J Korean Med Sci 2004; 19: 891-4 ISSN 1011-8934 Copyright The Korean Academy of Medical Sciences Hepatocellular Carcinoma, Polymyositis, Rhabdomyolysis, and Acute Renal Failure A 55 yr-old man presented with progressive muscle weakness and oliguria for 5 days. Laboratory findings suggested rhabdomyolysis complicated with acute renal failure. A diagnosis of polymyositis was based upon the proximal muscle weakness on both upper and lower limbs, elevated muscle enzyme levels, muscle biopsy findings and the needle electromyography findings. The muscle biopsy showed extensive muscle necrosis and calcification. Investigations for underlying malig- nancy demonstrated hepatocellular carcinoma. The patient was managed with hemodialysis and high dose prednisolone. His renal function was fully recovered and his muscle power did improve slightly, but he died of a rupture of the hepatic tumor. In our view, this is an interesting case in that the hepatocellular carcinoma was associated with polymyositis and fulminant rhabdomyolysis-induced acute renal failure requiring hemodialysis. Key Words : Carcinoma, Hepatocellular; Polymyositis; Rhabdomyolysis; Kidney Failure, Acute Mi-Jeong Kim, Jin-A Kim*, Mi-Sook Sung , Jun-Ki Min Division of Rheumatology, Department of Internal Medicine, Department of Pathology*, Department of Radiology , Holy Family Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea Received : 19 August 2003 Accepted : 22 December 2003 Address for correspondence Jun-Ki Min, M.D. Department of Internal Medicine, Division of Rheumatology, College of Medicine, The Catholic University of Korea, Holy Family Hospital, 2 Sosa-dong, Wonmi-gu, Bucheon 420-717, Korea Tel : +82.32-340-2114, Fax : +82.32-340-2669 E-mail : min6403@netian.com INTRODUCTION Polymyositis (PM) is an autoimmune inflammatory myopa- thy characterized by chronic inflammation of skeletal muscle with infiltration of lymphocytes. Although controversy still remains concerning the relationship between malignancy and myositis, most authorities agree that there is an increased incidence of malignancy in myositis patients, especially in the case of dermatomyositis (DM). For PM, however, the evi- dences which favor the association with malignacy is not suf- ficient than DM (1). This consideration is, partly, because of the interval between the time of cancer diagnosis and the time of myositis development. Zantos et al. found that the risk of cancer was increased in 1-5 yr after myositis in most cases of PM, in contrast to 4 yr prior through 4 yr after the myositis diagnosis in DM (2). Paraneoplastic syndromes including erythrocytosis, hypo- glycemia, hypercholesterolemia and porphyria cutanea tarda are reported in patients with hepatocellular carcinima (HCC), however, a few cases of PM associated with HCC have been reported (3-6). Skeletal muscle injuries without trauma including metabol- ic myopathy, certain drugs and toxins, infections, electrolyte imbalances, and endocrine disorders may cause rhabdomyol- ysis. Rhabdomyolysis is one of the leading causes of acute renal failure (ARF). Inflammatory myopathies including PM also rarely result in myoglobinuric ARF. There have been a few reported cases of PM with rhabdomyolysis leading to 891 ARF requiring hemodialysis (7-10). Here we describe a case with HCC associated with PM presenting as fulminant rhab- domyolysis and ARF. CASE REPORT A 55-yr-old man was admitted to our hospital because of oliguria and progressive proximal muscle weakness of the lower limbs. Two weeks earlier, prior to admission into the hospital, he felt fine. He began experiencing chill, malaise and myalgia. The patient complained of right upper quad- rant abdominal pain. Past medical history was not contrib- utory. The patient denied ethanol ingestion and recent use of drugs. He also denied any traumatic injury. On physical examination, he looked acutely ill. Temperature was 36.7℃, respiration rate 24/min, and blood pressure 110/70 mmHg. Auscultation of the heart and both lungs were normal. The abdomen was soft. The edge of the liver descended 3 cm below the right costal margin. Proximal muscle weakness was mark- ed and muscle power was grade 3 for the lower limbs and grade 4 for the upper limbs. The laboratory investigations were as follows: WBC count 12,700/ L (segmented neutrophil 81%), hemoglobin 13.9 g/dL, platelet 189,000/ L, total pro- tein 6.8 g/dL, albumin 3.0 g/dL, AST 1,074 U/L, ALT 764 U/L, alkaline phosphatase 82 IU/L, GGT 38 U/L, total biliru- bin 1.0 mg/dL, international normalized ratio for prothrom- bin 1.6, BUN 99 mg/dL, creatinine 9.1 mg/dL, calcium 6