Case Presentation: A 53-year-old male with no past medical history of seizures, and an otherwise limited medical history aside from a remote stroke, was admitted after witnessed seizure activity. He was loaded with Keppra. However, due to ongoing agitation and airway concerns, he was intubated and sedated with propofol. A CT of his head showed no acute abnormalities, although it did show the prior CVA. The patient was extubated and showed no ongoing seizure activity or focal deficits. An EEG showed no epileptiform discharges. However, he continued to have a persistent and rising CK. The differential diagnosis included several etiologies that were ultimately determined to be unlikely. Due to the short duration of intubation, and thus the short duration of propofol, the team felt that his rising CK was not due to propofol infusion syndrome. Given the lack of ongoing seizure activity and the exponentially rising CK, seizures also seemed an unlikely contributing factor. The patient had been on a statin prior to admission, due to the prior CVA. However, this had been initiated remotely at the time of the stroke, and the CK rise was new and temporally related to the onset of the seizures and Keppra load instead. Neurology was engaged but, due to efficacy and Keppra being well tolerated generally, they declined to discontinue the medication and chose to monitor the CK climb on Keppra until it stabilized and began to decline. Thereafter, he was able to be discharged with follow up monitoring.
Discussion: Our patient with seizures suffered from a rare and poorly understood medication-induced complication. The Keppra induced rhabdomyolysis diagnosis was questioned since he had various potentially contributing factors present during the admission. However, the temporal relationship of the Keppra initiation and the CK rise ultimately fit the best clinical picture. Although Keppra is generally well tolerated, previous studies have reported its potential to induce rhabdomyolysis. Clinicians should consider monitoring serum CK and creatinine levels within the first several days of treatment when starting Keppra, especially if renal function declines. Of note, should the renal function decline be more gradual, interstitial nephritis secondary to Keppra should also be considered in the differential diagnosis.
Conclusions: Keppra is a rare cause of rhabdomyolysis. Patients presenting with Keppra induced rhabdomyolysis can be further difficult to ascertain, as it typically happens with initiation, often after a seizure, which can also cause rhabdomyolysis itself.