Statin Associated Autoimmune Myonecrosis: Case Report With Delayed Onset and Treatment Challenges

Purpose: A case of delayed statin associated autoimmune myopathy (SAAM) is presented along with review of clinical findings and treatment strategies. Summary: A 54 year old male presented with proximal extremity weakness, difficulty ambulating, and dysphagia. Symptoms began when restarting atorvastatin 40 mg daily for a recent NSTEMI, following 10 years of statin use, interrupted after diagnosis of NASH. Relevant labs included CK of 13,618 IU/L, ALT/ AST of 568/407 IU/L, while additional liver, renal, and toxicology tests were normal. Following treatment response to prednisone 40 mg daily for 3 days, outpatient testing for anti-HMGCR antibodies was ordered. Twelve days from discharge, the patient was readmitted for myalgia and dysphagia, CK = 6042 IU/L, ALT/AST = 360/112 IU/L, and positive anti-HMGCR antibodies. Newly diagnosed with SAAM, symptoms improved with methylprednisolone and intravenous immunoglobulin (IVIG), continuing outpatient as daily prednisone and monthly IVIG. Four days later, the patient relapsed with worsened weakness and dysphagia, CK = 5812 IU/L, and ALT/AST = 647/337 IU/L. After response to methylprednisolone and rituximab, the patient was discharged on a corticosteroid taper, biweekly rituximab, and monthly IVIG. Two weeks later, a final admission involved a syncopal episode and fall, with a CK = 1461 IU/L. Treatment included IVIG, rituximab, and corticosteroid taper, which lead to remission for greater than 6 months. Conclusion: Statin associated autoimmune myopathy occurred when restarting atorvastatin, following 10 years of statin use. Clinical findings and positive anti-HMGCR antibodies confirmed the diagnosis. Recurrent relapses required triple combination therapy including addition of rituximab to achieve remission.

Comparative Gross Anatomical Studies on Pelvic Limb Long Bones of Crested Serpent Eagle (Spilornis cheela) and Brown Wood Owl (Strix leptogrammica)

There is no previously reported information on the morphological characteristics of pelvic limb long bones (femur, tibiotarsus and tarsometatarsus) in crested serpent eagle and brown wood owl. Thus, this study aimed to evaluate morphological and biometrical characteristics of pelvic limb long bones in crested serpent eagle and brown wood owl. The femur consisted of a curved shaft and two extremities. The shaft was wider proximally and distally and presented medial, lateral, anterior and lateral surfaces. The anterior, medial and lateral surfaces were smooth and continuous in both the species. An intermuscular line called linea aspera was present on the anterior and posterior surfaces in both the species. The proximal and distal extremities of the femur were almost of equal size. The proximal extremity presented a distinct, hemispherical head which was located in the level of the trochanter major in both the species. The distal extremity furnished a trochlea anteriorly for patella and medial, lateral condyles posteriorly for tibiotarsus bone. The patella was small and triangular and consisted of two surfaces, two borders, a base and an apex in both the species. Tibiotarsus was the longest bone in both the species which was formed by the fusion of distal extremity of the tibia with the proximal row of the tarsal bones. The proximal and distal extremity of the tibiotarsus consisted of medial and lateral condyles. In both the species, the fibula was a rod-shaped bone and reached up to distal third of the lateral border of the tibiotarsus. The tarsometatarsus was a long bone but smaller than tibiotarsus in both the species. Various biometrical parameters of the pelvic limb long bones were more in the crested serpent eagle as compared to the brown wood owl due to species differences.

Stroke Mimic: A Case of Unilateral Thyrotoxic Hypokalemic Periodic Paralysis

Thyrotoxic hypokalemic periodic paralysis (THPP) is a condition that results in transient skeletal muscle paralysis secondary to intracellular potassium sequestration. Susceptible individuals often have an underlying channelopathy, which may be exacerbated by lifestyle factors or underlying medical comorbidities such as hyperthyroidism or diarrheal illness. Classically, THPP presents with paralysis of proximal extremity musculature. In this case, we present a rare case of unilateral THPP. Such a presentation is relevant to emergency physicians as it mimics a stroke or transient ischemic attack and should be considered on the differential for unilateral neurologic deficits.

Incidence and Risk Factors of Deep Vein Thrombosis in Hospitalized COVID-19 Patients

Deep vein thrombosis (DVT) is prevalent in patients with coronavirus disease 2019 (COVID-19). However, the risk factors and incidence rate of DVT remains elusive. Here, we aimed to assess the incidence rate and risk factors of DVT. All patients diagnosed with COVID-19 and performed venous ultrasound by ultrasound deparment between December 2019 and April 2020 in Wuhan Jin Yin-tan hospital were enrolled. Demographic information and clinical features were retrospectively collected. Notably, a comparison between the DVT and the non-DVT groups was explored. The incidence rate of venous thrombosis was 35.2% (50 patients out of 142). Moreover, the location of thrombus at the proximal extremity veins was 5.6% (n = 8), while at distal extremity veins was 35.2% (n = 50) of the patients. We also noted that patients with DVT exhibited a high level of D-dimer (OR 10.9 (95% CI, 3.3-36.0), P < 0.001), were admitted to the intensive care unit (OR 6.5 (95% CI, 2.1-20.3), P = 0.001), a lower usage of the anticoagulant drugs (OR 3.0 (95% CI, 1.1-7.8), P < 0.001). Finally, this study revealed that a high number of patients with COVID-19 developed DVT. This was observed particularly in critically ill patients with high D-dimer levels who required no anticoagulant medication.

Linear porokeratosis presenting in adulthood: A diagnostic challenge: A case report

Linear porokeratosis is a rare variant of porokeratosis that most often presents in newborns and children; development of this porokeratosis variant in adulthood is far less common. We report the case of a 25-year-old female who presented with a progressive eruption on the proximal upper extremity of 6-year duration, which was ultimately diagnosed as adult-onset linear porokeratosis and safely treated with oral isotretinoin. We propose that a sporadic mutation resulting in mosaicism after birth may explain the development of linear porokeratosis in adulthood, although the exact trigger of such a somatic mutation is not known. This case also describes a unique clinical presentation, with linear porokeratosis lesions originating on the proximal extremity rather than on the more common distal extremity. This demonstrates a distinctive clinical presentation not seen in the pediatric forms of disease.

Comparative gross anatomical studies on the shoulder girdle of crested serpent eagle (Spilornis cheela) and brown wood owl (Strix leptogrammica)

The shoulder girdle gives strength and range of motion to the wings of birds and plays a functional role in flight mechanism of birds. The present study was designed to compare the morphological features of shoulder girdle bones in crested serpent eagle and brown wood owl. The shoulder girdle comprised of the scapula, coracoid and fused clavicle i.e. furculum in both species. The proximal extremities of bones of shoulder girdle formed a foramen triosseum in both the species for tendon of supracoracoideus muscle. The proximal end of the scapula of crested serpent eagle presents a pneumatic foramen which was absent in the brown wood owl. The coracoid of crested serpent eagle presents a large pneumatic foramen at the medial surface of the acrocoracoid process. A piercing type of foramen was characteristic in the coracoid of both species. Procoracoid process was triangular in shape with a broad base in both the species with pointed apex in brown wood owl and short apex in crested serpent eagle. The clavicle was thin, slender and highly curved in crested serpent eagle, whereas it was slender and rod-like in brown wood owl. Numerous pneumatic foramina were present in the proximal extremity of the clavicle of the crested serpent eagle, which were few in brown wood owl. The distal extremity of both clavicle fused to form a hypocleideum in crested serpent eagle, which was absent in brown wood owl.