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rhabdomyolysis

Etiology: 1) trauma: a) crush injuries b) long lie syndrome c) prolonged surgery d) burns 2) immobilization 3) strenuous exercise a) especially untrained persons b) sickle cell disease or sickle cell trait [9] 4) heat stroke 5) seizures 6) inflammatory myopathy a) polymyositis/dermatomyositis b) inclusion body myositis 7) alcoholic coma 8) ischemia 9) pharmaceutical agents a) cocaine b) fibrates: clofibrate c) HMG CoA reductase inhibitors (statins) 1] exercise &/or exertion exacerbates 2] concurrent use of colchicine increases risk d) drug overdose e) antipsychotics - neuroleptic malignant syndrome f) anesthetics 1] malignant hyperthermia 2] propofol g) SSRI h) zidovudine i) lithium carbonate j) antihistamines k) daptomycin l) valproic acid m) amphetamines, Ecstasy 10) dietary supplements a) ephedrine b) creatine 11) toxins a) multiple bee stings or wasp stings b) snake bite c) spider bite d) toxic shock syndrome d) carbon monoxide poisoning 12) infections a) viral: HIV, coxsackievirus, cytomegalovirus, Epstein-Barr virus, varicella, dengue, Herpes simplex, parainfluenza virus, adenovirus, echovirus b) bacterial: Staphylococcus, Salmonella, Clostridium, Pneumococcus, Legionella, Leptospira, Coxiella burnetii (Q fever), Rickettsia rickettsii (Rocky Mountain spotted fever) c) malaria 13) endocrinopathies a) hypothyroidism b) hyperthyroidism c) pheochromocytoma 14) electrolyte abnormalities - hypokalemia or hypophosphatemia Pathology: - myoglobin released from muscle damages the kidney Clinical manifestations: - muscle tenderness - pressure necrosis of skin may occur - signs of multiple trauma or crush injury may be present - increased muscle tone Laboratory: 1) marked elevation of serum creatine kinase (> 5x upper limit of normal) [13] - > 850 U/L male, > 675 U/L female - best test to assess rhabomyolsysis with acute kidney injury [13] 2) elevation of serum creatinine - decreased BUN/creatinine ratio 3) serum calcium: - hypocalcemia during acute phase of acute tubular necrosis (ATN) - hypercalcemia during the diuretic phase of ATN 4) serum K+: hyperkalemia 5) serum uric acid: hyperuricemia 6) serum phosphate: hyperphosphatemia 7) urinalysis: a) urine may be grossly positive for blood without RBC in sediment b) pigmented casts 8) urine chemistry a) urine myoglobin (myoglobinuria) - seldom necessary for assessment of rhabdomyolysis [13]] - however; see management [5] b) high urine sodium c) high fractional excretion of sodium (FENA) 9) elevated serum LDH, serum AST, serum ALT 10) anion gap metabolic acidosis 11) prolonged PT, PTT 12) complete blood count: thrombocytopenia Complications: - compartment syndrome may develop after fluid resuscitation with worsening edema - acute kidney injury aggravated by dehydration & NSAIDs [15] Management: 1) aggressive volume expansion with normal saline (even if serum creatinine 8.3 mg/dL & serum sodium 151 meq/L) [5,6] 2) osmotic diuresis with mannitol widely used in conjunction with alkaline diuresis - IV bicarbonate 2-3 ampules/liter D5W to maintain urine pH > 6.5 3) alkaline diuresis no more effective than saline diuresis 4) continue aggressive management until urine myoglobin is negative [5] 5) hemodialysis if volume overload develops with volume expansion [5,6]

Related

myoglobinuria

Specific

acute recurrent rhabdomyolysis; autosomal recessive acute recurrent myoglobinuria (ARARM)

General

muscular disease; myopathy pigment nephropathy

References

  1. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 265
  2. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 598
  3. Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004 Epstein M, J Am Soc Nephrol 7:1106, 1996
  4. Warren JD et al, Rhabdomyolysis: a review. Muscle Nerve 2002, 1:427 PMID: 11870710
  5. Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17, 18. American College of Physicians, Philadelphia 2009, 2012, 2015, 2018
  6. Better OS, Abassi ZA. Early fluid resuscitation in patients with rhabdomyolysis. Nat Rev Nephrol. 2011 May 17;7(7):416-22 PMID: 21587227
  7. Bosch X, Poch E, Grau JM. Rhabdomyolysis and acute kidney injury. N Engl J Med. 2009 Jul 2;361(1):62-72 PMID: 19571284
  8. Zimmerman JL, Shen MC. Rhabdomyolysis. Chest. 2013 Sep;144(3):1058-65. Review. PMID: 24008958
  9. Asplund CA, O'Connor FG. Challenging Return to Play Decisions: Heat Stroke, Exertional Rhabdomyolysis, and Exertional Collapse Associated With Sickle Cell Trait. Sports Health. 2016 Mar-Apr;8(2):117-25. PMID: 26896216 - Saxena P, Chavarria C, Thurlow J. Rhabdomyolysis in a Sickle Cell Trait Positive Active Duty Male Soldier. US Army Med Dep J. 2016 Jan-Mar:20-3. PMID: 26874092
  10. Cervellin G, Comelli I, Benatti M et al Non-traumatic rhabdomyolysis: Background, laboratory features, and acute clinical management. Clin Biochem. 2017 Aug;50(12):656-662. Review. PMID: 28235546
  11. Rowan C, Brinker AD, Nourjah P et al Rhabdomyolysis reports show interaction between simvastatin and CYP3A4 inhibitors. Pharmacoepidemiol Drug Saf. 2009 Apr;18(4):301-9. PMID: 19206087
  12. Rothaus C. A Woman with Weakness, Dark Urine, and Dysphagia. NEJM Resident 360. July 17, 2019 https://resident360.nejm.org/clinical-pearls/a-woman-with-weakness-dark-urine-and-dysphagia
  13. NEJM Knowledge+ Nephrology/Urology
  14. Long B, Koyfman A, Gottlieb M. An evidence-based narrative review of the emergency department evaluation and management of rhabdomyolysis. Am J Emerg Med. 2019;37:518-23. PMID: 30630682
  15. Sabouri AH, Yurgionas B, Khorasani S et al Acute Kidney Injury in Hospitalized Patients With Exertional Rhabdomyolysis. JAMA Netw Open. 2024 Aug 1;7(8):e2427464. PMID: 39136944 PMCID: PMC11322840 Free PMC article. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2822294
  16. Medline Plus: Rhabdomyolysis http://www.nlm.nih.gov/medlineplus/ency/article/000473.htm