Elevated Creatinine Kinase Levels Research Articles

COVID-19: Direct and Indirect Mechanisms of Statins

The virus responsible for the current COVID-19 pandemic is severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2): a new virus with high infectivity and moderate mortality. The major clinical manifestation of COVID-19 is interstitial pneumonia, which may progress to acute respiratory distress syndrome (ARDS). However, the disease causes a potent systemic hyperin-flammatory response, i.e., a cytokine storm or macrophage activation syndrome (MAS), which is associated with thrombotic complications. The complexity of the disease requires appropriate intensive treatment. One of promising treatment is statin administration, these being 3-hydroxy-3-methylglutaryl-CoA reductase inhibitors that exert pleiotropic anti-inflammatory effects. Recent studies indicate that statin therapy is associated with decreased mortality in COVID-19, which may be caused by direct and indirect mechanisms. According to literature data, statins can limit SARS-CoV-2 cell entry and replication by inhibiting the main protease (Mpro) and RNA-dependent RNA polymerase (RdRp). The cytokine storm can be ameliorated by lowering serum IL-6 levels; this can be achieved by inhibiting Toll-like receptor 4 (TLR4) and modulating macrophage activity. Statins can also reduce the complications of COVID-19, such as thrombosis and pulmonary fibrosis, by reducing serum PAI-1 levels, attenuating TGF-β and VEGF in lung tissue, and improving endothelial function. Despite these benefits, statin therapy may have side effects that should be considered, such as elevated creatinine kinase (CK), liver enzyme and serum glucose levels, which are already elevated in severe COVID-19 infection. The present study analyzes the latest findings regarding the benefits and limitations of statin therapy in patients with COVID-19.

Under (compartment) pressure in the intensive care unit: a case report

: Compartment syndrome by itself is an emergency, but when it is combined with acute renal failure (ARF) secondary to exertional and toxin-induced rhabdomyolysis in the setting of methamphetamine use, it takes on a new dimension of complexity. We report the case of a 37-year-old male with no past medical history who was brought in by emergency medical services (EMS) after being found underneath a sink in a hotel room after a weekend of illicit drug use. On admission, the patient had a potassium of 7.7 mmol/L, creatinine of 2.71 mg/dL, and creatinine kinase (CK) of 228,635 U/L with severe agitation and confusion, and required admission to the intensive care unit (ICU). He was also noted to have severe tightness in his left posterior deltoid and triceps on exam, with compartment pressure of 40 mmHg. Immediately after hemodialysis (HD), the patient was taken for an emergent fasciotomy which showed marked duskiness of the muscles but no frank necrosis. After multiple sessions of HD, the patient continued to have markedly elevated CK levels which slowly began decreasing. Unfortunately, he was unable to remain euvolemic after HD and a transthoracic echocardiogram (TTE) showed acute heart failure with a reduced ejection fraction (HFrEF) of 40%. Swelling in his left upper extremity was slow to resolve and required closure with a continuous external tissue expander. After recovery from his multiple comorbidities the patient slowly regained functional capacity of his upper extremity despite the numerous complications. This patient’s lengthy and complicated medical course emphasizes the seriousness of this rare condition, and the cruciality of vigilance to ensure the best possible outcomes in cases of posterior deltoid compartment syndrome.

Pregabalin-Induced Myopathy in a Double Lung Transplant Recipient

Pregabalin is a gamma-aminobutyric acid (GABA) derivative that was commercially approved by the Food and Drug Administration (FDA) in 2004. It is commonly used in the treatment of diabetic neuropathy, peripheral neuropathy, and spinal cord injury. We present the case of a 36-year-old Caucasian male double lung transplant recipient who presented with an 18-month history of fatigue and muscle weakness. He had elevated creatinine kinase level and his muscle biopsy showed evidence of drug-induced myopathy that improved after the cessation of pregabalin. We present a case of drug-induced myopathy as a rare complication of pregabalin therapy in a double lung transplant recipient.

Immune mediated necrotizing myopathy: A rare complication of statin therapy.

Immune mediated necrotizing myopathy (IMNM) is part of the inflammatory myopathies group of diseases and presents with muscle weakness, myalgias and elevated serum creatine phosphokinase (CPK). Statin-induced IMNM is a rare complication. We present a patient with IMNM secondary to simvastatin use. The patient presented with proximal myopathy, dysphagia, and elevated creatinine kinase levels, and was subsequently found to have anti-3- hydroxy-3-methylglutaryl-CoA reductase (HMGCR) autoantibodies with a necrotizing process on muscle biopsy. This patient’s case was further complicated by sequelae of multiple disease processes, ultimately leading to deterioration of his health.

Clinical characteristics of patients with 2019 coronavirus disease in a non-Wuhan area of Hubei Province, China: a retrospective study

BackgroundSince December 2019, the 2019 coronavirus disease (COVID-19) has expanded to cause a worldwide outbreak that more than 600,000 people infected and tens of thousands died. To date, the clinical characteristics of COVID-19 patients in the non-Wuhan areas of Hubei Province in China have not been described.MethodsWe retrospectively analyzed the clinical characteristics and treatment progress of 91 patients diagnosed with COVID-19 in Jingzhou Central Hospital.ResultsOf the 91 patients diagnosed with COVID-19, 30 cases (33.0%) were severe and two patients (2.2%) died. The severe disease group tended to be older (50.5 vs. 42.0 years; p = 0.049) and have more chronic disease (40% vs. 14.8%; p = 0.009) relative to mild disease group. Only 73.6% of the patients were quantitative polymerase chain reaction (qPCR)-positive on their first tests, while typical chest computed tomography images were obtained for each patient. The most common complaints were cough (n = 75; 82.4%), fever (n = 59; 64.8%), fatigue (n = 35; 38.5%), and diarrhea (n = 14; 15.4%). Non-respiratory injury was identified by elevated levels of aspartate aminotransferase (n = 18; 19.8%), creatinine (n = 5; 5.5%), and creatine kinase (n = 14; 15.4%) in laboratory tests. Twenty-eight cases (30.8%) suffered non-respiratory injury, including 50% of the critically ill patients and 21.3% of the mild patients.ConclusionsOverall, the mortality rate of patients in Jingzhou was lower than that of Wuhan. Importantly, we found liver, kidney, digestive tract, and heart injuries in COVID-19 cases besides respiratory problems. Combining chest computed tomography images with the qPCR analysis of throat swab samples can improve the accuracy of COVID-19 diagnosis.

A novel noncoding FKRP mutation in early onset limb-girdle muscular dystrophy.

Limb-girdle muscular dystrophy 2I (LGMD2I, LGMD R9) (OMIM: muscular dystrophy—dystroglycanopathy [limb-girdle], type C, 5) is an autosomal recessive disorder caused by mutations in the fukutin-related protein ( FKRP ) gene.1 The phenotypic spectrum associated with FKRP is heterogeneous; the most severe phenotype, Walker-Warburg-like syndrome, is characterized by congenital hypotonia, progressive muscle weakness and atrophy, ocular and brain malformations, severe motor developmental delay, and profound intellectual disability. Milder phenotypes include the onset of disease from infancy to adulthood and variable clinical course including asymptomatic elevated serum creatinine kinase (CK), early onset rapidly progressive course with loss of ambulation in teenage years, late onset with slow progression, and primary cardiomyopathy with minimal skeletal muscle weakness.1,2 LGMD2I is typically characterized by proximal muscle weakness, calf hypertrophy, hypotonia, elevated CK level, normal cognition, and no structural brain abnormalities. Dilated cardiomyopathy and respiratory muscle weakness can be seen.1 Mutations in the FKRP gene reduce specific O-mannose-linked glycosylation of alpha-dystroglycan, leading to the instability of the linkage between the dystrophin–glycoprotein complex and laminin alpha 2 in the basement membrane of skeletal muscle.3 The most common FKRP mutation seen in LGMD2I is c.826C>A (p.Leu276Ile). Patients who are homozygous for this mutation typically have a milder phenotype, whereas compound heterozygotes have a relatively severe clinical course. In patients heterozygous for c.826C>A, clinical severity may correspond best to the mutation in the second allele.1,4 We describe a 9-year-old boy with LGMD2I who has the c.826C>A mutation in FKRP on 1 allele and a novel variant on the second allele. The authors acknowledge Ms. Terese Nelson who performed the histology and immunostaining and Mr. Joel Carl for assembling the figure

2447 A Case of Daptomycin Causing Drug-Induced Liver Injury

INTRODUCTION: Drug-induced liver injury (DILI) is the most common cause of acute liver failure. DILI is rare and characterized by elevated creatinine kinase (CK) and liver enzymes without associated end-organ damage. We present a rare case of daptomycin associated hepatotoxicity without corresponding elevation in CK. CASE DESCRIPTION/METHODS: A 87-year-old man with a history of hypertension, hyperlipidemia, benign prostate hyperplasia, closed fracture of distal lateral malleolus of left ankle, and atrial fibrillation on apixaban presented to the ED from rehab facility with complaints of one day of shortness of breath, cough, diarrhea, and nausea. Patient was a poor historian. He also has had poor oral intake. He was unable to state if he had any prior gastrointestinal problems. No tobacco, alcohol, illicit drug use. On physical examination, patient was noted to have mild purulent drainage on plantar surface of right fifth metatarsal phalangeal joint. A CT scan of foot ruled out osteomyelitis. On admission, labs revealed elevated transaminases with AST 113, likely due to congestive hepatopathy, as per echocardiogram with elevated right ventricular systolic pressure. All other liver enzymes were within normal limits. Blood cultures resulted in Methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia and he was subsequently started on vancomycin (due to penicillin allergy). After 7 days of vancomycin therapy, he was switched to daptomycin due to the rising creatinine levels. Next 5 days, LFTs trended up dramatically with the initiation of daptomycin. All non-essential medications were discontinued at this time. LFTs peaked at total bilirubin 1.4, AST 432, ALT 535 and alkaline phosphatase (AP) 161. CK was normal. At this time, daptomycin was discontinued. LFTs started a steep downtrend one day after cessation of daptomycin (Figure 1). The rise in creatinine, total bilirubin, and initial CK levels were temporally related to the initiation of vancomycin infusions (Figure 2). Autoimmune work up and hepatitis panel were all negative. An abdominal ultrasound showed hepatomegaly (16.5 cm) with diffuse hypoechoic texture. Liver doppler showed normal flow. DISCUSSION: Daptomycin induced hepatotoxicity without evidence of elevated CK levels is rare. The pathophysiology is unclear. There is limited literature on DILI without renal failure or rhabdomyolysis in setting of daptomycin use. We only found one case in literature. The long-term sequela has not been fully studied, thus liver enzymes should be monitored closely.

Severe hypothyroidism presenting as reversible proteinuria: two case reports

BackgroundHypothyroidism is a common medical disorder which results in many metabolic effects, such as dyslipidemia, hypertension, accelerated atherosclerosis, and coronary artery disease. Hypothyroidism affects the renal physiology by affecting the renal blood flow, vascular resistance, and sodium handling. Recent studies have shown hypothyroidism is associated with decreased estimated renal function and proteinuria. Rhabdomyolysis and acute renal insufficiency have also been described in association with hypothyroidism. The severity of the proteinuria was directly proportional to thyroid-stimulating hormone levels. Currently, there is a lack of evidence on the reversibility of proteinuria in hypothyroidism. This is the first report in the literature, to the best of our knowledge, demonstrating the reversibility of proteinuria associated with hypothyroidism, with treatment.Case presentationHere we describe two cases, a 72-year-old Sinhalese man and a 47-year-old Tamil woman, from Sri Lanka, presenting with overt hypothyroidism; they were found to have elevated creatinine, proteinuria, and elevated creatinine kinase levels. Due to lack of active sediment in urine analysis, these patients were observed after the initiation of thyroxine therapy. They were investigated in the adult-onset proteinuria pathway, excluding common reasons for proteinuria. Both patients responded to treatment: their serum creatinine, creatinine kinase, and urine protein levels reverted to physiological levels within 6 months of treatment with thyroxine, and with normalization of thyroid-stimulating hormone.ConclusionHypothyroidism can present as renal insufficiency, proteinuria, and can mimic rhabdomyolysis. Prompt initiation of thyroxine treatment and control of thyroid-stimulating hormone levels could reverse these changes.

Monitoring the health of green turtles in northern Queensland post catastrophic events

Between 2014 and 2017, the Rivers to Reef to Turtles (RRT) project examined the health of green turtles at two coastal sites impacted by urban and agricultural human activities (Cleveland and Upstart Bays) and one proposed pristine site (Howick Group of Reefs) in northern Queensland, Australia, through blood biochemistry and haematology, plasma protein electrophoresis, and clinical assessments including body condition and barnacle counts. Furthermore, cases of mortality were subjected to comprehensive postmortem examination. In an attempt to advance diagnostics, associations between specific contaminants and health of turtles in this region were tested. No comprehensive health assessments had been conducted at these sites prior to this study.The coastal Cleveland and Upstart Bays both demonstrated effects likely to be in response to stressors suspected to be anthropogenic in origin (elevated total white cell counts and creatinine kinase levels across the populations, respectively). This was associated with a suite of trace elements, in particular cobalt. While these indicators of stress resolved by the final year of the study, a chronic stressor was suspected to be persisting with ongoing low albumin: globulin. Necropsies did not elucidate any specific diseases.Although body condition index did not closely correlate with site health, barnacle counts in juvenile turtles may prove a reliable indicator of site health. Based on previously established indicators of poor health, barnacle counts showed that 10% of the population was in poor health at Upstart Bay and nearly 20% of the population at Cleveland Bay. This is above what would be expected for a normal population.Overall, the health component of this study suggested that the pristine turtle population was healthy and the coastal turtle populations were under active stressors, possibly caused by anthropogenic effectors such as chemical pollutants, when initially examined in 2014. These stressors resolved by the conclusion of the study in 2017; but chronic stressors remained absent in the pristine site and present within each of the studied coastal populations.

Review of Statin-Associated Symptoms, Definition and Diagnosis, and Treatment Strategies. An Australian Lipid Clinic experience

Background: Statins are one of the most frequently prescribed medications in the reduction of cardiovascular disease. Although they are well-tolerated, there are known statin associated symptoms (SAS) that often result in discontinuation. The purpose of this article is to share an Australian lipid clinic experience with SAS, discuss possible management strategies and compare it with the existing literature. Method: A set of 306 patients were selected as a sample of the cohort that attended the lipid clinic at St Vincent's Hospital Melbourne from January 1995 to May 2014. Major journal articles, reviews and meta-analysis were identified in multiple databases from 1990 to 2017. Results: Seventy-eight patients (47.4%, 36 male, median age 73) referred with SAS were reviewed. Among SAS, SAMS was the most common (n = 42, 55.2%) followed by elevated creatinine kinase level (n = 19, 25.0%), then by hepatic enzymes derangement (n = 5, 6.6%). Management of SAS includes dose reduction and/or switching to a different statin, utilisation of alternate dosing regimens, and non-statin therapy. Following rechallenge, 68.4% (n = 52) of patients with SAS reported symptomatic improvement. 71.1% (n = 54) of patients could remain on regular statin therapy. There was a significant improvement in fasting lipid profiles with mean reduction in LDL-C by 38.7% (−1.28 mmol/L, p < 0.0001) with 27.6% (n = 21) of patients achieved target LDL-C levels (<2.6 mmol/L). Conclusion: Symptoms of statin intolerance are variable, however the most common were SAMS and CK elevation. Multiple statin treatment strategies exist and are effective in reducing SAS to improve both statin adherence and LDL-C profile.

THE SUPERINFECTION THAT’S A REAL HEADACHE

SESSION TITLE: Critical Care 1 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Legionnaires’ disease serves as one of the most ubiquitous causes of community-acquired pneumonia. We are reporting a rare case of influenza with a superinfection of Legionnaires disease presenting with altered mental status due to severe hyponatremia. CASE PRESENTATION: A 60-year-old woman with no significant medical history was brought to the ER by her sister after she was found on the ground. According to her sister, the patient had a right facial droop with dried blood in her nares and sub-conjunctival hemorrhage as well as an “unusual posturing” of her hands and feet. Prior to the event, she had been complaining of nausea and vomiting for the past two days for which she had been taking Alka-Seltzer and herbal teas. On physical examination, she remained unconscious with bilateral conjunctival swelling and injection but no nuchal rigidity or apparent head injury. Temperature was 99.7 F with heart rate of 70 bpm, blood pressure was elevated to 221/105 mmHg. She was intubated with subsequent improvement in BP. The initial laboratory results revealed hyponatremia with sodium of 109 mEq/L and elevated creatinine kinase level of 11108. Urine toxicology report was negative. CT imaging of head demonstrated cerebral edema with loss of the gray and white matter significant for global ischemia. After admission to the ICU for management of hyponatremia and cerebral edema, she was found to be influenza and legionella positive. She completed a course of Tamiflu and Levaquin and sodium was slowly corrected to 134mEq/L. She was extubated on hospital day 3, by day 6 she had complete restoration of mental status and strength and was discharged home. DISCUSSION: While the most common superinfections with influenza are S. pneumoniae, H. influenzae, and S. aureus, Legionella has been associated with influenza virus (1). There exists no particular set of clinical features that should raise suspicion for the disease as the presentations may differ. Legionella etiology of community acquired pneumonia serves as a strong predictor for low sodium level, independent of disease severity (2). Although previous studies suggested antidiuretic hormone-independent mechanisms such as direct renal effects of cytokines and toxins as the culprit, the mechanism still remains unknown. (3). However, since hyponatremia can cause a number of serious complications, such as coma and death, there still needs to be a careful management of those patients presenting as symptomatic hyponatremia. When dealt with the right management with correction of sodium level and appropriate antibiotics in a timely manner, one may expect a dramatic improvement in patients’ physical and mental status. CONCLUSIONS: Even though the extent of hyponatremia in patients with Legionella pneumonia may not correlate with the severity of the disease, hyponatremia in itself can lead to dangerous outcomes and suspicion for legionella infection should be high. Reference #1: Morris DE, Cleary DW, Clarke SC. Secondary Bacterial Infections Associated with Influenza Pandemics. Frontiers in Microbiology. 2017;8:1041. https://doi.org/10.3389/fmicb.2017.01041. Reference #2: Yu, Victor L. Legionnaires' Disease: Importance of High Index of Suspicion in Patients in the ICU with Community-Acquired Pneumonia. CHEST. 2014;145:2. DOI: https://doi.org/10.1378/chest.13-2170 Reference #3: Schuetz P, Haubitz S, Christ-Crain M, Albrich WC, Zimmerli W, Mueller B. Hyponatremia and anti-diuretic hormone in Legionnaires’ disease. BMC Infectious Diseases. 2013;13:585. https://doi.org/10.1186/1471-2334-13-585. DISCLOSURES: No relevant relationships by Erica Altschul, source=Web Response No relevant relationships by Cyra-Yoonsun Kang, source=Web Response

Successful treatment of out-of-hospital cardiopulmonary arrest due to streptococcal toxic shock syndrome \u2013 effectiveness of extracorporeal membrane oxygenation and the rapid antigen group A streptococcus test: a case report

BackgroundStreptococcal toxic shock syndrome caused by Streptococcus pyogenes, a group A streptococcus, infection is a rare condition that rapidly progresses to multiple organ failure, shock, and death. It is thus important to promptly establish a diagnosis, provide hemodynamic support, and initiate appropriate antibiotics therapy.Case presentationA 70-year-old Asian man presented with ventricular fibrillation. Extracorporeal membrane oxygenation was initiated 20 minutes after admission after unsuccessful conventional cardiopulmonary resuscitation including five attempts of electrical cardioversion. On the sixth attempt, a sinus rhythm was obtained. A physical examination revealed a large abscess in his right gluteal region, and computed tomography showed a large low-density area in the right gluteus maximus. Blood examination revealed elevated levels of inflammatory markers, hepatic enzymes, creatinine, and creatinine kinase. Transthoracic echocardiography demonstrated diffuse hypokinesis with an ejection fraction of 25%. A subsequent coronary angiography revealed normal findings. Therefore, we diagnosed our patient as having septic shock and conducted surgical drainage. A rapid antigen group A streptococcus test yielded positive results, which necessitated treatment comprising benzylpenicillin and clindamycin. He was successfully weaned from extracorporeal membrane oxygenation and continuous hemodiafiltration 4 days later and ventilation 9 days later; he was later transferred to another hospital to receive a skin graft.ConclusionsOur case report is the first to demonstrate the successful treatment of cardiac arrest caused by streptococcal toxic shock syndrome via extracorporeal membrane oxygenation and prompt initiation of antibiotic therapy. The rapid antigen group A streptococcus test may be an effective approach to promptly diagnose streptococcal toxic shock syndrome caused by group A streptococcus infection.

Clinico-pathological studies on black quarter in cattle

The present study was conducted on 42 clinical cases of black quarter in cattle to study the haemato-biochemical, gross and histopathological changes. The haemato-biochemical changes observed in affected animals included significant increase in absolute granulocyte count, serum glutamic oxaloacetic transaminase and creatinine kinase as compared to healthy control indicating muscular damage. The gross lesions were excessive bloated appearance of carcass immediately after death along with crepitating or non-crepitating swelling primarily at different sites viz. hind quarter, shoulder and neck region etc. On incision, the swelling showed oozing of dark red fluid with bubbles with rancid odour. The affected muscles were dark red in colour with sponge like appearance frequently with presence of gas bubbles indicating necrotizing hemorrhagic myositis. The spleen was frequently moderately enlarged and showed mushy appearance. The important histopathological lesions observed in affected skeletal muscles were extensive haemorrhages and marked inflammatory response predominantly containing neutrophilic infiltration in spaces between muscle fibers indicating haemorrhagic necrotizing myositis leading to architectural disruption of myofibrils. Focal coagulative necrosis of muscle bundles also observed. Frequently, many empty spaces within muscle bundles were evident indicating presence of gas bubbles (emphysema) and edema. In conclusion, the findings like granulocytosis, lymphocytopenia, anemia, elevated levels of serum glutamic oxaloacetic transaminase and creatinine kinase can be used as marker hemato-biochmical parameters for preliminary clinical diagnosis of black quarter in conjunction with other important parameters like clinical signs, conventional and molecular techniques for detection of causative agent, gross and histopathological changes.

Acute kidney injury in pediatric patients with rhabdomyolysis.

PurposeThis study aimed to evaluate the clinical findings in pediatric rhabdomyolysis and the predictive factors for acute kidney injury (AKI) in Korean children.MethodsMedical records of 39 Korean children, who were newly diagnosed with rhabdomyolysis from January 2008 to December 2015, were retrospectively analyzed. The diagnosis was made from the medical history, elevated serum creatinine kinase level >1,000 IU/L, and plasma myoglobin level >150 ng/mL. Patients with muscular dystrophy and myocardial infarction were excluded.ResultsThe median patient age at diagnosis was 14.0 years (range, 3–18 years), and the male to female ratio was 2.5. The most common presenting symptom was myalgia (n=25, 64.1%), and 14 patients (35.9%) had rhabdomyolysis-induced AKI. Eighteen patients (46.2%) had underlying diseases, such as epilepsy and psychotic disorders. Ten of these patients showed rhabdomyolysis-induced AKI. The common causes of rhabdomyolysis were infection (n=12, 30.7%), exercise (n=9, 23.1%), and trauma (n=8, 20.5%). There was no difference in the distribution of etiology between AKI and non-AKI groups. Five patients in the AKI group showed complete recovery of renal function after stopping renal replacement therapy. The median length of hospitalization was 7.0 days, and no mortality was reported. Compared with the non-AKI group, the AKI group showed higher levels of peak creatinine kinase and myoglobin, without statistical significance.ConclusionThe clinical characteristics of pediatric rhabdomyolysis differ from those observed in adult patients. Children with underlying diseases are more vulnerable to rhabdomyolysis-induced AKI. AKI more likely develops in the presence of a high degree of albuminuria.

Spontaneous Compartment Syndrome of the Thigh in the Absence of Trauma

BackgroundCompartment syndrome occurs when an increase in pressure results in vascular and functional impairment of the underlying nerve and muscles. Thigh compartment syndrome (TCS) is uncommon, but clinical suspicion warrants emergent surgical consultation and fasciotomy. Case ReportWe present a 42-year-old man evaluated for right lateral thigh pain, without a history of trauma, deep venous thrombosis (DVT), previous surgery, or intravenous drug use. He was febrile, tachycardic, with a mild leukocytosis, an elevated C-reactive protein level, and an elevated creatinine kinase level. Radiographs showed no abnormality and right lower extremity duplex ultrasound showed no DVT. A computed tomography scan of the right lower extremity was concerning for compartment syndrome. Surgical consultation was obtained, and the patient was taken to the operating room for fasciotomy. He was diagnosed with compartment syndrome intraoperatively. The patient was discharged on hospital day 10. Why Should an Emergency Physician be Aware of This?TCS is exceedingly rare, especially in the absence of underlying traumatic and nontraumatic etiologies. The diagnosis is challenging because more elastic fascia with larger space in the thigh allows for accommodation of acute increases in pressure. Consequently, there may not be the expected acute rise in compartment pressures; increased compartment pressure may only be a late sign, when underlying neurovascular damage has already occurred. TCS is complicated by high morbidity and mortality. Emergent surgical consultation should be obtained when there is a high clinical suspicion for TCS, and limb-saving fasciotomy should not be delayed. This case shows the importance of a high level of suspicion for TCS in patients with no identifiable etiology and no historical risk factors for development of compartment syndrome, because TCS may not present with classic symptoms.

İzotretinoin Tedavisi Alan Hastada Rabdomiyoliz ve Toksik Hepatit: Olgu Sunumu

Isotretinoin is a vitamin A derived drug used in resistant acne vulgaris cases. Elevated creatinine kinase levels can be seen in 15-50% of patients receiving isotretinoin treatment, but severe muscle damage or rhabdomyolysis are seen quite rarely. A 19-year-old male patient presented to our hospital with complaints of muscle weakness, myalgia and darkening urine colour that had started after severe exercise. The patient had been using isotretinoin for 2 months. Laboratory tests revealed creatinine 12 mg/dl, creatinine kinase: 18500 U/l, AST: 629 U/l, ALT: 749 U/l, and LDH: 1588 U/l. The patient was diagnosed as rhabdomyolysis due to isotretionin treatment, acute renal failure, and toxic hepatitis. Hemodialysis was performed. After 3 days of hemodialysis treatment, the urine output became normal and he had no hemodialysis need. Drug dosage and exercise are risk factors for rhabdomyolysis in patients receiving isotretionin treatment. Liver enzymes may elevate in 15-20% of patients after isotretinoin treatment. Rhabdomyolysis after isotretinoin treatment has previously been reported in the literature whereas acute renal failure requiring hemodialysis and toxic hepatitis had not been reported yet. Our patient is the first case with acute renal failure, rhabdomyolysis and toxic hepatitis due to isotretinoin usage. keY woRdS: Rhabdomyolysis, Acute renal failure, Hemodialysis, Toxic hepatitis, Isotretinoin

Martwicze autoimmunologiczne zapalenie mięśni indukowane statynami– opis przypadku.

Myositides comprise a large group of disorders involving limb muscle weakness. In differential diagnosis we have to consider idiopathic myositides, myositides associated with other diseases, and those induced by external factors, e.g. drug-induced. Statins are commonly used drugs, but many patients experience a broad spectrum of adverse effects including symptoms from skeletal muscle. Physicians should pay special attention to patients reporting muscle weakness lasting longer than 12 weeks, despite statin withdrawal, as well as other symptoms: dysphagia, disturbed grip function, elevated creatinine kinase (CK) levels and abnormal electromyography.&lt;br /&gt; The reported case deals with the problem of differential diagnosis of drug-induced muscle injury, polymyositis with a recently reported myopathy – statin-induced autoimmune necrotizing myositis, related to anti-HMGCR antibodies.

Additional postoperative cell salvage of shed mediastinal blood in cardiac surgery does not reduce allogeneic blood transfusions: a cohort study.

Does additional postoperative collection and processing of mediastinal shed blood with a cell salvage device reduce the number of allogeneic blood transfusions compared to intraoperative cell salvage alone? A single-centre cohort study in which adult patients with coronary artery bypass grafting or aortic valve replacement were allocated to either a C.A.T.S(®) group with intraoperative blood processing only or a CardioPat(®) group with both intra- and postoperative blood processing. The primary endpoint was the number of allogeneic blood transfusions during hospital admission. The study included 99 patients; 50 in the C.A.T.S(®) and 49 in the CardioPat(®) group.There was no difference in the number of red blood cells (RBC) (C.A.T.S(®) group 43 units versus CardioPat(®) 50 units, p=0.74), fresh frozen plasma (C.A.T.S(®) 8 units versus CardioPat(®) 8 units, p=1.00) or platelets (C.A.T.S(®) 5 units versus CardioPat(®) 4 units, p=1.00) transfused during the hospital stay.Cardiac creatinine kinase (CK-MB) and troponin levels did not differ between the groups although a significant time effect (p<0.001) was present. Creatinine kinase (CK) levels were not different between the groups three hours after arrival in the intensive care unit (ICU) (CardioPat(®) group versus C.A.T.S(®) group, p=0.17). But, compared to the C.A.T.S(®) group on the first (350 [232-469] IU/L) and second postoperative days (325 [201-480] IU/L), the increase in CK levels was more in the CardioPat(®) group on the first (431 [286-642] IU/L, p=0.02) and second postoperative days (406 [239-760] IU/L, p=0.05), resulting in a difference between the groups (p=0.04) CONCLUSIONS: Postoperative cell salvage does not reduce transfusion requirements compared to intraoperative cell salvage alone, but results in elevated total CK levels that suggest haemolysis.

Rhabdomyolysis in Clozapine Overdose.

ContextClozapine is used for decennia for the treatment of schizophrenia. Agranulocytosis, diabetic ketoacidosis, gastrointestinal hypomotility, and myocarditis are well-known adverse effects of clozapine, which are sometimes life threatening. Here we report a case of rhabdomyolysis upon an acute overdose of clozapine.CaseA male patient, 36 years, with elevated creatinine kinase levels (9899 U/l), developed rhabdomyolysis afterafter admission to the emergency department. Approximately 2–4 h earlier he had intoxicated himself with his maintenance oral medication clozapine 125 mg, temazepam 20 mg and lorazepam 1.5 mg. Co-medications, and physical and laboratory examinations did not reveal other risk factors for rhabdomyolysis. According to the Naranjo probability scale there was a probable relation between clozapine dose and symptoms, that developed approximately 2–4 h after the auto-intoxication of 125 mg tablets. At day 5 of hospitalization, clozapine and creatinine kinase levels returned to normal and the patient was discharged with no somatic sequelae.ConclusionsElevated creatinine kinase levels in acute clozapine intoxication may be an indicator that rhabdomyolysis may be involved.

Statins for acute coronary syndrome.

The early period following the onset of acute coronary syndrome (ACS) represents a critical stage of coronary heart disease, with a high risk of recurrent events and deaths. The short-term effects of early treatment with statins on patient-relevant outcomes in patients suffering from ACS are unclear. This is an update of a review previously published in 2011. To assess the effects, both harms and benefits, of early administered statins in patients with ACS, in terms of mortality and cardiovascular events. We updated the searches of CENTRAL (2013, Issue 3), MEDLINE (Ovid) (1946 to April Week 1 2013), EMBASE (Ovid) (1947 to 2013 Week 14), and CINAHL (EBSCO) (1938 to 2013) on 12 April 2013. We applied no language restrictions. We supplemented the search by contacting experts in the field, by reviewing the reference lists of reviews and editorials on the topic, and by searching trial registries. Randomized controlled trials (RCTs) comparing statins with placebo or usual care, with initiation of statin therapy within 14 days following the onset of ACS, follow-up of at least 30 days, and reporting at least one clinical outcome. Two authors independently assessed risk of bias and extracted data. We calculated risk ratios (RRs) for all outcomes in the treatment and control groups and pooled data using random-effects models. Eighteen studies (14,303 patients) compared early statin treatment versus placebo or no treatment in patients with ACS. The new search did not identify any new studies for inclusion. There were some concerns about risk of bias and imprecision of summary estimates. Based on moderate quality evidence, early statin therapy did not decrease the combined primary outcome of death, non-fatal myocardial infarction, and stroke at one month (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.80 to 1.08) or four months (RR 0.93, 95% CI 0.81 to 1.06) of follow-up when compared to placebo or no treatment. There were no statistically significant risk reductions from statins for total death, total myocardial infarction, total stroke, cardiovascular death, revascularization procedures, and acute heart failure at one month or at four months, although there were favorable trends related to statin use for each of these endpoints. Moderate quality evidence suggests that the incidence of unstable angina was significantly reduced at four months following ACS (RR 0.76, 95% CI 0.59 to 0.96). There were nine individuals with myopathy (elevated creatinine kinase levels more than 10 times the upper limit of normal) in statin-treated patients (0.13%) versus one (0.015%) in the control groups. Serious muscle toxicity was mostly limited to patients treated with simvastatin 80 mg. Based on moderate quality evidence, due to concerns about risk of bias and imprecision, initiation of statin therapy within 14 days following ACS does not reduce death, myocardial infarction, or stroke up to four months, but reduces the occurrence of unstable angina at four months following ACS. Serious side effects were rare.