Immune-Mediated Necrotizing Myopathy Manifesting after Five Years of Statin Therapy.

Immune-mediated necrotizing myopathy (IMNM) is an increasingly common and serious condition in which autoantibodies attack muscle fibers causing clinically significant muscle weakness, fatigue, and myalgias. Recognizing the clinical presentation of IMNM is difficult but necessary, as rapid intervention decreases morbidity. We present a case of a 53-year-old female with IMNM induced by statin therapy with confirmed anti-3-hydroxy-3-methylglutaryl coenzyme A reductase antibodies present on serologic testing. The patient's statin therapy was halted, and the patient was provided with one dose of methylprednisolone and ongoing therapy with mycophenolate. She showed subsequent slow improvements in her muscle weakness and myalgias. It is important for clinicians to be aware of the possible consequences of statin therapy, as these drugs are generally regarded as benign in the medical community. Clinicians should also be aware that statin-induced myopathy can occur at any time during statin therapy. The condition does not necessarily correlate with beginning a new statin medication, as demonstrated in this case in which the patient was on chronic statin therapy before developing symptoms. Continued clinician education and building the fund of medical knowledge regarding this disease are vital to enable clinicians to recognize this disease and act promptly to reduce patient morbidity and improve outcomes.

A Real Headache: Intracranial Extension and Epidural Abscess As Complication of Chronic Mucocele.

Mucoceles are benign lesions of salivary glands typically originating from the paranasal sinuses. Intracranial extension and superinfection of these lesions are rare but serious complications of chronic mucoceles. Here, we discuss a patient with a known mucocele, initially lost to follow-up, who presented three years later with headache, purulent rhinorrhea, and intracranial extension of his mucocele with development of an epidural abscess. This case highlights the potential complications of chronic, large mucoceles and emphasizes the importance of thorough evaluation in patients with facial abscesses in the setting of known sinus pathology. Any mucocele with signs of superinfection such as purulent rhinorrhea, abscess near the sinuses, or refractory symptoms should warrant cranial imaging. Mucoceles with evidence of intracranial extension require neurosurgical and/or otolaryngologic evaluation for evacuation and debridement to avoid neurologic injury or devastating infection.

A Rare Presentation of Primary Central Nervous System Lymphoma in an Immunocompetent Patient.

Primary central nervous system lymphoma (PCNSL) is a rare non-Hodgkin's lymphoma (NHL) that can develop in the brain, spinal cord, leptomeninges, and vitreoretinal space. The majority of cases are diffuse large B-cell lymphomas. Risk factors include immune dysfunction, prior Epstein-Barr viral infection, HIV, and a family history of non-Hodgkin's lymphoma. Although the majority of the patients are immunocompromised, PCNSL is still seen in immunocompetent patients. PCNSL has a poor prognosis and a high relapse rate despite its radiosensitive and chemosensitive nature. It is important to recognize and diagnose PCNSL early to improve outcomes. We present a case of PCNSL in an immunocompetent adult with no previously known risk factors. We present a case of a 66-year-old male who presented with a 1.5-week history of right-sided headache and left-sided weakness. After being admitted for further evaluation, he underwent multiple laboratory tests and imaging studies. The CT head indicated ill-defined hypodensities in the pons and left cerebellum. CTA revealed a 1.5 cm outpouching along the medial aspect of the distal left cervical internal carotid artery at the C1-C2 level concerning a pseudoaneurysm. Neurology was consulted, and an MRI of the brain revealed equivocal brain lesions. Neurosurgery was consulted, and the patient underwent an open brain biopsy, which revealed a high likelihood of primary CNS lymphoma based on intraoperative pathology findings. CSF analysis revealed an elevated percentage of lymphocytes, including the presence of atypical lymphocytes as well as elevated oligoclonal bands. Subsequent pathology results confirmed PCNSL. The oncology service was consulted, and the patient was started on corticosteroids and methotrexate for chemotherapy as well as leucovorin. This case represents a rare presentation of PCNSL in which the patient had no known history to support an immunocompromised state. Imaging findings, in this case, were also atypical for a primary CNS lesion as they were mostly equivocal. Furthermore, imaging findings showed diffuse CNS disease rather than an obvious primary lesion as typically demonstrated in the literature. In this case, the open brain biopsy was pivotal in making a timely diagnosis and beginning disease-modifying therapy as early as possible. This case demonstrates the imperative need for clinicians to be aware of varying presentations of PCNSL and possibly consider pursuing a definitive diagnosis with biopsy when the differential includes PCNSL but remains broad after advanced imaging.