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 Table of Contents  
LETTER TO EDITOR
Year : 2020  |  Volume : 15  |  Issue : 3  |  Page : 513-514

Creatine kinase-MB level more than total creatine kinase level: A macro creatine kinase type 2 phenomenon


1 RVT Medical Center, Bangkok, Thailand
2 Dr. DY Patil University, Pune, Maharashtra, India

Date of Submission08-Sep-2020
Date of Decision15-Sep-2020
Date of Acceptance27-Mar-2020
Date of Web Publication1-Feb-2021

Correspondence Address:
Dr. Won Sriwijitalai
RVT Medical Center, Bangkok
Thailand
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_147_19

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How to cite this article:
Sriwijitalai W, Wiwanitkit V. Creatine kinase-MB level more than total creatine kinase level: A macro creatine kinase type 2 phenomenon. J Datta Meghe Inst Med Sci Univ 2020;15:513-4

How to cite this URL:
Sriwijitalai W, Wiwanitkit V. Creatine kinase-MB level more than total creatine kinase level: A macro creatine kinase type 2 phenomenon. J Datta Meghe Inst Med Sci Univ [serial online] 2020 [cited 2021 Mar 7];15:513-4. Available from: http://www.journaldmims.com/text.asp?2020/15/3/513/308545



Sir,

Creatine kinase (CK) is an important enzyme. The measurement of CK is a routine laboratory investigation in the clinical laboratory. The measurement of an important CK isoenzyme, CK-MB, and total CK-MB is generally used as a cardiac marker test for acute cardiac disease.[1],[2] Here, the authors present an interesting case study with an aberrant laboratory result. The analysis of a blood sample of a 58-year-old female patient showed that CK-MB level was equal to 24 U/I and total CK was equal to 20 U/I. The same NAC-activated method was used in the analysis for both total CK and CK-MB tests (two different laboratory tests) in the laboratory. This patient had acute chest pain and the physician in-charge requested for CK and CK-MB test aiming at diagnosis of possible cardiac problem. The patient had no other known personal illness. Repeated analyses were performed in all laboratory tests under standard clinical chemistry laboratory quality control.

The interesting observation is the higher level of CK-MB level than the CK level. It is impossible that the CK-MB level can exceed the total CK level; therefore, the case is suspicious for a possible interference from a macroenzyme phenomenon. The explanation for this case is the macro CK phenomenon. In the measurement, the false overestimation is due to CK-BB isoenzyme. Regarding NAC-activated method for the measurement of total CK, overall of all forms of CK in the blood sample is directly measured. Regarding NAC-activated method for the measurement of CK-MB, only CK-B level is first measured, and then, the derived result is multiplied by 2 to get the final assumed CK-MB level. Therefore, in case that there is an overestimation of CK-BB, the abnormal result with CK-MB level exceeding the total CK level can be expected. The overestimation of CK-BB level might be due to several conditions, such as diseases of lung and kidney.[3],[4],[5] This kind of phenomenon is macro CK type 2.[3]

Liu et al. noted that the phenomenon of spuriously high CK-MB activity out of proportion to total CK is an important condition to be recognized for any cases with elevated CK-MB level despite there is no myocardial injury.[6] A macro CK usually causes a mild elevation, usually <500 IU/L, in CK or a high CK-MB/CK ratio with a normal level of total CK.[7] In laboratory medicine, there are two different types of macro CK, type 1 and type 2. Marco CK type 1 is resulted from immune complex phenomenon and observed in the patients with autoimmune disease.[3] Increased total CK and CK-MB proportion is observable in macro CK type 1.[3] Macro CK type 2 results from the existence of atypical polymeric of mitochondrial-derived CK, which is not related to an autoimmune process. The observation of CK-MB level exceeding the total CK level is a main unique clinical presentation of macro CK type 2.[3] The patient who has macro CK type 2 might be healthy without any comorbidity.[8]

The macro CK type 2 phenomenon is more common among female patient. In the previous study in referencing laboratory, the rate of macro CK type 2 phenomenon is up to 1.5%.[4] Therefore, the practitioner has to recognize the possibility of false overestimation of CK-MB level in clinical practice.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Nursalim A, Suryaatmadja M, Panggabean M. Potential clinical application of novel cardiac biomarkers for acute myocardial infarction. Acta Med Indones 2013;45:240-50.  Back to cited text no. 1
    
2.
Bruins Slot MH, van der Heijden GJ, Stelpstra SD, Hoes AW, Rutten FH. Point-of-care tests in suspected acute myocardial infarction: A systematic review. Int J Cardiol 2013;168:5355-62.  Back to cited text no. 2
    
3.
Devine JE. Macro-creatine kinase as interference in CK isoenzyme determination. Enzyme 1993;30:65-75.  Back to cited text no. 3
    
4.
Wiwanitkit V. CK-MB isoenzyme exceeding creatine kinase, a type of macro creatine kinase phenomenon in Thai hospitalized patients, retrospective data from King Chulalongkorn Memorial Hospital. Chula Med J 2003;47:27-34.  Back to cited text no. 4
    
5.
Vrbica Z, Durovic O, Oreb N. Interference of CK-BB isoenzyme in the determination of CK-MB using the immunoinhibition method in patients with pulmonary di?seases. Lijec Vjesn 1997;119:263-5.  Back to cited text no. 5
    
6.
Liu CY, Lai YC, Wu YC, Tzeng CH, Lee SD. Macroenzyme creatine kinase in the era of modern laboratory medicine. J Chin Med Assoc 2010;73:35-9.  Back to cited text no. 6
    
7.
Galarraga B, Sinclair D, Fahie-Wilson MN, McCrae FC, Hull RG, Ledingham JM. A rare but important cause for a raised serum creatine kinase concentration: Two case reports and a literature review. Rheumatology (Oxford) 2003;42:186-8.  Back to cited text no. 7
    
8.
Whelan PV, Malkus H. A macro creatine kinase isoenzyme in serum of apparently healthy individuals. Clin Chem 1983;29:1411-4.  Back to cited text no. 8
    




 

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