A Child with Refractory and Relapsing Anti-3-Hydroxy-3-Methylglutaryl-Coenzyme A Reductase Myopathy: Case-Based Review

Article type: Case Report

Authors: Sener, Seher^{a; 1} | Batu, Ezgi Deniz^{a; 1; *} | Sari, Seher^{b; 2} | Kasap Cuceoglu, Muserref^a | Yildiz, Adalet Elcin^c | Talim, Beril^d | Aydingoz, Ustun^c | Ozen, Seza^a | Haliloglu, Goknur^b

Affiliations: [a] Department of Pediatrics, Division of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey | [b] Department of Pediatrics, Division of Pediatric Neurology, Hacettepe University Faculty of Medicine, Ankara, Turkey | [c] Department of Radiology, Hacettepe University Faculty of Medicine, Ankara, Turkey | [d] Division of Pediatric Pathology, Hacettepe University Faculty of Medicine, Ankara, Turkey

Correspondence: [*] Correspondence to: Ezgi Deniz Batu, MD, MSc, Hacettepe University Faculty of Medicine, Department of Pediatrics, Division of Rheumatology, Ankara, Turkey. Postal address: Hacettepe Üniversitesi İhsan Doğramacı Çocuk Hastanesi, Çocuk Romatoloji Bölümü, Kat: 3 Sıhhiye 06100 Ankara/Türkiye. Tel.: +90 3123051863; Fax: +90 3123112398; E-mail: ezgidenizbatu@yahoo.com.

Note: [1] First two authors equally contributed to this work.

Note: [2] Currently at Ministry of Health, Agri Training and Research Hospital, Agri, Turkey.

Abstract: Background/Objective:Anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase (anti-HMGCR) myopathy is rare in children. Here, we present a boy with relapsing refractory anti-HMGCR myopathy along with a systematic literature review. Case Report:17-year-old boy with five years of muscle weakness, rash, high creatinine kinase (CK) levels, and muscle biopsy compatible with inflammatory myopathy was diagnosed with juvenile dermatomyositis. He was treated with corticosteroids, intravenous immunoglobulin (IVIG), and methotrexate. His muscle weakness improved with this treatment although never completely resolved. CK levels decreased from ∼15000 U/L to ∼3000 U/L. At the age of 15, muscle weakness relapsed after an upper respiratory tract infection; pulse corticosteroid treatment was administered. The re-evaluated muscle biopsy showed a necrotizing pattern and the HMGCR antibody was positive confirming anti-HMGCR myopathy when he was 16. The diagnostic delay was 50 months. Disease activity was monitored by Medical Research Council score, MRI and functional tests. Despite corticosteroids, methotrexate, IVIG, cyclosporine A, and rituximab therapies, muscle weakness improved only slightly during the first three months and remained stable afterwards. Results of the Literature Search:We identified 16 articles describing 50 children (76% female) with anti-HMGCR myopathy by reviewing the English literature up to March 1st, 2022. Proximal muscle weakness was the most common clinical symptom (70.8%). Corticosteroids (84.8%), IVIG (58.7%), and methotrexate (56.5%) were preferred in most cases. Complete remission was achieved in nine patients (28.1%). Conclusion:Diagnosis and management of children with anti-HMGCR myopathy are challenging. Complete remission is achieved in only one third of these patients. Imaging biomarkers may aid treatment.

Keywords: Anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase myopathy, children, necrotizing pattern, refractory

DOI: 10.3233/JND-221557

Journal: Journal of Neuromuscular Diseases, vol. 10, no. 2, pp. 279-291, 2023