Contributed by Rachel Vanderschelden, MD and Kenichi Tamama, MD, PhD
Contributed by Rachel Vanderschelden, MD and Kenichi Tamama, MD, PhD
CASE PRESENTATION
A man in his 50s presented to the emergency department complaining of abdominal pain and diffuse myalgias. He had recently arrived from a southern state, where he had been treated at an outside hospital for acute kidney injury and rhabdomyolysis, and had left against medical advice. The patient had been transported to the outside hospital by police, who reported that he was acting aggressively and may have sustained a back injury. At our institution, initial labs were significant for a markedly elevated creatine phosphokinase (CPK) (43,951IU/L) as well as elevated liver enzymes and creatinine, indicative of ongoing rhabdomyolysis and acute kidney injury (Tables 1 and 2). Urinalysis was significant for moderate protein and hematuria. The patient was admitted to the inpatient unit and aggressive fluid resuscitation was initiated. An MRI revealed a small tear in the right latissimus dorsi tendon. A urine drug screening immunoassay panel was negative (Table 3). A urine comprehensive drug screen was performed.
Table 1. Comprehensive metabolic panel
| Analyte (units) | Value | Reference Range |
|---|---|---|
| Albumin (g/dL) | 3.7 | 3.4 - 5.0 |
| Alkaline phosphatase (IU/L) | 94 | 38 - 126 |
| Alanine aminotransferase (IU/L) | 812 | 17 - 63 |
| Aspartate aminotransferase (IU/L) | 1042 | 15 - 41 |
| Blood urea nitrogen (mg/dL) | 21 | 8 - 26 |
| Calcium (mg/dL) | 9.0 | 8.4 - 10.2 |
| CO2 (mmol/L) | 28 | 21 - 31 |
| Chloride (mmol/L) | 105 | 98 - 107 |
| Creatinine (mg/dL) | 2.3 | 0.5 - 1.4 |
| Glucose (mg/dL) | 101 | 70 - 139 |
| Potassium (mmol/L) | 4.1 | 3.5 - 5.0 |
| Sodium (mmol/L) | 138 | 136 - 146 |
| Total bilirubin (mg/dL) | 1.3 | 0.3 - 1.5 |
| Total protein (g/dL) | 6.1 | 6.3 - 7.7 |
Table 2. Additional laboratory values
| Analyte | Value | Reference Range |
|---|---|---|
| Creatine phosphokinase (IU/L) | 43,951 | 0 - 200 |
| LDH (IU/L) | 2,601 | < 171 |
| Urine protein | Moderate | Negative |
| Urine blood | Large | Negative |
Table 3. Immune-based urine drug screen results. The cut-off value of each test is given in parentheses.
| Screening Test | Result |
|---|---|
| THC metabolite (100 ng/mL) | Negative |
| Buprenorphine (5 ng/mL) | Negative |
| Fentanyl (1 ng/mL) | Negative |
| Barbiturates (200 ng/mL) | Negative |
| Amphetamine (1,000 ng/mL) | Negative |
| Benzodiazepine (200 ng/mL) | Negative |
| Cocaine Metabolite (300 ng/mL) | Negative |
| Opiate (300 ng/mL) | Negative |
| Methadone (300 ng/mL) | Negative |
| Oxycodone (100 ng/mL) | Negative |
| Phencyclidine (25 ng/mL) | Negative |
Comprehensive drug screen was positive for a cocaine metabolite, benzoylecgonine, as well as noroxycodone and pentylone by mass spectrometry.
