Statin-Associated Immune-Mediated Necrotizing Myopathy Presenting as Persistent Hypertransaminasemia

Immune-mediated necrotizing myopathy is an uncommon autoimmune muscle disease that can be triggered by statin exposure and is often associated with antibodies against 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR). Typical presentations include subacute, symmetric proximal weakness with marked elevation of muscle enzymes, but some patients come to medical attention only because of abnormal laboratory tests, which can delay recognition. We report a middle-aged man with dyslipidemia and chronic hepatitis B virus infection who was referred for persistent elevation of aminotransferases on routine follow-up. Despite minimal muscle complaints, evaluation revealed marked hyperCKemia, strongly positive anti-HMGCR antibodies, and a muscle biopsy consistent with pauci-inflammatory necrotizing myopathy. Statins were discontinued, and combined glucocorticoid-methotrexate therapy led to progressive clinical improvement and complete biochemical remission. This case underscores the importance of considering an underlying myopathy in patients with otherwise unexplained hypertransaminasemia, particularly in the setting of statin exposure and coexisting liver disease.