RESUMO
The cranial nerves (CNs) are responsible for multiple functions, including extraocular mobility, facial sensation and movement, hearing, mastication, tongue movement and sensation, and swallowing. Beyond these vital roles, they can also demonstrate importance in their diagnostic value. Isolated or combined palsies provide insights into potential localizations and various underlying etiologies, including stroke, tumor, and infections that may guide further neurological evaluation. CN VI, the abducens nerve, singularly innervates the lateral rectus muscle, which is responsible for the abduction of the eyes. Despite its long anatomic trajectory, making it susceptible to intracranial injury, an isolated abducens nerve palsy is extremely rare. The most common clinical presentation includes headache, diplopia, and the inability to abduct the afflicted eye. This case report introduces a 71-year-old female with a medical history of malignancy and pancytopenia who presented to the emergency room with complaints of ear pain and swelling and subsequently developed diplopia secondary to unilateral CN VI palsy. Magnetic resonance imaging (MRI) revealed isolated sphenoid sinusitis for which she was clinically asymptomatic. She was treated with a regimen of ampicillin-sulbactam, an oral anti-inflammatory agent, and a tapered course of methylprednisolone with a rapid and complete resolution of the abducens nerve palsy and sinusitis. Acute isolated diplopia is an unusual neurologic condition prompting the need for rapid and thorough investigation. Although exceedingly rare and infrequently cited in the literature, isolated abducens nerve palsies secondary to sphenoid sinusitis should be entertained in the differential diagnosis of this presentation.
RESUMO
Statin medications act by inhibiting the enzyme hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase (HMGCR), thus decreasing hepatic cholesterol synthesis. They are considered the mainstay treatment of hypercholesterolemia due to their tremendous efficacy and mortality benefit. Although generally well tolerated, statins may adversely affect skeletal muscle resulting in side effects ranging from mild myalgia to life-threatening necrotizing myositis. Statin-induced necrotizing autoimmune myositis is a rare yet devastating adverse effect that may occur shortly after initiation of therapy or after several years of use. Unfortunately, medication discontinuation has shown no impact on prevention or alleviation of symptoms. Though there is currently no definitive guidance for the treatment of this condition, corticosteroids are generally considered to be first line, via high-dose oral prednisone or intravenous methylprednisolone. In this case report, we discuss the case of a 72-year-old male with an unusual presentation of statin-induced necrotizing autoimmune myositis: dysphagia, weakness, and weight loss. His diagnosis was confirmed by muscle biopsy indicating necrotizing myositis and his serum was found to be strongly positive for anti-HMG-CoA reductase antibodies. This patient had a very brief history of statin use, but his primary care provider discontinued the medication a couple of months prior to symptom onset due to elevated liver function tests. He was treated with aggressive intravenous fluid hydration and intravenous corticosteroids during an extended inpatient hospital stay. He was discharged to a rehabilitation facility. This report demonstrates the importance of creating a wide differential for patients who present with fatigue, generalized weakness, and dysphagia. It is essential to always consider statin-induced necrotizing myositis if a patient has a history of statin use, even if the statin has been discontinued. Necrotizing myositis demands timely diagnosis and management to improve mortality.
