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An Unusual Case of “High” CPK

Hari R Pokhrel, MD Chris M Lowry, DODeepa R Ovian, MD

Mount Ketu

Case Presentation

v  25 yo AA male to the ED

v  PMH/PSH: HTN/ Ankle fracture

v  No known psychiatric history

v  Family History: non -contributory

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Case Presentation

v  Medications: - Ibuprofen/Tylenol prn - No OTC/Herbals/Supplements

v  0.5 ppd x 8 yrs

v  No alcohol use

v  Denied illicit drugs

Physical Examination Vitals: 36.7C, 167/88 , 75, 22, 95% on RA

Physical: No tenderness in back or calf muscles.

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Investigations

Abnormal Labs: v  Creat 1.58, AG 17

v  U/A : 2+ blood, 2+ Albumin, sp gr: 1.037

v  CPK: 1416 (normal <260)

v  Hemogram: ↑ WBC with Neutrophilia

v  U-Tox: Negative

Treatment IV fluidsPain Control

By next day: Creatinine, Lytes, AG, WBC normal.

CPK Rising.

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The Turning Point

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K2 / Synthetic Cannabinoids

K2 Vs Marijuana

Receptor Drug (Agonist)

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Havoc of K2- “Deadly” & “Crazy”

↑ 330%

15 Deaths

Source: Data extracted from NMS Labs Laboratory Information Management System . October 2010 - January 2014.

What is the difficulty?

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syn

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ariju

ana

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Back to Our patient

0

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Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 9

CPK

Learning Points v Do not rule out drug abuse

completely based on “negative” U-tox Screen.

v Consider Synthetic Cannabinoids / K2 /designer drugs in the differential in appropriate patients.

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References 1.  - Acute kidney injury associated with synthetic cannabinoid use--multiple states, 2012. - MMWR Morb Mortal Wkly

Rep.2013 Feb 15;62(6):93-8. - 2013 Feb 15.

2. - van AJ, - BT, - van den BW. - The adverse health effects of synthetic cannabinoids with emphasis on psychosis-like effects. - J Psychopharmacol.2015 Mar;29(3):254-63.doi: 10.1177/0269881114565142.Epub 2015 Jan 13. - 2015 Mar.

3. - BG, - JG, - FH, - LL, - TD. - AKI associated with synthetic cannabinoids: a case series. - Clin J Am Soc Nephrol.2013 Apr;8(4):523-6.doi: 10.2215/CJN.05690612.Epub 2012 Dec 14. - 2013 Apr.

4. - BT, - CM. - A review of clinical manifestations in adolescent and young adults after use of synthetic cannabinoids. - J Spec Pediatr Nurs.2014 Apr;19(2):119-26.doi: 10.1111/jspn.12057.Epub 2013 Dec 10. - 2014 Apr.

5. - DD, - DL, - de la PD, - ND. - Psychosis and severe rhabdomyolysis associated with synthetic cannabinoid use: A case report. - Clin Schizophr Relat Psychoses.2015 Jan;8(4):205-8.doi: 10.3371/CSRP.DUDE.031513. - 2015 Jan.

6. - JT, - GR. - "Herbal incense": designer drug blends as cannabimimetics and their assessment by drug discrimination and other in vivo bioassays. - Life Sci.2014 Feb 27;97(1):64-71.doi: 10.1016/j.lfs.2013.07.011.Epub 2013 Jul 25. - 2014 Feb 27.

7. - KA, - AR. - Synthetic marijuana and acute kidney injury: an unforeseen association. - Clin Kidney J.2013 Jun;6(3):330-3.doi: 10.1093/ckj/sft047. - 2013 Jun.

8. - KB, - MM. - Toxicology and management of novel psychoactive drugs. - J Pharm Pract.2015 Feb;28(1):50-65.doi: 10.1177/0897190014544814.Epub 2014 Sep 26. - 2015 Feb.

9. - WD, - OC. - The "new" marijuana. - Ann Pharmacother.2011 Mar;45(3):414-7.doi: 10.1345/aph.1P580.Epub 2011 Feb 15. - 2011 Mar.

Thank You for listening!

Lake Gosaikunda, Nepal

Any ??? / Comments