A 79-year-old female patient was admitted to the Emergency Department on 21 September 2016 complaining of one-week history of diffuse limb myalgia and inability to stand or walk. Her medical history was notable for arterial hypertension, type 2 diabetes mellitus, chronic kidney disease, and dyslipidemia over the last 25, 15, 6, and 10 years, respectively. She underwent a right nephrectomy in 2013 for renal oncocytoma.
She had a three-month history of MSSA positive dermatitis of the right knee, which was initially treated with topical antibiotics. Due to inadequate response to treatment, she was prescribed a 3-week course of fusidic acid 250 mg four times daily and clindamycin 300 mg three times daily. At the same time, the patient remained on her therapeutic regimen, which included atorvastatin 20 mg once daily.
During the initial assessment of the patient, her vital signs were within normal range. Her physical examination was unremarkable, except for the significant decrease in muscle strength of the proximal leg muscles. Abnormal laboratory values were as follows: SGOT, 635 U/L; SGPT, 317 U/L; LDH, 1335 U/L; CPK, 17263 U/L; CK-MB, 534 U/L; TBIL, 1.54 mg/dl; DBIL, 0.91 mg/dl; IBIL, 0.63 mg/dl; urea, 121 mg/dl; and Crea., 2.6 mg/dl. Air blood gases test revealed the following: Ph, 7.45; PO2, 79.7 mmHg; PCO2, 37.9 mmHg; and HCO3, 26.0 mmol/l. Electrolytes were all within the normal range. Myoglobinuria was also present, while there was no hematuria. Abdominal ultrasonography did not reveal any pathology. Computerized tomography of the brain was also unremarkable.
She had no history of trauma, significant exertion, or immobilization. Screening for autoimmune diseases, including ANA, anti-dsDNA, c-ANCA, p-ANCA, and anti-Jo-1, was negative. The patient did not give a written consent for the performance of a muscle biopsy in order to confirm the diagnosis histologically. She was finally diagnosed with acute rhabdomyolysis due to coadministration of fusidic acid and atorvastatin.
Intravenous hydration and diuresis were the only therapeutic intervention, while sodium bicarbonate was administered only on the first day of hospitalization. Antibiotic treatment and statin therapy were discontinued.
The range of the main laboratory values of the patient during hospitalization is shown in Table 1.
The patient gradually regained muscle strength and was able to stand and walk before being discharged home. Ten days later, her CPK, SGOT, and SGPT values had normalized, while her serum creatinine level was at baseline. During her follow-up on a 3-month basis, she remains asymptomatic without issues.