Introduction: Statins are used for prevention of cardiovascular disease, and work by lowering serum cholesterol levels. These medications are generally well tolerated, but 0.1 percent of patient develop severe myonecrosis leading to rhabdomyolysis, which is the most severe form of statin-associated muscle symptoms (SAMS). Here, we present a case of a patient whose presentation was not recognized as SAMS, due to previous stroke, leading to a delay in proper management. 

Case: A 56 year old female with past medical history of stroke two and a half years prior to admission. At that time, patient had presented with right sided ptosis and left sided weakness. She was started on aspirin 81 mg, and atorvastatin 80 mg, and discharged to a rehabilitation facility. Her left sided residual weakness returned nearly to baseline, and she was able to exercise regularly. However, two and a half years after the stroke, patient began experiencing increased fatigue that progressed to left leg weakness; this was initially presumed to be stroke recrudescence. Statin dose was decreased, but weakness progressed to include the right thigh and distal upper extremities, spreading proximally. She tested negative for MG and ALS. Her CK was found to be 9,014, after which atorvastatin was discontinued, and she was admitted for IV hydration. For the next month, her CK ranged from 7,000-10,000, and she underwent muscle biopsy showing active myopathy. Testing was positive for ANA and HMGCR antibody, confirming SAMS; thus, she was started on a steroid taper and methotrexate. 

Discussion: The general recommendation for suspected SAMS is to calculate a SAMS clinical index, which determines likelihood that muscle symptoms are due to statin use. In patients on statins with unexplained myalgias, it is crucial to completely stop the medication for at least two to four weeks even if a more likely diagnosis exists.