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Serum Enzyme Abnormalities  -  Outlines in Clinical Medicine on Physicians' Online 2001

Creatinine Phosphokinase (CPK) Elevation

1. Myocardial Infarction (Increased MB Fraction)
2. Troponin T appears more sensitive indicator for cardiac damage than CPK [1]
3. Myocardial Cell Death due to procedures (eg. PTCA)
4. Rhabdomyolysis (Crush injury; severe dehydration with muscle breakdown)
5. Muscular Dystrophy*
6. Inflammatory Myostitis*: Dermatomyositis / Polymyositis
7. Hoffman's Syndrome: myositis due to hypothyroidism
8. Muscle Trauma, Intramuscular Injection
9. Brain Infarction (stroke), Seizure, Neuroleptic Malignant Syndrome: BB fraction of CK
10. CK is produced by some Prostatic and Bronchogenic CAs
11. *Note that regenerating skeletal muscle often expresses the MB isozyme of CK

ABNORMAL LIVER FUNCTION TESTS (LFTS)

A. AST (SGOT) and/or ALT (SGPT) Elevations

1. Alcoholic Liver Disease (AST usually <4 fold elevated ; AST/ALT ratio >2)

2. Acute Hepatitis

• a.Viral (Hepatitis A, B, C, E)
• b.Other Viruses (acute and chronic): EBV, CMV, adenovirus, HSV, Yellow Fever, VZV
• c.Drug Related

3. Chronic Hepatitis

• a.Chronic active viral hepatitis
• b.Chronic Autoimmune hepatitis
• c.Metobolic: Hemochromatosis, Wilson's Disease, a1 antitrypsin deficiency

4. Drug Related Hepatitis (partial list)

• a.  Isoniazid, rifampin, tetracyclines, griseofulvin, ketoconazole, fluconazole, itraconazole
• b.  Trimethoprim-Sulfamethoxazole (TMP/SMX)
• c.  Niacin, HMG-CoA reductase inhibitors
• d.  Acetaminophen (Tylenol®, Paracetamol), NSAIDs (high dose), methotrexate
• e.  Alpha-methyldopa, Vitamin A, propylthiouracil (PTU), halothane, chemotherapy
• f.  Toxins: carbon tetrachloride, benzenes

5. Other infectious processes

• a.  Focal Infections: Tuberculosis, MAI, Amoebiasis, Abscess (bacterial, fungal)
• b.  Pneumonia (especially pneumococcal, legionella)
• c.  Ascending Cholangitis

6. Vascular Disease

• a.  Anoxia (hypotension) - Shock Liver (extremely high and rapid increase in LFTs)
• b.  Budd-Chiari Syndrome
• c.  Severe Right Sided Congestive Heart Failure
• d.  Hepatic Venoocclusive Disease

7. Surgical obstruction of biliary ducts

8. HELLP Syndrome: hemorrhage, elevated liver enzymes, low platelets

9. Total Parenteral Nutrition (TPN)

10. ALT is more specific for liver than AST

• a.AST elevated in erythrocyte hemolysis/destruction
• b.AST elevated in myocardial ischemia and infarction

B. Alkaline Phosphatase Elevations

1.  with little or no AST, ALT elevations

2.  Liver (heat stable) and bone (heat labile) produce most of body's Alkaline Phosphate

3.  Gallstone Related: a.Cholelithiasis usually with jaundice     b.Acute cholecystitis

4.  Sclerosing cholangitis - predmoninantly male, many have Inflammatory Bowel Disease

5.  Primary biliary cirrhosis - Majority of cases in middle aged (20-45) females

6.  Steatosis: fatty liver (alcoholic, tetracyclines, pregnancy)

7.  Cholangiocarcinoma

8.  Infection or Tumor Infiltration in Bone or Liver

9.  Granulomatous Disease : Sarcoid , Tuberculosis , Fungal Infection , Various hepatic granulomatous diseases , Histiocytosis

10.  5'-nucleotidase (5'NT) is highly specific for liver cholestasis (obstruction)

11.  Gamma-glutamyl transferase (GGT) is less specific and is inducible with drugs

References

1.Hamm CW, Ravkilde J, Gerhardt W, et al. 1992. NEJM. 327(3):146

2.Pratt DS and Kaplan MM. 2000. NEJM. 342(17):1266

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