Dear all,
I appreciate your feedback on the following case:
A 33-year-old female, mentally retarded due to encephilitis during childhood, presented to A&E with H/O fever since 2 wks that was subsided 3 days ago. She gave a H/O taken IM injection and ?antibiotics. H/O poor oral intake resulted in dizziness. At the time of presentation, there was no H/O muscle pain or chest pain. Her examinations revealed severe hypotension (85/40 mmHg) and dehydration. Other examinations were unremarkable.
UE1 showed: Na: 174 mmol/L, K: 4.7 mmol/L, Cl-: 128 mmol/L, HCO3-: 19 mmol/L, Urea: 47 mmol/L, Creatinine: 429 umol/L.
Bone profile: corrected Ca++: 2.13 mmol/L (2.15-2.55), Phosphate: 2.76 mmol/L (0.7-1.45), ALP: 35 U/L (27-112).
Mg: 1.38 mmol/L, CRP: 28 (< 5 mg/L)
LFT: T.Bili: 28, ALT 139 IU/L, AST 173 IU/L, TP 83 g/L, albumin 40 g/L
After 3 days of admission, CK was measured because she had Rt-side calf muscle pain that was not severe. CK result was 5534 U/L, sample retrieved from previous day (2nd day of admission) for CK measurenemt. CK was 3600 U/L.
The patient started to recover and no muscular symptoms at all apart from very mild calf pain (according to the patient and her sister).
On 6th day of admission, hsTnT was measured which came high 0.22 ug/L, peaked at a level of 0.069 ug/L (day 12).
CK continued to increase peaking at a level of 6000 U/L (at day 9), then decline rapidly. Serum and Urine myoglobin was measured, the results were 3000 and 1246 ug/L, respectively.
She has secondary hyperparathyroidism as Vitamin D3 level is 35 nmol/L and her PTH is 39.6 pmol/L.
TSH level 0.26 uIU/mL.
Patient is going for EMG and Echo soon.
The preliminary differential diagnosis are ? Rhabdomyolysis ? Myositis ? dermatomyocytis ? asymptomatic hyperCKaemia
What is your thought of such gradual increase in CK in asymptomatic patient?
What are your DDx?
How high CK can reach in different diseases?
Your feedback is appreciated and thank you in advance.
Warm regards,
Asila Al-Musheifri
Al-Nahdha Hospital
Muscat-Oman
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