eMedicine Specialties > Physical Medicine and Rehabilitation > Myopathy

Corticosteroid-Induced Myopathy: Differential Diagnoses & Workup

Author: Steve S Lim, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, St Clare's Hospital of Dover
Coauthor(s): Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School
Contributor Information and Disclosures

Updated: Sep 28, 2009

Differential Diagnoses

Myasthenia Gravis

Other Problems to Be Considered

Myopathies

Inflammatory myopathies (eg, polymyositis/dermatomyositis)
Muscular dystrophies
Drug/toxin–induced myopathies

Neuropathies

Diabetic amyotrophy
Motor neuron disease
Critical illness neuropathy

Neuromuscular junction disease

Eaton-Lambert syndrome

Workup

Laboratory Studies

  • Chronic (classic) steroid myopathy
    • Serum levels of creatine kinase typically are within the reference range.
    • Creatinine excretion in the urine increases dramatically and can precede the clinical appearance of myopathy by several days.1
    • Myoglobinuria and rhabdomyolysis are absent.
  • Acute steroid myopathy - In most cases, high levels of serum creatine kinase are found, as well as associated myoglobinuria.

Other Tests

  • Muscle biopsy in chronic (classic) steroid myopathy10
    • Muscle biopsy shows preferential atrophy of type II fibers, particularly the fast-twitch glycolytic fibers (type IIB).7,11
    • Some atrophy of other type II fibers and, to a small degree, type I muscle fibers can occur.
    • Increased variation in the diameter of muscle fibers occurs.
    • A lack of evidence of muscle fiber inflammation is reported.
    • There is a distinct lack of necrosis or regeneration of muscle.
    • Less active muscles appear to be affected preferentially.
  • Muscle biopsy in acute steroid myopathy - Muscle biopsy shows focal and diffuse necrosis of all fiber types, without predilection for type II fibers.
  • Electromyography (EMG) and nerve conduction studies (NCSs) in chronic (classic) steroid myopathy12
    • Motor and sensory NCS results typically are normal.
    • Repetitive stimulation studies do not reveal significant decrement or increment.
    • EMG studies reveal normal insertional activity with little abnormal spontaneous activity (positive sharp waves and fibrillation potentials).
    • EMG may reveal a mild decrease in motor unit action-potential amplitude during maximal recruitment.
    • In moderate to severe cases, studies may show an early recruitment pattern.
  • EMG and NCS in acute steroid myopathy13 - Some case reports have indicated abnormal EMG findings, including abnormal spontaneous activity (positive sharp waves and fibrillation potentials), early recruitment, and small, polyphasic motor units. There have also been findings suggestive of the development of associated neuropathy following high-dose corticosteroid treatment.14

Histologic Findings

Muscle biopsy typically shows a preferential atrophy of type II fibers, particularly the fast-twitch glycolytic fibers (type IIB), with some atrophy of other fiber types.7,11 There is a distinct lack of necrosis or regeneration of muscle. Some studies, however, have reported focal and diffuse necrosis of all fiber types, without predilection for type II fibers.

More on Corticosteroid-Induced Myopathy

Overview: Corticosteroid-Induced Myopathy
Differential Diagnoses & Workup: Corticosteroid-Induced Myopathy
Treatment & Medication: Corticosteroid-Induced Myopathy
Follow-up: Corticosteroid-Induced Myopathy
References
Further Reading
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References

  1. Askari A, Vignos PJ Jr, Moskowitz RW. Steroid myopathy in connective tissue disease. Am J Med. Oct 1976;61(4):485-92. [Medline].

  2. Yamaguchi M, Niimi A, Minakuchi M, et al. Corticosteroid-induced myopathy mimicking therapy-resistant asthma. Ann Allergy Asthma Immunol. Oct 2007;99(4):371-4. [Medline].

  3. Lacomis D, Smith TW, Chad DA. Acute myopathy and neuropathy in status asthmaticus: case report and literature review. Muscle Nerve. Jan 1993;16(1):84-90. [Medline].

  4. Inder WJ, Jang C, Obeyesekere VR, et al. Dexamethasone administration inhibits skeletal muscle expression of the androgen receptor and IGF-1 - implications for steroid-induced myopathy. Clin Endocrinol (Oxf). Aug 4 2009;[Medline].

  5. Betters JL, Long JH, Howe KS, et al. Nitric oxide reverses prednisolone-induced inactivation of muscle satellite cells. Muscle Nerve. Feb 2008;37(2):203-9. [Medline].

  6. Kumar S. Steroid-induced myopathy following a single oral dose of prednisolone. Neurol India. Dec 2003;51(4):554-6. [Medline]. [Full Text].

  7. Dekhuijzen PN, Decramer M. Steroid-induced myopathy and its significance to respiratory disease: a known disease rediscovered. Eur Respir J. Sep 1992;5(8):997-1003. [Medline].

  8. Borba A, Guil D, Naveso G, et al. [Oral steroids effects on the respiratory muscles function in severe asthmatic patients.]. Rev Port Pneumol. Dec 2006;12(6 Suppl 1):39-40. [Medline].

  9. Stanton AE, Sellars C, Mackenzie K, et al. Perceived vocal morbidity in a problem asthma clinic. J Laryngol Otol. Jan 2009;123(1):96-102. [Medline].

  10. Afifi AK, Bergman RA, Harvey JC. Steroid myopathy. Clinical, histologic and cytologic observations. Johns Hopkins Med J. Oct 1968;123(4):158-73. [Medline].

  11. Danon MJ, Schliselfeld LH. Study of skeletal muscle glycogenolysis and glycolysis in chronic steroid myopathy, non-steroid histochemical type-2 fiber atrophy, and denervation. Clin Biochem. Jan 2007;40(1-2):46-51. [Medline].

  12. Dumitru D. Myopathies. In: Electrodiagnostic Medicine. San Antonio, Tex: University of Texas; 1995:1031-129.

  13. Hanson P, Dive A, Brucher JM, et al. Acute corticosteroid myopathy in intensive care patients. Muscle Nerve. Nov 1997;20(11):1371-80. [Medline].

  14. Ahlbeck K, Fredriksson K, Rooyackers O, et al. Signs of critical illness polyneuropathy and myopathy can be seen early in the ICU course. Acta Anaesthesiol Scand. Jul 2009;53(6):717-23. [Medline].

  15. Uchikawa K, Takahashi H, Hase K, et al. Strenuous exercise-induced alterations of muscle fiber cross-sectional area and fiber-type distribution in steroid myopathy rats. Am J Phys Med Rehabil. Feb 2008;87(2):126-33. [Medline].

  16. Batchelor TT, Taylor LP, Thaler HT, et al. Steroid myopathy in cancer patients. Neurology. May 1997;48(5):1234-8. [Medline].

  17. Menezes LG, Sobreira C, Neder L, et al. Creatine supplementation attenuates corticosteroid-induced muscle wasting and impairment of exercise performance in rats. J Appl Physiol. Feb 2007;102(2):698-703. [Medline]. [Full Text].

  18. Hollister JR. The untoward effects of steroid treatment on the musculoskeletal system and what to do about them. J Asthma. 1992;29(6):363-8. [Medline].

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Keywords

corticosteroid-induced myopathy, myopathy, steroid, steroids, corticosteroid, corticosteroids, polymyositis, dermatomyositis, adrenal tumor, adrenal tumors, hydrocortisone, prednisone, triamcinolone, dexamethasone, steroid myopathy, acute steroid myopathy, chronic steroid myopathy, critical illness myopathy, excess endogenous corticosteroid production, excess exogenous corticosteroid production, asthma, steroid treatment for asthma, steroid treatment for polymyositis, steroid treatment for connective tissue disorders, steroid treatment for rheumatoid arthritis, fluorinated steroids, nonfluorinated steroids, prolonged administration of prednisone

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Contributor Information and Disclosures

Author

Steve S Lim, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, St Clare's Hospital of Dover
Steve S Lim, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

Coauthor(s)

Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School
Patrick M Foye, MD, FAAPMR, FAAEM is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society
Disclosure: Nothing to disclose.

Medical Editor

Patrick J Potter, MD, FRCP(C), Associate Professor, Physical Medicine and Rehabilitation, The University of Western Ontario; Consulting Staff, Department of Physical Medicine and Rehabilitation, St Joseph's Health Care Centre
Patrick J Potter, MD, FRCP(C) is a member of the following medical societies: American Paraplegia Society, Canadian Association of Physical Medicine and Rehabilitation, Canadian Medical Association, College of Physicians and Surgeons of Ontario, Ontario Medical Association, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Kat Kolaski, MD, Assistant Professor, Departments of Orthopedic Surgery and Pediatrics, Wake Forest University School of Medicine
Kat Kolaski, MD is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine and American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Denise I Campagnolo, MD, MS, Director of Multiple Sclerosis Clinical Research and Staff Physiatrist, Barrow Neurology Clinics, St Joseph's Hospital and Medical Center; Investigator for Barrow Neurology Clinics; Director, NARCOMS Project for Consortium of MS Centers
Denise I Campagnolo, MD, MS is a member of the following medical societies: Alpha Omega Alpha, American Association of Neuromuscular and Electrodiagnostic Medicine, American Paraplegia Society, Association of Academic Physiatrists, and Consortium of Multiple Sclerosis Centers
Disclosure: Teva Neuroscience Honoraria Speaking and teaching; Serono-Pfizer Honoraria Speaking and teaching; Genzyme Corporation Grant/research funds investigator; Biogen Idec Grant/research funds investigator; Genentech, Inc Grant/research funds investigator; Eli Lilly & Company Grant/research funds Novaritis; Novaritis  Novaritis; MSDx LLC Grant/research funds investigator; BioMS Technology Corp Grant/research funds investigator; Avanir Pharmaceuticals Grant/research funds investigator

 
 
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