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Increased aminotransferases in a 12-year-old girl.


A 12-year-old female patient comes to the emergency department after complaining of pain in her thighs and noticing blood-colored urine. Her notable initial chemistry results are shown in Table 1; urinalysis showed red urine and large blood but no red blood cells.


1. What other tests would be useful?

2. What is the likely diagnosis?

3. What is the likely cause of the urine findings?

The answers are below.


Increased aminotransferases often indicate hepatic injury but are also increased with damage to heart and muscle (1). Testing for creatine kinase is helpful, especially when the ratio of aspartate aminotransferase to alanine aminotransferase is >3:1, a value uncommon with liver injury. In acute liver injury the aspartate aminotransferase/alanine aminotransferase ratio is usually <2:1. When measured, the patient's creatine kinase was >32 000 (reference interval 72-367 U/L), confirming that increased aminotransferases were from acute muscle injury (rhabdomyolysis). She had participated in physical education activities (that were extreme sport-like and/or very highly strenuous) 2 days earlier. Breakdown of muscle also releases myoglobin and potassium (2). The positive urine blood with negative red blood cells was due to myoglobinuria, although hemolysis could also cause similar findings.

Author Contributions: All authors confirmed they have contributed to the intellectual content of this paper and have met the following 3 requirements: (a) significant contributions to the conception and design, acquisition of data, or analysis and interpretation of data; (b) drafting or revising the article for intellectual content; and (c) final approval of the published article.

Authors' Disclosures or Potential Conflicts of Interest: Upon manuscript submission, all authors completed the author disclosure form. Disclosures and/or potential conflicts of interest:

Employment or Leadership: A. Smith, Cook Children's Hospital.

Consultant or Advisory Role: None declared.

Stock Ownership: None declared.

Honoraria: None declared.

Research Funding: None declared.

Expert Testimony: None declared.

Patents: None declared.


(1.) Panteghini M, Bais R. Enzymes. In: Burtis CA, Ashwood ER, Bruns DE, eds. Tietz fundamentals of clinical chemistry. 6th ed. St. Louis: Elsevier Saunders; 2008. p 317-36.

(2.) Elsayed EF, Reilly RF. Rhabdomyolysis: a review, with emphasis on the pediatric population. Ped Nephrol 2010; 25:7-18.

Alisha Smith and Van Leung-Pineda *

Department of Pathology and Laboratory, Cook Children's Medical Center, Fort Worth, TX.

* Address correspondence to this author at: Department of Pathology and Laboratory, 801 7th Ave., Fort Worth, TX 76104. E-mail van.leungpineda@

Received October 15, 2013; accepted November 14, 2013.

DOI: 10.1373/clinchem.2013.217760
Table 1. Initial chemistry results.

Test                            Result      Reference interval

Sodium                        140 mmol/L    135-145 mmol/L
Potassium                       5 mmol/L    3.5-5 mmol/L
Chloride                      105 mmol/L     95-110 mmol/L
Anion gap                       4             3-16
Blood urea nitrogen            10 mg/dL       6-20 mg/dL
Creatinine                      0.6 mg/dL     0-0.8 mg/dL
Glucose                        97 mg/dL      60-115 mg/dL
Calcium                         9.3 mg/dL   8.6-11 mg/dL
Total bilirubin                 0.5 mg/dL     0-1.5 mg/dL
CO2                            31 mmol/L     18-27 mmol/L
Aspartate aminotransferase   3669 U/L        15-40 U/L
Alanine aminotransferase      676 U/L        27-42 U/L
Alkaline phosphatase          150 U/L        92-336 U/L
7-Glutamyl transpeptidase      10 U/L        14-35 U/L
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Title Annotation:What Is Your Guess?
Author:Smith, Alisha; Leung-Pineda, Van
Publication:Clinical Chemistry
Article Type:Report
Date:Jun 1, 2014
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