(Kiosk 1) Atypical Presentation of Immune-mediated Myopathy

Case Diagnosis: Patient with history of diabetes (on SGLT-2 inhibitor, statin, and Ozempic) presenting with new-onset immune-mediated myopathy.

Case Description or Program Description: Patient X who has a history of diabetes (on SGLT-2 inhibitor, statin, and Ozempic) noticed painless weakness in bilateral lower extremities in the weeks prior to seeking care. He presented to the emergency department with chief complaints of weakness and malaise. At that time, he was diagnosed with dehydration and was discharged. He then presented to ED with worsening weakness and malaise. Labs indicated that he was in euglycemic diabetic ketoacidosis (DKA). Creatinine kinase at that time was not elevated. He was admitted and continued to have worsening proximal LE and then UE weakness. CK remained normal. Patient was eventually diagnosed with irritable myopathy via EMG which was treated as an immune mediated myopathy following muscle biopsy results consistent with immune myopathy. He received immunoglobulin therapy and high dose steroid therapy.

Setting: Acute Inpatient Rehabilitation

Assessment/Results: Patient completed 3 hours daily of PT/OT with ongoing high dose prednisone and repeated IVIG treatments. Patient made steady progress throughout month-long admission, and was ambulatory with rollator upon discharge.

Discussion (relevance): In this patient, the diagnosis of myopathy was initially missed despite his chief complaint of weakness. There have been case reports of patients taking SGLT-2 inhibitors developing myopathies especially when taken in combination with statins. However, this patient without elevation in CK and muscle biopsy consistent with immune mediated myopathy likely had idiopathic onset of his disease. His lack of elevated CK as well as his presentation in DKA likely delayed his diagnosis and treatment—including time to rehabilitation.

Conclusions: This patient’s case of nearly missed immune-mediated myopathy stresses the importance of thorough musculoskeletal and neurological assessments during emergency triage. Early recognition of such presentations of myopathies is imperative to early medical and rehabilitative treatment.