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Test Catalog

Test ID: HMGCR    
3-Hydroxy-3-Methylglutaryl Coenzyme-A (HMG-CoA) Reductase, Serum

Useful For Suggests clinical disorders or settings where the test may be helpful

Evaluating patients with suspected necrotizing autoimmune myopathy

 

Measuring 3-hydroxy-3-methylglutaryl-CoA reductase (HMGCR) antibodies

Clinical Information Discusses physiology, pathophysiology, and general clinical aspects, as they relate to a laboratory test

Necrotizing autoimmune myopathy (NAM) is a serious but rare muscle disease strongly associated with autoantibodies to either signal recognition protein (SRP) or 3-hydroxy-3-methylglutaryl-CoA reductase (HMGCR).(1) NAM typically manifests with subacute proximal limb muscle weakness and persistently elevated serum creatine kinase (CK) concentrations, but slower onsets can occur and complicate diagnosis. Muscle biopsies in affected patients can demonstrate necrotic and regenerating myofibers without inflammatory infiltrates, suggesting the diagnosis.(2) However, sampling issues and lack of access to persons having expertise in obtaining, preparing, and interpreting muscle biopsy specimens may delay a diagnosis.(3)

 

Early identification of NAM and subsequent aggressive immune-modulating therapy is critical.(1,3) Discovery of SRP- or HMGCR-IgG autoantibodies can aid in establishing an earlier diagnosis and treatment initiation. In addition, the discovery of SRP or HMGCR autoantibodies should prompt a search for an underlying malignancy.(4) Serial testing for these autoantibodies can delay diagnosis with the discovery of either antibody aiding in establishing an earlier diagnosis and treatment initiation.(1,3)

 

The clinical onsets are not specific to NAM, consisting of proximal limb weakness in association with an elevated serum creatinine kinase, with or without exposure to lipid-lowering statin medications.(1,3-9) The clinical presentation can be confused with forms of inflammatory (dermatomyositis, polymyositis), toxic, metabolic, or even neurodegeneration (ie, muscular dystrophy) and the diagnosis delayed without serological testing by SRP- or HMGCR-autoantibody testing. Panel testing of both HMGCR and SRP autoantibodies is the preferred strategy for the best patient care.

Reference Values Describes reference intervals and additional information for interpretation of test results. May include intervals based on age and sex when appropriate. Intervals are Mayo-derived, unless otherwise designated. If an interpretive report is provided, the reference value field will state this.

<20.0 CU

Interpretation Provides information to assist in interpretation of the test results

Seropositivity for 3-hydroxy-3-methylglutaryl-CoA reductase (HMGCR) autoantibodies supports the clinical diagnosis of necrotizing autoimmune myopathy (NAM). Confirmation with muscle biopsy is recommended. A paraneoplastic basis should be considered, according to age, sex, and other risk factors.(4) In cases of NAM, immune therapy is required and often multiple simultaneously utilized immunotherapies are needed to successfully treat patients.

Cautions Discusses conditions that may cause diagnostic confusion, including improper specimen collection and handling, inappropriate test selection, and interfering substances

Negative results do not exclude the diagnosis of necrotizing autoimmune myopathy (NAM). Only approximately 35% of cases of NAM are associated with autoantibodies against 3-hydroxy-3-methylglutaryl-CoA reductase (HMGCR). The remainder of cases are either positive for signal recognition protein (SRP) autoantibodies (approximately 20%-30%) or are seronegative (approximately 35%).

 

Very rarely HMGCR antibodies can be detected in diseases other than NAM. A muscle biopsy is recommended.

Clinical Reference Recommendations for in-depth reading of a clinical nature

1. Kassardjian CD, Lennon VA, Alfugham NB, et al: Clinical Features and Treatment Outcomes of Necrotizing Autoimmune Myopathy. JAMA Neurol 2015 Sep;72(9):996-1003

2. Emslie-Smith A M, Engel A G: Necrotizing myopathy with pipestem capillaries, microvascular deposition of the complement membrane attack complex (MAC), and minimal cellular infiltration. Neurology 1991;41(6):936-939

3. Ramanathan S, Langguth D, Hardy T, et al: Clinical course and treatment of anti-HMGCR antibody-associated necrotizing autoimmune myopathy. Neurol Neuroimmunol Neuroinflamm 2015 June;2(3):e96

4. Allenbach Y, Keraen J, Bouvier AM, et al: High risk of cancer in autoimmune necrotizing myopathies: usefulness of myositis specific antibody. Brain 2016 Aug;139(Pt 8):2131-2135

5. Christopher-Stine L, Casciola-Rosen L, Hong G, et al: A novel autoantibody recognizing 200-kd and 100-kd proteins is associated with an immune-mediated necrotizing myopathy. Arthritis Rheum 2010 May;62(9):2757-2766

6. Mammen AL, Chung T, Christopher-Stine L, et al: Autoantibodies against 3-hydroxy-3-methylglutaryl-coenzyme A reductase in patients with statin-associated autoimmune myopathy. Arthritis Rheum 2011 Mar;63(3):713-721

7. Hengstman GJ, ter Laak HJ, Vree Egberts WT, et al: Anti-signal recognition particle autoantibodies: marker of a necrotising myopathy. Ann Rheum Dis 2006;65(12):1635-1638

8. Miller T, Al-Lozi MT, Lopate G, Pestronk A: Myopathy with antibodies to the signal recognition particle: clinical and pathological features. J Neurol Neurosurg Psychiatry 2002 Oct;73(4):420-428

9. Watanabe Y, Uruha A, Suzuki S, et al: Clinical features and prognosis in anti-SRP and anti-HMGCR necrotising myopathy. J Neurol Neurosurg Psychiatry 2016 Oct;87(10):1038-1044