Endocrine Abstracts

Introduction: Rhabdomyolysis, myocyte injury with the release of intracellular contents into the circulation, can result from various causes, the commonest being trauma or a fall with a long lie, less commonly statins or general anaesthetic agents (GAA), but literature on rhabdomyolysis due to the synergistic effects of statins and GAA is limited.

Case Report: A 75-year-old female with known ischemic heart disease, familial hypercholesterolemia, pre-diabetes, chronic kidney disease IIIa, osteoporosis and primary hyperparathyroidism. Medications included Aspirin, Ramipril, Ezetimibe and Rosuvastatin (40 mg) for the past 15 years without any hepatotoxic or myotoxic side-effects. Two-weeks before the presentation, she had an uneventful parathyroidectomy but developed generalised myopathy, progressive weakness and pain predominantly in the legs. She had proximal myopathy but no other features of endocrinopathy. There was no history of trauma, long-lie, strenuous exercise, seizures or electric shock injury. No personal or family history of autoimmune conditions.

Investigations: The baseline investigations were normal (including full blood count, renal and thyroid functions, C-reactive protein, bone, coagulation, and lipid profiles). However, Creatine Kinase (CK) was very high, 27096 (25-200U/l), and Alanine transaminase was 717 (0-34 U/l). Extensive autoantibody profile was negative, including antinuclear and anti-Jo antibodies.

Management: Conservative management, including intravenous fluid and suspending statins, resulted in clinical improvement and normalisation of liver functions and CK.

Conclusion: Since she tolerated the statins very well for more than 15 years without any side effects and symptoms started right after the surgery, we consider this was most likely due to the synergistic effects of statins, surgery and GAA (Sevoflurane & Propofol, both of which are known cause of rhabdomyolysis).

Learning points: Patients undergoing general anaesthesia while on statins are at a higher risk of rhabdomyolysis due to the synergistic effects. Whether statins should be withheld preoperatively remains a clinical decision depending on individualised cardiovascular risk.