Correspondence

Proximal-Muscle Weakness Induced by Herbs

N Engl J Med 1993; 329:1430November 4, 1993

Article

To the Editor:

We report a case of muscle weakness induced by herbs that is associated with the boom in unconventional therapy. A 69-year-old man had an eight-month history of painless, nonfluctuating weakness, primarily of the lower extremities, without other associated neurologic or constitutional symptoms. The results of magnetic resonance imaging of the head, electromyography including nerve-conduction study with repetitive stimulation, and blood tests were normal. The patient had paroxysmal supraventricular tachycardia, as well as chronic obstructive pulmonary disease.

When seen initially (April 1992), the man was taking theophylline, verapamil, digoxin, and quinidine gluconate. He was cachectic, with numerous ecchymoses involving the arms, without striae. There was a suggestion of moon facies. The neurologic examination was notable for moderate-to-severe weakness of the proximal lower extremities, with mild weakness of the neck flexors. The remainder of the examination was negative. Results were normal on repeat electromyographic nerve-conduction studies with repetitive stimulation; blood chemistry studies, including measurement of serum potassium, creatine kinase, aldolase, and the erythrocyte sedimentation rate; thyroid-function studies; serum protein electrophoresis; and testing for anti-neuronal nuclear antibodies and myasthenia gravis antibodies. The hematocrit was 38.3 percent, and the white-cell count was 16,500 per cubic millimeter, with 90 percent granulocytes, 5 percent lymphocytes, and 2 percent basophils. The chest film showed midthoracic compression fractures, which the radiologist commented were suggestive of a “steroid etiology.”

Given the suspicion of possible use of an exogenous steroid, 24-hour urine collection was carried out. High-performance liquid chromatography detected triamcinolone in the sample.

The patient subsequently stated that he had taken two to four “herbal” tablets daily for more than a year. He had obtained these tablets while in Mexico, to avoid “taking more medications.” The “herbs” were analyzed at the steroid laboratory at the Mayo Clinic (Rochester, Minn.). Each tablet was found to contain 5.4 mg of triamcinolone. The steroid intake was tapered, and the patient regained full strength.

Proximal-muscle weakness is a well-recognized complication of glucocorticoid excess. Lower extremities are more involved than upper extremities1. Possible use of unconventional medical treatment should be considered during history taking2. In seeking to avoid medications, this patient unknowingly consumed a substance that induced a severe disability.

David J. Capobianco, M.D.
Paul W. Brazis, M.D.
Thomas P. Fox, M.D.
Mayo Clinic Jacksonville, Jacksonville, FL 32224

2 References

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   Ruff RL. Endocrine myopathies (hyper/ and hypofunction of adrenal, thyroid, pituitary, parathyroid gland, and iatrogenic steroid myopathy). In: Angel AG, Banker BQ, eds. Myology. New York: McGraw-Hill, 1986:1871.
   

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   Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States -- prevalence, costs, and patterns of use. N Engl J Med 1993;328:246-252
   Full Text | Web of Science | Medline

Citing Articles (9)

Citing Articles

1. 1

   Shmuel M Giveon, Nicky Liberman, Shmuel Klang, Ernesto Kahan. (2004) Are people who use “natural drugs” aware of their potentially harmful side effects and reporting to family physician?. Patient Education and Counseling 53:1, 5-11
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   Dena James Smith, Kenneth E. Olive. (2003) Chinese Red Rice-induced Myopathy. Southern Medical Journal 96:12, 1265
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   S Giveon. (2003) A survey of primary care physicians' perceptions of their patients' use of complementary medicine. Complementary Therapies in Medicine 11:4, 254-260
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   E. Ernst. (2003) Serious psychiatric and neurological adverse effects of herbal medicines - a systematic review. Acta Psychiatrica Scandinavica 108:2, 83-91
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   E. Ernst. (2002) Adverse effects of unconventional therapies in the elderly: A systematic review of the recent literature. AGE 25:1, 11-20
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   Joseph I. Boullata, Angela M. Nace. (2000) Safety Issues with Herbal Medicine. Pharmacotherapy 20:3, 257-269
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   Bruce Way, Antony Stewart, Bill Croker. (1996) Usage of alternative medicines by patients presenting to an emergency department. Emergency Medicine 8:1, 5-10
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   Lucu Rosti, Annumaria Nardini, Maria Enrica Bettinelli, Dario Rosti. (1994) Toxic effects of a herbal tea mixture in two newborns. Acta Paediatrica 83:6, 683-683
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9. 9

   &NA;. (1993) Triamcinolone. Reactions Weekly &NA;:477, 12
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