A Case of Psychosis and Elevated AST and ALT

Diagnosis of rhabdomyolysis and liver-related sequelae

Back to the case

In this case, creatinine kinase was elevated on admission to 83,000 U/L indicating skeletal muscle injury.

Back to the case

In order to definitively diagnose or exclude a case of drug-induced liver injury from either vortioxetine or marijuana, a thorough workup for intrinsic causes of liver disease and a liver biopsy would be needed.

Given the significant elevation in CK, rhabdomyolysis is the most likely cause of abnormal liver enzymes.

Natural history of liver-related sequelae

Figure 1: Changes in AST and ALT levels after their peak in a case series of muscle injury patients.

ALT: alanine aminotransferase; AST: aspartate aminotransferase. Taken from: Nathwani, R, et al. Serum Alanine Aminotransferase in Skeletal Muscle Diseases.Hepatology 2005. 41(2): 380-382.

Figure 2: Decreases in AST mirror decreases in CK as rhabdomyolysis is treated.

Triangles are ALT values, squares are AST values, and diamonds are CK values. CK: creatine kinase; ALT: alanine aminotransferase; AST: aspartate aminotransferase. Taken from: Weibrecht, K, et al. Liver Aminotransferases are Elevated with Rhabdomyolysis in the Absence of Significant Liver Injury. J Med Toxicol 2010. 6:294-300.

  • Another important point to keep in mind: The transaminase increase is not a result of liver injury, but rather skeletal muscle injury.

  • As the patient continues to improve, serial liver chemistry tests should be performed to ensure improvement in the AST and ALT values. Liver chemistry tests should be checked after resolution of the rhabdomyolysis to document normalization of the AST and ALT values.

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