Occasionally, the hepatologist is consulted for markedly elevated transaminase levels…that turn out to be secondary to a non-liver pathology. In this case, a middle aged female was admitted to the liver service with AST > 1000 and ALT > 500. There was an antecedent prodrome of vague symptoms including fatigue and muscle weakness.
The patient also had a markedly elevated CPK (>20,000) and was subsequently diagnosed with dermatomyositis. A photograph of her hands depicts a severe purpuric rash, consistent with this autoimmune entitiy.
The most common alternative source of elevated transaminase levels is skeletal muscle; in such cases CPK, LDH and aldolase levels can help confirm suspicions. Other sources include the heart, kidneys, brain and red blood cells.