Serum Creatinine Phosphokinase Levels Research Articles

Effects of statin use on serum creatinine phosphokinase levels in normal thyroid function.

Statins are common lipid-lowering agents used in dyslipidemia. However, they increase serum creatinine phosphokinase (CPK) levels. Currently, there are no studies on the effect of thyroid-stimulating hormone (TSH) levels on CPK levels after statin administration. Therefore, this study aimed to investigate CPK level alterations after statin administration according to TSH quartiles in participants with euthyroidism. This retrospective analysis included 25,047 patients with euthyroidism. CPK levels were measured before and 6 months after statin administration. Normal TSH levels were divided into four quartiles, and the CPK levels and proportions of patients with normal CPK levels after statin administration for each TSH quartile were evaluated. The baseline CPK level was significantly higher in the lowest TSH quartile (Q1) compared to the other quartiles but decreased after statin administration. Thus, the difference between the CPK levels and the other quartile groups was not significant. The proportion of patients with normal CPK levels was also significantly lowest in Q1 before statin administration; however, no significant difference was noted in the ratio among each group after statin administration. These findings were consistent with the findings of the analysis according to statin intensity. In patients in the lowest TSH quartile of the normal TSH range, the CPK level decreased, and the proportion of normal CPK levels increased significantly after statin administration. However, similar changes were not observed in other TSH quartiles. Therefore, further studies are required to mechanistically confirm these conclusions.

Usefulness of Ultrasound Shear Wave Elastography for Detection of Quadriceps Contracture in Immobilized Rats.

Quadriceps contracture is an abnormal pathological shortening of the muscle-tendon unit. To improve the prognosis of quadriceps contracture, improvement of its diagnostic method is needed. In this study, we evaluated the diagnostic utility of ultrasound shear wave elastography in a rat model of quadriceps contracture induced by immobilization. Fifty Wistar rats were randomly divided into control and immobilization groups. During up to 4 weeks of joint immobilization, the quadriceps elastic modulus, muscle hardness, creatinine phosphokinase levels, joint range of motion, histopathologic parameters, and levels of fibrosis-associated mRNA expression were measured every week in the immobilization and control groups and compared. In the immobilization group, the elastic modulus gradually but significantly increased (p < 0.05) throughout the immobilization period. However, muscle hardness and serum creatinine phosphokinase levels only increased at 1 and 2 weeks after the start of immobilization, respectively. Muscle atrophy and shortening progressed throughout the immobilization group. Collagen type I and III, α-SMA protein, and mRNA expression of IL-1β and TGF-β1 significantly increased (p < 0.05) throughout in the immobilization group. Ultrasound shear wave elastography is the most useful method for clinical assessment of muscle contracture.

Assessment of Serum cholinesterase and Serum Creatinine Phosphokinase Levels in Organophosphorus Poisoning Patients at a Tertiary Care Centre of Northern India

Introduction: Poisoning with Organophosphorus compounds is an important global health problem, possibly the most common acute poisoning in developing countries. This study was done to correlate the severity of acute organophosphorus poisoning with serum cholinesterase and serum creatine phosphokinase level.Materials and Methods: A Prospective observational clinical study was done on 42 patients suspected of Organophosphorus poisoning of age &gt;15 years admitted to the emergency unit at a tertiary healthcare center in northern India. Serum cholinesterase levels and serum Creatinine phosphokinase levels were estimated at the time of admission in all patients and the severity of Organophosphorus poisoning was assessed according to Peradeniya Organophosphorous Poisoning (POP) Scale.Results: In this study, among 42 patients of acute organophosphorus poisoning 32(76.2%)were males and 10(23.8%) were females. Our study authors observed a significant correlation between the severity of poisoning categorized by the POP scale and the serum cholinesterase and Serum CPK level at the time of the patients’ initial presentation. Also found that there was a significant correlation between serum cholinesterase and serum CPK with the outcome of the patients.Conclusion: In our study severity as well as outcomes of OP poisoning was directly correlated with serum cholinesterase level and serum Creatinine phosphokinase.

AASLD practice guidance on drug, herbal, and dietary supplement-induced liver injury.

AASLD practice guidance on drug, herbal, and dietary supplement-induced liver injury.

Efficacy and Safety of SH-1028 in Patients With EGFR T790M-Positive NSCLC: A Multicenter, Single-Arm, Open-Label, Phase 2 Trial

IntroductionAs a novel third-generation EGFR tyrosine kinase inhibitor (TKI), SH-1028 (formerly oritinib) is developed to inhibit both sensitizing EGFR mutations and EGFR T790M mutation. MethodsThis was a multicenter, single-arm, open-label, phase 2 trial (NCT03823807). Eligible patients were those with advanced NSCLC with centrally confirmed EGFR T790M mutation who progressed after first- or second-generation EGFR TKIs or with primary EGFR T790M mutations. Each patient received SH-1028 tablets orally at 200 mg/d until disease progression or intolerable toxicity. Tumor response was evaluated every 6 weeks per the Response Evaluation Criteria in Solid Tumors, version 1.1. The primary end point was objective response rate by an independent review committee. The secondary end points were progression-free survival, overall survival (OS), disease control rate, safety, and so on. ResultsA total of 286 patients with EGFR T790M-positive advanced NSCLC were enrolled in this study, including 59 patients in part A (dose-verification study) and 227 patients in part B (second-line registration study). By data cutoff on September 17, 2021, the independent review committee–assessed objective response rate was 55.9% (95% confidence interval [CI]: 42.4–68.8) in part A and 60.4% (95% CI: 53.7–66.8) in part B. The median progression-free survival was 12.4 months (95% CI: 8.3–20.8) in part A and 12.6 months (95% CI: 9.7–15.3) in part B. The median OS was 26.0 months (95% CI: 23.3–not reached) in part A, and OS was immature in part B. Among the 286 patients, 44 of them experienced at least one grade 3 or higher treatment-related adverse event, with the most common ones as increased serum creatinine phosphokinase level (13 [4.5%]), diarrhea (six [2.1%]), and prolonged QT interval (three [1.0%]). Treatment-related skin rash was reported in 26 patients (9.1%), all grade 1 or 2. There was no interstitial lung disease reported in this study. ConclusionsSH-1028 is efficacious and tolerable in second-line treatment of patients with advanced NSCLC with positive EGFR T790M.

POS0841 HIGH-INTENSITY INDUCTION THERAPY COMBINING TOFACITINIB, RITUXIMAB, AND PLASMAPHERESIS IN RAPIDLY PROGRESSIVE INTERSTITIAL LUNG DISEASE ASSOCIATED WITH ANTI-MDA5 ANTIBODY POSITIVE DERMATOMYOSITIS

BackgroundRapidly progressive interstitial lung disease (RP-ILD) associated with anti-melanoma differentiation-associated protein 5 (MDA5) autoantibody (Ab) -positive dermatomyositis (DM) is one of the most life-threatening autoimmune conditions. The clinical course is very rapid, leading to death within three months after the onset of symptoms. Although triple therapy which consists of corticosteroids, cyclophosphamide, and tacrolimus has been considered as standard therapy and additional treatments including plasma exchange (PE) and rituximab (RTX) have been reported, the survival rate of patients with poor prognostic factors is still poor even if all of these treatments were applied. Recently, there exist increasing evidences regarding the efficacy of tofacitinib (TOF) in refractory DM. We have treated anti-MDA5Ab-positive RP-ILD with multiple poor prognostic factors with high-intensity induction therapy which combined triple therapy, PE, RTX, and TOF.ObjectivesThis study aimed to investigate the therapeutic efficacy of high-intensity induction therapy for patients with anti-MDA5Ab-positive RP-ILD with multiple poor prognostic factors.Methods31 patients who were diagnosed with anti-MDA5Ab-positive DM during 2014 to 2021 in our institution were included in this study. The clinical characteristics for poor prognosis were retrospectively analyzed, and the outcomes of high-intensity induction therapy were analyzed for the survival and adverse events.Results17 cases were treated before the introduction of TOF. Although triple therapy with RTX, PE, or intravenous immunoglobulin (IVIG) were used, eight out of 10 RP-ILD cases with a ferritin level &gt;400 ng/mL (range, 402.5-5,831; mean, 2,342 ± 2,069) died in median 2.5 months. Poor prognosis was predicted by followings; elevated levels of serum ferritin, lactate dehydrogenase, transaminases, creatinine phosphokinase, and C-reactive protein; decrease in platelets, serum albumin, and oxygen saturation; use of oxygen; higher age; shorter disease duration to admission. The addition of RTX and PE was not enough to control RP-ILD in anti-MDA5Ab positive DM, and prevention of the initial exacerbation of ILD following induction therapy was considered to be important. Based on these observations, high-intensity induction therapy was consisted as follows; triple therapy with decreasing the dose of methylprednisolone by half from 1g to 1 mg/kg, liposteroid to suppress macrophage activity, TOF, PE, and RTX. High-intensity induction therapy was applied in eight patients (ferritin levels; range, 412.2-7,095 ng/mL; mean, 3,558±3,152 ng/mL) with multiple poor prognostic factors described above. Although deaths at two months and eight months due to ILD were observed, significant improvement of survival was documented (Figure 1). Two patients in whom RTX was not initially administered, exacerbation of ILD was observed one month later, which prompted the use of RTX. Several adverse events were observed in high-intensity induction therapy. The most common events were reactivation of cytomegalovirus, meanwhile herpes zoster was not documented. Sustained leukocytopenia and thrombocytopenia were observed in three patients, and two patients developed thrombotic microangiopathy which led to the discontinuation of tacrolimus. Fungal infections in lung were also documented. These adverse events were controllable.Figure 1.ConclusionSignificant improvement of survival was observed in patients treated with high-intensity induction therapy. Meanwhile, stratification of patients for poor prognosis would be important.ReferencesNoneDisclosure of InterestsNone declared

Tamarindus indica. Linn leaves ameliorates experimental induced heart failure in Wistar rats

Cardiovascular diseases (CVDs) are highly prevalent in various countries, and heart failure accounts for the majority of deaths. The present study focuses on determining the protective effect of ethanol extract of leaves of Tamarindus indica (TIEE) by in vitro and in vivo methods. In vitro cardiotonic activity was determined using Langendorff's heart perfusion assembly. In vivo studies were performed using Doxorubicin (1.5mg/kg, i.p for sevendays) induced cardiotoxicity in rats. These animals were simultaneously treated with the TIEE at a low dose (200mg/kg, p.o), high dose (400mg/kg, p.o) and standard drug Digoxin (100μg/kg, p.o) for sevendays. At the end of the study, various parameters like electrocardiogram (ECG) recording, serum levels of serum glutamic pyruvic transaminase (SGPT), lactate dehydrogenase (LDH), creatinine phosphokinase (CPK), and presence of cardiac troponin (cTnI) were determined. Isolated hearts were subjected to histopathological studies. The TIEE at a concentration of 60μg/mL showed a significant cardiotonic effect in vitro that was evident by increased force of contraction, heart rate, and cardiac output. In vivo studies revealed that the TIEE decreased the prolongation of QT and RR interval of ECG, lowered the serum enzyme levels like LDH, CPK indicating cardiac protection, and the same was established by the absence of cTnI in blood. Histopathological examinations of heart tissue sections showed improved architecture in the treatment groups when compared with diseased groups. The study revealed the cardioprotective activity of T.indica leaf extract by both in vitro and in vivo methods.

Impact of Anesthetic Agents on Endothelial Glycocalyx Injury during Total Knee Arthroplasty: Desflurane- vs. Propofol-Based Anesthesia-A Prospective Randomized Controlled Trial.

Background Ischemia-reperfusion injury and inflammation after tourniquet deflation in total knee arthroplasty are known to be associated with endothelial glycocalyx (EG) injury. This study is aimed at comparing EG injury between desflurane- and propofol-based anesthesia in patients undergoing total knee arthroplasty. Materials and Methods Patients were allocated to the desflurane group or propofol group. The opioid remifentanil was administered intraoperatively in both groups. Blood samples were obtained from the arterial line preoperatively, immediately before and 5 min after tourniquet deflation, and at 1, 6, and 24 h, postoperatively. Serum syndecan-1, cytokines (interleukin-1β, 6, 10, and tumour necrosis factor-α), and other laboratory values were investigated. Results Eighty patients were included in the final analysis. The change in syndecan-1 did not significantly differ between the desflurane and propofol groups (peak median level of syndecan-1; 754.5 pg/ml vs. 780.3 pg/ml, respectively, P = 0.512). Laboratory values (serum cytokines, creatinine phosphokinase, lactate dehydrogenase, and lactate levels) were also similar between the two groups. Pulmonary oxygenation was briefly improved after tourniquet deflation in the desflurane group but was similar between the two groups begging at 1 h, postoperatively. Conclusions The effect of desflurane was not superior to that of propofol in protecting the EG from ischemia-reperfusion injury during total knee arthroplasty. This trial is registered with Trial Registry Number NCT02756715 (http://clinicaltrials.gov).

Effect of Different Tourniquet Pressure on Postoperative Pain and Complications After Total Knee Arthroplasty: A Prospective, Randomized Controlled Trial

BackgroundTourniquet pressure inflation is commonly selected between 100 and 150 mm Hg above the systolic blood pressure (SBP). Given the lack of evidence to support a given inflation pressure, our study aimed to ascertain the lowest tourniquet pressure that facilitated total knee arthroplasty (TKA) and resulted in the least postoperative pain and complications. MethodsIn a double-blind, randomized controlled trial of patients scheduled for unilateral primary TKA, 150 were assigned to use tourniquet pressures of SBP + 75 mm Hg (group I), SBP + 100 mm Hg (group II), and SBP + 150 mm Hg (group III). The quality of the bloodless field, total blood loss, and limb swelling were determined perioperatively. Clinical outcomes were evaluated by visual analog scale for pain at thigh and surgical site, serum creatinine phosphokinase levels, wound complications, range of motion, and Knee Society Score. ResultsVisual analog scale for pain at thigh and surgical site were lowest in group I (P < .01) and highest in group III (P < .01). However, the quality of bloodless field at the tibial cutting surface was significantly better in group III compared to group I/II but not at the femoral cutting surface. The total blood loss and limb swelling showed no difference among 3 groups. Postoperative serum creatinine phosphokinase levels at 24 and 48 hours and wound complications in group III were significantly higher than group I (P < .01) and group II (P < .01). Nevertheless, postoperative knee range of motion and Knee Society Score were not significantly different among 3 groups. ConclusionPost TKA, the lowest tourniquet pressure was associated with significantly less postoperative tourniquet and surgical site pain, muscle damage, and wound complications.

Electromuscular Incapacitation Current Induced Neuromuscular Tissue Injury.

Electrical stun devices (ESDs) serve a basic role in law enforcement and provide an alternative to lethal options for target control by causing electromuscular incapacitation (EMI). A fundamental concern is the adverse health consequences associated with their use. The capability of EMI electric field pulses to disrupt skeletal muscle cells (i.e. rhabdomyolysis) was investigated over the operational range commonly used in commercial EMI devices. Functional and structural alteration and recovery of muscle and nerve tissue were assessed. In an anesthetized swine model, the left thigh was exposed to 2 min of electrical pulses, using a commercially available ESD or a custom-made EMI signal power amplifier. Serum creatinine phosphokinase (CPK), troponin, aspartate aminotransferase (AST), and lactate dehydrogenase (LDH) levels were monitored intermittently for 6 h post-EMI exposure. A standard external cardiac defibrillator served as a positive control. Muscle and nerve tissue histology adjacent to the EMI contacts were examined. Post-EMI shock skeletal muscle function was evaluated by analyzing the compound muscle action potentials (CMAPs) of the rectus femoris muscle. Maximal energy cardiac defibrillator pulses resulted in rhabdomyolysis and marked elevation of CPK, LDH, and AST 6 h post-shock. EMI field pulses resulted in the animals developing transient acidosis. CMAP amplitudes decreased approximately 50% after EMI and recovered to near-normal levels within 6 h. Within 6 h post-EMI exposure, blood CPK was mildly increased, LDH was normal, and no arrhythmia was observed. Minimal rhabdomyolysis was produced by the EMI pulses. These results suggest that EMI exposure is unlikely to cause extremity rhabdomyolysis in normal individuals. Bioelectromagnetics. © 2020 Bioelectromagnetics Society.

Coronavirus disease 19 in minority populations of Newark, New Jersey

BackgroundThe purpose of this study is to report the clinical features and outcomes of Black/African American (AA) and Latino Hispanic patients with Coronavirus disease 2019 (COVID-19) hospitalized in an inter-city hospital in the state of New Jersey.MethodsThis is a retrospective cohort study of AA and Latino Hispanic patients with COVID-19 admitted to a 665-bed quaternary care, teaching hospital located in Newark, New Jersey. The study included patients who had completed hospitalization between March 10, 2020, and April 10, 2020. We reviewed demographics, socioeconomic variables and incidence of in-hospital mortality and morbidity. Logistic regression was used to identify predictor of in-hospital death.ResultsOut of 416 patients, 251 (60%) had completed hospitalization as of April 10, 2020. The incidence of In-hospital mortality was 38.6% (n = 97). Most common symptoms at initial presentation were dyspnea 39% (n = 162) followed by cough 38%(n = 156) and fever 34% (n = 143). Patients were in the highest quartile for population’s density, number of housing units and disproportionately fell into the lowest median income quartile for the state of New Jersey. The incidence of septic shock, acute kidney injury (AKI) requiring hemodialysis and admission to an intensive care unit (ICU) was 24% (n = 59), 21% (n = 52), 33% (n = 82) respectively. Independent predictors of in-hospital mortality were older age, lower serum Hemoglobin < 10 mg/dl, elevated serum Ferritin and Creatinine phosphokinase levels > 1200 U/L and > 1000 U/L.ConclusionsFindings from an inter-city hospital’s experience with COVID-19 among underserved minority populations showed that, more than one of every three patients were at risk for in-hospital death or morbidity. Older age and elevated inflammatory markers at presentation were associated with in-hospital death.

Effect of Fentanyl and Nalbuphine for Prevention of Etomidate-Induced Myoclonus.

Background:Etomidate is a potent intravenous inducing agent with known undesirable side effects such as myoclonus and pain on injection in nonpremedicated patients.Aims:The aim of this study is to compare the effect of fentanyl and nalbuphine in the prevention of etomidate-induced myoclonus.Settings and Design:Randomized double-blind, placebo-controlled, and prospective comparative study.Materials and Methods:A total of 120 patients were randomly allocated to one of the three groups containing 40 patients each for intravenous administration of fentanyl 2 μg/kg diluted in 10 mL normal saline (NS) (Group 1), nalbuphine 0.3 mg/kg diluted in 10 mL NS (Group 2), and only 10 mL NS (Group 3) over 10 min. All groups subsequently received 0.3 mg/kg etomidate by intravenous bolus injection over 15–20 s and were assessed for the severity of pain using Grade IV pain scale and observed for myoclonus for 2 min and graded according to clinical severity. Serum creatinine phosphokinase (CPK) levels were obtained prior and postetomidate injection.Statistical Analysis:Statistical analysis was performed by the SPSS program version 17.0 for Windows. Tests used are Shaipro–Wilk test, ANOVA, Tukey's multiple comparison test, Tamhane's T2, and the Chi-square test. For all statistical tests, P < 0.05 was considered statistically significant with 5% level of significance (α).Results:The incidence of myoclonus in Group 1 and 2 was 52.5% and 17.5%, respectively, whereas it was 92.45% in Group 3. There was no pain observed in 70%, 92.5%, and 50% of patients in Group 1, 2, and 3, respectively. There was a statistically significant difference in mean CPK level after induction among three groups (P < 0.001).Conclusion:Nalbuphine is more effective than fentanyl in the prevention of etomidate-induced myoclonus and pain with the minimum rise in CPK levels.

Rhabdomyolysis and Acute Poisoning; a Brief Report.

Some studies have reported creatinine phosphokinase (CPK) as a new emerging way in predicting the outcomes of poisoned patients. This study aimed to evaluate the association of serum CPK level in the first 24 hours with outcomes of poisoned patients. This retrospective cross-sectional study was performed using the medical profiles of poisoned patients aged between 13 and 70 years old who were referred to the emergency department of a big referral medical toxicology center during 6 years and whose necessary data for this study was available. 318 patients with the mean age of 34.9±14.5 years were studied (77.1% male). The mean serum CPK level of patients was 4693.1 ± 10303.8 (35-89480) IU/L. There was no significant correlation between serum CPK level and cause of poisoning (r= 0.16; p=0.51), age (r = -0.021; p = 0.651), sex (r = 0.131; p = 0.281), seizure (r = -0.022; p = 0.193), level of consciences (r = -0.138; p = 0.167), and duration of hospital stay (r= 0.242, p = 0.437). The mean serum CPK level was significantly higher in ICU admitted (p<0.0001), AKI (p<0.0001), hyperkalemia (p<0.0001), hypophosphatemia (p=0.045), and hypocalcaemia (p=0.008) cases. The best cut off point of serum CPK level in predicting acute kidney injury (AKI) was estimated to be 10000 IU/L (sensitivity = 83.8% and specificity = 68.8%). It seems that CPK could be considered as a candidate tool for screening the intoxicated patients in need for ICU admission and at risk for AKI.

Risk factors for delayed-onset rhabdomyolysis in doxylamine succinate intoxication patients

Background and Objectives: Patients who overdose on doxylamine, hypnotic agent, usually exhibit good outcomes, but some experience serious complications. Some patients who present with normal creatinine phosphokinase levels in the emergency department later develop rhabdomyolysis during observation. We investigated factors associated with delayed-onset rhabdomyolysis in patients with doxylamine overdoses. Methods: Our investigation period was between 1 January 2011 and 29 February 2016. The initial blood samples were obtained for arterial blood gas analysis and measurements of the levels of electrolytes, creatinine phosphokinase, blood urea nitrogen, creatinine, aspartate aminotransferase, alanine aminotransferase, and lactate dehydrogenase. Urine analyses including pH and occult blood analyses were performed. Follow-up samples were obtained at 6 and 12 h after admission. Delayed-onset rhabdomyolysis was defined by a follow-up serum creatinine phosphokinase level greater than fivefold the upper limit of normal (&gt;1000 IU/L). Comparisons of categorical variables between groups were performed using either the χ2 or Fisher exact tests. Continuous variables were compared between groups using the Mann–Whitney U test. Results: A total of 337 patients were enrolled. The large amount of ingested doxylamine (odds ratio = 7.002), tachycardia (odds ratio = 2.809), low arterial blood gas analysis pH (odds ratio = 2.267), and presence of occult blood in the urine (odds ratio = 2.048) were significant associated with delayed-onset rhabdomyolysis. Conclusion: Laboratory follow-up examinations were required for patients, ingested more than 18 mg/kg doxylamine poisoning, who had pulses exceeding 120 beats/min, had arterial blood gas analysis pH values below 7.3 on blood and urine testing, and/or exhibited the presence of occult blood in the urine, even if the initial creatinine phosphokinase level was normal.

Molecular Characterization, Hematological and Biochemical Studies on Foot and Mouth Disease Virus Serotype O in Buffaloes and Cows in Dakahlia Governorate, Egypt

The present study aimed to evaluate the hematological and serum biochemical parameters in buffaloes and cows infected with foot and mouth disease (FMD) virus. Forty buffaloes and cows (6 months - 2 years old) were used. Twenty buffaloes and cows clinically healthy and were used as control, the other twenty buffaloes and cows showed characteristic clinical signs of FMD. Blood samples were collected and serum was separated from both groups to measure the hematological and biochemical parameters. Infected buffaloes and cows showed fever, anroxia, excessive foamy salivation and ulcer formation in the mouth. Compared to the control buffaloes, erythrocytic count (RBCs), hemoglobin (Hb) and packed cell volume (PCV) in the FMD infected buffaloes were significantly decreased, while mean corpascular hemoglobin (MCH) was significantly increased. In addition, significant increase in toltal leukocyte count (TLC), neutrophils, with a significant decrease in eosinophil and lymphocyte counts were observed. Moreover, cows infected with FMD virus showed no significant changes in the erythrogram, while, significant increases in TLC and neutrophils, with a significant decrease in eosinophil and lymphocyte counts were observed when compared with the control group. There were significant decreases in the levels of serum total proteins, albumin and globulin, while serum asprtate transferase (AST), creatinine phospho-kinase (CPK), glucose and cortisol levels were significantly increased in the infected animals. Tissue and saliva specimens were collected and analyzed by using universal primer using reverse-transcription polymerase chain reaction (RT-PCR). All the identified viruses were of serotype ‘O’. It is concluded that FMDV serotype ‘O’ is circulating among cows and buffaloes in the study area.

Acute rhabdomyolysis associated with levetiracetam therapy in a child

Objective: Levetiracetam (LEV) is a new antiepileptic drug that is effective in adults and children with partial-onset seizures or idiopathic or symptomatic generalized seizures. Side effects include fatigue, somnolence, infection, headache, behavioral changes and skin rashes. Methods: A 13-year-old girl presented with a history of myalgia since last 2–3 days to our hospital. On medical history, she had partial onset of secondarily generalized seizures during sleep since 2 months. The patient was administered LEV monotherapy. One week after starting LEV therapy, she experienced mild myalgia. The physical and neurological examinations were normal. Results: On laboratory examination, creatinine phospho kinase (CPK) was 986 U/L (normal range 27–168). Rhabdomyolysis was diagnosed with clinical and biochemical findings. After stopping LEV, serum CPK level gradually decreased and returned into normal values. Conclusion: We conclude that LEV may cause rhabdomyolysis. Children treated with LEV should be warned regarding these potential adverse effects, to facilitate early withdrawal of drug.

Role of Serum Creatinine Phosphokinase in Outcome Prediction of Intoxicated Patients; a Brief Report.

Several mechanisms were introduced as causes of serum creatinine phosphokinase (CPK) raise in intoxicated patients. This study aimed to assess the relationship between serum CPK level in the first 24 hours and baseline characteristics as well as outcomes of these patients. This one year retrospective cross-sectional study was conducted on all intoxicated patients, who were admitted to a referral toxicology center, Northwest of Iran, stayed for at least 24 hours and had serum CPK level more than 500 IU/L in the first 24 hours of admission. The relationship between serum CPK level and some baseline and outcome variables were studied using SPSS version 21. 413 patients with the mean age of 34.52 ± 15.24 years were studied (78.7% male). The mean CPK level at the time of presentation to ED was 3702.85 ± 6375.29 IU/L. There was not any significant relationship between presenting CPK level and type of poisoning (p = 0.258), sex (p = 0.587), and age (p = 0.817). The area under the ROC curve of CPK in prediction of need for dialysis, need for intensive care unit (ICU) admission, and mortality was 0.67 (95% CI: 0.57 - 0.77), 0.60 (95% CI: 0.52 - 0.69), and 0.60 (95% CI: 0.51 - 0.68), respectively. Based on the finding of present study, there was no significant association between serum CPK level in the first 24 hours and age, sex, and type of poisoning of intoxicated patients and it had poor accuracy in prediction of their need to do dialysis, need for ICU admission, and mortality.

Can Rhabdomyolysis Lead to Transaminitis?

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

A Case of Dematomyositis in a Cancer Patient Presenting as Dysphagia

Dermatomyositis (DM) is a rare idiopathic inflammatory muscle and skin disorder with a 2:1 female predominance, and peak incidence in the 5th and 6th decades of life. DM presents acutely or progressively as painless proximal skeletal muscle weakness and can be associated with the characteristic heliotropic rash around the eyes and Gottron's papules on extensor surface of the hands. Individuals may also present with symptoms of dysphagia, and cardiac or pulmonary involvement. We report a 72-year-old female with renal clear cell carcinoma, breast cancer, and papillary serous carcinoma of the uterus, who presented with progressive weakness, 30 pound weight loss, and difficulty swallowing over the past three months. She also reported difficulty ambulating, facial rash, and inability to extend her fingers. Physical examination revealed a cachectic-appearing woman and areas of hyperpigmentation on her face, arms, and legs. She also had symmetric proximal muscle weakness in both upper and lower extremities. Laboratory findings were significant for an elevated serum creatinine phosphokinase level of 3222 U/L, creatine kinase isoform MB 369.7 ng/mL, aldolase 31.7 U/L, erythrocyte sedimentation rate 40 mm/hr, C-reactive protein 8.41 mg/L, lactate dehydrogenase 804 U/L, and antinuclear antibody positive >1:640. Barium esophagram revealed significant difficulty initiating swallow with laryngeal penetration and aspiration of contrast. Esophagogastroduodenoscopy showed pooling of saliva in the piriform fossa with a normal appearing esophagus. A left biceps muscle biopsy revealed inflammatory myositis with significant necrotizing component suggestive of DM. Further staining with nicotinamide adenine dinucleotide tetrazolium reductase (NADH-TR) stain identified frequent myofibers with targetoid-like changes consistent with DM. She was treated with intravenous corticosteroids, however, she did not respond to the treatment. Thus, a percutaneous gastrostomy tube was placed for enteral feeding. DM is an inflammatory myopathy with cutaneous manifestations and associated with malignancy. Striated muscle in the oropharynx and upper one-third of the esophagus are affected, which results in oropharyngeal dysphagia. Patients with muscle weakness and progressive dysphagia can be a hallmark of malignancy. In our patient, DM presented as dysphagia with multiple malignancies with lack of a response to corticosteroid treatment, which portends a poor prognosis.Figure 1Figure 2Figure 3

Spinning: an arising cause of rhabdomyolysis in young females.

'Spinning' is an indoor cycling regimen. The number of case reports of spinning-induced rhabdomyolysis (SIR) has increased since 2004 in South Korea. The aim of this study is to evaluate the clinical characteristics of SIR and compare it with other causes of rhabdomyolysis. Patients who were diagnosed with rhabdomyolysis from 1 September 2011 to 30 April 2015 were included. We analysed the incidence of rhabdomyolysis, biochemical parameters and forced hospitalisation, which was defined as the days from admission to creatinine phosphokinase < 2000 IU/L. Among 70 included patients, 13 (18.6%) patients were diagnosed with SIR. The mean age of the patients with SIR was 25.69 ± 5.0 years, and most were females under 35 years old (12, 92.3%). Interestingly, the mean duration of spinning exercise before admission was only 59.23 min. Moreover, the patients with SIR showed more severe progress than the all-patients-except-SIR (AESIR) group. The serum creatinine phosphokinase, aspartate transaminase and alanine transaminase levels of the patients with SIR were statistically significantly higher than the patients with AESIR. Additionally, the duration of forced hospitalisation was longer than that of the AESIR (P < 0.01). Spinning could be an important cause of rhabdomyolysis in young, unfit females, which is typically severe. A graded exercise programme is advised at the first session.