Elevated serum creatine kinase levels in psychiatric practice: differential diagnosis and clinical significance: A brief, practical guideline for clinicians

Abstract

Introduction. Elevated serum CK levels often occur in psychiatric in-patient practice. Although the majority of cases are benign and temporary, it is important to recognize and treat these conditions. Aims. To discuss the etiology, the clinical significance and the management of elevated creatine kinase levels in psychiatric in-patient practice, focusing on antipsychotic-induced rhabdomyolysis. To compare the pathogenesis and the clinical features of rhabdomyolysis and neuroleptic malignant syndrome. Methods. Review of the literature. Results. A brief, practical guideline is introduced, which may help clinicians in the differential diagnosis and in the management of patients with elevated creatine kinase activity in emergent psychiatric practice. Conclusions. The most common etiologic factors (prescription drugs, alcohol, physical reasons, cardiac etiology) and clinical syndromes (rhabdomyolysis, neuroleptic malignant syndrome, acute coronary syndrome) should be considered, when elevated creatine kinase levels are encountered in psychiatric in-patients. Routine creatine kinase measurements in asymptomatic patients on antipsychotic medications are not recommended, but patients should be carefully followed for the development of rhabdomyolysis, when muscular symptoms arise. Careful monitoring of symptoms and potential complications is critical in order to avoid devastating clinical consequences. Cautiously challenging patients with another antipsychotic after an antipsychotic-induced rhabdomyolysis is recommended to decrease the possibility of recurrence.

Creatine kinase elevation and discontinuation of clozapine: fear-driven clinical practice in a forensic case with treatment-resistant schizophrenia and persistent violent behaviour

“…18 Periodic monitoring of clinical symptoms and creatine kinase levels has been recommended by several studies. 18,19 A systematic review of 42 published cases of MACKE – nine with clozapine treatment – found a prevalence of 2–7%. 20 MACKE was more frequent in males and in SGA-treated patients.…”

Alcohol Induced Rhabdomyolysis

“…The muscle damage was caused by activated neutrophils that infiltrate the damaged muscle tissue and release protease in response to liberated toxic cellular contents (9,12). Considering the induction of immune pathway by ethanol, one hypothesis should be contemplated: Corticosteroid administration helped diminish the inflammatory exacerbation of muscle damage and potentially decreased secondary immune-mediated muscle damage.…”

“…Ethanol causes rhabdomyolysis through disruption of Adenosine triphosphates pump function, break down of the muscle membrane, alteration of the sarcoplasmic reticulum, sodium permeability and disrupting calcium homeostasis, inducing cytokine releasing the levels of "interleukin (IL) 1, IL-2, IL-6", and" tumor necrosis factor α" (8)(9)(10)(11)(12).…”

Valproate-Associated Isolated Serum Creatine Kinase Elevation

“…On the other hand, serum CK evaluation is important in patients not only with symptoms of muscular pathologies such as muscle weakness, spasms, and myalgia, but also essential in patients using psychotropic medication. 8 Serum CK elevation in muscular pathologies characterized to be accompanied by increased serum levels of liver enzymes including aspartate aminotransferase, alanine aminotransferase, lactate dehydrogenase, and aldolase 9 ; therefore, because our patient had an increased serum CK without any liver enzyme elevation and had not muscle-related symptoms, we excluded a muscle disorder for the diagnosis. We also excluded NMS because its characteristic findings that hyperthermia, muscle rigidity, autonomic dysfunction, altered mental status, and leukocytosis were not observed.…”