Myalgias and Myopathies: Rhabdomyolysis

Rhabdomyolysis is the rapid breakdown of skeletal muscle with release of electrolytes, myoglobin, and other proteins into the circulation. The clinical presentation encompasses a spectrum of patients ranging from those with asymptomatic increases in creatine kinase (CK) levels to those with fulminant disease complicated by acute kidney injury (AKI), severe electrolyte abnormalities, compartment syndrome, and disseminated intravascular coagulation. A CK level at least 10 times the upper limit of normal typically is considered diagnostic, as is myoglobinuria. AKI is the most significant complication. Prompt recognition and management of rhabdomyolysis is crucial to preserving renal function. Management consists of rapidly initiating aggressive intravenous saline resuscitation to maintain a urine output of at least 300 mL/hour. Sodium bicarbonate can be used for patients who are acidotic, and mannitol can be used for those whose urine output is not at goal. Significant electrolyte abnormalities may be present and must be managed to avoid cardiac arrhythmias and arrest. Compartment syndrome can develop as an early or late finding and requires decompressive fasciotomy for definitive management. Intravenous fluids typically are continued until CK levels are lower than 1,000 U/L.

Neurological Involvement and Hepatocellular Injury Caused by a Snake With Hematotoxin Envenomation

Venomous snakes with hematotoxin-Russell's viper (Daboia spp), Malayan pit viper (Calloselasma rhodostoma), and green pit viper (Cryptelytrops albolabris and C macrops, previously named Trimeresurus spp) are commonly found in Thailand. Coagulation factor activation, thrombocytopenia, hyperfibrinolysis, and disseminated intravascular coagulation are the main mechanisms of hemorrhaging from these snake bites. The neurological involvement and hepatocellular injury after Russell's viper bites were reported in Sri Lanka, but there is no report from Southeast Asia. This case was a 12-year-old hill tribe boy who had ptosis and exotropia of the left eye, respiratory distress, and prolonged venous clotting time, prothrombin time, and activated partial thromboplastin time; low fibrinogen and platelet count; and transaminitis after being bitten by a darkish-colored snake. He did not respond to antivenom for cobra, Malayan pit viper, or Russell's viper. However, his neurological abnormalities, respiratory failure, and hepatocellular injury improved, and coagulopathy was finally corrected after receiving antivenom for green pit viper. The unidentified snake with hematotoxin was alleged for all manifestations in this patient.

Determination of muscle mitochondrial respiratory capacity in Standardbred racehorses as an aid to predicting exertional rhabdomyolysis

This prospective cohort study evaluated the potential of high-resolution respirometry applied to permeabilized muscle fibers for fitness evaluation in French Standardbred racehorses. Fitness evaluation by means of respirometric parameters did not correlate with racing performance registered over the following racing season. However, altered mitochondrial energy metabolism was associated with higher risk of developing exertional rhabdomyolysis, a common cause of exercise intolerance in racehorses. These data represent a first step towards establishing reference values for muscle OXPHOS capacity in this breed.

Clinical Impact of Speed Variability to Identify Ultramarathon Runners at Risk for Acute Kidney Injury

BACKGROUND

Ultramarathon is a high endurance exercise associated with a wide range of exercise-related problems, such as acute kidney injury (AKI). Early recognition of individuals at risk of AKI during ultramarathon event is critical for implementing preventative strategies.

OBJECTIVES

To investigate the impact of speed variability to identify the exercise-related acute kidney injury anticipatively in ultramarathon event.

METHODS

This is a prospective, observational study using data from a 100 km ultramarathon in Taipei, Taiwan. The distance of entire ultramarathon race was divided into 10 splits. The mean and variability of speed, which was determined by the coefficient of variation (CV) in each 10 km-split (25 laps of 400 m oval track) were calculated for enrolled runners. Baseline characteristics and biochemical data were collected completely 1 week before, immediately post-race, and one day after race. The main outcome was the development of AKI, defined as Stage II or III according to the Acute Kidney Injury Network (AKIN) criteria. Multivariate analysis was performed to determine the independent association between variables and AKI development.

RESULTS

26 ultramarathon runners were analyzed in the study. The overall incidence of AKI (in all Stages) was 84.6% (22 in 26 runners). Among these 22 runners, 18 runners were determined as Stage I, 4 runners (15.4%) were determined as Stage II, and none was in Stage III. The covariates of BMI (25.22 ± 2.02 vs. 22.55 ± 1.96, p = 0.02), uric acid (6.88 ± 1.47 vs. 5.62 ± 0.86, p = 0.024), and CV of speed in specific 10-km splits (from secondary 10 km-split (10th - 20th km-split) to 60th - 70th km-split) were significantly different between runners with or without AKI (Stage II) in univariate analysis and showed discrimination ability in ROC curve. In the following multivariate analysis, only CV of speed in 40th - 50th km-split continued to show a significant association to the development of AKI (Stage II) (p = 0.032).

CONCLUSIONS

The development of exercise-related AKI was not infrequent in the ultramarathon runners. Because not all runners can routinely receive laboratory studies after race, variability of running speed (CV of speed) may offer a timely and efficient tool to identify AKI early during the competition, and used as a surrogate screening tool, at-risk runners can be identified and enrolled into prevention trials, such as adequate fluid management and avoidance of further NSAID use.

Haff disease associated with the ingestion of the freshwater fish Mylossoma duriventre (pacu-manteiga)

Haff disease associated rhabdomyolysis is correlated with the ingestion of certain freshwater fish and shellfish and is caused by an unidentified toxin. We report the case of a patient who experienced rhabdomyolysis approximately 2 hours after ingestion of the freshwater fish Mylossoma duriventre (pacu-manteiga) approximately 3 years after an outbreak had been reported in Manaus, Brazilian Amazon.

Hair dye poisoning and rhabdomyolysis

Hair dye ingestion is a rare cause of toxicity in Pakistan. We are presenting the case report of a 55 year old male who presented with accidental hair dye ingestion and developed laryngeal oedema requiring emergent tracheostomy. He had also developed aspiration pneumonitis and chemical oesophagitis. However, the most alarming manifestation was rhabdomyolysis. Hair dye toxicity can be fatal if not recognized early. There is no antidote available. Rhabdomyolysis is a complication and needs to be managed aggressively in order to prevent long term morbidity.

"It's What Color?"

The series objective is to review various clinical conditions/presentations, including the latest evidence on management, and to dispel common myths. In the process, core knowledge and management principles are enhanced. A clinical case will be presented. Cases will be drawn from real life but phrased in a context that is applicable to the Special Operations Forces (SOF) or tactical emergency medical support (TEMS) environment. Details will be presented in such a way that the reader can follow along and identify how they would manage the case clinically depending on their experience and environment situation. Commentary will be provided by currently serving military medical technicians. The medics and author will draw on their SOF experience to communicate relevant clinical concepts pertinent to different operational environments including SOF and TEMS. Commentary and input from active special operations medical technicians will be part of the feature.

Mechanisms and assessment of statin-related muscular adverse effects

Statin-associated muscular adverse effects cover a wide range of symptoms, including asymptomatic increase of creatine kinase serum activity and life-threatening rhabdomyolysis. Different underlying pathomechanisms have been proposed. However, a unifying concept of the pathogenesis of statin-related muscular adverse effects has not emerged so far. In this review, we attempt to categorize these mechanisms along three levels. Firstly, among pharmacokinetic factors, it has been shown for some statins that inhibition of cytochrome P450-mediated hepatic biotransformation and hepatic uptake by transporter proteins contribute to an increase of systemic statin concentrations. Secondly, at the myocyte membrane level, cell membrane uptake transporters affect intracellular statin concentrations. Thirdly, at the intracellular level, inhibition of the 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase results in decreased intracellular concentrations of downstream metabolites (e.g. selenoproteins, ubiquinone, cholesterol) and alteration of gene expression (e.g. ryanodine receptor 3, glycine amidinotransferase). We also review current recommendations for prescribers.

Genetic aspects of exercise and rhabdomyolysis

Rhabdomyolysis is a syndrome characterized by muscle necrosis and the release of intracellular muscle constituents into the circulation. Consequently, the circulatory levels of intracellular molecular components, such as creatine kinase, are commonly used to evaluate the severity of muscle damage. Nevertheless, there is a wide inter-individual variability in the phenotypic expression of muscle damage, which cannot be predicted by the age, race, body composition, and fitness level of each subject. This suggests that apart from environmental factors, genetic factors might also contribute to the development and progression of exercise-induced muscle damage. Recently, several gene-specific single nucleotide polymorphisms (SNPs) were found to be associated with severe exercise-induced muscle damage. The present manuscript reviews the pathophysiology of exertional muscle damage, emphasizing the influence of gene polymorphisms on its inter-individual severity. This knowledge may be useful for pediatricians for identifying individuals more susceptible to severe exertional muscle damage and related life-threatening comorbidities.

[Rhabdomyolysis]

Rhabdomyolysis is the common denomination of conditions with destruction of skeletal muscle tissue. Complications are disturbances in the electrolyte and acid-base balance and circulatory and renal insufficency. The pathophysiology and treatment of these systemic complications is discussed. Different recommendations exist for the prevention of renal failure; of these, only fluid therapy to restore euvolaemia has been shown to be efficient with reasonable certainty, whereas the effect of diuretic therapy, alkalinisation of the urine and haemofiltration of myoglobin remains to be proved.

[Renoprotective efficacy of different doses of statins in experimental acute renal failure]

The effect of three statins (atorvastatin, lovastatin, simvastatin) on the renal function under conditions of experimental acute renal failure in rats was studied. The relatively effective doses were found to possess the most considerable renoprotective properties. All the statins were established to cause the restoration of functional activity of the kidneys under conditions of experimental rhabdomyolytic acute renal failure at various doses, but with the dose of 20 mg/kg they showed the most significant improvement in key indices of kidney function: an increase in diuresis by an average of 32% and glomerular filtration rate by an average of 90%, reduction of proteinuria in more than twice. At the same time, in the animals with acute renal failure the level of creatine phosphokinase was increased by 141%. However, the activity of blood plasma creatine phosphokinase of all animals treated with statins was 14% higher than in the intact control, indicating the minor myotrphic activity of statins in selected mode of administration. Thus, the use of 20 mg/kg dose is the most reasonable from the standpoint of renoprotective efficacy and safety.

McArdle's disease: a clinical review and case report

McArdle's Disease is a rare glycogen disease involving deficiency in muscle phosphorylase. This deficiency can lead to rhabdomyolysis and subsequently renal failure. McArdle's Disease has a similar presentation as several other metabolic myopathies with exercise-induced fatigue, myalgias, weakness or unexplained rhabdomyolysis. Suspicion should be raised in the presence of unexplained symptoms, and muscle biopsy can be done to confirm the diagnosis.

Clinical spectrum of rhabdomyolysis presented to pediatric emergency department

BACKGROUND

Rhabdomyolysis is a potentially life-threatening syndrome that can develop from a variety of causes. The aim of the work is to analyze the clinical spectrum and to evaluate the prevalence of various etiologies in children, who present to the emergency department (ED) with rhabdomyolysis.

METHODS

During a 6-year study period, we retrospectively analyzed the medical charts of patients, aged 18 years or younger, with a definite diagnosis of rhabdomyolysis and serum creatinine phosphokinase (CK) levels greater than 1000IU/L. We analyzed the clinical spectrum and evaluated the potential risk factors of acute renal failure (ARF).

RESULTS

Thirty-seven patients (mean age = 10.2 ± 5.5 years), including 26 males and 11 females, were enrolled in the study. Two of the most common presented symptoms in these 37 patients were muscle pain and muscle weakness (83.8% and 73%, respectively). Dark urine was reported in only 5.4% of the patients. The leading cause of rhabdomyolysis in the 0- to 9-year age group was presumed infection, and the leading cause in the 10- to 18-year age group was trauma and exercise. The incidence of ARF associated with rhabdomyolysis was 8.1 % and no child needed for renal replacement therapy (RRT). We did not identify any reliable predictors of ARF or need for RRT.

CONCLUSIONS

The classic triad of symptoms of rhabdomyolysis includes myalgia, weakness and dark urine are not always presented in children. The cause of rhabdomyolysis in younger age is different from that of teenager group. However, the prognosis of rhabdomyolysis was good with appropriate management.

Methocarbamol suspension for the treatment of rhabdomyolysis in equines

Rhabdomyolysis in equines occurs in horses due to physical overexertion or underlying pathologic myopathy. Methocarbamol is a muscle relaxant that can be used in equines to treat symptoms associated with Rhabdomyolysis. Methocarbamol is available as a solution for injection but is not commercially available as an oral suspension. This article focuses on the treatment of Tying-up caused by overexertion, and details the treatment of Rhabdomyolysis with an oral suspension that was prepared for a veterinarian by a compounding pharmacist.

Simvastatin-loaded β-TCP drug delivery system induces bone formation and prevents rhabdomyolysis in OVX mice

Bone formation and regeneration is a prolonged process that requires a slow drug release system to assist in the long-term recovery. A drug-delivery system is developed that allows for the controlled release of simvastin, without exhibiting the side effects associated with high concentrations of simvastatin, and is still capable of inducing constant bone formation.

Perspective on rhabdomyolysis-induced acute kidney injury and new treatment options

AIM

The purpose of this study was to assess the role of caspase-dependent apoptosis, caspase 1, calpain 1, inducible nitric oxide synthase (iNOS) and endothelial nitric oxide synthase (eNOS) and the protective effect of grape seed proanthocyanidin extract (GSPE) in the development of rhabdomyolysis-induced acute kidney injury (AKI).

MATERIALS AND METHODS

Twenty-one rats were divided into 3 groups - control, rhabdomyolysis and rhabdomyolysis + GSPE. Rhabdomyolysis was induced in the rhabdomyolysis and rhabdomyolysis + GSPE groups with the injection into both hind limbs of 10 ml/kg hypertonic (50%) glycerol following 24-hour dehydration on the 6th day. The rhabdomyolysis + GSPE group was given GSPE at 100 mg/kg by gavage for 7 days. The experiment was concluded 48 h after glycerol injection. Blood specimens were collected, and kidney tissues were extracted for histopathological examination.

RESULTS

We identified an increase in blood urea nitrogen, creatinine, histopathological score, iNOS, caspase 3, caspase 1 and calpain 1 expression in the rhabdomyolysis group compared to the controls and a decrease in eNOS expression. In the rhabdomyolysis + GSPE group, however, there was a decrease in these mediators, together with an increase in eNOS expression.

CONCLUSION

This study shows for the first time in the literature that calpain 1 is involved in the pathogenesis of rhabdomyolysis-induced AKI, and that GSPE may have a renoprotective effect.

[Rhabdomyolysis related to physical activity in young subjects]

The aim of the work was to study the possibility of development, clinical picture and outcome of rhabdomyolysis (R) caused by physical activity in young conscript personnel. It included 141 men aged 18-25 years. Group I was comprised of 48 patients treated in a military hospital, group 2 consisted of 98 healthy conscripts examined before and 12 days after regular physical exercises. General clinical examination was supplemented by measuring blood CPK. LDH, AST, ALT, and myoglobin levels. Erroneous diagnosis was made in 32 cases of group 1.37 (77.08%) subjects fell ill within the first month of service, the main symptoms being myalgia, muscular tissue compaction, and brown urine. Renal dysfunction occurred in 31 (61.58%) patients. Acute renal insufficiency with oligo/anuria developed in 9 (18.75%) patients and was treated by hemodialysis. All patients had elevated CPK, LDH, AST, ALT levels. CPK increased to 98050.0 +/- 12245. 1 U/l vs 300.4 +/- 57.3 U/l in control. All patients recovered In group 2 there were no cases of R but 29 (31.2%) subjects suffered myalgia and 84 (90.32%) had elevated CPC levels (up to 759 +/- 172.6 U/l on the average). Physical activity in servicemen may cause R with the highest risk of its development during the first month after conscription, i.e. in the period of adaptation. This finding should be taken into account in the organization of medical control of the subscripts' health.

[The role of aldehydes in development of oxidative stress under rhabdomyolysis in rats]

We investigated the changes in the forms of plasma iron and participation of aldehydes in the development of oxidative stress under glycerol-induced rhabdomyolysis in rats. Rhabdomyolysis was caused by intramuscular injection of 50% glycerol in the dose 10 ml/kg. We detected an increase in indexes of oxidative stress. On the day 4, the content of TBA-reactive products in the liver increased by 38%, CO-group proteins in serum in 3,5 times and in the liver in 2,8 times. The content of aldehydes in the liver was increased in 2,9 times. Accumulation of not shielded redox-active iron in the blood plasma in concentrations up to 2,6 mg/l, which is almost three times of iron content of transferring was showed. The formation of this form of iron is one of the triggers of oxidative stress. To explore the participation of endogenous aldehydes in the development of oxidative stress in this model, in additional group of animals glycerol was injected simultaneously with a daily 1% solution of dimedone, aldehydes acceptor at a dose of 10 ml/kg. In this group, at 4th day a decrease in the content of aldehydes in the liver by 79% was recorded. Normalization of aldehydes followed by normalization of the indicators of oxidative stress: decrease the content of TBA-reactive products in the liver by 62%, CO-group proteins in serum by 38% in the liver by 46%. These results demonstrate that elevated level of aldehydes is not only a "product" of oxidative stress, but the aldehydes themselves are actively involved in the development of this process.

Crayfish-related Haff disease rhabdomyolysis; diagnosis supported by bone scintigraphy

A number of people suffered rhabdomyolysis caused by eating crayfish in China and the final diagnosis was a rare disease called Haff disease. In this study, we present a 26 years old man with a history of severe muscular soreness for whole body after eating crayfish and this status lasted for about 3 months. Blood analysis showed significant increase in serum creatine kinase and lactate dehydrogenase. The pathology of left biceps brachii muscle revealed rhabdomyolysis. Technetium-99m-methylene diphosphonate ((99m)Tc-MDP) whole body bone scintigraphy showed increased uptake of nearly all muscles, especially those of proximal extremities. The diagnosis was Haff disease supported by histology and clinical characteristics. In conclusion, this case report shows that using bone imaging supports the diagnosis of Haff disease and locates the sites of rhabdomyolysis.

[Rhabdomyolysis associated with cocaine use]

Cocaine is a drug that has been used by humans for 15 centuries. In our environment, the prevalence of alcohol consumption, and emergencies arising from it, has increased over the last 10 years. Cocaine has been used by 2.6% of the Spanish population between 15 and 64 years old at some time in their life, placing it among the most widely consumed illicit drug after cannabis. Cocaine use is associated with multiple complications: neurological, cardiovascular, psychiatry, nephrology, pulmonary and gastrointestinal. The first cases of rhabdomyolysis and kidney failure were found in the medical literature in 1987. Rhabdomyolysis is a potentially lethal clinical syndrome that results from the necrosis of muscle fibres, with the passage of its components into the circulation, and is underdiagnosed in primary care.

Rhabdomyolysis in a recreational swimmer

Rhabdomyolysis is a clinical and biochemical syndrome resulting from skeletal muscle injury, which may ultimately lead to acute renal failure (ARF) and death. Exertional rhabdomyolysis refers to skeletal muscle injury that is usually induced by strenuous eccentric exercises in a hot and humid environment. It is usually seen in marathoners and military personnel. We present the case of a 32-year-old Malaysian man who had rhabdomyolysis and myoglobinuria without ARF after two episodes of unaccustomed swimming. He was treated conservatively, and recovered uneventfully. A brief discussion on the pathophysiology of rhabdomyolysis, the principles of management and recuperation is included.