A case report supports the hypothesis that diet may provide a source of statin-like compounds in patients with immune-mediated necrotizing myopathy who have never taken statins.
The report, published as a letter February 20 in Annals of Internal Medicine, focuses on a 57-year-old woman with immune-mediated necrotizing myopathy with antibodies directed against 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR), the enzyme targeted by statins, yet who had never been treated with a statin.
“Although people had speculated that dietary sources of statin-like compounds were a potential link with HMGCR myositis in the absence of prescribed statins, no such case had ever been reported,” said senior author, Marie Hudson, MD, MPH, Jewish General Hospital, Montreal, Quebec, Canada.
“Our patient, who was consuming large quantities of plant sterols in the months preceding her myositis, provides some evidence to support this claim.
“Clinicians should enquire about dietary habits in patients with inflammatory myositis and HMGCR antibodies who deny ever taking a statin,” Hudson advised.
The woman presented with a 2-week history of progressively severe myalgia and profound weakness in her shoulder abductors and hip and neck flexors, as well as dysphagia. She had no other medical problems and did not take medications, herbs, supplements, or recreational drugs. Her serum creatine kinase (CK) level was elevated.
An enzyme-linked immunosorbent assay was “highly positive” for anti-HMGCR antibodies, despite her never having been exposed to statins. However, the woman told her doctors that she had been eating at least two cups of Camargue red rice each day for the past few months, which was the likely culprit.
While Camargue red rice does not contain a statin component, the amount she was consuming provided about 2 g of phytosterol daily, which can lower low-density lipoprotein cholesterol levels by inhibiting HMGCR “through a statin-like mechanism,” Hudson and colleagues report.
“Thirty percent of people with HMGCR-associated myositis have no known exposure to prescribed statins,” Hudson told theheart.org | Medscape Cardiology.
There are nutritional sources of statin-like compounds, for example red yeast rice, which is marketed as a natural way to maintain normal cholesterol, she noted.
The woman’s condition improved “minimally” with a 4-week course of prednisone (60 mg/d). When intravenous (IV) immunoglobulin therapy (2 g/d body weight every 4 weeks) was added, her weakness and myalgia decreased but the dysphagia persisted.
After 4 months, her CK level returned to normal and prednisone therapy was tapered and discontinued.
One year after presentation, the patient still had dysphagia that required a pureed diet and continued on monthly IV immunoglobulin therapy.
The authors have disclosed no relevant financial relationships.
Ann Intern Med. Published online February 20, 2018. Abstract
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