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Janice L. Zimmerman, MD, FCCP; Michael C. Shen, MD
Author and Funding Information

From Houston Methodist Hospital (Drs Zimmerman and Shen); and Weill Cornell Medical College (Dr Zimmerman), New York, NY.

Correspondence to: Janice L. Zimmerman, MD, FCCP, Houston Methodist Hospital, 6550 Fannin, Ste 1001, Houston, TX 77030; e-mail: janicez@houstonmethodist.org


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;145(2):416. doi:10.1378/chest.13-2400
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To the Editor:

We thank Drs A. E. Mirrakhimov and E. M. Mirrakhimov and Drs Nobre and Thomas for their letters in response to our review article on rhabdomyolysis.1 We agree that elevations of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) concentrations can be excellent clues for the astute clinician to recognize the possibility of inapparent rhabdomyolysis and to order additional testing.2 Of note, the AST to ALT ratio > 2:1 usually seen in acute rhabdomyolysis may not be present with more indolent forms of muscle breakdown, such as in inflammatory myositis.3 Unexpected elevations of lactate dehydrogenase concentrations may also be another nonspecific clue suggesting rhabdomyolysis.2

Measurement of cardiac-specific troponins is useful for cardiac injury screening, but as Drs Nobre and Thomas point out, there are still limitations of these biomarkers to diagnose acute coronary syndrome. An early study found that troponin I and troponin T levels may be elevated in patients with rhabdomyolysis.4 Other studies have suggested that troponin T level is more commonly elevated than troponin I in rhabdomyolysis due to several different etiologies.2,5 Interpretation of an elevated troponin concentration in patients with rhabdomyolysis may be difficult because of limitations of the assay itself5 or concomitant risk factors that could predispose to cardiac muscle injury. Further evaluation for acute coronary syndrome in patients with rhabdomyolysis and an elevated troponin concentration is best left to the judgment of the clinician caring for the patient. We strongly agree that exposure to contrast agents for diagnostic testing should be avoided if at all possible in patients with rhabdomyolysis.

References

Zimmerman JL, Shen MC. Rhabdomyolysis. Chest. 2013;144(3):1058-1065. [CrossRef] [PubMed]
 
Brancaccio P, Lippi G, Maffulli N. Biochemical markers of muscular damage. Clin Chem Lab Med. 2010;48(6):757-767. [CrossRef] [PubMed]
 
Nathwani RA, Pais S, Reynolds TB, Kaplowitz N. Serum alanine aminotransferase in skeletal muscle diseases. Hepatology. 2005;41(2):380-382. [CrossRef] [PubMed]
 
Lavoinne A, Hue G. Serum cardiac troponins I and T in early posttraumatic rhabdomyolysis. Clin Chem. 1998;44(3):667-668. [PubMed]
 
Jaffe AS, Vasile VC, Milone M, Saenger AK, Olson KN, Apple FS. Diseased skeletal muscle: a noncardiac source of increased circulating concentrations of cardiac troponin T. J Am Coll Cardiol. 2011;58(17):1819-1824. [CrossRef] [PubMed]
 

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References

Zimmerman JL, Shen MC. Rhabdomyolysis. Chest. 2013;144(3):1058-1065. [CrossRef] [PubMed]
 
Brancaccio P, Lippi G, Maffulli N. Biochemical markers of muscular damage. Clin Chem Lab Med. 2010;48(6):757-767. [CrossRef] [PubMed]
 
Nathwani RA, Pais S, Reynolds TB, Kaplowitz N. Serum alanine aminotransferase in skeletal muscle diseases. Hepatology. 2005;41(2):380-382. [CrossRef] [PubMed]
 
Lavoinne A, Hue G. Serum cardiac troponins I and T in early posttraumatic rhabdomyolysis. Clin Chem. 1998;44(3):667-668. [PubMed]
 
Jaffe AS, Vasile VC, Milone M, Saenger AK, Olson KN, Apple FS. Diseased skeletal muscle: a noncardiac source of increased circulating concentrations of cardiac troponin T. J Am Coll Cardiol. 2011;58(17):1819-1824. [CrossRef] [PubMed]
 
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