Elevated Serum Muscle Enzymes Research Articles

A typical case of Dermatomyositis

Dermatomyositis, a connective tissue disorder, is an idiopathic inflammatory myopathy characterized by skin manifestation. The diagnosis of dermatomyositis is based on characteristic skin rash, progressive muscle weakness, elevated serum muscle enzymes, abnormal EMG and muscle biopsy findings. Here we present an atypical case of a 68year old lady with all typical clinical findings failed to show response despite proper stepwise management.

Severe myopathy in a patient with chronic neurological disease – diagnostic challenges

Polymyositis is a rare disease that belongs to the idiopathic inflammatory myopathies (IIMs) group, characterized by chronic muscle inflammation, and in rare cases a life-threatening condition due to extra-muscular involvement. Even though steroids constitute the building block of treatment of this disease, in severe cases, escalation treatment should be considered in order to obtain good clinical outcomes. We report a clinical case of a 22-year-old female who developed progressive severe systemic muscular weakness, dysphagia and dysphonia, accompanied by elevated serum muscle enzymes, positive myositis-specific antibodies, and muscle biopsy suggestive of inflammatory myopathy. The clinical features and laboratory results led us to the diagnosis of polymyositis. On additional laboratory tests the patient tested positive for Borrelia burgdorferi (Borrelia b) specific antibodies. Due to life-threatening organ involvement the immunosuppressive treatment, immunoglobulin intravenous infusion and pulse therapy with methylprednisolone were initiated and she needed nasogastric tube in order to be fed. Furthermore antibiotic treatment was administrated. The patient improved almost completely after 3 months of treatment.

Dermatomyositosis: a rare case report

Dermatomyositis (DM) is a connective tissue disorder and is an idiopathic inflammatory myopathy characterized by skin manifestations. Diagnosis is based on progressive muscle weakness, skin rashes, elevated serum muscle enzymes, muscle biopsy, and abnormal electromyography. In this case study we report a case of classic DM without co-existing malignancy. Timely diagnosis and administration of corticosteroids and physiotherapy led to a better prognosis for the patient. Corticosteroids are the foundation of the treatment. However, the patient remained generally weak and treatment was advised to be continued on discharge.

“Playing detective” in a case of paraneoplastic polymyositis

Adult-onset polymyositis (PM) belongs to the idiopathic inflammatory myopathy (IIM) group and manifests with proximal muscle weakness, elevated muscle enzymes and positive myositis- specific antibodies. The subset of autoantibodies can indicate a higher risk for cancer association. An 82-year-old diabetic patient, with multiple cardio-vascular comorbidities, was hospitalized for muscle weakness of the upper girdle, dysphagia and dysphonia, accompanied by elevated serum muscle enzymes. Muscle biopsy showed an inflammatory infiltrate while immunological assays found positive ANA and anti-NXP2 antibodies. The diagnosis of PM was established, thus a screening for underlying neoplasia was required. Upper endoscopy visualized an area of ectopic mucosa in the esophagogastric junction and the biopsy confirmed a squamous cell carcinoma in situ. Patient had favorable muscle outcome under methylprednisolone pulse therapy. It is worth noting that polymyositis is more rarely associated with cancers as compared to dermatomyositis (DM). In conclusion, the type of antibodies identified in myositis can represent an alarm signal for oncologic screening, making possible an early diagnosis and efficient treatment of a hidden tumor.

An interesting case of dermatomyositis with classical presentation

Dermatomyositis, a connective tissue disorder, is an idiopathic inflammatory myopathy characterised by skin manifestation. The diagnosis of dermatomyositis is based on rashes on the skin, progressive muscle weakness, elevated serum muscle enzymes, abnormal electromyogram, and abnormal findings on muscle biopsy. Hereby presenting this rare case of a 57-year-old female with dermatomyositis with all the typical clinical findings with interstitial lung disease.

A DEEP-TISSUE MASSAGE WITH UNINTENDED CONSEQUENCES

SESSION TITLE: Fellows Critical Care Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Rhabdomyolysis is a common clinical syndrome that can result from a variety of insults that are generally evident, and well-described. We report a patient with rhabdomyolysis associated with an unusual inciting event. CASE PRESENTATION: A 44-year-old gentleman presented to the hospital with upper extremity myalgias. About 48 hours prior to presentation, he received an upper body massage at a commercial spa over a 30-60 minute duration. Hours after, he sustained a fall from standing via a relatively low mechanism of injury. After waking from sleep the following day his symptoms worsened and he developed dark-brown urine discoloration, prompting his presentation to the hospital. He denied any new medications, excessive physical exertion, or prior similar episodes in himself or relatives. His medication list included gabapentin, oxycodone, and doxepin, without concurrent anabolic steroid use, or illicit drug use. On examination, he was mildly tachycardic but otherwise hemodynamically normal. He had a general muscular build, and bilateral deltoid, upper arm, and forearm edema and tenderness. There was no evidence of neurovascular compromise. Workup showed an elevated creatine phosphokinase (CPK) (66,100 U/L), myoglobinuria (3+ blood, 0-5 RBCs), with unremarkable potassium, phosphate, urine drug screen, and plain films of the affected extremities. The patient was admitted to the medical ICU for hydration and neurovascular monitoring. His serial CPK levels gradually improved over days (1,483 U/L) and he was discharged home. DISCUSSION: Rhabdomyolysis occurs when injured myocytes release their intracellular contents into the extracellular space, which results in subsequent myoglobinuria. Supporting diagnostic features include elevated serum muscle enzymes (CPK =500-1000 U/L), myoglobinuria, proteinuria, hyperkalemia, hyperphosphatemia, and acute kidney injury. Insults include physical, ischemic, chemical and biologic causes. Physical insults such as prolonged exertion and immobilization are established causes for rhabdomyolysis. However, only one previously published report has implicated massage therapy, in which an elderly man developed rhabdomyolysis after a 120-minute massage by two therapists. While massage remains a common Complementary and Alternative Medicine modality, serious adverse events rarely may occur. CONCLUSIONS: Our patient's course highlights a rare encounter which associates deep-tissue massage and rhabdomyolysis by close temporal association, anatomic distribution, and lack of other significant contributing causes. Reference #1: Zimmerman JL, Shen MC. Rhabdomyolysis. Chest. 2013 Sep;144(3):1058-1065. doi: 10.1378/chest.12-2016. Review. PubMed PMID: 24008958. Reference #2: Lai MY, Yang SP, Chao Y, Lee PC, Lee SD. Fever with acute renal failure due to body massage-induced rhabdomyolysis. Nephrol Dial Transplant. 2006 Jan;21(1):233-4. Epub 2005 Oct 4. PubMed PMID: 16204282. Reference #3: Yin P, Gao N, Wu J, Litscher G, Xu S. Adverse events of massage therapy in pain-related conditions: a systematic review. Evid Based Complement Alternat Med. 2014;2014:480956. doi: 10.1155/2014/480956. Epub 2014 Aug 12. Review. PubMed PMID: 25197310; PubMed Central PMCID: PMC4145795. DISCLOSURES: No relevant relationships by Jason Stankiewicz, source=Web Response No relevant relationships by Nevins Todd, source=Web Response

ASSESSMENT AND MANAGEMENT OF A PATIENT WITH PARANEOPLASTIC DERMATOMYOSITIS

Dermatomyositis (DM) is an idiopathic inflammatory myopathy, that can be associated with malignancy. We report the case of a 60-years-old woman, diagnosed and treated for left breast cancer, with residual neoplasm following treatment, who was admitted for generalized myalgias and tetraparesis with predominance of paraparesis. Clinical exam revealed heliotrope rash with bilateral palpebral edema and an erythematous eruption on both thighs and anterior thorax. Motor deficits were predominantly proximal. Paraclinical evaluation excluded other etiologies and revealed elevated serum muscle enzymes and electromyographic pattern of myopathy. An MRI was performed and showed diffuse edematous infiltration of skeletal muscles. Symptoms diminished under corticotherapy, intravenous immunoglobulins and cyclophosphamide. Left mastectomy was eventually performed, but DM symptoms reappeared a few months later. Despite extensive search, no recurrence of tumor was found. However, under treatment, the patient once again recovered, and later resumed her activity.

Primary Aldosteronism with Rhabdomyolysis: A Case Report

AbstractBackground: Most cases of primary aldosteronisms present classic symptoms such as refractory hypertension, hypokalemia, elevated aldosterone and inhibition of renin, and angiotensin. However, some cases with rare clinical manifestations, such as skeletal muscle damage with elevated serum muscle enzymes [rhabdomyolysis], are more difficult to diagnose, and may result in a delayed clinical management.Findings: This paper reports a case of primary aldosteronism presented with rhadomyolysis due to severe hypokalemia. A 43-year-old male with a seven-year history of hypertension was admitted to the hospital with skeletal muscle weakness which he thought progressed rapidly over a period of four days, and resulted in quadriplegia for the preceding 12 hours. His laboratory tests showed hypokalemia [1.7 mmol/l] with elevations of serum creatine kinase and myocardial enzymes. An abdominal computed tomography revealed a 1.4 cm hypodense mass in the right adrenal gland, which suggested adrenocortical adenoma. ...

Sarcoïdose musculaire : à propos d’un cas avec atteinte des muscles et des fascias et revue de la littérature

IntroductionMuscular involvement in sarcoidosis is noted in 50 to 80% of the patients when systematic muscle biopsies are carried out. Nevertheless, symptomatic forms are rare and three different types can be distinguished: nodular, chronic myopathy and acute myositis. Case reportWe report a 43-year-old man who presented with sarcoidosis involving in muscles, fascia and articulations. The diagnosis of sarcoidosis was supported by magnetic resonance imaging and positron emission tomography imaging and confirmed by a muscle biopsy. Clinical manifestations resolved with corticosteroids and methotrexate. ConclusionWe review 23 cases of sarcoidosis myosistis most similar to ours. The commonest presentation is the involvement of the proximal limb muscles in association with elevated serum muscle enzymes.

Rituximab in refractory idiopathic inflammatory myopathies and antisynthetase syndrome: personal experience and review of the literature

In this paper, we report our experience with the use of rituximab (RTX) in the treatment of refractory idiopathic inflammatory myopathies (IIM) and review the literature on this topic. Six adult patients (5 female, 1 male) with active IIM, as defined by persistent proximal muscle weakness, elevated serum muscle enzymes, muscle magnetic resonance imaging, electromyographic and histological abnormalities, refractory to at least one immunosuppressant, including methotrexate, were treated with RTX (1,000 mg twice, 2 weeks apart). Patients were regularly followed up for serial assessment of muscle strength by manual muscle test 8 and creatine kinase serum levels. Three patients were affected with polymyositis (PM) and three with anti-t-RNA synthetase syndrome (ASS). A complete B-cell depletion was observed in all patients by 3 months after RTX. A significant clinical improvement was observed in 5 out of 6 cases 6 months after RTX. Only one mild infusion reaction and one case of Herpes zoster infection were observed. A review of the literature to find all the available cases of refractory patients affected with IIM from 1980 to 2012, using the PubMed database, was performed. We were able to find 27 papers, 18 on PM and dermatomyositis and 9 on ASS, including 88 and 40 patients, respectively. A significant improvement was observed in 80% of patients overall and the drug was well tolerated in the majority of cases. In conclusion, RTX can be considered a therapeutic option in refractory IIM.

P5.25 Inflammatory myopathies – Characteristics of a population

The inflammatory muscle diseases represent a group of rare autoimmune diseases of unknown etiology which can have an acute, subacute or chronic presentation. Polymyositis (PM), Dermatomyositis (DM) and Inclusion Body Myositis (IBM) are the largest group of acquired and potentially treatable inflammatory myopathies. Clinically these entities share the presence of symmetric proximal muscle weakness caused by muscle inflammation and necrosis, heralded by elevated serum muscle enzymes. Frequently there are extramuscular manifestations associated and the presence of myositis-specific auto-antibodies.

Elevated muscle enzymes and muscle biopsy in idiopathic hypoparathyroidism patients.

To study idiopathic hypoparathyroidism (IHP) myopathy and its pathogenesis by histology method. We retrospectively analyzed the clinical data of nine IHP patients during the years 2006-2010. We found that: 1) there was an inverse relationship between the decreased serum calcium level and the elevated muscle enzymes level; 2) the IHP patients had mild-to-moderate muscle cells vacuolar degeneration and focal hyaline degeneration by hematoxylin-eosin (HE) staining; 3) except for 2 patients, the others' muscles striations were undetectable by phosphotungstic acid hematoxylin staining; 4) 2 patients with extremely high level of creatine kinase and relatively longer disease duration had muscle atrophy, multiple focal muscle fiber hyaline degeneration and sarcolemma cells hyperplasia by HE staining; 5) all patients had different degree of immune complex deposition along the muscle cell membranes by immunofluorescence staining. The patients with IHP had some histological changes in skeletal muscles but with no specificity. The changes in muscles and the elevated serum muscle enzymes were related to hypocalcemia. The severity of changes in muscles was related to the duration of hypocalcemia and not only to its degree.

Benign Pneumatosis Intestinalis in a Patient with Juvenile Dermatomyositis

To the Editor: Juvenile dermatomyositis (JDM) is an autoimmune vasculopathy involving primarily the proximal muscles and skin but can involve other organ systems, particularly the gastrointestinal (GI) tract1. In the presence of cutaneous vasculitic ulcerations, one needs to monitor for signs and symptoms suggestive of GI vasculopathy2, which can lead to bowel ischemia, necrosis, ulceration, and perforation1,2,3,4,5. The presence of gas in the bowel wall, also referred to as pneumatosis intestinalis (PI), is an ominous finding when it is due to a GI vasculopathy3. PI is a radiographic finding that is associated with both benign and life-threatening causes. The benign variant of PI has been described in relation to immunosuppressive therapy6 and to JDM itself7. We describe a child with JDM complicated by cutaneous ulcerations and benign PI. An 8-year-old girl, following a 1-month history of rash and fatigue, was diagnosed with JDM based on the presence of Gottron sign, heliotrope rash, symmetric proximal muscle weakness, elevated serum muscle enzymes [creatine kinase (CK) 533 U/l (normal 44–189); lactate dehydrogenase 442 U/l (normal 142–261); aldolase 9.3 U/l (normal 0–7.6)] and findings consistent with myositis on magnetic resonance imaging of the proximal hip and shoulder girdle muscles. Antinuclear and anti-Jo1 antibodies were … Address correspondence to Dr. Scuccimarri; E-mail: rosie.scuccimarri{at}muhc.mcgill.ca

Dermatomiosite juvenil: revisão e atualização em patogênese e tratamento

Juvenile dermatomyositis (JDM) is an autoimmune disease characterized by systemic vasculopathy. Its main manifestations include symmetrical proximal muscle weakness, elevated serum muscle enzymes and cutaneous lesions, among which the heliotrope and Gottron's papules are pathognomonic. Early recognition and prompt therapy allow better prognosis and prevent the development of calcinosis. Although the treatment is based on glucocorticoids, the more commonly associated immunosuppressors include methotrexate, azathioprine, cyclosporine, and cyclophosphamide, depending on the severity of disease. The use of immunobiologicals for refractory cases remains under investigation, but the results are controversial or inexpressive. In this review, we highlight recent updates on the pathogenesis and treatment of JDM.

A Case of Hypercapnic Respiratory Failure in a Patient with Eosinophilic Polymyositis

Eosinophilic infiltration into skeletal muscles has been rarely reported in a variety of conditions such as parasite infection, sarcoidosis, rheumatoid arthritis, eosinophilia-myalgia syndrome, and idiopathic hypereosinophilic syndrome. Eosinophilic myositis (EM) is one of idiopathic inflammatory muscle diseases associated with muscle and/or blood eosiophilia. The case of EM complicated with hypercapnic respiratory failure has been extremely rarely reported. A 61-year-old woman was admitted with sudden-onset pain in both calves. She had elevated serum muscle enzymes and peripheral eosinophil count. Findings of electromyography were consistent with inflammatory myopathy. MRI showed diffuse hyperintensity of calf muscles on T2-weighted and enhanced T1 images. Muscle biopsy showed eosinophils' infiltration in the endomysium and perivascular area. During the diagnostic work-up, she presented with hypercapnic respiratory failure. She was successfully treated with mechanical ventilation and high doses of prednisolone. This case suggests EM can cause respiratory failure secondary to respiratory muscle involvement.

A rare complication of generalized edema in juvenile dermatomyositis: a report of one case

Juvenile dermatomyositis (JDM) is a rare autoimmune disease characterized by inflammation of the muscle, connective tissue, skin, gastrointestinal tract and small nerves. Periorbital and facial edema may also be associated. Although localized edema is a common feature of juvenile dermatomyositis, generalized edema has been reported rarely. In this article, we report a 14-year-old boy with juvenile dermatomyositis presenting with generalized edema. Of the diagnostic criteria of JDM, severe symmetric weakness of the proximal musculature, characteristic cutaneous changes, elevated serum muscle enzymes and myopathic electromyographic abnormalities were observed. Magnetic resonance imaging (MRI) of the lower extremities and pelvis showed marked diffuse edema in the subcutaneous tissue, muscles and myofascia. We suggest that MRI findings, which are not among the diagnostic criteria, may also be included in the diagnostic criteria of JDM. To the best of our knowledge, this is the 19th case of JDM reported for generalized edema in the English literature.

Emergency pharmacological management of aggression among agitated psychotic patients in Japan.

Another study in the same intensive care unit showed that of 259 male patients with acute schizophrenia, 7 percent were dehydrated, a third had hypokalemia and leukocytosis, and twothirds of these patients showed elevated serum muscle enzymes (4). A quarter of the patients required medical management.

Laboratory findings in acute schizophrenia: Relevance to medical management on emergency admission

This study documents the prevalence of abnormal laboratory findings in schizophrenic patients who were admitted, because of acute disease, to a psychiatric intensive care unit in Japan. Patient laboratory data were evaluated retrospectively prior to treatment. Of 259 male acute schizophrenic patients (ICD-10: F2 group), nearly 10% were dehydrated, 33% had hypokalemia and leukocytosis, and 66% showed elevated serum muscle enzymes. This prevalence was statistically significant compared with that of psychiatric outpatients (F1 group). In addition, these medical problems in the F2 group were as frequent as those in the F1 group, i.e., alcohol and/or psychoactive substance abusers (ICD-10), although the problems in the F2 group occurred less often than in the F1 group. Current medication, obvious complications, or the presence of alcohol and/or psychoactive substance abuse in the F2 group were not major causes of these results. The medical problems significantly improved after 8 hours of fluid therapy. These findings strongly suggest the significance of medical management for acute schizophrenic patients on emergency admission as well as for alcohol and/or psychoactive substance abusers.

Rhabdomyolysis as a complication of canine babesiosis

Rhabdomyolysis was diagnosed in two dogs with babesiosis. The first animal presented with muscle pain and caramel-coloured urine, and had markedly elevated serum myoglobin and muscle enzymes. Acute renal failure complicated the clinical picture. The second dog exhibited muscle pain and tremors, together with neurological signs and pulmonary oedema, and died soon after admission. Muscle necrosis and haemorrhage were found at necropsy. In human malaria, a disease clinically similar to canine babesiosis, rhabdomyolysis is unusual, but clinically silent muscle damage appears to be common. Likewise, biochemical evidence of muscle damage is readily found in experimental bovine babesiosis. Muscle enzymes were mildly elevated in three dogs with severe babesiosis and pigmenturia but there was no obvious muscle damage, indicating that this might also apply to canine babesiosis. The pathogenesis of infection-associated rhabdomyolysis and acute renal failure remains unclear, but inflammatory cytokines and nitric oxide could play an important role.

Exercise-Induced Upper Extremity Rhabdomyolysis and Myoglobinuria in Shipboard Military Personnel

During a 6-month Amphibious Task Force deployment to the Mediterranean Sea, five sailors and Marines were admitted to the ship's ward with severe upper extremity pain, elevated serum muscle enzymes, and a urinalysis dip positive for blood in the absence of microscopic hematuria-a finding highly suggestive of myoglobinuria. Each patient had begun a vigorous upper-extremity work-out program in the ship's weight room 1 to 3 days prior to development of symptoms. All responded well to vigorous intravenous hydration, mannitol diuresis, alkalinization of the urine, and skeletal muscle rest. No patient developed acute tubular necrosis. With increasing emphasis on physical fitness and body building, this condition is likely to become more frequent. The most important preventive measure is gradual conditioning. Awareness of this entity and early aggressive management are necessary to avoid the potentially severe complication of renal failure.