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Thread: Dr Gus-thoughts?...CPK level in blood work

  1. #1
    Senior Member GailS's Avatar
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    Default Dr Gus-thoughts?...CPK level in blood work

    Hello Dr Gus, I'd like your thoughts on this.

    Case History:

    Tolly is 11 + years old, and has a seizure disorder, which started when he was one month shy of 3 years old. He takes phenobarbital to control the seizures, and has for over 8 years. In January 2010 his ALT shot through the roof, very scary. A reduction in his phenobarbital dose (from 18.25 mg a day to 15 mg a day) and Denosyl daily was started.

    Six months after this his ALT has gone back to normal range, and with testing every 3 months has remained there. ()

    However for the past three years his CPK enzymes have been elevated above normal range, usually in the 800s. My vet explained that this usually indicates heart trouble or neuro-muscular issues, or some trauma such as being hit by a car, none of which is applicable to Tolly.

    We also wondered if the phenobarbital somehow had any bearing on this. his Phenobarbital levels are checked annually and are in normal range.

    She is going to talk to the techs at the lab they use, but I wondered if you had ever encountered this or had any thoughts on it.

    Thanks for reading, I tried to keep it short but I am not very good at keeping it short.

    Gail

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    Staff - Veterinary DrGus's Avatar
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    I talked with an internal medicine specialist about this, she said phenobarb wouldn't cause the CK increase, but a seizure certainly could due to the muscle exertion.

    From Idexx Reference Lab's web site:


    Creatine Kinase (CK)


    --------------------------------------------------------------------------------

    •CK characteristics:
    ◦Located in cell cytosol (cytoplasm) and catalyzes a reversible reaction involving the transfer of phosphate (PO4) from creatine-phosphate to ADP, to form ATP.
    ◦Creatine-phosphate is produced in resting muscle and the opposite reaction provides energy during periods of muscle activity.
    •Tissue sources of measured serum CK:
    ◦Highest: skeletal muscle, cardiac muscle
    ◦Low: gastrointestinal tract, uterus, kidney, urinary bladder and thyroid gland
    •CK activity:
    ◦Serum half-life of CK:
    ■2 to 4 hours (short)
    ◦After muscle injury, serum CK activity:
    ■Increases rapidly, peaks in 6 to 12 hours
    ■Can return to normal (reference intervals) within 24 to 48 hours after a single minor injury, but several days may be required to return to reference intervals after cessation of the injury.


    Common Causes of Decreased CK

    •Not clinically significant


    Common Causes of Increased CK (*More common causes)

    •Hemolysis (artifact, interference with assay)
    •*Trauma
    ◦*Traumatic restraint, hit by car, difficult venipuncture, prolonged recumbency, muscle manipulation, surgical procedures, intramuscular injections and muscle biopsy
    •*Skeletal muscle disorders
    ◦Injury/necrosis (trauma, post-infarct ischemia, cardiomyopathy, saddle thrombus, DIC, snake/spider envenomation, heatstroke)
    •Myositis
    ◦Clostridial diseases, pyogenic bacterial infections, endocarditis/systemic infections, immune-mediated polymyositis, eosinophilic myositis, toxoplasmosis, neosporosis. Uncommon, but can cause significant and sustained increases.
    •*Exertional disorders
    ◦Exertional rhabdomyolysis, seizures, azoturia/tying up syndrome, capture myopathy
    •Inherited or congenital degenerative myopathies/myotonia
    ◦Musculodystrophy, hyperkalemic myopathy
    •Nutritional myopathies (vitamin E/selenium deficiency, hypokalemia of cats, taurine deficiency)
    •Toxic (ionophore toxicity, castor bean, gossypol, monensin)
    •Neoplastic- metastatic neoplasia
    •Miscellaneous disorders
    ◦Hypothyroidism in dogs (inconsistent CK results and unknown mechanism), urinary obstruction, vomiting, shivering/trembling, transport myopathy, malignant hyperthermia, porcine stress syndrome, hypothermia, endometritis in cattle.


    Related Findings

    •AST may be increased, especially with muscle necrosis
    •LDH may be increased, especially with muscle necrosis


    Other Diagnostic Tests

    •Serial determination of CK to differentiate active versus resolving muscle injury
    •AST may help to assess the severity of muscle injury
    •Urinalysis, urine myoglobin: myoglobinuria indicates severe muscle injury and may alert the clinician to the need to monitor renal function
    •Glutathione peroxidase (for selenium) and vitamin E assays- identify possibly nutritional myopathies
    •Serologic tests: antibody titers for suspected infection with Toxoplasma gondii and Neospora caninum
    •Anti-nuclear antibody if suspected immune-mediated polymyositis
    •Serum potassium and fractional renal excretion of potassium for cats with suspected hypokalemic polymyopathy
    •Thyroid function tests: total T4, free T4, and cTSH for confirmation of canine hypothyroidism


    References:

    •Ettinger SJ, Feldman EC, eds. Textbook of Veterinary Internal Medicine, 6th ed. St. Louis, MO: Elsevier Saunders; 2005
    •Kaneko JJ, Harvey JW, Bruss ML. Clinical Biochemistry of Domestic Animals, 6th ed. San Diego, CA: Academic Press; 2008.
    •Stockham SL, Scott MA. Fundamentals of Veterinary Clinical Pathology, 2nd ed. Ames, IA: Blackwell; 2008
    •Thrall MA, Baker DC, Campbell TW, et al. Veterinary Hematology and Clinical Chemistry. Philadelphia, PA: Lippincott Williams and Wilkins; 2004.

    Last updated 1/1/2010
    Dr. Gus

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    Senior Member GailS's Avatar
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    Dr Gus thank you very much for the information. Tolly has not been having any seizures, only three since we reduced his phenobarbital, and none in the last 6 months, and before that none in over 6 years.

    Vet also wondered if stress, tensing of his muscles, could cause this.

    He was five weeks old when I rescued him, but there was no indication he had suffered any physical trauma at the time.

    All other blood work is normal, as was his last UA, which was in July.

    One thing I noticed, when I looked over his blood work from 5 or more years ago, that the CK range was different. I know it can vary from lab to lab but way back when, his values were in the 500 range, and 800 was listed as the high end of normal. These days however 500 is listed as the high end of normal, but Tolly's numbers are 700-800 range for the past three years.

    I don't know if my vet has spoken with the lab techs yet.

    Thank you for taking the time to reply and share the info.

    Gail

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    I will say one other thing, we run a lot of Wellness blood panels on healthy pets and we see unexplained high CK's fairly often in pets with no problems at all.
    Dr. Gus

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    Senior Member GailS's Avatar
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    Thanks Dr Gus, that is reassuring, and probably what my vet thinks too. She likes to get to the bottom of things though, so she's got me digging too. I worry she'll burn herself out.

    Gail

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    One thing that will result in elevated CPK is hemolysis of the blood sample. Of course, that should give other results that are a bit off, but CPK is one that often is the first noticed. Even a small amount of hemolysis will cause an elevation. That's always a question I would ask if I saw an elevation in that parameter when I was reviewing data in my past life. Sometimes it was mentioned, but often I had to start to dig into the raw data to find it.

    Handling of an animal can also cause problems, getting them into a crate or struggling while in the crate, etc. can cause some slight elevation as well.

    Linda

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    Quote Originally Posted by LindaD View Post
    One thing that will result in elevated CPK is hemolysis of the blood sample. Of course, that should give other results that are a bit off, but CPK is one that often is the first noticed. Even a small amount of hemolysis will cause an elevation. That's always a question I would ask if I saw an elevation in that parameter when I was reviewing data in my past life. Sometimes it was mentioned, but often I had to start to dig into the raw data to find it.

    Handling of an animal can also cause problems, getting them into a crate or struggling while in the crate, etc. can cause some slight elevation as well.

    Linda
    You are quite correct. What did you do in your previous life? Even restraint for the blood draw in a fractious cat can cause an elevation. Some labs include with the results a note if hemolysis is present in the sample, the degree of hemolysis, and a list of the various tests it could affect.
    Dr. Gus

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    Senior Member GailS's Avatar
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    Linda, thanks for chiming in, but I don't know what hemolysis means, can you explain?

    I do know that Tolly does not struggle at all during blood taking, and he always allows me to put him in his crate. He's so used to it, he just sits there like a pro and lets them get on with it. He does the same as when I trim his claws, he looks away as if he can't bear to watch.

    Gail

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    Quote Originally Posted by GailS View Post
    Linda, thanks for chiming in, but I don't know what hemolysis means, can you explain?

    I do know that Tolly does not struggle at all during blood taking, and he always allows me to put him in his crate. He's so used to it, he just sits there like a pro and lets them get on with it. He does the same as when I trim his claws, he looks away as if he can't bear to watch.

    Gail
    Hemolysis is the rupture of red blood cells. Cat red blood cells are more fragile than those of dogs, and hemolysis is more common in cats as a result (and cats are usually less cooperative having a blood sample drawn). It happens sometimes no matter how the sample is drawn; a veterinary pathologist told me "cat blood just doesn't like being sucked up through a needle, put in a tube, and shipped off to the lab."
    Dr. Gus

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