Can Rhabdomyolysis Lead to Transaminitis?

Abstract

Introduction: Rhabdomyolysis occurs secondary to muscle injury in the setting of physical exertion, immobilization, infection or medications. This injury results in the accumulation of cellular proteins, such as creatinine phosphokinase (CPK), in the serum. Our case describes an association of elevated transaminases and CPK with rhabdomyolysis. Case: An 81 year old male with history of hypertension and lacunar stroke was brought in by his home health aid to a tertiary care center after a presumed mechanical fall with unknown downtime. Review of systems was largely negative including lack of gastrointestinal symptoms. In the emergency room, he was found to be hypothermic to 93.9°F with otherwise stable vital signs. Physical exam was significant for marked confusion and disorientation. He was placed in a forced-air warming blanket and temperature improved to 97°F. At this time, the decision was made to admit the patient to the General Medicine service for further evaluation. The ensuing workup resulted negative, including complete blood count, electrocardiogram, chest x-ray, blood cultures, transthoracic echocardiogram, CT of the head, MRI brain and MRA of the brain and neck. Labs were significant for CPK of greater than 7000 and marked transaminitis. He was administered aggressive intravenous crystalloid hydration for a working diagnosis of rhabdomyolysis, and subsequently improved. Serum markers down-trended over the next few days, and the patient was discharged to a sub-acute rehabilitation center. Discussion: Rhabdomyolysis is commonly associated with an elevation of CPK in the setting of muscle injury. Limited data suggests an association of elevated aminotranferases with CPK. When identifying this relationship, it is important to first exclude alternate etiologies for transaminitis. A concomitant improvement in liver enzymes with CPK is highly suggestive. AST, located in the liver, heart, skeletal muscle, kidney, brain, pancreas, lungs, leukocytes, and erythrocytes, tends to be the predominant aminotransferase to rise. Studies suggest that the elevation of serum AST in rhabdomyolsysis is likely secondary to its release from damaged skeletal muscle fibers. Another possible explanation is that the transaminases released during muscle injury may propagate acute hepatic inflammation. Summary: Our case highlights the association of transaminitis with elevated serum CPK levels in rhabdomyolysis despite the lack of pathologic liver injury.Figure 1Figure 2