Case Report: Refractory Immune-Mediated Necrotizing Myositis and Limited English Proficiency




Immune-mediated necrotizing myositis, mycophenolate mofetil, Methotrexate, Limited English Proficiency


Statement of Significance

We report the case of a 76-year-old Spanish-speaking patient with a three-year history of statin induced immune-mediated necrotizing myositis (IMNM) who presented with worsening symptoms and increasing creatinine kinase levels despite escalating treatment strategies. IMNM is a rare and challenging diagnosis. This case report details a myositis flare refractory to first and second-line therapies. Our report also examines limited English proficiency as a structural barrier to care in the United States, particularly in the setting of visits conducted via telehealth modalities.  


Purpose: To report a rare presentation of statin-induced IMNM and the clinical impacts of language barriers and telehealth.

Methods: Case report.

Results: A 76-year-old male with a three-year history of statin-induced IMNM presented for follow-up to the rheumatology clinic. He reported worsening weakness after beginning leucovorin to mitigate side effects ascribed to methotrexate therapy. He had previously achieved baseline strength and normal creatinine kinase (CK) levels with a regimen of weekly methotrexate and monthly infusion of intravenous immunoglobulin (IVIG). His decline in condition appeared to result from inappropriate medication scheduling due to a language barrier. The patient was taking weekly leucovorin on the day before his weekly dose of methotrexate, thus mitigating the efficacy of methotrexate. However, his condition continued to decline with three months of the recommended treatment schedule. The patient was then switched to mycophenolate mofetil as an alternative immunosuppressant. This therapy has demonstrated benefit thus far and provided the patient with symptomatic relief.

Author Biography

Emma Astrike-Davis, University of North Carolina School of Medicine, Chapel Hill, North Carolina

Emma Astrike-Davis is a fourth-year medical student at the University of North Carolina School of Medicine.


Tai H, Cui L, Guan Y, et al. Correlation of Creatine Kinase Levels with Clinical Features and Survival in Amyotrophic Lateral Sclerosis. Front Neurol. 2017;8:322. doi:10.3389/fneur.2017.00322

Stenzel W, Goebel H-H, Aronica E. Review: Immune-mediated necrotizing myopathies – a heterogeneous group of diseases with specific myopathological features. Neuropathol Appl Neurobiol. 2012;38(7):632-646. doi:10.1111/j.1365-2990.2012.01302.x

Allenbach Y, Mammen AL, Benveniste O, et al. 224th ENMC International Workshop:: Clinico-sero-pathological classification of immune-mediated necrotizing myopathies Zandvoort, The Netherlands, 14–16 October 2016. Neuromuscul Disord. 2018;28(1):87-99. doi:10.1016/j.nmd.2017.09.016

Ward NC, Watts GF, Eckel RH. Statin Toxicity. Circ Res. 2019;124(2):328-350. doi:10.1161/CIRCRESAHA.118.312782

Sharma P, Timilsina B, Adhikari J, Parajuli P, Dhital R, Tachamo N. Statin-induced necrotizing autoimmune myopathy: an extremely rare adverse effect from statin use. J Community Hosp Intern Med Perspect. 2019;9(6):503-506. doi:10.1080/20009666.2019.1702272

Essers D, Schäublin M, Kullak-Ublick GA, Weiler S. Statin-associated immune-mediated necrotizing myopathy: a retrospective analysis of individual case safety reports from VigiBase. Eur J Clin Pharmacol. 2019;75(3):409-416. doi:10.1007/s00228-018-2589-z

Pinal-Fernandez I, Casal-Dominguez M, Mammen AL. Immune-Mediated Necrotizing Myopathy. Curr Rheumatol Rep. 2018;20(4):21. doi:10.1007/s11926-018-0732-6

Oosterom N, de Jonge R, Smith DEC, et al. Changes in intracellular folate metabolism during high-dose methotrexate and Leucovorin rescue therapy in children with acute lymphoblastic leukemia. PLoS ONE. 2019;14(9):e0221591. doi:10.1371/journal.pone.0221591

Alqarni AM, Zeidler MP. How does methotrexate work? Biochem Soc Trans. 2020;48(2):559-567. doi:10.1042/BST20190803

Crowley R. Patient Safety in the Office-Based Practice Setting. :24.

Wilson JH. Investing in English Skills: The Limited English Proficient Workforce in U.S. Metropolitan Areas. Brookings. Published September 24, 2014. Accessed August 30, 2021.

Peter D, Robinson P, Jordan M, Lawrence S, Casey K, Salas-Lopez D. Reducing Readmissions Using Teach-Back: Enhancing Patient and Family Education. JONA J Nurs Adm. 2015;45(1):35-42. doi:10.1097/NNA.0000000000000155

Allison AC, Eugui EM. Mycophenolate mofetil and its mechanisms of action. Immunopharmacology. 2000;47(2-3):85-118. doi:10.1016/s0162-3109(00)00188-0

Additional Files



How to Cite

Astrike-Davis, E. (2021). Case Report: Refractory Immune-Mediated Necrotizing Myositis and Limited English Proficiency. Carolina Journal of Interdisciplinary Medicine, 1(1), 78 – 82.