pain after he had been prescribed omeprazole one month prior. A creatine phosphokinase (CPK) elevation was noted, which persisted despite treatment with IV fluids, sodium bicarbonate, and close correction of electrolytes. Further workup, including autoimmune and infectious etiologies, was notable for elevated antinuclear antibodies (ANA), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP). Furthermore, a muscle biopsy showed evidence of endomysial inflammatory cells, consistent with a diagnosis of polymyositis. Steroids were initiated with significant improvement in symptoms and a decrease in CPK levels. The patient was discharged on a tapering dose of steroids and, on follow-up with the rheumatologist, transitioned to methotrexate with control of symptoms. In patients with rhabdomyolysis who do not respond to first-line therapy, obtaining a detailed medication history and screening with ANA and ESR are encouraged. Given the link between medication and autoimmune disease, clinicians should consider autoimmune myopathy in the differential for cases with persistently elevated creatine kinase. Prompt diagnosis with early initiation of immunosuppressive medication may improve outcomes and avoid complications associated with untreated rhabdomyolysis or polymyositis.

Highlights

Rhabdomyolysis is a clinical syndrome that results in muscle necrosis and the release of muscle cell contents into the circulation, most notably myoglobin
Rhabdomyolysis is a clinical syndrome with a wide range of presentations; it results in muscle necrosis and release of intracellular muscle contents into the circulation
Prompt diagnosis with early initiation of immunosuppressive medication may improve outcomes and avoid complications associated with untreated rhabdomyolysis or polymyositis

Summary

Introduction

Rhabdomyolysis is a clinical syndrome that results in muscle necrosis and the release of muscle cell contents into the circulation, most notably myoglobin. Rhabdomyolysis is associated with a wide-spectrum manifestation, from remaining clinically silent as a benign course to a severe systemic presentation causing pigment-induced nephropathy [1] It may arise from a traumatic or non-traumatic etiology including toxins, electrolyte disturbances, infection, medications, immobilization, seizures, and, rarely, autoimmune myopathies. The patient had an MRI of the left shoulder without contrast, which demonstrated a diffuse increase in T2 signal of the cuff muscles, suggestive of edema, and possibly active inflammation (Figure 4). He was seen by a rheumatologist who started him on methotrexate. A repeat CPK two months later was noted to be 1271 with other muscle enzymes showing a downward trend

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