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
- 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 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]
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://www.ncbi.nlm.nih.gov/pubmed/11870710
- ↑ 5.0 5.1 5.2 5.3 5.4 Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17, 18. American College of Physicians, Philadelphia 2009, 2012, 2015, 2018
- ↑ 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://www.ncbi.nlm.nih.gov/pubmed/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://www.ncbi.nlm.nih.gov/pubmed/19571284
- ↑ Zimmerman JL, Shen MC. Rhabdomyolysis. Chest. 2013 Sep;144(3):1058-65. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/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://www.ncbi.nlm.nih.gov/pubmed/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://www.ncbi.nlm.nih.gov/pubmed/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://www.ncbi.nlm.nih.gov/pubmed/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://www.ncbi.nlm.nih.gov/pubmed/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://www.ncbi.nlm.nih.gov/pubmed/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://www.ncbi.nlm.nih.gov/pubmed/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