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Steroid Myopathy

Steroid myopathy is a condition characterized by weakness of the proximal muscles of the arms and legs and the flexor muscles of the neck. It can be caused by excessive endogenous or exogenous steroids and can be either acute in onset or chronic.


Presentation

Steroid myopathy (SM) was first described in 1932 by Cushing [1]. It can be caused by excessive endogenous or exogenous corticosteroids. Adrenal tumors are associated with excessive endogenous corticosteroid production while excessive exogenous corticosteroid is due to steroid treatment for medical conditions like asthma, chronic obstructive pulmonary disease, and autoimmune diseases such as polymyositis, connective tissue disorders, and rheumatoid arthritis. [2] [3] [4]. On an average, 12% of patients on steroid treatment develop SM [5] with glucocorticoid-induced myopathy being the commonest drug-induced myopathy [6]. Risk factors for the development of SM include the advanced age, patients with cancer, patients with respiratory muscle weakness, debilitation and physical inactivity.

SM can develop either acutely or insidiously. Acute SM is the rapid onset of progressive generalized weakness as well as proximal and distal muscles weakness [7] including respiratory muscle weakness occurring within a week after the onset of treatment with high-dose corticosteroids [8]. It is commonly seen in patients admitted to intensive care who are on mechanical ventilation with neuromuscular blockade. In chronic SM, there is an insidious onset of progressive proximal muscle weakness in the arms and legs. Pelvic girdle muscles are affected more than the arms with sparing of the sphincteric muscles and the muscles innervated by the cranial nerves. Patients may be unable to rise from chairs or climb stairs or raise their arms above their heads to perform activities. With time, myalgias become constant and studies have reported pulmonary symptoms secondary to weakness of the respiratory muscles like the diaphragm [8]. The pattern of SM is identical in iatrogenic SM as well as endogenous SM [5].

Fatigue
  • We ask about general symptoms (anxious mood, depressed mood, fatigue, pain, and stress) regardless of condition. Last updated: November 24, 2018[patientslikeme.com]
  • In addition, patients complain of fatigue, loss of appetite and fever. Polymyalgia rheumatica is often treated with a low-dose of steroids to relieve the muscular pain. Treatment may be needed for two to six years.[livestrong.com]
  • Other symptoms of myositis may include Fatigue after walking or standing Tripping or falling Trouble swallowing or breathing Doctors may use a physical exam, lab tests, imaging tests and a muscle biopsy to diagnose myositis.[fpnotebook.com]
  • Adrenal insufficiency commonly causes muscle fatigue. The degree of weakness may be difficult to assess but is typically mild.[frontiersin.org]
  • Metabolic Myopathies The primary goal in treating metabolic myopathies is to avoid situations that tax the muscles and promote muscle pain and fatigue.[consultantsinneurology.com]
Difficulty Climbing Stairs
  • Her headaches are gone , but she has difficulty climbing stairs and getting up form a chair.Her blood pressure is 120/70mm Hg, pulse 82/min and respiration are 12/min.Physical examination show 4/5 muscle power in her proximal lower extremities bilaterally[forums.studentdoctor.net]
  • Proximal muscle weakness is associated with difficulty climbing stairs, arising from a chair, combing hair or lifting objects overhead. On the other hand, distal muscle weakness can lead to difficulty opening or closing jars, foot drop.[frontiersin.org]
Myopathy
  • We recommend that muscle derived enzyme levels should not be used to differentiate steroid myopathy from inflammatory myopathies.[ncbi.nlm.nih.gov]
  • Steroid myopathy was identified in 29 (41%) patients. Steroid myopathy was generally of moderate severity with severe debilitating steroid myopathy seen in only 3% of patients.[ncbi.nlm.nih.gov]
  • We present here this case to direct attention to drug-induced myopathy besides myopathy due to primary disease in connective tissue disorders whenever myopathy exists.[ncbi.nlm.nih.gov]
  • There are many reports showing preventive effects of either growth hormone (GH) or insulin-like growth factor (IGF)-I on steroid myopathy. The pathogenesis of steroid myopathy is not fully understood.[ncbi.nlm.nih.gov]
  • Long-term steroid use has a well-documented risk of myopathy that imposes functional limitations for patients and challenges for health care providers.[ncbi.nlm.nih.gov]
Muscular Atrophy
  • Palpation revealed symmetric muscular atrophy at the pelvic and shoulder girdles. No signs of effusion or ecchymosis were present.[jaoa.org]
Quadriceps Muscle Weakness
  • muscle weakness and finger flexor muscle weakness Dysphagia Hypothyroid myopathy Affects 30%–80% of patients with hypothyroidism Proximal symmetrical pelvic shoulder girdle weakness Pseudohypertrophy of muscles Peripheral neuropathy Delayed relaxation[clevelandclinicmeded.com]
Asthenia
  • Prognosis Poor prognostic indicators include recalcitrant disease, delay in diagnosis, older age, malignancy, fever, asthenia-anorexia, pulmonary interstitial fibrosis, dysphagia and leukocytosis.[aafp.org]

Workup

The workup in SM is focused on differentiating between endogenous hypercortisolism and exogenous glucocorticoid use. Laboratory tests include creatine kinase, lactate dehydrogenase (LDH), and aldose. In acute SM, patients have elevated levels of serum creatine kinase and aldolase [5] [9] with myoglobinuria. On the other hand, in chronic SM the serum levels of creatine kinase are normal but the urine creatinine clearance increases dramatically and can even appear several days prior to the appearance of symptoms of myopathy [2]. Myoglobinuria and rhabdomyolysis are absent in chronic SM.

Electromyography (EMG) and nerve conduction studies (NCS) in acute SM may reveal abnormal spontaneous activity, early recruitment, and small, polyphasic motor units as well as findings suggestive of neuropathy subsequent to high-dose corticosteroid treatment [10] [11].

Muscle biopsy in acute SM shows focal and diffuse necrosis of all types of muscle fibers without the involvement of type II fibers. In chronic SM, the muscle biopsy demonstrates specific atrophy of type IIb muscle fibers, an absence of inflammatory infiltrate, variations in fiber size with centrally placed nuclei, and occasional muscle necrosis [9].

Treatment

  • Combined treatment with high-dose GCs, tacrolimus, and intravenous immunoglobulin resulted in beneficial effects against myositis.[ncbi.nlm.nih.gov]
  • […] evaluate effects of steroid treatment.[ncbi.nlm.nih.gov]
  • On an average, 12% of patients on steroid treatment develop SM with glucocorticoid-induced myopathy being the commonest drug-induced myopathy.[symptoma.com]
  • We suggest that the measurement of LDH levels is useful for diagnosis and the subsequent treatment of patients with steroid myopathy in SLE.[ncbi.nlm.nih.gov]
  • Epidural steroid injections are widely used for the treatment of lumbago and sciatica although their efficacy has not yet been demonstrated in a convincing way. Moreover, systemic complications, although rare, have been documented.[ncbi.nlm.nih.gov]

Prognosis

  • (B) prognosis Most patients recovered a few weeks after the withdrawal, muscle strength gradually restored and improved. A small number of patients with muscle weakness can last more than 1 year.[healthfrom.com]
  • Differential diagnosis between critical illness myopathy and critical illness polyneuropathy is important, as prognosis is more favorable in critical illness myopathy ( Latronico and Bolton 2011 ; Latronico et al 2012 ).[medlink.com]
  • Idiopathic Inflammatory Myopathy: Managementand Prognosis. Rheum Dis Clin N Am. 2002;28:979–1001. Dalakas M C. Polymyositis, Dermatomyositis and Inclusion BodyMyositis. In: Braunwald E, Fauci A S, Kasper D L, Hauser S L,Longo D L, Jameson J L, eds.[revistas.unimilitar.edu.co]
  • PROGNOSIS If the underlying cause of the myopathy can be treated successfully, as in the case of endocrine myopathies, the prognosis is usually good.[consultantsinneurology.com]
  • Prognosis With proper management, a complete resolution from steroid myopathy is likely; however, residual weakness and atrophy is possible.[jaoa.org]

Etiology

  • Introduction Etiology Prevention Complication Symptom Examine Diagnosis Treatment Basic Nursing Introduction Introduction to steroid myopathy 1934 Chushing first observed that corticosteroids can lead to muscle atrophy and muscle weakness, and put the[healthfrom.com]
  • Use Additional Use Additional Help Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology.[icd10data.com]
  • Rhabdomyolysis may also be seen with infectious etiologies, alcohol, and toxic exposures.[clevelandclinicmeded.com]
  • Objective: To study the etiology, varied presentations, and outcome after therapy of patients with endocrine myopathies.[annalsofian.org]
  • The etiology of dermatomyositis remains unknown; some studies have reported an association with histocompatability antigens, environmental agents (e.g., virus, drugs) and autoimmunity. 1 The average age at diagnosis is 40, and almost twice as many women[aafp.org]

Epidemiology

  • Pathogenesis and Epidemiology The mechanism of steroid myopathy is unclear but is possibly related to the steroid's influence on cellular receptors and intracellular signaling molecules. 9 , 10 This influence may reduce protein synthesis, increase protein[jaoa.org]
  • Table 1 Clinical Features of Common Myopathies Myopathy Epidemiology Distribution of Weakness Other Systemic Manifestations Acquired Myopathies Dermatomyositis Female male Peak incidence: children and ages 40–60 yr Symmetrical proximal muscle weakness[clevelandclinicmeded.com]
Sex distribution
Age distribution

Pathophysiology

  • The first classifies the wide variety of disorders that can cause neurologic symptoms the patient with cancer, discusses the pathophysiology of nervous system metastases, the pathophysiology and treatment of brain edema and the approach to supportive[books.google.com]
  • The pathophysiology of steroid myopathy has not been clarified and may be pronounced.[ard.bmj.com]
  • Glucocorticoid-induced myopathy: pathophysiology, diagnosis, and treatment. Indian J Endocrinol Metab 2013;17:913–6. [11]. Caplan A, et al.[journals.lww.com]
  • Back to Top Pathophysiology Disruption of the structural integrity and metabolic processes of muscle cells can result from genetic abnormalities, toxins, inflammation, infection, and hormonal and electrolyte imbalances.[clevelandclinicmeded.com]
  • The pathophysiology is likely due to depletion of the intramuscular energy stores from an overworking Na–K pump to correct the intracellular electrolyte imbalance ( Hiromatsu et al., 1994 ).[frontiersin.org]

Prevention

  • There are many reports showing preventive effects of either growth hormone (GH) or insulin-like growth factor (IGF)-I on steroid myopathy. The pathogenesis of steroid myopathy is not fully understood.[ncbi.nlm.nih.gov]
  • Interventions aimed at preventing and treating this complication are warranted and need to be explored in prospective clinical trials.[ncbi.nlm.nih.gov]
  • Prevention Prevention of steroid myopathy Male assimilate hormone phenylpropionic acid Nuo-long part of the anti-protein decomposition of the role of steroids can be used to prevent the occurrence of steroid myopathy.[healthfrom.com]
  • Knowledge of the pathogenesis, genetics, and molecular biology of neuromuscular disorders is essential both in developing and applying new therapies and preventive measures, and in formulating genetic and prognostic advice.[books.google.com]
  • The physician who promptly recognizes neurologic symptoms occurring in a patient with cancer and makes an early diagnosis may prevent the symptoms from becoming permanently disabling or sometimes lethal.[books.google.com]

References

Article

  1. Cushing H. The basophil adenoma of the pituitary body and their clinical manifestation. Johns Hopkins Med J. 1932;50:137
  2. Askari A, Vignos PJ Jr, Moskowitz RW. Steroid myopathy in connective tissue disease. Am J Med. 1976 Oct;61(4):485-92.
  3. Yamaguchi M, Niimi A, Minakuchi M, et al. Corticosteroid-induced myopathy mimicking therapy-resistant asthma. Ann Allergy Asthma Immunol. 2007 Oct;99(4):371-4.
  4. Lacomis D, Smith TW, Chad DA. Acute myopathy and neuropathy in status asthmaticus: case report and literature review. Muscle Nerve. 1993 Jan;16(1):84-90.
  5. Alshekhlee A, Kaminski HJ, Ruff RL. Neuromuscular manifestations of endocrine disorders. Neurol Clin. 2002;20:35–58.
  6. Gupta A, Gupta Y. Glucocorticoid-induced myopathy: pathophysiology, diagnosis, and treatment. Indian J Endocrinol Metab. 2013 Sep-Oct; 17(5): 913-916
  7. Van Balkom RH, van Der Heijden HF, van Herwaarden CL, Dekhuijzen PN. Corticosteroid-induced myopathy of the respiratory muscles. Neth J Med. 1994;45:114–22.
  8. Dekhuijzen PN, Decramer M. Steroid-induced myopathy and its significance to respiratory disease: a known disease rediscovered. Eur Respir J. 1992 Sep;5(8):997-1003.
  9. Pereira RM, Freire de Carvalho J. Glucocorticoid-induced myopathy. Joint Bone Spine. 2011;78:41–4.
  10. Ahlbeck K, Fredriksson K, Rooyackers O, et al. Signs of critical illness polyneuropathy and myopathy can be seen early in the ICU course. Acta Anaesthesiol Scand. 2009 Jul; 53(6):717-23.
  11. Hanson P, Dive A, Brucher JM, et al. Acute corticosteroid myopathy in intensive care patients. Muscle Nerve. 1997 Nov; 20(11):1371-80

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Last updated: 2018-06-22 08:07