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Gunasekaran M, Littel HR, Wells NM, Turner J, Campos G, Venigalla S, Estrella EA, Ghosh PS, Daugherty AL, Stafki SA, Kunkel LM, Foley AR, Donkervoort S, Bönnemann CG, Toledo-Bravo de Laguna L, Nascimento A, Benito DND, Draper I, Bruels CC, Pacak CA, Kang PB. Effects of HMGCR deficiency on skeletal muscle development. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.05.06.591934. [PMID: 38903061 PMCID: PMC11188090 DOI: 10.1101/2024.05.06.591934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/22/2024]
Abstract
Pathogenic variants in HMGCR were recently linked to a limb-girdle muscular dystrophy (LGMD) phenotype. The protein product HMG CoA reductase (HMGCR) catalyzes a key component of the cholesterol synthesis pathway. The two other muscle diseases associated with HMGCR, statin-associated myopathy (SAM) and autoimmune anti-HMGCR myopathy, are not inherited in a Mendelian pattern. The mechanism linking pathogenic variants in HMGCR with skeletal muscle dysfunction is unclear. We knocked down Hmgcr in mouse skeletal myoblasts, knocked down hmgcr in Drosophila, and expressed three pathogenic HMGCR variants (c.1327C>T, p.Arg443Trp; c.1522_1524delTCT, p.Ser508del; and c.1621G>A, p.Ala541Thr) in Hmgcr knockdown mouse myoblasts. Hmgcr deficiency was associated with decreased proliferation, increased apoptosis, and impaired myotube fusion. Transcriptome sequencing of Hmgcr knockdown versus control myoblasts revealed differential expression involving mitochondrial function, with corresponding differences in cellular oxygen consumption rates. Both ubiquitous and muscle-specific knockdown of hmgcr in Drosophila led to lethality. Overexpression of reference HMGCR cDNA rescued myotube fusion in knockdown cells, whereas overexpression of the pathogenic variants of HMGCR cDNA did not. These results suggest that the three HMGCR-related muscle diseases share disease mechanisms related to skeletal muscle development.
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Chérif MY, Raftakis I, Weynand M, Dragan E, Nagant C, Lecomte S, Badot V. A case of anti-HMGCR myopathy in a patient with breast cancer and anti-Th/To antibodies. Oxf Med Case Reports 2023; 2023:omad097. [PMID: 37771688 PMCID: PMC10530299 DOI: 10.1093/omcr/omad097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 06/15/2023] [Accepted: 06/15/2023] [Indexed: 09/30/2023] Open
Abstract
Statins competitively inhibit the activity of HMGCR (3-hydroxy-3-methylglutaryl coenzyme A reductase), which is a key enzyme in cholesterol synthesis. These are effective drugs for the management of cardiovascular disease and are generally well tolerated but several side effects have been reported. Muscular adverse symptoms are various and, rarely, statin exposure may lead to authentic immune-mediated necrotizing myopathy (IMNM), namely anti-HMGCR myopathy. However, cases of IMNM associated with cancer have been described. We discuss herein a case of IMNM in a patient with breast cancer previously exposed to statins and with the presence of anti-Th/To antibodies without clinical correlation.
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Affiliation(s)
- Mohammad Yassine Chérif
- Department of Rheumatology, Centre Hospitalier Universitaire (CHU) Brugmann, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Ioannis Raftakis
- Department of Rheumatology, Centre Hospitalier Universitaire (CHU) Brugmann, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Marjolaine Weynand
- Department of Rheumatology, Centre Hospitalier Universitaire (CHU) Brugmann, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Elena Dragan
- Department of Rheumatology, Centre Hospitalier Universitaire (CHU) Brugmann, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Carole Nagant
- Department of Immunology, Centre Hospitalier Universitaire (CHU) Brugmann, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Sophie Lecomte
- Department of Pathology, Centre Hospitalier Universitaire (CHU) Brugmann, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Valérie Badot
- Department of Rheumatology, Centre Hospitalier Universitaire (CHU) Brugmann, Université Libre de Bruxelles (ULB), Brussels, Belgium
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Rodrigues de Carvalho M, Sá de Deus Rocha MM, Alves Bezerra V, de Pontes ME, del Negro MC, Antunes JS, Montanaro VVA, Fernandez RNM. Anti-3-Hydroxy-3-Methylglutaryl-Coenzyme A Reductase Immune-Mediated Necrotizing Myopathy following mRNA SARS-CoV-2 Vaccination. Case Rep Neurol Med 2023; 2023:7061783. [PMID: 37275628 PMCID: PMC10239300 DOI: 10.1155/2023/7061783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 04/19/2023] [Accepted: 05/20/2023] [Indexed: 06/07/2023] Open
Abstract
The new coronavirus (COVID-19) pandemic has resulted in the unprecedented production of vaccines. In this context, the possible adverse effects remain to be identified and reported. In this article, we report the case of a young female patient who developed anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase (anti-HMG-CoA) immune-mediated necrotizing myositis (IMNM) after receiving the Pfizer-BioNTech (BNT162b2) COVID-19 vaccine. The diagnosis of probable post-vaccination IMNM was made due to the absence of other factors that may have led to the development of autoantibodies (medicines; e.g., statins, drugs) and the temporal relationship between exposure and event. This case report is the first to suggest that a COVID-19 vaccine may trigger anti-HMG-CoA reductase necrotizing myopathy.
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Affiliation(s)
- Marta Rodrigues de Carvalho
- Department of Neurology and Clinical Neurophysiology, Base Hospital of the Federal District, Brasília, Distrito Federal, Brazil
| | | | | | - Maciel Eduardo de Pontes
- Department of Neurology and Clinical Neurophysiology, Base Hospital of the Federal District, Brasília, Distrito Federal, Brazil
| | - Maria Cristina del Negro
- Department of Neurology, Sarah Network of Rehabilitation Hospitals, Brasília, Distrito Federal, Brazil
| | - Julio Salgado Antunes
- Department of Pathology, Sarah Network of Rehabilitation Hospitals, Brasília, Distrito Federal, Brazil
| | | | - Rubens Nelson Morato Fernandez
- Department of Neurology and Clinical Neurophysiology, Base Hospital of the Federal District, Brasília, Distrito Federal, Brazil
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Chen BH, Zhu XM, Xie L, Hu HQ. Immune-mediated necrotizing myopathy: Report of two cases. World J Clin Cases 2023; 11:3552-3559. [PMID: 37383916 PMCID: PMC10294185 DOI: 10.12998/wjcc.v11.i15.3552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 02/25/2023] [Accepted: 04/24/2023] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND Immune-mediated necrotizing myopathy is a rare autoimmune myopathy characterized by muscle weakness and elevated serum creatine kinase, with unique skeletal muscle pathology and magnetic resonance imaging features.
CASE SUMMARY In this paper, two patients are reported: One was positive for anti-signal recognition particle antibody, and the other was positive for anti-3-hydroxy-3-methylglutaryl coenzyme A reductase antibody.
CONCLUSION The clinical characteristics and treatment of the two patients were analysed, and the literature was reviewed to improve the recognition, diagnosis, and treatment of this disease.
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Affiliation(s)
- Bi-Hong Chen
- Department of Clinical Medicine, Weifang Medical University, Weifang 261053, Shandong Province, China
| | - Xue-Min Zhu
- School of Clinical Medicine, Weifang Medical University, Weifang 261053, Shandong Province, China
| | - Lei Xie
- School of Clinical Medicine, Weifang Medical University, Weifang 261053, Shandong Province, China
| | - Huai-Qiang Hu
- Department of Neurology, The 960th Hospital of People′s Liberation Army, Jinan 250031, Shandong Province, China
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Walters J. Twists and turns along a diagnostic trail and the importance of practical neurologists. Pract Neurol 2023; 23:190-191. [PMID: 36914253 DOI: 10.1136/pn-2023-003704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2023] [Indexed: 03/15/2023]
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Muacevic A, Adler JR, Silver A. Statin-Induced Anti-3-Hydroxy-3-Methylglutaryl-Coenzyme A Reductase (Anti-HMGCR) Myopathy. Cureus 2023; 15:e34121. [PMID: 36843759 PMCID: PMC9947569 DOI: 10.7759/cureus.34121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2023] [Indexed: 01/26/2023] Open
Abstract
Statins are known to pharmacologically target 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR). Several subtypes of anti-HMGCR autoimmune myopathies have been reported as a result of statin use. Although these types vary widely, a severe and rare form of statin-induced myopathy is immune-mediated necrotizing myopathy (IMNM), resulting in severe muscle injury that does not respond to statin cessation and is associated with poor outcomes. Diagnosis is confirmed through biopsy confirming the necrosis of biopsy fibers, in addition to elevated anti-HMGCR serum levels. Management lacks proper guidelines, however, immunosuppressive therapy has been proposed as a possible intervention. The aim of this report is to increase providers' knowledge of the presentation and possible treatment of statin-induced immune-mediated necrotizing myopathy.
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Sener S, Batu ED, Sari S, Kasap Cuceoglu M, Yildiz AE, Talim B, Aydingoz U, Ozen S, Haliloglu G. A Child with Refractory and Relapsing Anti-3-Hydroxy-3-Methylglutaryl-Coenzyme A Reductase Myopathy: Case-Based Review. J Neuromuscul Dis 2023; 10:279-291. [PMID: 36617789 DOI: 10.3233/jnd-221557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND/OBJECTIVE Anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase (anti-HMGCR) myopathy is rare in children. Here, we present a boy with relapsing refractory anti-HMGCR myopathy along with a systematic literature review. CASE REPORT 17-year-old boy with five years of muscle weakness, rash, high creatinine kinase (CK) levels, and muscle biopsy compatible with inflammatory myopathy was diagnosed with juvenile dermatomyositis. He was treated with corticosteroids, intravenous immunoglobulin (IVIG), and methotrexate. His muscle weakness improved with this treatment although never completely resolved. CK levels decreased from ∼15000 U/L to ∼3000 U/L. At the age of 15, muscle weakness relapsed after an upper respiratory tract infection; pulse corticosteroid treatment was administered. The re-evaluated muscle biopsy showed a necrotizing pattern and the HMGCR antibody was positive confirming anti-HMGCR myopathy when he was 16. The diagnostic delay was 50 months. Disease activity was monitored by Medical Research Council score, MRI and functional tests. Despite corticosteroids, methotrexate, IVIG, cyclosporine A, and rituximab therapies, muscle weakness improved only slightly during the first three months and remained stable afterwards.Results of the Literature Search:We identified 16 articles describing 50 children (76% female) with anti-HMGCR myopathy by reviewing the English literature up to March 1st, 2022. Proximal muscle weakness was the most common clinical symptom (70.8%). Corticosteroids (84.8%), IVIG (58.7%), and methotrexate (56.5%) were preferred in most cases. Complete remission was achieved in nine patients (28.1%). CONCLUSION Diagnosis and management of children with anti-HMGCR myopathy are challenging. Complete remission is achieved in only one third of these patients. Imaging biomarkers may aid treatment.
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Affiliation(s)
- Seher Sener
- Department of Pediatrics, Division of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ezgi Deniz Batu
- Department of Pediatrics, Division of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Seher Sari
- Department of Pediatrics, Division of Pediatric Neurology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Muserref Kasap Cuceoglu
- Department of Pediatrics, Division of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Adalet Elcin Yildiz
- Department of Radiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Beril Talim
- Division of Pediatric Pathology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ustun Aydingoz
- Department of Radiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Seza Ozen
- Department of Pediatrics, Division of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Goknur Haliloglu
- Department of Pediatrics, Division of Pediatric Neurology, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Barp A, Merve A, Shah S, Desikan M, Hanna MG, Bugiardini E. Anti-HMGCR myopathy: barriers to prompt recognition. Pract Neurol 2022; 23:239-242. [PMID: 36564213 DOI: 10.1136/pn-2022-003589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2022] [Indexed: 12/25/2022]
Abstract
Anti-HMGCR (3-hydroxy-3-methylglutaryl coenzyme A reductase) myopathy is an immune-mediated necrotising myopathy. Atypical presentations hinder its recognition and its prompt treatment. We present two patients with atypical clinical or pathological features. A 45-year-old woman had an asymptomatic serum creatine kinase (CK) of ~10 000 IU/L and muscle biopsy showing minimal changes. She then developed slowly progressive proximal weakness, diagnosed as limb-girdle muscular dystrophy but with negative genetics. Twelve years later, now with severe proximal weakness, her MR scan of muscle showed diffuse asymmetrical fatty degeneration, with conspicuous hyperintense STIR signal abnormalities. HMGCR antibodies were positive and she partially improved with immunosuppression. The second patient developed slowly progressive proximal limb weakness with a high serum CK (~4000 IU/L); muscle biopsy showed a lymphocyte infiltrate with angiocentric distribution suggesting vasculitis. Serum HMGCR antibodies were positive. Anti-HMGCR myopathy can present as a slowly progressive myopathy with atypical pathology. HMGCR antibody screening is indicated for people with suspected limb-girdle muscular dystrophy or atypical inflammatory muscle conditions.
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Affiliation(s)
- Andrea Barp
- Centro Clinico NeMO Trento, Ospedale Riabilitativo Villa Rosa, Pergine Valsugana, Italy.,Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | - Ashirwad Merve
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK.,Department of Neuropathology, National Hospital for Neurology and Neurosurgery, London, UK
| | - Sachit Shah
- Lysholm Department of Neuroradiology, University College London Hospitals NHS Foundation Trust, National Hospital for Neurology and Neurosurgery, London, UK
| | - Mahalekshmi Desikan
- Neuromuscular Complex Care Centre, National Hospital for Neurology and Neurosurgery, London, UK
| | - Michael G Hanna
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | - Enrico Bugiardini
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
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Hiebeler M, Franke R, Ingenerf M, Krause S, Mohassel P, Pak K, Mammen A, Schoser B, Bönnemann CG, Walter MC. Slowly Progressive Limb-Girdle Weakness and HyperCKemia - Limb Girdle Muscular Dystrophy or Anti-3-Hydroxy-3-Methylglutaryl-CoA-Reductase-Myopathy? J Neuromuscul Dis 2022; 9:607-614. [PMID: 35754285 DOI: 10.3233/jnd-220810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Anti-3-hydroxy-3-methylglutaryl-CoA reductase (HMGCR)-myopathy is a usually rapidly progressive form of immune-mediated necrotizing myopathy (IMNM). Rarer clinical courses show slow progression and resemble the phenotype of limb-girdle dystrophy (LGMD). OBJECTIVE We demonstrate the difficulties in differentiating LGMD versus anti-HMGCR-myopathy. METHODS We report on a 48-year-old patient with slowly progressive tetraparesis and hyperCKemia for more than 20 years. RESULTS Due to myopathic changes in initial and second muscle biopsy and typical clinical presentation, the patient was diagnosed with LGMD 20 years ago; despite comprehensive genetic testing including exome diagnostics, the genetic cause of disease could not be identified. Finally, HMG-CoA reductase antibodies were detected, confirming the diagnosis of anti-HMGCR-myopathy. By re-work-up of a second muscle biopsy specimen from year 2009, the diagnosis of a IMNM was made in retrospect. Seven cycles of high-dose immunoglobulins were administered; patient reported outcome measures have mildly improved. CONCLUSION Patients with clinical LGMD phenotype, degenerative changes in muscle biopsy but without genetic confirmation of the disease should be tested for HMG-CoA-myopathy, thereby allowing for an early start of treatment.
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Affiliation(s)
- Miriam Hiebeler
- Friedrich-Baur-Institute, Department of Neurology, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Raimo Franke
- Department of Chemical Biology, Helmholtz Centre for Infection Research, Braunschweig, Germany
| | - Maria Ingenerf
- Department of Radiology, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Sabine Krause
- Friedrich-Baur-Institute, Department of Neurology, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Payam Mohassel
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Katherine Pak
- Muscle Disease Unit, Laboratory of Muscle Stem Cells and Gene Regulation, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Andrew Mammen
- Muscle Disease Unit, Laboratory of Muscle Stem Cells and Gene Regulation, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Benedikt Schoser
- Friedrich-Baur-Institute, Department of Neurology, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Carsten G Bönnemann
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Maggie C Walter
- Friedrich-Baur-Institute, Department of Neurology, Ludwig-Maximilians-University of Munich, Munich, Germany
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