Weakness Due to Anemia? Go Fish! Melena as a Red Herring in the Diagnosis of Statin-Induced Myopathy

Statins are a ubiquitous medication class in the primary care setting where they provide effective primary and secondary prevention of coronary artery disease by lowering cholesterol. While statins are mostly safe, muscle-related adverse events are well described. Very rarely patients can actually develop elevated creatine kinase (CK) consistent with myonecrosis. We present a case of progressive anti-hydroxymethylglutaryl coenzyme A reductase (anti-HMGCR) inflammatory myopathy, which was misdiagnosed for many months. Our patient was a 67-year-old gentleman sent to the ER by the Internal Medicine Clinic for profound weakness and melena. He had recently undergone esophagogastroduodenoscopy (EGD) for evaluation of progressive dysphagia and was found to be significantly anemic. Repeat EGD demonstrated a bleeding ulcer, and his weakness was attributed to anemia; however, careful examination demonstrated objective muscle weakness which could not be attributed to anemia alone. Subsequent work-up demonstrated myositis due to HMGCR antibody. Statin cessation and treatment with steroids and intravenous immunoglobulin (IVIG) led to a nearly full recovery in strength and resolution of dysphagia over the next several months.