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Corticosteroid-Induced Myopathy Workup

  • Author: Patrick M Foye, MD; Chief Editor: Stephen Kishner, MD, MHA  more...
 
Updated: Jun 22, 2015
 

Laboratory Studies

In 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.

In acute steroid myopathy, most patients have high levels of serum creatine kinase, as well as associated myoglobinuria.

Although circulating muscle proteins such as creatine kinase and myoglobin are increased in acute steroid myopathy, glucocorticoid down-regulation of protein synthesis may lead to decreased levels of these proteins in chronic steroid myopathy.

A recent, randomized, placebo-controlled study aimed to determine the effects of dexamethasone on circulating levels of muscle protein. Following 1 week of dexamethasone 8 mg by mouth daily, the 10 subjects in the experimental group all had significantly decreased serum creatine kinase levels, 4 of which fell below the lower limit of normal. Serum myoglobin was also decreased in all 10 subjects; however, there was a trend of greater decrease in creatine kinase than myoglobin, which corresponds to the greater expression of creatine kinase in type II muscle fibers. As mentioned previously, corticosteroid-induced myopathy causes preferential atrophy of type II muscle fibers.[13]

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Other Tests

Muscle biopsy in chronic (classic) steroid myopathy [14]

Muscle biopsy shows preferential atrophy of type II fibers, particularly the fast-twitch glycolytic fibers (type IIB).[10, 15] 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 myopathy [16]

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 myopathy [17]

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.[18]

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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.[10, 15] 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.

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Contributor Information and Disclosures
Author

Patrick M Foye, MD Director of Coccyx Pain Center, Professor and Interim Chair of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School; Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, University Hospital

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, International Spine Intervention Society, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists

Disclosure: Nothing to disclose.

Coauthor(s)

Steven S Lim, MD, MD 

Steven S Lim, MD, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Leia Rispoli Rutgers New Jersey Medical School

Disclosure: Nothing to disclose.

Gloria E Hwang, MD, MPA Rutgers New Jersey Medical School

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

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, American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Chief Editor

Stephen Kishner, MD, MHA Professor of Clinical Medicine, Physical Medicine and Rehabilitation Residency Program Director, Louisiana State University School of Medicine in New Orleans

Stephen Kishner, MD, MHA is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Patrick J Potter, MD, FRCSC Associate Professor, Department of Physical Medicine and Rehabilitation, University of Western Ontario School of Medicine; Consulting Staff, Department of Physical Medicine and Rehabilitation, St Joseph's Health Care Centre

Patrick J Potter, MD, FRCSC is a member of the following medical societies: Academy of Spinal Cord Injury Professionals, College of Physicians and Surgeons of Ontario, Canadian Association of Physical Medicine and Rehabilitation, Canadian Medical Association, Ontario Medical Association, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Acknowledgements

Dena Abdelshahed Rutgers New Jersey Medical School

Disclosure: Nothing to disclose.

Debra Ibrahim New York College of Osteopathic Medicine

Disclosure: Nothing to disclose.

Evish Kamrava St George's University School of Medicine

Disclosure: Nothing to disclose.

Cyrus Kao St George's University School of Medicine

Disclosure: Nothing to disclose.

Dev Sinha, MD American University of Antigua School of Medicine and Health Sciences

Disclosure: Nothing to disclose.

References
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