Ronald is a spritely, widowed, retired, 78 year old fella who loves working part-time as a greeter at his local Walmart for the social life it gives him. He had a particularly busy & tiring Saturday on his feet all day, came home & set chicken to heat up in his oven for supper while he lay on his couch watching TV. When the oven timer went off, he couldnt get off the couch ! He could move his limbs weakly, could still speak and see but just wasn’t strong enough to get off the couch. So he lay there helpless and freaking out, trying to reach his phone unsuccessfully, yup just like the movies. The chicken started burning and the smoke set off the fire alarm in his apartment. Concerned neighbors called 911, firefighthers broke in 15 minutes later to find him in his couch appearing to be chilling while his oven was billowing smoke !
In the ED his vitals and mentation were normal, no clinical evidence for stroke, had some mild overall weakness and achiness but was now able to walk slowly. A stat Head CT was normal. He only takes meds for high cholesterol & hypertension which include daily Lisinopril 20mg, Diltiazem 240mg, Tylenol 650mg 1-2 times daily for aches & bedtime Simvastatin 40mg. Doesn’t smoke, harldy drinks alcohol. He said he felt slightly achy overall, but had no tender areas. With your coffee in hand, you login to CoffeeClinicals EMR and Labs pop up as follows:
Since he takes Tylenol (Acetaminophen) daily, you order a tylenol level, comes back undetectable. INR is normal. He is not much of an alcohol drinker so it isn’t alcohol hepatitis seems. Perhaps a GB infection causing weakness and transaminitis? After admission to floor, a Liver U/S is done which is normal, Muphy’s sign negative. Acute Hepatitis A/B/C viral panel all normal. The next day he is feeling stronger, AST/ALT is improved to 500s/200s. Physical therapist takes him for a walk but after 15 mins he is weak again and ends up sitting on the floor ! He is rushed back to bed, Vitals are stable, no stroke like changes. A stat lab panel shows normal Glucose, Potassium, Calcium and similar LFTs. Thats when it hits you ! Muscle weakness ! You order a CK levels, which comes back at 26,000 !! Bingo ! that solves it, our Ronald has Rhabdomyolysis or “HyperCKemia” since creatinine is normal, which was driving his intermittent weakness from muscle inflammation. Many causes exist for elevated CK, in this case it was determined that a combination of Simvastatin and Diltiazem was the likely culprit. Indeed FDA has a black box warning for this. In older population often meds may not get reviewed for years until they cause an issue like this.
Learning Point = If AST / ALT are high but liver seems clinically fine, think of muscle as a source – especially if bilirubin & alkaline phosphatase are normal or relatively low. Skeletal muscle & cardiac muscle both carry AST/ALT (more AST usually). So if AST/ALT are unexpectedly elevated or you cant explain why, consider checking CK levels 🙂
