rhabdomyolysis
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Etiology
- trauma:
- crush injuries
- long lie syndrome
- prolonged surgery
- burns
- immobilization
- strenuous exercise
- especially untrained persons
- sickle cell disease or sickle cell trait[9]
- heat stroke
- seizures
- inflammatory myopathy
- alcoholic coma
- ischemia
- pharmaceutical agents
- cocaine
- fibrates: clofibrate
- HMG CoA reductase inhibitors (statins)
- exercise &/or exertion exacerbates
- concurrent use of colchicine increases risk
- drug overdose
- antipsychotics
- anesthetics
- SSRI
- zidovudine
- lithium carbonate
- antihistamines
- daptomycin
- valproic acid
- amphetamines, Ecstasy
- dietary supplements
- toxins
- infections
- viral: HIV, coxsackievirus, cytomegalovirus, Epstein-Barr virus, varicella, dengue, Herpes simplex, parainfluenza virus, adenovirus, echovirus
- bacterial: Staphylococcus, Salmonella, Clostridium, Pneumococcus, Legionella, Leptospira, Coxiella burnetii (Q fever), Rickettsia rickettsii (Rocky Mountain spotted fever)
- malaria
- endocrinopathies
- electrolyte abnormalities
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
- marked elevation of serum creatine kinase (> 5x upper limit of normal)[13]
- > 850 U/L male, > 675 U/L female
- MKSAP20 discards value of 800 U/L in 72 year old woman[5]
- offers > 5000 U/L as the new standard[5]
- best test to assess rhabomyolsysis with acute kidney injury[13]
- elevation of serum creatinine
- decreased BUN/creatinine ratio
- serum calcium:
- hypocalcemia during acute phase of acute tubular necrosis (ATN)
- hypercalcemia during the diuretic phase of ATN
- serum K+: hyperkalemia
- serum uric acid: hyperuricemia
- serum phosphate: hyperphosphatemia
- urinalysis:
- urine may be grossly positive for blood without RBC in sediment
- no blood in urine rules out rhabdomyolysis (MKSAP20)
- pigmented casts
- urine may be grossly positive for blood without RBC in sediment
- urine chemistry
- elevated serum LDH, serum AST, serum ALT
- anion gap metabolic acidosis
- prolonged PT, PTT
- complete blood count: thrombocytopenia
Complications
- compartment syndrome may develop after fluid resuscitation with worsening edema
- acute kidney injury aggravated by dehydration & NSAIDs[15]
Differential diagnosis
- acute tubular necrosis
- case of normotensive invoked
Management
- aggressive volume expansion with normal saline (even if serum creatinine 8.3 mg/dL & serum sodium 151 meq/L)[5][6]
- osmotic diuresis with mannitol widely used in conjunction with alkaline diuresis
- IV bicarbonate 2-3 ampules/liter D5W to maintain urine pH > 6.5
- alkaline diuresis no more effective than saline diuresis
- continue aggressive management until urine myoglobin is negative[5]
- hemodialysis if volume overload develops with volume expansion[5][6]
More general terms
More specific terms
Additional terms
References
- ↑ Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 265
- ↑ Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 598
- ↑ Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004 Epstein M, J Am Soc Nephrol 7:1106, 1996
- ↑ Warren JD et al, Rhabdomyolysis: a review. Muscle Nerve 2002, 1:427 PMID: https://pubmed.ncbi.nlm.nih.gov/11870710
- ↑ 5.0 5.1 5.2 5.3 5.4 5.5 5.6 Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17, 18. American College of Physicians, Philadelphia 2009, 2012, 2015, 2018
Medical Knowledge Self Assessment Program (MKSAP) 20 American College of Physicians, Philadelphia 2025 - ↑ 6.0 6.1 6.2 Better OS, Abassi ZA. Early fluid resuscitation in patients with rhabdomyolysis. Nat Rev Nephrol. 2011 May 17;7(7):416-22 PMID: https://pubmed.ncbi.nlm.nih.gov/21587227
- ↑ Bosch X, Poch E, Grau JM. Rhabdomyolysis and acute kidney injury. N Engl J Med. 2009 Jul 2;361(1):62-72 PMID: https://pubmed.ncbi.nlm.nih.gov/19571284
- ↑ Zimmerman JL, Shen MC. Rhabdomyolysis. Chest. 2013 Sep;144(3):1058-65. Review. PMID: https://pubmed.ncbi.nlm.nih.gov/24008958
- ↑ 9.0 9.1 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: https://pubmed.ncbi.nlm.nih.gov/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: https://pubmed.ncbi.nlm.nih.gov/26874092 - ↑ 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: https://pubmed.ncbi.nlm.nih.gov/28235546
- ↑ 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: https://pubmed.ncbi.nlm.nih.gov/19206087
- ↑ 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
- ↑ 13.0 13.1 13.2 13.3 NEJM Knowledge+ Nephrology/Urology
- ↑ 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: https://pubmed.ncbi.nlm.nih.gov/30630682
- ↑ 15.0 15.1 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: https://pubmed.ncbi.nlm.nih.gov/39136944 PMCID: PMC11322840 Free PMC article. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2822294
- ↑ Medline Plus: Rhabdomyolysis http://www.nlm.nih.gov/medlineplus/ency/article/000473.htm