113) A 44-year-old HIV-infected man with a CD4 count of 280cell/mm3 presents to your office with complaints of fatigue, body aches, leg cramps and muscle pain. His viral load is undetectable. His medications include tenofovir, lamivudine and Ritonavir. The patient was recently seen in the office for lipodystrophy and hyperlipidemia. His LDL cholesterol was 190 during last visit and hence, he was started on Simvastatin about 2 weeks ago. On physical examination, he is afebrile and he has diffuse muscle tenderness. Laboratory studies show a serum creatinine of 3.2 mg/dL ( his baseline = 1.0 mg/dl), serum urea nitrogen = 55 mg/dL , total bilirubin 0.8gm/dl, aspartate aminotransferase (AST) level of 632 U/L and alanine aminotransferase (ALT) level of 140 U/L . Urinalysis was positive for blood on dipstick. Urine microscopy shows no red cells or white cell casts. The most useful test in determining the etiology of the liver enzyme elevations in this patient:
A) Ultrasound Abdomen
B) Serum Creatinine Phosphokinase
C) Gamma glutamyl transferase (GGTP)
D) CT abdomen with contrast
E) Hepatitis C antibodies
Archer USMLE Step 3 Blog 
c
yeas. it is c. GGTP is the best indicator for alcohol ingetion
B->Rhabdomyolysis-Statin Induced
b
CK due to myopathy with interaction of ritonavir n statins
b
Common side effects (>1% incidence) may include abdominal pain, diarrhea, indigestion, and a general feeling of weakness. Rare side effects include joint pain, memory loss, and muscle cramps.[2] Cholestatic hepatitis, hepatic cirrhosis, rhabdomyolysis and myositis have been reported in patients receiving the drug chronically
the patient absolutely has rabdomylosis but myoglobine cant cause elevation of liver enzymes
e is ans
The patient absolutely has rhabdo which can, among other things, cause elevation of only AST. Chronic hepatitis C can have normal ast or elevated
Answer B
statin causes increased LFT not myoglobin, pt has both the side effects
Answer: B
Protease inhibitors (PIs) and nonnucleoside reverse transcriptase inhibitors (NNRTIs) can affect hepatic metabolism of HMG-coenzyme A reductase inhibitors (statins). Antiretrovirals generally do not affect the metabolism of other classes of lipid-lowering agents.
http://hivinsite.ucsf.edu/InSite?page=md-rr-30
Aminotransferase abnormalities, particularly AST, are common in the setting of rhabdomyolysis.
http://www.ncbi.nlm.nih.gov/pubmed/20407858
The most reliable test in the diagnosis of rhabdomyolysis is the level of creatine kinase (CK) in the blood–The transaminases, enzymes abundant in both liver and muscle tissue, are also usually increased; this can lead to a confused with acute liver injury,