Elevated Creatinine Kinase Levels Research Articles

Macrophagic myofasciitis and vaccination: consequence or coincidence?

Macrophagic myofasciitis (MMF) characterized by specific muscle lesions assessing long-term persistence of aluminum hydroxide within macrophages at the site of previous immunization has been reported with increasing frequency in the past 10 years. We describe clinical and laboratory findings in patients with MMF. We did a retrospective analysis of 16 cases observed in our Neuropathology Laboratory, between January 2000 and July 2013. The mean age of the 16 patients was 48.8 ± 18.0 years; 80.0 % were female. Chronic fatigue syndrome was found in 8 of 16 patients. Half of the patients had elevated creatinine kinase levels, and 25.0 % had a myopathic electromyogram. Thirteen patients received intramuscular administration of aluminum-containing vaccine prior to the onset of symptoms. MMF may mirror a distinctive pattern of an inflammatory myopathy. The vaccines containing this adjuvant may trigger MMF in some patients.

Transverse Myelitis Associated With an Itchy Rash and HyperCKemia

Neuromyelitis optica is associated with severe neurodisability if not recognized and treated promptly. Several autoimmune disorders are associated with this condition and may vary in their presentation. It is essential that clinicians are aware of the uncommon presenting features of neuromyelitis optica and associated autoimmune conditions. A 53-year-old woman presented with nausea and vomiting and was noted to have an asymptomatic elevated creatinine kinase level, which improved with conservative management. She had a history of iron-deficiency anemia due to long-standing celiac disease that was managed with a gluten-free diet. She then presented with recurrent transverse myelitis and a vesicobullous rash over her arms and feet that was pruritic and excoriating. Skin biopsy results confirmed a clinical diagnosis of dermatitis herpetiformis and antibody test findings against aquaporin-4 were positive, leading to a diagnosis of neuromyelitis optica spectrum disorder. She was treated with methylprednisolone sodium succinate, plasma exchange, and azathioprine and has remained in remission. This report highlights the association of neuromyelitis optica with dermatitis herpetiformis, which can present even without clinical features of celiac disease. Nausea, vomiting, and asymptomatic hyperCKemia should be recognized as rare presenting features of neuromyelitis optica.

Telbivudin May Cause Increased Polineuropathy/Myopathy in Liver Transplant Recipients

Purpose: Liver transplantation (LT) is often complicated by chronic renal disease with multifactorial causes. Some recent studies have suggested that telbivudine treatment can contribute to provide an improvement on renal functions, compared with lamivudine in patients with hepatitis B virus (HBV)-related cirrhosis. This study was initiated to examine the effects of switching to telbivudine treatment on renal functions in LT recipients receiving lamivudine treatment for prophylaxis of HBV recurrence. Because of the high percentage of polyneuropathy and myopathy that we observed in the study group, we did an interim analysis, and report our preliminary 6-month results. Methods: Forty patients (35 men) with an average age of 57 years (SD ± 9.38), who had been transplanted for HBV-related cirrhosis were enrolled. All patients had a serum creatinine concentration more than the upper limit of the normal range. Creatinine clearance (CrCl) and modification of diet in renal disease (MDRD) formulation were used to estimate glomerular filtration rate. Serum creatinine kinase (CK) and myoglobin levels were monitored. Electrophysiological tests were performed if the patient had elevated CK and muscle pain and/or weakness. All patients continued their regular immunosuppressive medications. Results: Six-month data were available in 25 of 40 patients. Mean (± SD) of CrCl at baseline (CrCl0), 3-month (CrCl3), and 6-month (CrCl6) were: 53.42±21.19, 51.52±23.08, and 57.81±19.53, respectively. Mean (± SD) of MDRD at baseline (MDRD0), 3-month (MDRD3), and 6-month (MDRD6) were: 47.18±10.59, 48.06±12.89, and 51.67±12.99, respectively. No statistical difference was found between CrCl0 vs. CrCl3, CrCl0 vs. CrCl6, and MDRD0 vs. MDRD3, but the difference was significant between MDRD0 vs. MDRD6 (p=0.017). Of 10 patients who had elevated CK levels underwent electrophysiological tests, seven patients (18%) diagnosed polyneuropathy (n=5) or myopathy (n=2), with a median duration of 6 (range, 2-9) months after switching to telbivudine. Conclusion: Although telbivudine may provide a promising beneficial effect on renal functions in LT recipients, high polyneuropathy/myopathy rates observed in our study group indicate that it is necessary to be very careful with its use in LT settings.

Effect of Spironolactone on Cardiovascular Complications Associated with Type-2 Diabetes in Rats

We have studied the effect spironolactone (20 mg/kg/day) on cardiovascular complications in neonatal model of diabetes in rats, induced by administering 90 mg/kg streptozotocin (STZ), i.p. in 2 day old rats. Diabetes was checked after 12 weeks. At the end of 8 weeks of treatment, various biochemical and cardiac parameters were measured. STZ produced hyperglycemia, hyperinsulinemia, dyslipidemia, increased creatinine, cardiac enzyme and C-reactive protein (CRP) levels, worsened hemodynamic parameters, cardiac hypertrophy and oxidative stress. Chronic treatment with spironolactone significantly reduced serum glucose levels but did not alter insulin levels. It also significantly prevented the dyslipidemia and reduced elevated Lactate de-hydrogenase, creatinine kinase, CRP and creatinine levels. Chronic treatment with spironolactone prevented STZ-induced hypertension, tachycardia and elevated rate of pressure development and decay. Spironolactone also produced beneficial effect by preventing cardiac hypertrophy as evident from left ventricular collagen levels, cardiac and left ventricular hypertrophic indices and prevented oxidative stress. In conclusion, our data suggests that spironolactone prevents STZ induced metabolic abnormalities and cardiovascular complications in animal model of type 2 diabetes.

An unusual case of "renal failure"

Myopathy is common in hypothyroidism, but a very high creatinine kinase (CK) level in the range commonly seen with inflammatory myopathy is rare. Reversible elevation of creatinine is known to occur in hypothyroidism due to a decrease in the glomerular filtration rate, but it can also occur rarely due to enhanced creatinine production. We present a case of severe hypothyroidism with massively elevated CK levels and high creatinine levels, both of which reversed on treatment of hypothyroidism.

Postoperative rhabdomyolysis following pars-plana vitrectomy under general anesthesia

ImportanceRhabdomyolysis is a known, but rare, complication of general anesthesia. To the authors’ knowledge, it has never before been reported following an ocular surgery, and we could find no similar cases in the surgical literature following any brief surgical procedure. We believe this case to be unique in those regards and aim to raise awareness among ophthalmologists of this postoperative complication, as timely intervention can prevent renal failure and death.ObservationsWe report the case of a 58-year-old male who developed rhabdomyolysis following vitrectomy for retinal detachment repair under general anesthesia. The patient had several risk factors for this complication including morbid obesity, type II diabetes mellitus, and American Society of Anesthesia class III risk profile. His postoperative course was notable for significant myalgias in the postoperative recovery area, followed several hours later by oliguria, “root beer” colored urine, and a markedly elevated creatinine kinase level. He was hospitalized for two days for intravenous hydration and monitoring of his renal function and has fully recovered.RelevanceAs the prevalence of obesity and type II diabetes mellitus increase worldwide, ophthalmologists need to be aware of the signs and symptoms of postoperative rhabdomyolysis. Treatment often requires inpatient hospitalization to prevent the associated morbidity and mortality.

Rhabdomyolysis with acute kidney injury in deceased donors is not a contraindication for kidney donation

Deceased patients with acute kidney injury (AKI) from rhabdomyolysis can be considered as potential kidney donors. We performed a retrospective chart review from January 2005 to January 2011 of three donors with AKI from rhabdomyolysis and the four recipients of the donated kidneys. Three donors had AKI from rhabdomyolysis as evidenced by elevated serum creatinine levels, myoglobinuria, and plasma creatinine kinase levels greater than five times the upper limit of normal. All grafts were maintained on pulsatile machine perfusion (MP) prior to transplantation. In one of the patients, serial venous perfusate myoglobin levels were measured from the donor kidney while on MP. Three of the four recipients had delayed graft function, but all had normalized creatinine function after 1 month. One recipient had a creatinine of 1.2 after 79 months, the longest documented follow-up of this kind. Although we measured venous perfusate myoglobin levels from one of the grafts, we found the levels to decrease with increasing time spent on MP. Potential donors with AKI secondary to rhabdomyolysis should not be restricted from the donor pool. MP may play a role in minimizing the effects of AKI in these types of donors.

Bilateral idiopathic orbital inflammatory syndrome with grossly elevated creatinine kinase levels

Sir, Idiopathic orbital inflammatory syndrome (IOIS) is a heterogeneous group of disorders characterized by orbital inflammation without any identifiable cause.1, 2 It commonly affects the EOMs, particularly the lateral rectus,3 lacrimal gland,4 and cavernous sinus.5 Classically it presents with unilateral pain, swelling, proptosis, diplopia, and reduced vision. We report the first case of bilateral IOIS involving all EOMs with an unusually grossly elevated creatinine kinase (CK) level and with a favourable response to steroids.

Polymyositis associated with hepatitis B: management with entacavir and prednisolone

We report a 57-year-old woman with a 20-year history of hepatitis B presenting with progressive proximal lower limb weakness for the previous 1 month. Previous medical history included a pericardial and pleural effusion, of which no cause was found and pulmonary tuberculosis which has been adequately treated. Examination revealed multiple telangiactasia over face and nail beds and bilateral proximal lower limb weakness of power 4/5. Biochemical investigation revealed a raised erythrocyte sedimentation rate of 36 mm/h, elevated creatinine kinase levels (14,363 IU/L) and raised liver enzymes (alanine aminotransferase 445 IU/L, aspartate aminotransferase 606 IU/L) with high hepatitis B virus DNA (1,021,158 copies/mL). Nerve conduction tests and muscle biopsy were consistent with polymyositis. She received entacavir for hepatitis B treatment. Despite treatment with entacavir for 10 weeks, her weakness persisted and prednisolone was added. Upon commencement of prednisolone, her symptoms and biochemical profiles returned to normal.

Left ventriculoplasty for dilated cardiomyopathy in Fukuyama-type muscular dystrophy

A 29-year-old man was hospitalized because of heart failure causing dilated cardiomyopathy (DCM). On admission, he had elevated creatinine kinase levels (hyper CKemia) (4283IUl⁻) and false enlargement of bilateral calves. By a muscular biopsy, he was diagnosed as Fukuyama-type muscular dystrophy. Although neuromuscular diseases are often related to cardiomyopathy, reports showing a relation between cardiomyopathy and Fukuyama-type muscular dystrophy have been rare. Our group performed the partial left venticulectomy of the posterior wall and approximation of the papillary muscle, mitral valve annuloplasty, and tricuspid valve annuloplasty for DCM in the patient with Fukuyama-type muscular dystrophy, after obtaining informed consent from the patient and his family. At the 1-year follow-up examination, the neuromuscular symptoms had not progressed, and the left ventricular function was improved (left ventricular end-diastolic dimension (LVDd) 77-66 mm, left ventricular end-systolic dimension (LVDs) 73-59 mm, and ejection fraction (EF) 26-30%). This is the first case report of a left ventriculoplasty in a patient with Fukuyama-type muscular dystrophy.

Epidemic Pleurodynia Caused by Coxsackievirus B3 at a Medical Center in Northern Taiwan

Epidemic pleurodynia is seldom reported in Southeast Asia and there has been no report from Taiwan. We conducted a retrospective chart review of children = 18 years of age in the National Taiwan University Hospital from January 1 to December 31, 2005. Epidemic pleurodynia was defined as an acute illness characterized by sharp localized pain over the chest or upper abdomen. Patients with known heart diseases or pulmonary consolidations were excluded. In total, 28 patients met the case definition of epidemic pleurodynia. Coxsackievirus B3 (CB3) was isolated in 15 (60%) of the 25 throat swab specimens. Four (14%) of the 28 patients presented chest wall tenderness and only one (6%) of the 18 patients tested had an elevated creatinine kinase level. Twenty-one (75%) of the 28 patients described pleuritic chest pains and 10 (45%) of the 22 chest radiographies exhibited pulmonary infiltrates or pleural effusions. Six patients were observed with tonsillar exudates and one was confirmed to have a CB3 urinary tract infection. The clinical features and radiological findings suggest that CB3-associated epidemic pleurodynia might be a disease of the pleura and occasionally spreads to nearby tissues, resulting in chest wall myositis, pulmonary infiltrates and myopericarditis.

Rhabdomyolysis: a review, with emphasis on the pediatric population

Rhabdomyolysis is a common clinical syndrome and accounts for 7% of all cases of acute kidney injury (AKI) in the USA. It can result from a wide variety of disorders, such as trauma, exercise, medications and infection, but in the pediatric population, infection and inherited disorders are the most common causes of rhabdomyolysis. Approximately half of patients with rhabdomyolysis present with the triad of myalgias, weakness and dark urine. The clinical suspicion, especially in the setting of trauma or drugs, is supported by elevated creatinine kinase levels and confirmed by the measurement of myoglobin levels in serum or urine. Muscle biopsy and genetic testing should be performed if rhabdomyolysis is recurrent or metabolic myopathy is suspected. Early recognition is important to prevent AKI through the use of aggressive hydration. Prevention is important in patients with inherited forms, but novel therapies may be developed with the better understanding of the pathophysiology and genetics of rhabdomyolysis.

Investigation Into the Cardiac Effects of Spironolactone in the Experimental Model of Type 1 Diabetes

We have studied the effect of 8-week treatment with spironolactone (20 mg*kg(-1)*day(-1)) on cardiovascular complications associated with streptozotocin (STZ)-diabetic rats. Wistar rats were made diabetic with STZ (45 mg/kg, intravenously). Various biochemical and cardiac parameters were measured at the end of 8 weeks. STZ produced hyperglycemia; hypoinsulinemia; hyperlipidemia; increased blood pressure; increased creatinine, cardiac enzyme, and C-reactive protein levels; reduction in heart rate; and cardiac hypertrophy. Chronic treatment with spironolactone significantly prevented STZ-induced bradycardia, hypertension, and elevated fasting glucose level with simultaneous increase in serum insulin levels. It significantly reduced the elevated cholesterol, very-low-density lipoprotein, and triglyceride levels and increased the lower high-density lipoprotein-cholesterol levels in diabetic rats. Furthermore, spironolactone also produced a significant reduction in the elevated creatinine levels, C-reactive protein, and levels of lactate dehydrogenase and creatinine kinase. It also produced beneficial effect in diabetic rats by preventing cardiac hypertrophy as evident from decrease in left ventricular collagen levels, cardiac hypertrophy index, and left ventricular hypertrophy index. Our data suggest that spironolactone prevents not only the STZ-induced metabolic abnormalities but also cardiovascular complications.

Neuroleptic Malignant Syndrome or a Statin Drug Reaction? A Case Report

A 60-year-old woman with a long psychiatric history presented with delirium and mutism. She was febrile, with marked limb rigidity and elevated creatinine kinase (CK) level. Current medications included pericyazine. Current or recent use of dopamine-blocking agents, such as pericyazine, together with a disturbance in conscious state, autonomic dysfunction, and an elevated CK level may be suggestive of neuroleptic malignant syndrome (NMS). The diagnosis was confirmed as NMS, and she was successfully treated with bromocriptine. Eight years later, she represents with symptoms suggesting recurrence of NMS including elevated CK level and myalgia, however, without limb rigidity. Current medications include quetiapine, lithium, simvastatin, and a recent course of clarithromycin. Macrolide antibiotics such as clarithromycin inhibit the metabolic pathway of statins via the cytochrome CYP450 3A4 hepatic enzyme system and may result in elevated CK level, myopathy, or rhabdomyolysis producing symptoms that may be confused with NMS. Simvastatin was ceased with rapid decrease in CK level and resolution of symptoms. This case highlights the importance of considering other diagnoses in any patient presenting with a disturbance in conscious state, autonomic dysfunction, and an elevated CK level. Particularly in a patient with a history of NMS, a thorough medication history is essential to aid diagnosis and avoid confusion with presenting symptoms and medical history.

Pediatric influenza‐associated myositis – Nebraska, 2001–2007

Objective Influenza‐associated myositis (IAM), characterized by severe lower‐extremity myalgia and reluctance to walk, is a complication of influenza among children. We investigated IAM in Nebraska during six influenza seasons, 2001–2007. Methods During 2006–2007, we requested reports of severe influenza illness among persons aged <18 years and investigated medical records to identify and confirm IAM cases defined as severe myalgia with elevated serum creatinine kinase level in a patient aged <18 years, occurring within 7 days of laboratory confirmed influenza illness onset. Statewide hospital discharge data (HDD) were reviewed to identify retrospectively confirmed IAM cases during 2006–2007 and five previous seasons, by using surveillance data to define periods of influenza activity. Statewide IAM incidence was estimated for 2001–2002 through 2006–2007. Results During 2006–2007, a total of 13 IAM cases were confirmed by enhanced surveillance. Median age was 6 years (range, 4–11 years). Influenza diagnosis was established by viral isolation from six patients (one influenza A and five influenza B) and rapid diagnostic tests for seven. Twelve (92%) patients, including one who died, were hospitalized for a median of 3 days (range, 1–4 days). Review of HDD identified 12 retrospectively confirmed IAM cases during 2006–2007, including four not reported through enhanced surveillance, and only one during five previous seasons (2003–2004). The HDD‐derived, retrospectively confirmed statewide IAM incidence estimates/1 00 000 population aged <18 years were 2·693 and 0·225 during 2006–2007 and 2003–2004, respectively. Conclusion An IAM epidemic occurred in Nebraska during the 2006–2007 influenza season.

Myasthenia Gravis Complicated with Primary Aldosteronism and Hypokalemic Myopathy

A 34-year-old Japanese man was admitted to an outside hospital with an elevated creatinine kinase level and suspected myositis. He was treated with high dose methylprednisolone, which caused severe aggravation of muscle weakness. He was transferred to our hospital at that time. On admission, chest computed tomography (CT) and the presence of anti-acetylcholine receptor antibodies supported a diagnosis of myasthenia gravis and thymoma. Laboratory findings showed hypokalemia, low plasma renin activity and high serum aldosterone. Further studies, including abdominal CT and adrenal venous sampling suggested primary aldosteronism. At first, thymectomy was performed, and one month later, he was treated with laparoscopic adrenalectomy. Immediately after this procedure, he suffered from myasthenic crisis, which was successfully managed with mechanical ventilation and steroid pulse therapy followed by oral prednisolone. This case presented a serious difficulty in differentiating from various myopathies and giving proper treatment because of a rare combination of independent diseases and their masquerading clinical features.

Dermatomyositis with a Pityriasis Rubra Pilaris‐like Eruption: An Uncommon Cutaneous Manifestation in Dermatomyositis

A pityriasis rubra pilaris-like eruption has been described in patients with dermatomyositis. We describe an 11-year-old girl with dermatomyositis who had additional clinical findings of pityriasis rubra pilaris. Over a year, she developed muscle weakness, increasing fatigue, and a markedly elevated creatinine kinase level in addition to her cutaneous eruption and was seen in our clinic for these complaints. A year earlier, when a generalized, scaly erythematous eruption had appeared, she had been diagnosed as pityriasis rubra pilaris clinically and histopathologically. Dermatologic examination found scaling erythematous plaques involving the trunk and upper and lower extremities. Islands of unaffected skin were intermingled with erythematous plaques that were characteristic of pityriasis rubra pilaris. A skin biopsy specimen showed the findings of dermatomyositis and that diagnosis was made. The laboratory findings, electromyographic pattern, and muscle biopsy were also consistent with dermatomyositis. Her presentation is interesting, as she had been diagnosed as pityriasis rubra pilaris both clinically and histopathologically 1 year earlier and, although the cutaneous lesions had not changed, a diagnosis of dermatomyositis was made a year later.

Facioscapulohumeral Muscular Dystrophy Can Be a Cause of Isolated Childhood Cognitive Dysfunction

Facioscapulohumeral muscular dystrophy is one of the most prevalent muscular dystrophies in the world, resulting from the deletion of tandem repeats on chromosome 4q35. Extramuscular associations include sensorineural hearing loss, mental retardation, and epilepsy. These manifestations are commonly found in those with large deletions and early onset of weakness. A 26-year-old patient with a long-standing history of hearing loss, learning disabilities, and epilepsy presented with new-onset weakness and an elevated serum creatinine kinase level. Genetic testing confirmed sporadic facioscapulohumeral muscular dystrophy with a fragment length of 12 kilobases (normal > 35 kilobases). This unique presentation suggests that facioscapulohumeral muscular dystrophy should be considered in the differential diagnosis of children with cognitive impairment, seizures, and hearing loss.

Monitoring of Creatinine Kinase During Weaning of Intrathecal Baclofen and with Symptoms of Early Withdrawal

Abrupt withdrawal from intrathecal baclofen (ITB) can result in severe rebound spasticity, confusion, and seizures. It has been recently recognized that abrupt withdrawal from ITB may, in rare cases, result in life-threatening rhabdomyolysis, hyperthermia, autonomic disturbances, and sepsis-like presentations. Early recognition of the most severe forms of the withdrawal syndrome is essential for effective intervention. The common and unique features in such individuals seem to be severe increased spasticity and marked elevation in creatinine kinase levels. This case of an individual with T4 paraplegia with recurrent episodes of ITB withdrawal associated with severe spasticity and elevated creatinine kinase levels who required rapid weaning of high-dose ITB to allow removal of an infected pump and catheter illustrates the value of monitoring creatinine kinase levels in evaluation of suspected ITB withdrawal and during rapid weaning of ITB when necessary.

Severe Acute Respiratory Syndrome: The Evolution of a New Epidemic

Severe Acute Respiratory Syndrome: The Evolution of a New Epidemic