Serum Transaminase Changes in Severe Burns *
MANUEL BOCANEGRA,* * M.D., FIDEL HINOSTROZA N., M.D.,
NICHOLAS A. KEFALIDES, M.D.
From the Hosptals del Nino, Arzobispo Loayza, Dos de Mayo and the Institutes of Arthritis
and Metabolic Diseases, National Institutes of Health, Bethesda, Maryland
IT IS WELL KNOWN that in a large num-
ber of clinical and experimental conditions
accompanied by tissue necrosis, the levels
of serum glutamic oxalacetic transaminase
(SGOT) and to a lesser degree of serum
glutamic pyruvic transaminase (SGPT) in-
crease. CS1 12"16 1, 18 Little is known, how-
ever, about changes in these enzymes in
skin damage produced by burns. There are
contradictory reports with respect to some
aspects of the problem. While Ticktin et
al.1- and Nickell et al.1" found no increase
in SGOT in patients with burns up to 25
per cent of body surface no increase in
SGOT in patients with burns up to 25 per
cent of body surface area, Allegra 1 noted
an early rise in both SGOT and SGPT in
80 per cent of adults with burns from 3.0 to
20 per cent of body surface area. In some
cases, a second increase was observed at
the end of the first week.' No studies in
burned children have been found in the
literature. Recently, Arturson 2 showed in
rats with burns of 25 and 45 per cent of
body surface area that the SGOT reaches
maximum levels 48 hours after burning. He
reported that the highest levels were seen
in animals with more extensive burns and
suggested that these changes are due to
liver necrosis which accompanies severe
burns in these animals.
* Submitted
for publication May 10, 1962.
* * Assistant Professor of Medicine, Facultad de
Medicina, Cayetane lieredia, Lima, Peru.
Supported by a grant from the National In-
stitute of Health, U.S.P.H.S.
438
The purpose of the present study was to
determine levels of serum GOT and GPT
in burned children and adults and to cor-
relate these changes with those seen in the
blister fluid. Determinaitons of these en-
zymes in the normal skin of children were
also made.
Our data show that in children there is a
moderate increase in serum levels of both
enzymes between the second and the
fourth day after burning with a gradual re-
turn to normal by the end of the second
week. In adults, these changes were less
frequent and not as marked. On the other
hand, in blister fluid of both children and
adults, levels of GOT and GPT were well
above those observed in serum in the first
three hours after burning when samples
were taken simultaneously from both
sources.
Materials and Methods
This report includes the study of 42 pa-
tients with burns between 10 and 70 per
cent of body surface area.7 Patients were
admitted between one and three hours
after burning. Twenty-six were children, 13
boys and 13 girls, aged one to 12 years.
Sixteen were adults, four men and 12
women, aged 14 to 49 years. Fire was the
thermal agent in 46 per cent of the children
and 88 per cent of the adults. Hot liquids
were responsible for the burns in the re-
maining patients. Patients who in addition
to the burn had other types of tissue injury
or systemic infection were excluded from
the study.
Volutme 157
Nuniber 3
SERUM TRANSAMINASE CHANGES IN SEVERE BURNS 439
Patients received shock therapy accord-
ing to methods described previously.5' 8 Ve-
nous blood was drawn on admission, at the 0o 0oo00 _ ~00 0 8-t c 00 0O
C: C cd
end of 24 and 48 hours, and then every cuzcn
o 00 o 0- o o o

other day until the eighteenth day. In nine

children and nine adults blister fluid and
blood samples were obtained simultane- 00 cN C- C- 0
- - \ t
ously during the first four days after ad- cC
N

mission. oo
g a 4 o o
o1- A
Samples of healthy skin, 3.0 mm. in
thickness, were obtained using the Brown
dermatome in 30 patients aged one to 11 cC
years. These patients were admitted to the
surgical service of the Hospital del Nino 11-1 -4
o
r-
Cq n -1
"
'I
0008-
"t rn _ _,- _

either for treatment or uncomplicated in- Cl)

14)
Cl)
1!3 C)
guinal hernias, contracture scars or with 1)
IC
U-)
0-
C)

third degree burns of more than two weeks N

I.-I
C)
:;ll
duration. The skin was immediately ;11
C)
1f0
weighed within 0.1 mg. and then was
.j CC
triturated in a tissue grinder under re- C-i
. c
Lfn ~ ~ .0
frigeration, using distilled water in a ratio 31-
'-0=
.)C)
of 1:100 with respect to sample weight. pq 0 *
t 4_ 00 to M

Specimens of serum, blister fluid and skin .1

CII)
ql)
OC)

>C)
homogenate immediately were subjected t4
tlt
o - o

to analysis. Occasionally, when specimens -Z:

.j C-4 - - -

were analyzed from one to three days after Cl)

tz.
C)
;z
they were obtained, they were kept at .114

.0 0
-4.0 C. Glutamic oxalacetic transaminase tt
CII)
-1

and glutamic pyruvic transaminase were tz.

E-q
determined according to the method de- .-X cz
M
-

C 00
C
scribed by Reitman and Frankel.13 The 1'..
141)
cn
reagents and standards used were obtained 0.-
from the Sigma Company, St. Louis. With WI
.4
P.
the above method, normal values for SGOT E-4
range between 8 and 40 U./ml.; and for o
00 E
SGPT between 5 and 35 U./ml. Using this C)
,. 0
method we obtained similar values in 30 0 0i
normal children and 29 normal adults. CC
C)
0X 4 -
Lrf, c-
C)C)
cnCs
o U
Lc) C

Results 0 * C)0
C-i C N 0000 oC t m I
0o
OC
C-I (- C

1. SGOT and SGPT in Burned Chil-

dren. The average values for GOT and * *_

101
GPT and a statistical analysis in 26 burned
children are shown in Table 1. An average
admission value of 38 U./ml. was obtained o
-._ ~I o0 0CI o0

for SGOT. However, eight patients had

P-4
values up to 63 U./ml. Subsequently, there
440 BOCANEGRA, HINOSTROZA AND KEFALIDES Annals of Surgery
March 1963
was a rise in the serum concentration of
E-4 H 0
this enzyme to a maximum average of 94
00 + _0 ce '0 e s oo- '000o
0o
0 Pq ;4; r# C- rs e -0 r 00
_0
_0 Uo oUo o
U./ml. 48 hours after burn. Then levels
vi) En P4 slowly fell to reach a normal value of 31
U./ml. by the twelfth day. No changes
were registered during the remaining pe-
a) %0 Ca-, to
0 tn
% 0 0
riod of study. In six cases (23%), a sec-
Ce
f) 0 1- r- - tn \# U) 0% 0 - ondary rise was noted by the end of the
first week after burning, maximum values
of 70 to 100 U./ml. being observed on the
eighth and tenth day; typical case is shown
Cni in Figure 1. No correlation should be estab-
lished between these values and the ther-
H
I
-
00
r,
--
U4 Lof)
_--4 -I
vo co
-4C
o6 C-I
ef) C-i
t-I
coC-oo- - mo mal agent, extent of burn or other local
H C- O . -0 Wf t4
0 \0 000
. .
%0
m
skin complications.
44 . .. . .

U) ) %0 C- C- CN 00 %0 *f-0n 00o The average admission value for SGPT

1*
cii was 23 U./ml. (Table 1). In only one of 26
"I,
'0
CA cases was a level above normal obtained
ce
0 C e '-
C- C-i C-t C- of
0
o) C--
00
oo rr-
(40 U./ml.). Subsequently, there was a
gradual rise in the serum concentration of
04

Ce
C
this enzyme until it reached its maximum
of 72 U./ml. on the fourth day. During
ao
0
the following five days the level declined
*;-- slowly and then more rapidly until it
0
NsNe el c Xel cl reached a normal value of 34 U./ml. by the
.E14 aL) "0

Ce
twelfth day. There were no variations from
Ce
0 I) If V4 -i -o0-4 0o
.0
normal during the remaining period of
C-Z
-.a
.0 study. Behavior to SGOT was observed
Hi 0%r-i oo
with SGPT in that a second rise occurred
000% 0 if) 00 00%
in 23 per cent of the patients by the end
00 '0C- t- %0 C
i C- 00
siU)

Ici
Cd of the first week (Fig. 1). Maximum values
ll-
Cd* 4,
0 C during this period ranged between 52 and
~ _1 C-I _00 00CI C-. (f) I
170 U./ml.
-
C-4 .0.0
H O When serum levels for these two en-
0D
ut Ce
.5
'O
zymes are compared, it is noted the first
of)4 U)
\0 00
w e I \0
-
four days SGOT shows a greater elevation
-- -4T-q V-- -4W-4-4
0-4

than SGPT. In subsequent days this rela-

ceaL) + o% - C-N - C-i o-I 0% 0 U)r--
cd 5)
Co
, 4z. _Q tionship is preserved until both enzymes
~C reach normal levels.
*
U) I ) U) +4 e4 N C- U)C
._
4-C
._
2. SGOT and SGPT in Burned Adults.
0.*
o
-v U %0 _1) if 4 _1 C-I _I0-0
"]00 It can be seen in Table 2 that average
values for both enzymes during the time of
o E study fell within normal limits, except for
* * a slight rise of SGOT to 50 U./ml. seen on
the second day, and the definite tendency
*S
-n C- + '0 000 C- +4 '0 00
---
**
toward high normal values noted for the
"0
SGPT between the eighth and sixteenth day
Volume 157
Number 3
SERUM TRANSAMINASE CHANGES IN SEVEIRE BIJRNS 441
180r

160k
* * G0 1 r N " %
*----- G P 1
140[
E

1201
FIG. 1. Secondary in- Un
crease in serum transa-
minases, with SGPT
Li
cn
ioc I X~~~~~~~~~~~~~i
higher than SGOT. Pa- z
tient: Female, 4 years of - 8s I-
age, Thermal agent: Hot
water; area burned: 24
per cent, 14 per cent U)
third degree. Z 6C
Hx

L
40n
At% 06-..
i- ^- -_ ~P It -__
-----------------------

--1-A-'---------- --- --- -

20

c
A() 1 2 4 6 8 10 12 14 16 18
D A Y S A F T E R B U R N

160r
*-* G0T
I G PT
1401
"A%
I I

E
I.-
120- r~~~~~~~~~
III~~~~~~~~~~~~
,, 100 I
FIG. 2. Later increase
in serum transaminases,
with SGPT higher than
SGOT. Patient: Male, 14
years of age, Thermal
w
U)
<

I
80I- I/S
I

agent: Fire; area burned: < 60

22 per cent, 1 per cent
third degree. z

H 40-%L
)F. -St .'

.1

---
-d
20 4I.-

()

A() 1 2 4 6 8 10 12 14 16 18
D A Y S A F T E R B U R N

Admission.
412 BOCANEGRA, HINOSTROZA AND KEFALIDES Annals of Surgery
March 1963
* - Serum
0- * Blister fluid

A
A
n
D U L T S C H L D R E N
240
(6)
200 \ G 0 T G P T G 0 T G P T

160 \ FIG. 3. Changes in

UN (6)
serum and blister fluid
GOT and GPT. Admis-
4
z 120 8 sion values are for sam-
(6) ples taken 1 to 3 hours
I
(6) (5) after burning.
80 \8)
z
.#

cr
40 r"
--
0---4k, 8)

I
A(1)1 2 3 4 A() 1 2 3 4 A()12 3 4 A(') 1 2 3 4

D A Y S A F T E R B U R N

* Admission.
Number of patients in a total of nine in whom it was possible to do the above determinations.

after burning. However, analysis of the high values were found, ranging between
data shows that during the first six days 60 and 76 U./ml.
after burning, in 31 per cent of the cases In five patients (31%o), a later rise of
the SGOT showed values within normal both enzymes occurred between the eighth
limits; in 44 per cent there were values up and sixteenth day after burning. The values
to 50 U./ml. and 19 per cent moderate for SGOT ranged between 46 and 120 U./
elevations ranging from 60 to 100 U./ml. ml. and for SGPT between 36 and 141
In only one patient markedly elevated U./ml.; a characteristic case is shown in
values were encountered, that reached 270 Figure 2. There was no correlation between
U./ml. 48 hours after burning. In this case, these changes and the thermal agent, ex-
despite our careful selection, it is probable tent of burn or other local skin changes.
that, because of the marked severity of the 3. Transaminases in the Blister Fluid.
skin burn, the tissue necrosis also involved Shortly after burning, and particularly be-
underlying muscle. tween the first and third hour following
A similar behavior was observed with thermal trauma, marked elevations were
SGPT. In 69 per cent of cases the values noted in the concentrations of both en-
fell within normal limits. There were slight zymes in the blister fluid (Fig. 3). In chil-
elevations in 13 per cent, with a range of dren, the average value for GOT was 146
36 to 50 U./ml.; in 19 per cent moderately U./ml. and for GPT 78 U./ml. In adults

TABLE 3. Transaminases in Healthy Skin of Children

U./Gm of Wet Tissue (30 Cases)*
Mean S.E. S.D. S.E. Range
GOT 3,399 346 1,866 245 1,150-8,000
GPT 2,050 183 986 129 650 4,600
GOT
1.7 0.1 0.53 0.07 0.89-2.8
GPT
*
Age range from 1 to 11 years.
Volume 15 7
Number 3
SERUM TRANSAMINASE CHANGES IN SEVERE BURNS
TABLE 4. Ratio of GOT/GPT in Blister Fluid and Healthy Skin
Children
Days No.
Postburn Det.* Mean
Blister Fluid Admission 6 2.01
1 9 2.13
2 5 2.85
4 5 2.87
Skin 30 1.70
* Number of patients in a total of nine in whom it was possible to do the above determinations.
the corresponding values were 224 and 93
U./ml., respectively. These values were
three to five times higher than those ob-
served in simultaneously obtained serum
specimens (P < 0.001).
During subsequent hours the levels of
both the enzymes decreased rapidly until,
by the end of the first 48 hours, levels com-
comparable to those in the serum were
reached. During the remaining days of
study, no major variations were observed.
However, while in adults the values for
both enzymes in blister fluid fell within the
range considered normal for serum at the
end of the first 48 hours, in children the
levels averaged 100 U./ml. for GOT and
45 U./ml. for GPT.
4. Transaminases in Healthy Skin. The
average values of GOT and GPT concen-
trations per gram of wet tissue in normal
skin of 30 children are shown in Table 3.
The skin content for GOT was 3,399 U./
Gm. of wet tissue and for GPT 2,050
U./Gm. The ratio GOT/GPT in the skin
was 1.7 and it is similar to that in blister
fluid during the first 48 hours after burn-
ing (Table 4).
Discussion
Changes in serum GOT and GPT ob-
served in burned children and adults fol-
low the general trend reported by Artur-
son in experimentally burned rats.
Early increase in the serum concentra-
443
Adults
No.
S.E. P Det.* Mean S.E. P
0.36 0.580 6 2.62 0.57 0.14
0.27 0.190 8 2.37 0.34 0.06
0.30 0.001 8 2.04 0.23 0.19
0.39 0.004 9 2.64 0.38 0.02
0.10
tion of these enzymes following thermal
trauma indicates, as Allegra et al.' have
suggested, that the skin may be the princi-
pal source of these enzymes and skin injury
may account for the changes seen. Simi-
larly, other investigators'0' 14 have shown
a direct relationship between the quantity
of necrotic tissue and serum levels of trans-
aminases in experiments involving myo-
cardial or liver damage. In our burned
patients three facts corroborate this hy-
pothesis: 1) The amount of GOT liberated
by injury of the skin involving about 10
per cent of body surface area would be
of the order of 480,000 U. in a one-year-old
child. In an adult with 1.70 M.2 of body
surface area and 10 per cent burn, the
GOT liberated would be of the order of
1,440,000 U.* These values would corre-
* GOT and GPT content of skin corresponding
to 10 per cent body surface area was calculated
by the equation:
(Skin GOT or GPT U./Gm. wet tissue) X (Body
surface cm.2)0.1 X (skin thickness)0.3 cm.X (Sp.
Gr.) 1.037.
Skin content of GOT and GPT in U./Gm.
of wet tissue is determined as described in the
text. Body surface area was calculated according
to a nomogram based on Meeh-Du Bois formula.4
The factor 0.1 represents 10 % of body surface.
Skin thickness of 0.3 cm. represents the average
thickness of specimens obtained by the Brown
dermatome. The specific gravity was determined
on 10 of the above samples by measurement of
the weights and volumes.
 BOCANEGRA, HINOSTROZA AND KEFALIDES
444
spond to an injury of myocardium equiva-
lent to 13 Gm. of tissue.17 According to the
ratio GOT/GPT of 1.7 found for healthy
skin (Table 3) we can assume that the
amount of GPT liberated from a 10 per
cent burn would be approximately one-half
that of GOT. It follows, therefore, that
even though transaminase content of skin
is relatively low in comparison with other
normal human tissue,17 in our patients,
with burns over 10 per cent of body surface
area, one would expect liberation of large
amounts of enzymes, which could explain
high levels seen in the serum. 2) Blister
fluid, immediately following thermal trau-
ma, contains large amounts of these en-
zymes and the ratio GOT/GPT is similar
to that observed for normal skin (Fig. 3,
Table 4. 3) Delayed equilibrium is estab-
lished between transaminase levels of blis-
ter fluid and serum.
However, it should be pointed out, that
changes observed in transaminase levels of
our patients, and particularly in adults,
were not of the same degree and did not
occur as early as seen in myocardial or
liver necrosis.10 11, 16-18 This fact could be
due to 1) a delay in the equilibration of
the protein molecules between the edema
fluid accumulated around the burned area
and the intravascular fluid in a manner
similar to that described for tourniquet
trauma;9 and 2) a partial loss of enzymes
to the outside in fluid that oozes from
these lesions in which high content in
transaminases is indicated by high initial
levels in blister fluid (Fig. 3). While the
evidence indicates that early increases in
serum enzyme levels can be attributed to
acute damage to skin, the basis for lower
values in adults and for secondary rises ob-
served in about 30 per cent of cases is not
clear. It is possible that liver damage is
responsible for the secondary rise, since it
is characterized by predominance of SGPT
over SGOT, a pattern associated with liver
Annals of Surgery
March 1963
injury.16' While liver necrosis has been
17
reported in burned animals,2 lesions in the
liver are not frequently encountered in
human burns;3 and in five of our cases
dying within the first week, no liver ne-
crosis was demonstrable at autopsy.**
Summary
Serum levels of GOT andGCPT were
determined in 26 children and 16 adults
with burns between 10 and 70 per cent of
body surface area. Simultaneous determi-
nations of these enzymes were made in
serum and blister fluid of patients. Trans-
aminase content of normal skin was deter-
mined in 30 children.
In children there were early and mod-
erate increases in the serum level of both
enzymes, with maximum values observed
between the second and fourth day after
burning. In only 25 per cent of adults were
such changes noted. In about 30 per cent
of patients a secondary rise occurred by
the end of the first week.
Blister fluid of both children and adults
contained higher levels of transaminases
than serum during the first three hours
after burning. By the end of the second day
these values fell to levels similar to those
of serum. The mechanism for this phe-
nomenon is discussed.
Transaminase content of normal human
skin was found to be 3,399 U./Gm. of wet
tissue for GOT and 2,050 U. for GPT. The
ratio GOT/GPT was 1.7.
It is suggested that the early rise in both
transaminases in serum and blister fluid are
due to destruction of skin and that the late
increase observed in a number of patients
by the second week after burning is prob-
ably due to other factors in addition to
skin necrosis.
** Histologic examinations performed by Dr.
Gerardo Boisset, Hospital del Nino, Lima, Peru.
Volume 157 SERUM TRANSAMINASE CHANGES IN SEVERE BURNS
Number 3
References
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Corso della Malattia da Ustione. Giorn. It.
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