Rhabdomyolysis: review of the literature

Rhabdomyolysis in patients with COVID-19: A cause or consequence of acute kidney injury or mortality?

Rhabdomyolysis can occur due to many traumatic and nontraumatic causes. Rhabdomyolysis has been reported in new type of coronavirus disease (COVID-19) cases. The aim of our study was to examine the effects of rhabdomyolysis on mortality and renal outcomes in patients hospitalized in our hospital's COVID-19 wards. In our single-center and retrospective study, we included patients who were admitted with a diagnosis of COVID-19 by a thorax-computed tomography finding who were older than 18 years of age and with a measured creatinine kinase (CK) > 1000 U/L on any day of hospitalization. The same number of patients hospitalized in COVID-19 services with CK < 1000 U/L and with similar gender and age were determined as the control group. We analyzed the data of 2065 patients, and compared 154 patients in the rhabdomyolysis group (group 1) and 154 patients in the control group (group 2). Acute kidney injury (AKI) (44.2% vs 21.4%; P < .001), intensive care unit (ICU) admissions (53.2% vs 13.6%; P < .001), intubation (75.6% vs 23.8%; P < .001), mortality (36.4% vs 3.2%; P < .001) and the need for dialysis (3.9% vs 0.6%; P = .005) were seen more in the rhabdomyolysis group. When that group was divided into the early rhabdomyolysis group (group 1a), where the CK value reached its highest value in ≤3 days, and the late rhabdomyolysis group (group 1b), where it was ≥ 4 days, AKI (29.7% vs 65.1%; P < .001), ICU (35.2% vs 79.4%; P < .001), intubation (56.2% vs 88%; P = .001), mortality (18% vs 61.9%; P < .001), and dialysis (1.1% vs 7.9%; P = .031), the results were higher in the group 1b. The available data suggest that rhabdomyolysis seen in COVID-19 patients is not a direct predictor of mortality and poor renal outcomes, but is a secondary outcome to multiple-organ failure caused by worsening clinical status.

Veno-venous extracorporeal membrane oxygenation application for patient with acute lung injury due to rhabdomyolysis; a case report

A 47-year-old male patient, who underwent open reduction and internal fixation with plate for a Gustilo-Anderson type II open proximal tibiofibular fracture of the right lower leg, experienced rhabdomyolysis. Rapid progression of acute respiratory distress syndrome and acute renal failure occurred due to rhabdomyolysis. After veno-venous extracorporeal membrane oxygenation, he exhibited a relatively smooth clinical recovery. Our case report suggests that circulating cytotoxic substances from rhabdomyolysis resulted in concomitant acute respiratory distress syndrome and acute renal failure. This case was successfully treated after applying extracorporeal membrane oxygenation.

Lipin phosphatidic acid phosphatases: Structure, function, regulation, and disease association

Lipids play essential roles as structural barriers in cell membranes, long-term energy storage, and as signaling molecules. One class of enzymes involved in lipid synthesis are lipins. Lipins are magnesium-dependent phosphatidic acid phosphatases that produce diacylglycerol, playing key roles in TAG synthesis, de novo phospholipid synthesis and metabolism. Here, we review recent advances on the structure, function, and regulation of lipins with a particular focus on the structural impacts of missense mutations associated with rhabdomyolysis, Majeed syndrome and neuropathies. Structural insights reveal that while some disease-associated mutations directly disrupt catalysis, many missense mutations are not near the active site, but still play a key role in PAP activity. With the resolved crystal structure of a lipin homolog Tt Pah2, AlphaFold, and AlphaMissense it has become increasingly possible to predict the pathogenicity and structural contributions of individual residues and mutations. Going forward, this structural information can be used to predict and understand new mutations as they arise.

A Homozygous MYH1 Variant Underlies Autosomal Recessive Isolated Recurrent Rhabdomyolysis

Rhabdomyolysis is a severe condition involving the breakdown of skeletal muscle fibers, leading to the release of muscle components into the bloodstream, which can lead to potential complications such as acute kidney injury and electrolyte imbalances. The etiology of rhabdomyolysis is multifactorial, encompassing traumatic, exertional, metabolic, infectious, toxic, and genetic causes. Genetic causes, including variants in LPIN1, RYR1, and CACNA1S, are increasingly recognized as significant contributors to recurrent rhabdomyolysis. MYH1 has recently been identified as a candidate gene for recurrent rhabdomyolysis with limited evidence originating from a single patient. In this report, we describe a 35-year-old male, born to consanguineous parents, who presented with recurrent rhabdomyolysis attacks, beginning at age 28, characterized by muscle pain, weakness, and episodes of acute kidney injury requiring dialysis. During attacks, the patient exhibited remarkably elevated markers of muscle breakdown and mildly elevated creatine kinase levels between episodes. A muscle biopsy revealed non-specific myopathic changes. Exome sequencing analysis was carried out and revealed a novel homozygous variant (NM_005963.4: c.1825G>A [p.Val609Met]) in MYH1 segregating in a manner compatible with an autosomal recessive pattern. In summary, this case provides confirmatory support for the role of pathogenic MYH1 variants in the pathogenesis of recurrent rhabdomyolysis and emphasizes the importance of comprehensive genetic testing in patients with unexplained recurrent episodes of muscle breakdown. Further cases are necessary to fully elucidate the genotypic and phenotypic spectrum of MYH1-related muscle disorders.

276th ENMC workshop: recommendations on optimal diagnostic pathway and management strategy for patients with acute rhabdomyolysis worldwide. 15th-17th March 2024, Hoofddorp, The Netherlands

The 276th ENMC Workshop on rhabdomyolysis brought together 21 experts to address the compelling need for standardized guidelines on the clinical approach of rhabdomyolysis. There was a general agreement that a diagnosis of rhabdomyolysis require that 1) clinical symptoms include severe muscle swelling, weakness and/or myalgia; 2) serum CK-levels exceed 10,000 IU/L in case of exertional, and >5000 IU/L in non-exertional rhabdomyolysis; 3) CK-levels reaching a maximum 1-4 days after the event and normalizing to baseline within 1-2 weeks of rest. In case of an underlying neuromuscular condition, CK-levels should exceed 5-10 times the patient's baseline level. Treatment should be initiated only in case of high risk on acute kidney injury, which can be predicted by the McMahon score. Furthermore, recommendations on performing genetic testing were formulated and the use of the 'RHABDO'- acronym was generally agreed upon as a tool to aid clinicians in deciding which patients require genetic testing. Moreover, recommendations on follow-up were made, with a particular emphasis on evaluation of physical and psychological sequelae. Patient representatives present during the workshop emphasized the importance of the current recommendations for future clinical guidelines on rhabdomyolysis.

Primary Aldosteronism and Hypokalemia-induced Rhabdomyolysis in a Patient with Aldosterone-producing Adenoma: A Case Report and Literature Review

Many cases of primary aldosteronism (PA) in patients who developed hypokalemia-induced rhabdomyolysis and underwent adrenalectomy for aldosterone-producing adenoma (APA) have been reported; however, the immunohistopathological and molecular features remain unknown. We herein report the case of a 28-year-old woman with PA who presented with hypokalemia-induced rhabdomyolysis and underwent adrenalectomy for unilateral APA. An immunohistochemical analysis revealed that most adenoma cells were positive for steroidogenic enzymes, including CYP11B2. A genetic analysis revealed a somatic mutation in the KCNJ5. These findings suggest a strong aldosterone production capacity in our patient's adenoma, which was presumably related to her severe hyperaldosteronism and the resultant hypokalemia-induced rhabdomyolysis.

Trans-sodium crocetinate attenuates acute kidney injury induced by rhabdomyolysis in rats: focusing on PI3K/AKT, apoptosis, and autophagy pathways

Rhabdomyolysis (RM) is a clinical disorder characterized by the release of potentially toxic muscle cell components into the bloodstream, with acute kidney injury (AKI). Trans-sodium crocetinate (TSC) is derived from the carotenoid crocetin known for its renoprotective, anti-inflammatory, and antioxidant properties. This study aimed to assess the protective effects of TSC on RM-induced AKI in rats. Six groups of rats (n = 6) were used: control, AKI (50% glycerol 10 mL/kg, intramuscularly), AKI treated with TSC (10, 20, and 40 mg/kg, intraperitoneally), and TSC (40 mg/kg) alone groups. Two days after the initial injection, urine and blood samples were collected over 24 h to investigate creatine phosphokinase (CPK), kidney function markers, and electrolyte levels. Additionally, kidney tissue was collected to assess renal oxidative markers, histological alterations, and the expression of protein markers related to autophagy, apoptosis, renal injury, inflammation, and the PI3K/AKT signaling pathway. After glycerol administration, there was an increase in oxidative stress, autophagy, apoptosis, renal injury, and inflammatory marker levels, accompanied by a decrease in the proteins of the PI3K/AKT signaling pathway in the kidney. The co-administration of TSC with glycerol resulted in the improvement of renal dysfunction and structural abnormalities, achieved through a reduction in oxidative stress. TSC also down-regulated autophagy, apoptotic, renal injury, and inflammatory markers. Furthermore, TSC treatment led to a decrease in the renal expression of PI3K/AKT signaling pathway proteins. In conclusion, TSC exhibited a protective effect against RM-induced AKI by modulating oxidative stress, autophagy, apoptosis, and the PI3K/AKT pathway.

Two Cases of Levetiracetam-Induced Rhabdomyolysis With Low Levetiracetam Blood Concentrations

Levetiracetam is an antiepileptic drug used to treat tonic-clonic convulsions and partial seizures. In general, levetiracetam is well tolerated; however, rhabdomyolysis has been reported as a rare side effect. The underlying mechanism is unclear. This case report describes two cases of rhabdomyolysis during levetiracetam treatment for convulsive status epilepticus, both of whom developed rhabdomyolysis a few days after starting levetiracetam. When levetiracetam was replaced with lacosamide, creatinine kinase decreased to the normal range within approximately 10 days. Furthermore, blood levels of levetiracetam were measured at the onset of rhabdomyolysis, and the results suggest that its adverse effects may not be correlated with its levels in the blood. Monitoring creatinine kinase is important for early detection of levetiracetam-induced rhabdomyolysis.

Risk of rhabdomyolysis in patients with mental disorders

OBJECTIVES

Rhabdomyolysis is caused by rapid muscle breakdown. Although patients with mental disorders are more susceptible to rhabdomyolysis, its incidence in this group is poorly established. Therefore, we conducted a population-based cohort study to investigate its incidence and risk in this group.

METHODS

We conducted a retrospective cohort study of 120,094 patients with mental disorders and 120,094 control patients from the Taiwan National Health Insurance Research Database. We excluded patients with rhabdomyolysis diagnosed before the index date, which was defined as the date of the first diagnosis of the mental disorder and beginning of antipsychotic medication. We matched the case cohort 1:1 with a control cohort by a propensity score method.

RESULTS

The overall incidence of rhabdomyolysis were 3.21 per 1000 person-years in the patients with mental disorders and 1.16 per 1000 person-years in the patients without mental disorders. After controlling for potential covariates, the patients with mental disorders showed an adjusted hazard ratio (aHR) of 2.77 (95% Cl: 2.62-2.92) compared with the controls. Men exhibited a risk of rhabdomyolysis 1.29-fold that exhibited by women (95% CI: 1.22-1.35). Alcoholic liver disease (aHR, 2.35) and generalized convulsive epilepsy (aHR, 2.06) were independent risk factors for rhabdomyolysis. Phenothiazines with aliphatic side-chains (aHR, 1.43), or piperidine structures (aHR, 1.54); butyrophenone derivatives (aHR, 1.24); lithium (aHR, 1.18) were independent risk factors for rhabdomyolysis after adjustment for covariates.

CONCLUSIONS

The risk of rhabdomyolysis is significantly higher for patients with mental disorders than that for patients without mental disorders.

Advances in rhabdomyolysis: A review of pathogenesis, diagnosis, and treatment

Rhabdomyolysis (RM) is a multifactorial clinical syndrome characterized by the disintegration and necrosis of muscle tissue, leading to the release of cellular contents into the circulation. One of the most severe complications of RM is acute kidney injury, with a mortality rate of 20%-50%. Early and timely diagnosis is the key to improving the prognosis of patients with RM. The etiology of RM is complex and associated with various traumas, drugs, medications, and hereditary diseases, and the clinical symptoms are nonspecific. Therefore, its diagnosis highly relies on the doctor's experience and the level of medical equipment. However, RM often occurs in situations with limited medical resources, such as natural disasters, battlefields, and large-scale traffic accidents. In these scenarios, the varying levels of expertise among rescue personnel can lead to delays in diagnosis and treatment, thereby increasing the risk of mortality. This article provides a comprehensive review of the etiology, pathogenesis, complications, diagnostic, and treatment methods of RM. It also aims to offer new perspectives on the diagnosis and prognosis of RM by integrating machine learning and artificial intelligence. It is believed that this article can help pre-hospital rescuers and in-hospital doctors have a comprehensive understanding of RM to improve the patients' outcomes and overcome the challenges.

Predictive model for assessing the prognosis of rhabdomyolysis patients in the intensive care unit

Background

Rhabdomyolysis (RM) frequently gives rise to diverse complications, ultimately leading to an unfavorable prognosis for patients. Consequently, there is a pressing need for early prediction of survival rates among RM patients, yet reliable and effective predictive models are currently scarce.

Methods

All data utilized in this study were sourced from the MIMIC-IV database. A multivariable Cox regression analysis was conducted on the data, and the performance of the new model was evaluated based on the Harrell's concordance index (C-index) and the area under the receiver operating characteristic curve (AUC). Furthermore, the clinical utility of the predictive model was assessed through decision curve analysis (DCA).

Results

A total of 725 RM patients admitted to the intensive care unit (ICU) were included in the analysis, comprising 507 patients in the training cohort and 218 patients in the testing cohort. For the development of the predictive model, 37 variables were carefully selected. Multivariable Cox regression revealed that age, phosphate max, RR mean, and SOFA score were independent predictors of survival outcomes in RM patients. In the training cohort, the AUCs of the new model for predicting 28-day, 60-day, and 90-day survival rates were 0.818 (95% CI: 0.766-0.871), 0.810 (95% CI: 0.761-0.855), and 0.819 (95% CI: 0.773-0.864), respectively. In the validation cohort, the AUCs of the new model for predicting 28-day, 60-day, and 90-day survival rates were 0.840 (95% CI: 0.772-0.900), 0.842 (95% CI: 0.780-0.899), and 0.842 (95% CI: 0.779-0.897), respectively.

Conclusion

This study identified crucial demographic factors, vital signs, and laboratory parameters associated with RM patient prognosis and utilized them to develop a more accurate and convenient prognostic prediction model for assessing 28-day, 60-day, and 90-day survival rates.

Implications for clinical practice

This study specifically targets patients with RM admitted to ICU and presents a novel clinical prediction model that surpasses the conventional SOFA score. By integrating specific prognostic indicators tailored to RM, the model significantly enhances prediction accuracy, thereby enabling a more targeted and effective approach to managing RM patients.

Cellular mechanisms of acute rhabdomyolysis in inherited metabolic diseases

Acute rhabdomyolysis (RM) constitutes a life-threatening emergency resulting from the (acute) breakdown of skeletal myofibers, characterized by a plasma creatine kinase (CK) level exceeding 1000 IU/L in response to a precipitating factor. Genetic predisposition, particularly inherited metabolic diseases, often underlie RM, contributing to recurrent episodes. Both sporadic and congenital forms of RM share common triggers. Considering the skeletal muscle's urgent need to rapidly adjust to environmental cues, sustaining sufficient energy levels and functional autophagy and mitophagy processes are vital for its preservation and response to stressors. Crucially, the composition of membrane lipids, along with lipid and calcium transport, and the availability of adenosine triphosphate (ATP), influence membrane biophysical properties, membrane curvature in skeletal muscle, calcium channel signaling regulation, and determine the characteristics of autophagic organelles. Consequently, a genetic defect involving ATP depletion, aberrant calcium release, abnormal lipid metabolism and/or lipid or calcium transport, and/or impaired anterograde trafficking may disrupt autophagy resulting in RM. The complex composition of lipid membranes also alters Toll-like receptor signaling and viral replication. In response, infections, recognized triggers of RM, stimulate increased levels of inflammatory cytokines, affecting skeletal muscle integrity, energy metabolism, and cellular trafficking, while elevated temperatures can reduce the activity of thermolabile enzymes. Overall, several mechanisms can account for RMs and may be associated in the same disease-causing RM.

The Approach to Altered Mental Status in the Intensive Care Unit

Altered mental status (AMS) is a syndrome posing substantial burden to patients in the intensive care unit (ICU) in both prevalence and intensity. Unfortunately, ICU patients are often diagnosed merely with syndromic labels, particularly the duo of toxic-metabolic encephalopathy (TME) and delirium. Before applying a nonspecific diagnostic label, every patient with AMS should be evaluated for specific, treatable diseases affecting the central nervous system. This review offers a structured approach to increase the probability of identifying specific causal etiologies of AMS in the critically ill. We provide tips for bedside assessment in the challenging ICU environment and review the role and yield of common neurodiagnostic procedures, including specialized bedside modalities of diagnostic utility in unstable patients. We briefly review two common etiologies of TME (uremic and septic encephalopathies), and then review a selection of high-yield toxicologic, neurologic, and infectious causes of AMS in the ICU, with an emphasis on those that require deliberate consideration as they elude routine screening. The final section lays out an approach to the various etiologies of AMS in the critically ill.

Rhabdomyolysis secondary to COVID-19 infection and vaccination: a review of literature

Rhabdomyolysis (RML), characterized by the breakdown of skeletal muscle fibers and the release of muscle contents into the bloodstream, has emerged as a notable complication associated with Coronavirus disease 2019 (COVID-19) infection and vaccination. Studies have reported an increased incidence of RML in individuals with severe COVID-19 infection. However, the exact mechanisms remain unclear and are believed to involve the host's immune response to the virus. Furthermore, RML has been documented as a rare adverse event following COVID-19 vaccination, particularly with mRNA vaccines. Proposed mechanisms include immune responses triggered by the vaccine and T-cell activation against viral spike proteins. This study aims to review the current literature on the incidence, pathophysiology, clinical presentation, and outcomes of RML secondary to COVID-19 infection and vaccination. We identify common risk factors and mechanisms underlying this condition by analyzing case reports, clinical studies, and pharmacovigilance data. Our findings suggest that while RML is a relatively rare adverse event, it warrants attention due to its potential severity and the widespread prevalence of COVID-19 and its vaccines. This review underscores the need for heightened clinical awareness and further research to optimize management strategies and improve patient outcomes in this context.

Rhabdomyolysis Without Acute Kidney Injury in a 14-Year-Old Child With a Sedentary Lifestyle

A 14-year-old African American female patient presented to the emergency department with moderate right calf pain of unknown origin. The pain was present for a couple of days without radiation and progressed with an inability to bear weight. Physical examination revealed tenderness to palpation over the right calf. The patient had no history of overweight, trauma, infection, or extreme physical exertion. She took no medications, supplements, herbals, or used any illegal drugs. Of note, the patient was sedentary. Her blood work revealed elevated creatine kinase and liver enzymes, diagnostic of rhabdomyolysis. All other diagnostic evaluations, including EKG, chest X-ray, leg ultrasound, creatine kinase-MB, urinalysis, thyroid levels, and CBC were unremarkable. No other inherited conditions were identified in lab work. The patient was given dextrose 5% in water with sodium bicarbonate and switched to aggressive hydration via normal saline until discharge.

Inter-individual differences in muscle damage following a single bout of high-intense whole-body electromyostimulation

Purpose

This brief report aimed to characterize inter-individual training responses following a single session of high-intense whole-body electromyostimulation (WB-EMS) using markers of muscle damage over a period of 72 h.

Methods

Twelve healthy individuals (5 men, 7 women; 32.0 ± 7 years) participated in a single 20-minute high-intensity WB-EMS training session. Markers of muscle damage, creatine kinase (CK) and myoglobin (Mb), were assessed before and immediately after training, as well as at 1.5, 3, 24, 48 and 72 h post-exercise. Lactate levels were determined pre- and post-exercise.

Results

Overall, WB-EMS induced significant CK elevations, peaking at 72 h (18.358 ± 21.380 U/L; p < 0.01), and correlating Mb levels peaking at 48 h (1.509 ± 1.394 ng/dl, p < 0.01). Despite significant inter-individual variability in CK levels, both slow (SR) and fast responders (FR) were identified. FR showed significant increases in CK at all time points post WB-EMS (p < 0.05), whereas CK in SR significantly elevated after 48 h. Post-WB-EMS lactate concentration was identified to predict peak CK and Mb levels (r ≥ 0.65, both p < 0.05).

Conclusion

High-intensity WB-EMS has the potential to induce severe muscle damage, as indicated by elevated levels of CK and Mb. We identified two distinct groups of individuals, SR and FR, indicating variability in response to WB-EMS. Furthermore, we suggest that individual responses to WB-EMS can be predicted based on post-WB-EMS lactate concentration.

Rhabdomyolysis Induced by Levetiracetam: A Case Report in Kuwait

Epilepsy is a common disorder caused by a myriad of drugs, of that levetiracetam is being commonly used late because of its strong safety profile and efficacy. With the increasing usage of drugs, some rare side effects may sometimes appear that can escape the most stringent checks, possibly due to the rarity of their occurrence. Rhabdomyolysis is known to occur in some patients owing to a variety of causes, even leading to kidney injury. When a drug has a side effect that is not well recognized in the literature, especially when the side effect can mimic an adverse effect of an uncommon primary illness, identifying the causal factor can be doubly difficult. To date, only limited studies have been published suggesting rhabdomyolysis linked to levetiracetam use. We report the first case of levetiracetam-induced rhabdomyolysis in Kuwait.

Rhabdomyolysis associated with concomitant use of colchicine and statins in the real world: identifying the likelihood of drug-drug interactions through the FDA adverse event reporting system

Background

Currently, there remains substantial controversy in research regarding whether the concomitant use of colchicine and statins increases the occurrence of rhabdomyolysis, warranting further substantiation.

Objective

This study aimed to identify the likelihood drug-drug interactions (DDIs) for the co-administration of colchicine and statins resulting in rhabdomyolysis.

Methods

A disproportionality analysis was conducted by using data sourced from the US Food and Drug Administration Adverse Event Reporting System (FAERS) to detect rhabdomyolysis signals associated with the combined use of colchicine and statins. The association between (colchicine/statins/colchicine and statins) and rhabdomyolysis were evaluated using information component (IC). DDI signals were calculated based on the Ω shrinkage measure and Bayesian confidence propagation neural network (BCPNN) method. Furthermore, stratification was performed based on colchicine and individual statins agents.

Results

In total, 11,119 reports of rhabdomyolysis were identified in the FAERS database, 255 (2.29%) involved both colchicine and statins. Our analysis showed potential DDI signals of rhabdomyolysis (Ω025 = 1.17) among individuals concurrent use of colchicine and statins. Moreover, further drug-specific analysis suggests DDI signals in the colchicine-atorvastatin pair (Ω025 = 1.12), and colchicine-rosuvastatin pair (Ω025 = 1.05), along with a higher proportion of rhabdomyolysis (IC025 = 5.20) and (IC025 = 4.26), respectively.

Conclusion

The findings suggest that concomitant use of colchicine and statins may increase the risk of rhabdomyolysis, particularly when combined with atorvastatin or rosuvastatin. Therefore, healthcare professionals should pay special attention to life-threatening AE such as rhabdomyolysis, when co-prescribing colchicine statins.

Recurrent Rhabdomyolysis in a Medical Cadet during Military Training as a Rare Initial Presentation in Calpainopathy

Rhabdomyolysis, an emergency medical condition linked to muscle necrosis and intracellular substances released into the bloodstream, significantly endangers military personnel in heat-stress conditions. Rhabdomyolysis can also be an initial presentation in inherited muscle disorders. This study reports a novel case of calpainopathy (LGMDR1) diagnosed in a 19-year-old male military cadet who initially presented with recurrent rhabdomyolysis during training, a rare presentation in LGMD patients. Furthermore, a persistent creatine kinase (CK) elevation was observed at baseline. The diagnosis was confirmed by identifying a compound heterozygous of a novel frameshift, c.606dup (p.Ala203CysfsTer9), a mutation in exon 4, and a missense, c.956C > T (p.Pro319Leu), a mutation in exon 7 of the CAPN3 gene, via whole exome sequencing. This case highlights the necessity of diagnostic investigation in individuals who have persistent high CK levels during the rhabdomyolysis episodes and possibly CK screening prior to military training to preemptively identify and mitigate complications from undiagnosed muscular dystrophies in military personnel in the future.

Rhabdomyolysis following colorectal endoscopic submucosal dissection: A case report

The occurrences of rhabdomyolysis after endoscopic submucosal dissection surgery were rarely reported. This is a case involving rhabdomyolysis affecting the muscles of the left buttocks and left hip following a prolonged endoscopic submucosal surgery.

Acute Kidney Injury in Rhabdomyolysis: A 5-Year Children's Hospital Network Study

Rhabdomyolysis is a skeletal muscle injury that can cause myoglobinuria and acute kidney injury (AKI). Risk factors for AKI in children are not clearly understood with no standardized treatment guidelines for rhabdomyolysis. Our study explores factors associated with AKI and management of pediatric patients with rhabdomyolysis. Medical records from a children's hospital network over a 5-year period were retrospectively reviewed. The results are described with respect to the presence or absence of AKI. Of the 112 patients who met the inclusion criteria, AKI incidence was 7.1% (n = 8), with all affected patients having exertional etiology. The overall mean age was 13.5 years; patients without AKI were younger than patients with AKI (13.3 versus 17; p < 0.001). Using regression models for hypothesis generation, we found that patients with AKI were more likely to be older (OR = 1.44, 95%CI [1.11-2.19]; p = 0.03), have myoglobinuria (OR = 22.98, 95%CI [2.05-432.48]; p = 0.02), and have received intravenous bicarbonate (OR = 16.02, 95%CI [1.44-228.69]; p = 0.03). In our study, AKI was uncommon and associated with older age, myoglobinuria and bicarbonate treatment. Larger, prospective studies are needed to further understand AKI risk factors and optimal management of pediatric rhabdomyolysis.

Asymptomatic COVID-19 Infection-Induced Rhabdomyolysis in the Backdrop of Statin-Cyclosporine Drug Interaction

Rhabdomyolysis involves skeletal muscle breakdown leading to high serum creatine kinase (CK) levels and myoglobinuria. Here, we report the case of a middle-aged man who developed rhabdomyolysis, resulting in acute kidney injury (AKI) over pre-existing chronic kidney disease (stage 3a) secondary to focal segmental glomerulosclerosis (primary FSGS), during an asymptomatic COVID-19 infection. The patient had been on treatment with cyclosporine and statin, among other drugs, for his comorbidities. He had initially presented to the hospital after a fall due to difficulty walking in the setting of increasing edema. Lab workup revealed elevated CK and AKI. Urinalysis showed "large" blood on a dipstick with only two RBCs per high-power field on microscopy, suggesting myoglobinuria. A standard respiratory pathogen polymerase chain reaction panel revealed positive SARS-CoV-2. The chest X-ray and oxygenation were normal, and he had no respiratory symptoms. He was treated with intravenous fluids and albumin, with a steady improvement in renal function. Our case underlines that rhabdomyolysis can occur in asymptomatic COVID-19 infection. Therefore, it may be worth monitoring CK levels in COVID-19-positive patients with risk factors for rhabdomyolysis, such as the concurrent usage of statins and cyclosporine, even if they are otherwise asymptomatic.

Exertion induced rhabdomyolysis in both triceps muscles in a 36-year old woman: A case report

Rhabdomyolysis is a condition, often caused by strenuous exercise, which can lead to acute kidney injury, severe electrolyte imbalances, coagulopathies, compartment syndromes, and even have a fatal outcome in a few cases. Recognition and management of fluid and electrolyte abnormalities is one of the first steps of treatment and key to a good outcome. We report a case of a 36-year old woman who was referred to the ER by her general practitioner with severe muscle tenderness to the upper arms and highly elevated creatine kinase (CK) serum levels. Initial ultrasound imagery showed a patent venous system but demonstrated a moderate edematous infiltration of the muscle bellies of both m. triceps. Additional magnetic resonance imagery showed a hyperintense signal in T2 in both triceps' muscles. Given the clinical presentation, the MRI-findings were consistent with a form of exertion-induced rhabdomyolysis of both triceps' muscles. The patient was admitted for administration of IV-fluids to prevent acute kidney injury. Symptoms resolved in a few days and new magnetic resonance imagery showed a regression of the subcutaneous soft tissue infiltration. The aim of this paper is to raise awareness about this diagnosis. If overlooked, severe complications as mentioned above can occur.

The utility of electrodiagnostic testing in unprovoked rhabdomyolysis in the era of next-generation sequencing

INTRODUCTION/AIMS

Rhabdomyolysis is an etiologically heterogeneous, acute necrosis of myofibers characterized by transient marked creatine kinase (CK) elevation associated with myalgia, muscle edema, and/or weakness. The study aimed to determine the role of electrodiagnostic (EDX) testing relative to genetic testing and muscle biopsy in patients with unprovoked rhabdomyolysis in identifying an underlying myopathy.

METHODS

EDX database was reviewed to identify unprovoked rhabdomyolysis patients who underwent EDX testing between January 2012 and January 2022. Each patient's clinical profile, EDX findings, muscle pathology, laboratory, and genetic testing results were analyzed.

RESULTS

Of 66 patients identified, 32 had myopathic electromyography (EMG). Muscle biopsy and genetic testing were performed in 41 and 37 patients, respectively. A definitive diagnosis was achieved in 15 patients (11 myopathic EMG and 4 nonmyopathic EMG; p = .04) based on abnormal muscle biopsy (4/11 patients) or genetic testing (12/12 patients, encompassing 5 patients with normal muscle biopsy and 3 patients with nonmyopathic EMG). These included seven metabolic and eight nonmetabolic myopathies (five muscular dystrophies and three ryanodine receptor 1 [RYR1]-myopathies). Patients were more likely to have baseline weakness (p < .01), elevated baseline CK (p < .01), and nonmetabolic myopathies (p = .03) when myopathic EMG was identified.

DISCUSSION

Myopathic EMG occurred in approximately half of patients with unprovoked rhabdomyolysis, more likely in patients with weakness and elevated CK at baseline. Although patients with myopathic EMG were more likely to have nonmetabolic myopathies, nonmyopathic EMG did not exclude myopathy, and genetic testing was primarily helpful to identify an underlying myopathy. Genetic testing should likely be first-tier diagnostic testing following unprovoked rhabdomyolysis.

A review of complications after ureteral reconstruction

Objective

This study aimed to provide a comprehensive overview of the complications unique to ureteral reconstruction in adults, emphasizing their presentation, diagnosis, and management in the treatment of ureteral structure disease.

Methods

This review involves an in-depth analysis of existing literature and case studies pertaining to ureteral reconstruction, with a focus on examining the range of complications that can arise post-surgery. Special attention is given to the presentation of each complication, the diagnostic process involved, and the subsequent management strategies.

Results

Ureteral reconstruction can treat ureteral stricture disease with low morbidity; however, complications, although uncommon, can have severe consequences. The most notable complications include urinary extravasation, stricture recurrence, urinary tract infections, compartment syndrome, symptomatic vesicoureteral reflux, and Boari flap necrosis. Each complication presents unique diagnostic challenges and requires specific management approaches.

Conclusion

Ureteral reconstruction is a highly effective treatment for ureteral stricture disease. Having a strong understanding of the potential complications that patients may experience following ureteral reconstruction is not only critical to adequately counsel patients but also facilitate prompt diagnosis and management of complications when they arise.

Neurodengue, a narrative review of the literature

Dengue fever (DF) is the most frequent arboviral disease globally. Deforestation, armed conflicts, and climate change have caused an unprecedented global spread of DF, raising concerns in healthcare systems worldwide. Systemic manifestations of the disease range from mild to severe and, in some cases, can lead to death. Although neurological complications have been reported over the last few decades, they are often neglected or underreported. The present narrative review aims to describe the most important central and peripheral nervous system complications and provide guidance to neurologists in terms of diagnosis and management.

Abdalsalam R, A. Khalil I, M. Khattab M, A. Hamzawy M. Revolutionizing Hyperlipidemia Treatment: Nanoencapsulated CoQ10 and Selenium Combat Simvastatin-Induced Myopathy and Insulin Resistance in Rats

Purpose

The objective of this study was to develop a nanoencapsulated platform for coenzyme Q10 nanoparticles (coQNPs) or selenium nanoparticles (SeNPs) and explore their potential therapeutic benefits in treating hyperlipidemia and combating simvastatin (SV)-induced myopathy and adverse reactions in hyperlipidemic rats.

Methods

The physical and chemical properties of the solid nanoparticles, coQNPs, and SeNPs were characterized, including zeta potential studies. Male Wistar albino rats were treated with various interventions for 112 days, including a nano-vehicle only, high-fat diet (HFD), HFD with SV alone, or with coQNPs or/and SeNPs for the last 30 days.

Results

The coQNPs and SeNPs exhibited uniform spherical shapes with high encapsulation efficiency (EE% 91.20±2.14 and 94.89±1.54, respectively). The results demonstrated that coQNPs and SeNPs effectively reduced hyperlipidemia, insulin resistance, SV-induced myopathy, and hepatotoxicity. However, combining SV with coQNPs and SeNPs resulted in severe liver and muscle damage. Treatment with SV and SeNPs or SV and coQNPs alone showed significant improvements compared to SV treatment alone.

Conclusion

These findings suggest that the CoQNPs or SeNPs platforms offer advanced relief for hyperlipidemia and insulin resistance while limiting adverse effects such as myopathy and hepatotoxicity.

Pregabalin-induced rhabdomyolysis: a case series and literature analysis

Pregabalin is a prescription medicine that has recently been approved for individuals who suffer from fibromyalgia, neuropathic pain, anxiety disorder, or epilepsy. Pregabalin has the side effects of dizziness, sleepiness, and angioedema. Pregabalin-induced rhabdomyolysis has been rarely reported, with only four reports to date. We report two cases of rhabdomyolysis after pregabalin treatment. A man aged older than 90 years presented with exhaustion, muscle aches, and a high serum creatine kinase concentration after taking 75 mg of pregabalin on the first day of treatment. A woman in her 90s with long-term use of pregabalin presented with considerably elevated serum creatine kinase concentrations. Both patients had a long history of taking statins. Pregabalin therapy was stopped, high-volume intravenous fluids were administered, and serum electrolytes were frequently checked. Alkalinisation was performed with excellent outcomes. The Naranjo Adverse Drug Reaction scale and previous research suggest an association between pregabalin and rhabdomyolysis. Clinicians should be alert to the possibility of rhabdomyolysis occurring with the use of pregabalin, especially when taking statins.

Dengue Fever Accompanied by Neurological Manifestations: Challenges and Treatment

Dengue, commonly referred to as 'breakbone fever,' is a mosquito-borne arboviral infection transmitted by Aedes aegypti, featuring an average incubation period of approximately seven days. Key cytokines such as interferon-gamma (IFN-γ), tumor necrosis factor (TNF)-α, and interleukin (IL)-10 are pivotal in the pathogenesis of dengue. Travelers are particularly susceptible to contracting dengue fever, with disease severity often associated with CD8+ T cell response. Without proper hospitalization during severe cases like dengue hemorrhagic fever (DHF)/dengue shock syndrome (DSS), mortality rates can escalate to 50%. Dengue fever can lead to various complications, including neurological manifestations such as encephalopathy, encephalitis, cerebral venous thrombosis, myelitis, posterior reversible encephalopathy syndrome, strokes (both ischemic and hemorrhagic), immune-mediated neurological syndromes (such as mononeuropathy, acute transverse myelitis, Guillain-Barre syndrome, and acute disseminated encephalomyelitis), and neuromuscular complications. Treatment protocols typically involve assessing disease activity using composite indices, pursuing treatment objectives, and administering intravenous fluids according to symptomatology. Given the absence of specific antiviral treatment for dengue, supportive care, particularly hydration, remains paramount during the early stages. It is crucial to recognize that dengue viruses may contribute to the development of neurological disorders, particularly in regions where dengue is endemic. Furthermore, there is a necessity for well-defined criteria for specific neurological complications. Primary prevention strategies primarily revolve around vector control measures, which play a critical role in curtailing the spread of dengue.

Super-refractory status epilepticus, rhabdomyolysis, central hyperthermia and cardiomyopathy attributable to spinal anesthesia: a case report and review of literature

BACKGROUND

There are only six past reports of super-refractory status epilepticus induced by spinal anesthesia. None of those patients have died. Only < 15 mg of bupivacaine was administered to all six of them and to our case. Pathophysiology ensuing such cases remains unclear.

CASE PRESENTATION

A 27 year old gravida 2, para 1, mother at 37 weeks of gestation came to the operating theater for an elective cesarean section. She had no significant medical history other than controlled hypothyroidism and one episode of food allergy. Her current pregnancy was uneventful. Her American Society of Anesthesiologists (ASA) grade was 2. She underwent spinal anesthesia and adequate anesthesia was achieved. After 5-7 min she developed a progressive myoclonus. After delivery of a healthy baby, she developed generalized tonic clonic seizures that continued despite the induction of general anesthesia. She had rhabdomyolysis, one brief cardiac arrest and resuscitation, followed by stress cardiomyopathy and central hyperthermia. She died on day four. There were no significant macroscopic or histopathological changes in her brain that explain her super refractory status epilepticus. Heavy bupivacaine samples of the same batch used for this patient were analyzed by two specialized laboratories. National Medicines Quality Assurance Laboratory of Sri Lanka reported that samples failed to confirm United States Pharmacopeia (USP) dextrose specifications and passed other tests. Subsequently, Therapeutic Goods Administration of Australia reported that the drug passed all standard USP quality tests applied to it. Nonetheless, they have detected an unidentified impurity in the medicine.

CONCLUSIONS

After reviewing relevant literature, we believe that direct neurotoxicity by bupivacaine is the most probable cause of super-refractory status epilepticus. Super-refractory status epilepticus would have led to her other complications and death. We discuss probable patient factors that would have made her susceptible to neurotoxicity. The impurity in the drug detected by one laboratory also would have contributed to her status epilepticus. We propose several possible mechanisms that would have led to status epilepticus and her death. We discuss the factors that shall guide investigators on future such cases. We suggest ways to minimize similar future incidents. This is an idiosyncratic reaction as well.

NEW PREDICTIVE BIOMARKERS FOR SCREENING COVID-19 PATIENTS WITH RHABDOMYOLYSIS IN COMBINATION WITH CYSTATIN C

ABSTRACT

Purpose: Cystatin C (CysC) has been linked to the prognosis of corona virus disease 2019 (COVID-19). The study aims to investigate a predictor correlated with CysC screening for poor prognosis in COVID-19 patients combined with skeletal muscle (SKM) impairment and rhabdomyolysis (RM). Methods: A single-center retrospective cohort analysis was carried out. Demographic information, clinical data, laboratory test results, and clinical outcome data were gathered and analyzed. Results: According to the inclusion and exclusion criteria, 382 patients were included in this study. The subjects were divided into three groups based on CysC tertiles. Multivariate analysis revealed that SaO 2 (hazard ratio [HR], 0.946; 95% confidence interval [CI], 0.906-0.987; P = 0.011), CysC (HR, 2.124; 95% CI, 1.223-3.689; P = 0.008), aspartate aminotransferase (AST) (HR, 1.009; 95% CI, 1.000-1.018; P = 0.041), and hypersensitive C-reactive protein (HR, 1.005; 95% CI, 1.000-1.010; P = 0.045) were significantly associated with survivals. The area under curve (AUC) in the model characterized by RM incidence was 0.819 (0.698-0.941), as shown by CysC receiver operating characteristic curves. LDH*CysC and AST*CysC had better predictive values than CysC and the best prediction for RM, with an AUC of 0.880 (0.796,0.964) for LDH*CysC ( P < 0.05, vs CysC) and 0.925 (0.878,0.972) for AST*CysC ( P < 0.05, vs CysC). Conclusion: CysC is an essential evaluation indicator for COVID-19 patients' prognosis. AST*CysC and LDH*CysC have superior predictive value to CysC for SKM, RM, and death, and optimal classification for RM.

A Case of Rhabdomyolysis Induced by Antipsychotic Medication With Creatine Kinase (CK) Levels Elevated to 420,000 U/L, Resulting in Acute Kidney Injury (AKI) and Necessitating Hemodialysis

A 45-year-old man on public welfare, who had been visiting a psychiatric hospital for schizoaffective disorder, began working as a package delivery person for the first time in the morning after receiving welfare. In the afternoon, he noticed pain in his lower back. By evening, he was unable to move, prompting an emergency call and transportation to our hospital. Blood tests revealed renal damage and elevated creatine kinase (CK) levels, resulting in hospitalization. Although he received fluid replacement after admission, he did not urinate, and his CK levels increased to 420,000 U/L, necessitating hemodialysis. Subsequently, his CK levels gradually improved over time, accompanied by increased urine output. Approximately three weeks after initiating hemodialysis, he was weaned off the treatment and discharged home 40 days after admission.

Urate-Lowering Drugs and Muscle Injury: A Systematic Review and Network Meta-Analysis

Several urate-lowering drugs have been linked to muscle injury. This study investigated the association of oral urate-lowering drugs with the risk of muscle injury by performing a network meta-analysis of randomized and non-randomized controlled trials. A systematic search of MEDLINE, via PubMed, the ClinicalTrials.gov website, and the Cochrane Central Register of Controlled Trials was conducted to identify relevant studies with a primary outcome of "all muscle injuries." A random-effects model was used to perform a frequentist network meta-analysis to estimate whether there was significant heterogeneity among the studies. In total, 32 studies including 28,327 participants with 2694 (9.5%) "all muscle injuries" were assessed, and the overall risk of bias was judged to be low to moderate. No statistically significant differences were found between placebo and 6 urate-lowering therapies: allopurinol (risk ratio, RR, 1.05; 95% confidence interval, 95%CI, 0.63-1.73), febuxostat (RR 1.10, 95%CI 0.71-1.70), lesinurad (RR 7.00, 95%CI 0.31-160.36), lesinurad concomitant with allopurinol (RR 0.85, 95%CI 0.34-2.11), lesinurad concomitant with febuxostat (RR 1.97, 95%CI 0.55-7.03), and topiroxostat (RR 0.99, 95%CI 0.37-2.65). The findings suggest that there is little need to consider the risk of muscle injury when using urate-lowering drugs in the clinical setting.

Status epilepticus resulted in rhabdomyolysis-induced AKI associated with hepatotoxicity induced by synergistic carbamazepine and diazepam: A case report

RATIONALE

Rhabdomyolysis is a serious complication of status epilepticus (SE) caused by muscle cell damage and can lead to a life-threatening acute kidney injury (AKI).

PATIENT CONCERNS

A 35-year-old man with a history of seizures treated with 3 different antiepileptic drugs (carbamazepine, lamotrigine, and levetiracetam) presented with SE. The patient received 5 doses of diazepam to control the SE in another hospital and was transferred to our emergency due to AKI.

DIAGNOSES

Laboratory tests corresponded with rhabdomyolysis-induced AKI and disseminated intravascular coagulation. Thereafter, the decrease in renal excretion of both drugs (diazepam and carbamazepine) caused acute liver injury and neurotoxicity. The carbamazepine concentration was 16.39 mcg/mL, which considered in toxic level, despite using the usual dose.

INTERVENTIONS

The patient was treated with hydration and sodium bicarbonate, however; severe AKI mandated a hemodialysis session.

OUTCOMES

The diuresis started to increase, kidney and liver functions improved, and altered mental status reversed.

LESSONS

This case alerts physicians to consider the synergistic drug side effects and interactions, especially when patients present with impaired liver or kidney functions. The reduction in metabolism or excretion of drugs can cause an increase in serum concentrations and induce toxicity, even when the drug intake at the usual dose.

Myoglobin Cast Nephropathy Diagnosed on Renal Biopsy in a Patient Treated for Malarial Infection

Myoglobin cast nephropathy occurs in cases of acute renal injury in which large amounts of myoglobin accumulate in the renal tubules, presenting as muscle pain, reddish-brown urine, and elevated creatine kinase levels. Our case describes a 60-year-old male who came to the emergency department with fevers, mild abdominal pain, and constitutional symptoms one day after returning to the United States from a trip to Nigeria. Initial workup demonstrated an acute kidney injury and elevated aminotransferase levels and the patient was started onatovaquone-proguanil for possible malaria given a recent diagnosis in Nigeria. Two days later, the patient was found to have rhabdomyolysis, resulting in a renal biopsy that showed myoglobin cast nephropathy. Previous literature has suggested mechanisms for the development of rhabdomyolysis in malarial infection, including inflammatory processes, direct effect of parasite accumulation, and drug-induced toxicity. Our case further implicates antimalarial therapy as a cause of rhabdomyolysis and increases awareness of myoglobin cast nephropathy as a potential complication of malaria.

Rhabdomyolysis Following Prolonged Entrapment on a Fence: A Case Report

It is well documented that prolonged immobilization and heavy alcohol consumption can independently cause rhabdomyolysis; however, entrapment on a fence following alcohol consumption resulting in rhabdomyolysis without prolonged coma or seizures has not been reported. We report a case of a 25-year-old man who, following alcohol consumption, whilst attempting to climb a fence, became entrapped and desperately had to clinch on the fence with both forearms for over three hours, resulting in rhabdomyolysis. This case report highlights the importance of recognizing the potential complications associated with prolonged immobilization and the subsequent management of rhabdomyolysis.

Neurological Complications in Dengue Among Males of the Adult Age Group

Neurological problems are more frequently linked to dengue, a mosquito-transmitted virus common in tropical areas. This review study thoroughly examines the effects of dengue on adult males' neurological systems. Dengue hemorrhagic fever (DHF) or dengue shock syndrome (DSS) can develop in severe cases of dengue fever caused by the dengue virus (DENV). Unsettlingly, it is thought that a sizable portion of DENV infections impact the central nervous system (CNS), which calls into question the former theory that the DENV is not neurotropic. This review dissects the many neurological manifestations of dengue, spanning from encephalopathy, encephalitis, and other CNS implications to peripheral neuromuscular issues, through the systematic analysis of publications gathered from PubMed. The essay emphasizes the immunological reactions brought on by DENV infections and offers a deeper understanding of the pathophysiology. Given that they exhibit similar first symptoms, Zika and chikungunya are two more illnesses that must be distinguished from dengue. The mainstay of current diagnostic methods is serum and cerebrospinal fluid (CSF) tests, although supportive care is still used. This review highlights the importance of tracking neurological symptoms in dengue patients and encourages more studies in this area.

Tweak/Fn14 system is involved in rhabdomyolysis-induced acute kidney injury

BACKGROUND

Rhabdomyolysis is a severe clinical syndrome associated to acute kidney injury (AKI) and chronic kidney disease (CKD). TWEAK/Fn14 signaling axis regulates renal inflammation and tubular cell death. However, the functional role of TWEAK/Fn14 in rhabdomyolysis remains unknown.

METHODS

Rhabdomyolysis was induced in wild-type, TWEAK- and Fn14-deficient mice or mice treated with TWEAK blocking antibody. Renal injury, inflammation, fibrosis and cell death were assessed. Additionally, we performed in vivo and in vitro studies to explore the possible signalling pathways involved in Fn14 regulation.

FINDINGS

Fn14 renal expression was increased in mice with rhabdomyolysis, correlating with decline of renal function. Mechanistically, myoglobin (Mb) induced Fn14 expression via ERK and p38 pathway, whereas Nrf2 activation diminished Mb-mediated Fn14 upregulation in cultured renal cells. TWEAK or Fn14 genetic depletion ameliorated rhabdomyolysis-associated loss of renal function, histological damage, tubular cell death, inflammation, and expression of both tubular and endothelial injury markers. Deficiency of TWEAK or Fn14 also decreased long-term renal inflammation and fibrosis in mice with rhabdomyolysis. Finally, pharmacological treatment with a blocking TWEAK antibody diminished the expression of acute renal injury markers and cell death and lessened residual kidney fibrosis and chronic inflammation in rhabdomyolysis.

INTERPRETATION

TWEAK/Fn14 axis participates in the pathogenesis of rhabdomyolysis-AKI and subsequent AKI-CKD transition. Blockade of this signaling pathway may represent a promising therapeutic strategy for reducing rhabdomyolysis-mediated renal injury.

FUNDING

Spanish Ministry of Science and Innovation, ISCIII and Junta de Andalucía.

Acute Effects of Combining Whole-Body Electromyostimulation with Resistance Training in Active Women

Strength training elicits benefits both in performance and on a psychological level in women, such as increased muscle strength and improved self-esteem. Whole-body electromyostimulation (WB-EMS) could be a training strategy for enhancing muscular strength. The aim of this study was to assess the acute effects of a single session of WB-EMS superimposed over classic resistance training on isometric strength, endurance strength and flexibility. Furthermore, the safety of the protocol was assessed by monitoring the levels of creatine kinase (CK) 48 h after the training protocol was completed. Sixteen active women (aged 22.06 ± 1.88) were randomly assigned to an experimental group (EG) (n = 8) and a control group (CG) (n = 8). The EG performed four sets of 12 repetitions of three strength exercises with superimposed WB-EMS, while the CG performed the same protocol without WB-EMS. RM-ANOVA showed a significant time*group interaction on posterior kinetic chain extensors' mean and peak strength in the EG (F(1,14) = 10.036; p = 0.007; and F(1,14) = 20.719; p < 0.001; respectively). A significant time*group interaction was found in the sit and reach test for the EG (F(1,14) = 10.362; p = 0.006). Finally, ANOVA performed on the CK levels showed no significant difference between the groups (F(1,14) = 0.715; p = 0.412). WB-EMS training led to an immediate improvement in strength performance and flexibility, and this protocol was shown to be safe in terms of CK levels, 48 h after completing the training protocol.

Management of acute metabolic crisis in TANGO2 deficiency: a case report

OBJECTIVES

TANGO2 deficiency is a rare inborn error of metabolism, with distinct clinical features. The clinical presentations of TANGO2 deficiency are developmental delay, speech difficulties, intellectual disability, non-life-threatening paroxysmal neurologic episodes (TANGO2 spells), acute metabolic crises, cardiac crises, seizures and hypothyroidism. Patients may die in acute metabolic crises. Here we report our experience in the management of an acute metabolic crisis in TANGO2 deficiency.

CASE PRESENTATION

A 9-year-old patient diagnosed with TANGO2 deficiency was admitted with fever, fatigue, unable to walk. In follow up, encephalopathy, rhabdomyolysis and arrhythmia were detected. Vitamin B-complex was started. Our patient's mental status and rhabdomyolysis improved dramatically, and cardiac crises ended without Torsades de pointes, ventricular tachycardia and/or fibrillation or myocardial dysfunction.

CONCLUSIONS

With this report, we aimed to show the effectiveness of vitamin B-complex in the management of acute metabolic crises.

Tissue Perfusion and Diffusion and Cellular Respiration: Transport and Utilization of Oxygen

This article provides an overview of the journey of inspired oxygen after its uptake across the alveolar-capillary interface, and the interplay among tissue perfusion, diffusion, and cellular respiration in the transport and utilization of oxygen. The critical interactions between oxygen and its facilitative carriers (hemoglobin in red blood cells and myoglobin in muscle cells), and with other respiratory and vasoactive molecules (carbon dioxide, nitric oxide, and carbon monoxide), are emphasized to illustrate how this versatile system dynamically optimizes regional convective transport and diffusive gas exchange. The rates of reciprocal gas exchange in the lung and the periphery must be well-matched and sufficient for meeting the range of energy demands from rest to maximal stress but not excessive as to become toxic. The mobile red blood cells play a vital role in matching tissue perfusion and gas exchange by dynamically regulating the controlled uptake of oxygen and communicating regional metabolic signals across different organs. Intracellular oxygen diffusion and facilitation via myoglobin into the mitochondria, and utilization via electron transport chain and oxidative phosphorylation, are summarized. Physiological and pathophysiological adaptations are briefly described. Dysfunction of any component across this integrated system affects all other components and elicits corresponding structural and functional adaptation aimed at matching the capacities across the entire system and restoring equilibrium under normal and pathological conditions.

Anoctamin-5 related muscle disease: clinical and genetic findings in a large European cohort

Anoctamin-5 related muscle disease is caused by biallelic pathogenic variants in the anoctamin-5 gene (ANO5) and shows variable clinical phenotypes: limb-girdle muscular dystrophy type 12 (LGMD-R12), distal muscular dystrophy type 3 (MMD3), pseudometabolic myopathy or asymptomatic hyperCKaemia. In this retrospective, observational, multicentre study we gathered a large European cohort of patients with ANO5-related muscle disease to study the clinical and genetic spectrum and genotype-phenotype correlations. We included 234 patients from 212 different families, contributed by 15 centres from 11 European countries. The largest subgroup was LGMD-R12 (52.6%), followed by pseudometabolic myopathy (20.5%), asymptomatic hyperCKaemia (13.7%) and MMD3 (13.2%). In all subgroups, there was a male predominance, except for pseudometabolic myopathy. Median age at symptom onset of all patients was 33 years (range 23-45 years). The most frequent symptoms at onset were myalgia (35.3%) and exercise intolerance (34.1%), while at last clinical evaluation most frequent symptoms and signs were proximal lower limb weakness (56.9%) and atrophy (38.1%), myalgia (45.1%) and atrophy of the medial gastrocnemius muscle (38.4%). Most patients remained ambulatory (79.4%). At last evaluation, 45.9% of patients with LGMD-R12 additionally had distal weakness in the lower limbs and 48.4% of patients with MMD3 also showed proximal lower limb weakness. Age at symptom onset did not differ significantly between males and females. However, males had a higher risk of using walking aids earlier (P = 0.035). No significant association was identified between sportive versus non-sportive lifestyle before symptom onset and age at symptom onset nor any of the motor outcomes. Cardiac and respiratory involvement that would require treatment occurred very rarely. Ninety-nine different pathogenic variants were identified in ANO5 of which 25 were novel. The most frequent variants were c.191dupA (p.Asn64Lysfs*15) (57.7%) and c.2272C>T (p.Arg758Cys) (11.1%). Patients with two loss-of function variants used walking aids at a significantly earlier age (P = 0.037). Patients homozygous for the c.2272C>T variant showed a later use of walking aids compared to patients with other variants (P = 0.043). We conclude that there was no correlation of the clinical phenotype with the specific genetic variants, and that LGMD-R12 and MMD3 predominantly affect males who have a significantly worse motor outcome. Our study provides useful information for clinical follow up of the patients and for the design of clinical trials with novel therapeutic agents.

Dramatic recovery of left ventricular dysfunction in a patient with pseudoaldosteronism, hypokalaemia, and rhabdomyolysis: a case report

Background

Excessive liquorice ingestion sometimes causes pseudoaldosteronism. The association between liquorice-induced pseudoaldosteronism and acute heart failure has not been well described.

Case summary

An 89-year-old woman was referred to the hospital due to muscle weakness with rhabdomyolysis and severe hypokalaemia. The electrocardiogram in the emergency department revealed pulseless ventricular tachycardia, thus, emergent defibrillation was delivered. Laboratory findings revealed severe hypokalaemia with metabolic alkalosis. Plasma renin activity and serum aldosterone were highly suppressed. Her medications included herbal medicines containing a great amount of liquorice. The patient was diagnosed with pseudoaldosteronism caused by liquorice over-ingestion. She developed acute pulmonary oedema with unexpected left ventricular (LV) dysfunction after the peak out of creatine kinase. She was managed with acute heart failure therapy, as well as optimal medical therapy. She accidentally developed an acute embolic stroke but fully recovered due to emergent thrombolytic therapy. Cardiac magnetic resonance imaging revealed banding late gadolinium enhancement in the basal-mid segments, which was inconsistent with takotsubo cardiomyopathy. As time passed, LV function unexpectedly improved, and congestive heart failure was completely compensated.

Discussion

Liquorice contains glycyrrhetinic acid that inhibits 11βHSD2. This invites the over-activation of mineralocorticoid receptors by cortisol in the kidneys and eventually causes hypokalaemia and hypertension. Acute heart failure caused by excessive liquorice ingestion is scarcely described. The triggering factors for LV dysfunction and acute congestive heart failure remain unclear. Rhabdomyolysis could affect massive catecholamine release and cause LV dysfunction.

Assessment of renal function indexes in methamphetamine or tramadol intoxication adults to the emergency departments: a systematic review and meta-analysis

BACKGROUND

Renal dysfunction is one of the adverse effects observed in methamphetamine (MET) or tramadol abusers. In this study, we aimed to review articles involving intoxication with MET or tramadol to assess the occurrence of renal dysfunction.

METHODS

Two researchers systematically searched PubMed, Scopus, Web of Sciences, and Google Scholar databases from 2000 to 2022. All articles that assessed renal function indexes including creatine, Blood Urea Nitrogen (BUN), and Creatine phosphokinase (CPK) in MET and tramadol intoxication at the time of admission in hospitals were included. We applied random effect model with Knapp-Hartung adjustment for meta-analysis using STATA.16 software and reported outcomes with pooled Weighted Mean (WM).

RESULTS

Pooled WM for BUN was 29.85 (95% CI, 21.25-38.46) in tramadol intoxication and 31.64(95% CI, 12.71-50.57) in MET intoxication. Pooled WM for creatinine in tramadol and MET intoxication was respectively 1.04 (95% CI, 0.84-1.25) and 1.35 (95% CI, 1.13-1.56). Also, pooled WM for CPK was 397.68(376.42-418.94) in tramadol and 909.87(549.98-1269.76) in MET intoxication. No significance was observed in publication bias and heterogeneity tests.

CONCLUSION

Our findings showed that tramadol or MET intoxication is associated with a considerably increased risk of renal dysfunction that may result in organ failure.

Exploring the association between selective serotonin reuptake inhibitors and rhabdomyolysis risk based on the FDA pharmacovigilance database

Rhabdomyolysis is a syndrome potentially fatal and has been associated with selective serotonin reuptake inhibitors (SSRIs) treatment in a few case reports. Herein, we purpose to establish the correlation between SSRIs use and rhabdomyolysis using the U.S. Food and Drug Administration Adverse Event Reporting System (FAERS) database. We conducted an analysis on reports that were submitted to the FAERS database during the period between January 1, 2004, and December 31, 2022. Four algorithms, including reporting odds ratio (ROR), proportional reporting ratio (PRR), Bayesian confidence propagation neural network (BCPNN), and empirical Bayes geometric mean (EBGM), were employed to quantify the signals of rhabdomyolysis associated with SSRIs. In total, 16,011,277 non-duplicated reports were obtained and analyzed. Among 33,574 reports related to rhabdomyolysis, SSRIs were classified as primary suspected drug in 889 cases. Disproportionality analysis identified a positive signal between rhabdomyolysis and SSRIs (ROR: 2.86, 95% CI 2.67-3.05; PRR: 2.84, χ²: 1037.16; IC_0.25 = 1.39; EBGM_0.5 = 2.64). Among six SSRIs, fluvoxamine had the strongest signal (ROR: 11.64, 95% CI 8.00-16.93; PRR: 11.38, χ²: 265.51; IC_0.25 = 2.41; EBGM_0.5 = 8.31), whereas no significant signal of rhabdomyolysis was detected for paroxetine (ROR: 1.83, 95% CI 1.55-2.15; PRR: 1.82, χ²: 53.82; IC_0.25 = 0.73; EBGM_0.5 = 1.59). After excluding cases co-administered with statins, the signal of rhabdomyolysis associated with SSRIs remains significant. Our analysis reveals that there are differences in safety signals among six SSRIs in respect to the risk of rhabdomyolysis, with fluvoxamine displaying the highest risk signal, while paroxetine did not show a significant signal. Given the potentially lethal nature of rhabdomyolysis, healthcare professionals should inform patients of the potential risk of rhabdomyolysis associated with SSRIs prior to initiating treatment.

Real-world safety of Lacosamide: A pharmacovigilance study based on spontaneous reports in the FDA adverse event reporting system

INTRODUCTION

Lacosamide is licensed for the treatment of focal seizures in both adults and children, however there is little information available on its adverse reactions. Using the FDA Adverse Event Reporting System (FAERS), we seek to assess adverse occurrences that may be related to Lacosamide.

METHODS

On the basis of the FAERS database from the fourth quarter of 2008 to the second quarter of 2022, disproportionality analysis was carried out using the reporting odds ratio (ROR) method, the United Kingdom Medicines and Healthcare Products Regulatory Agency omnbius standard (MHRA) method, and the bayesian confidence propagation neural network (BCPNN) method. We extracted valuable positive signals for designated medical event (DME) screening, focused on the evaluation and comparison of safety signals appearing in DME with system organ classification (SOC) analysis.

RESULTS

A total of 10,226 adverse reaction reports with Lacosamide as the primary suspect drug were obtained, with 30,960 reported cases, detecting 232 valuable positive signals, involving a total of 20 SOCs, of which the most frequently reported SOCs were nervous system disorders (6537 cases, 55.21%), psychiatric disorders (1530 cases, 12.92%), injury poisoning and procedural complications (1059 cases, 8.94%). According to 232 valuable positive signals with DME screening results, two signals of stevens-johnson syndrome and ventricular fibrillation were consistent with PT signals on the DME list, with the two SOCs focusing on skin and subcutaneous tissue disorders and cardiac disorders, respectively.

CONCLUSIONS

Our research demonstrates that the clinical use of Lacosamide should be noticed and avoided in relation to ADRs since it raises the risk of cardiac arrest, ventricular fibrillation, stevens-johnson syndrome, and rhabdomyolysis.

A first in literature: anesthesia management in kidney transplant surgery of a patient with McArdle disease

McArdle disease is an inherited myopathy that autosomal recessive inheritance and is also known as glycogen storage disease type 5. Myoglobinuria, increase in serum CK level and darkening of urine color secondary to myoglobinuria are typical. Patients may have symptoms associated with increased rhabdomyolysis secondary acute renal failure or hyperkalemia after long and strenuous exercise periods. Today, many studies in the literature have shown that transplantation is superior to dialysis in patients with end-stage renal disease. Our case is a 53-year-old male patient with the diagnosis of McArdle syndrome who was going to have a kidney transplant. The patient had essential hypertension and history of HBsAg+. Total intravenous anesthesia technique was chosen as the anesthesia technique because inhaled anesthetic agents may trigger malignant hyperthermia in the patient. We didn't experience any perioperative complications in our patient. In conclusion, renal transplantation performed with total intravenous in a McArdle syndrome patient may be a simple and effective technique.

Clinical Diagnosis of Rhabdomyolysis without Myoglobinuria or Electromyographic Abnormalities in a Dog

A 2-year-old female neutered Old German Shepherd was presented for acute non-ambulatory tetraparesis. Upon presentation to the emergency department, hematology and biochemical blood tests revealed no abnormalities aside from mildly elevated C-reactive protein levels (22.5 mg/L, reference range 0.0-10.0) and immeasurable creatine kinase (CK) activity. Neurological evaluation the next day revealed ambulatory tetraparesis, general proprioceptive deficits, mild ataxia and dubious diffuse myalgia. Withdrawal reflexes were weak on both thoracic and pelvic limbs. The CK was determined to be significantly elevated at that point (32.856 U/L, ref. range 10.0-200.0). Urinalysis revealed no abnormalities. An electromyographic (EMG) study of thoracic limb, paraspinal and pelvic limb muscles revealed no abnormalities. A magnetic resonance imaging (MRI) study of the cervicothoracic spinal cord was performed and revealed no abnormalities. A presumptive clinical diagnosis of rhabdomyolysis without myoglobinuria or EMG abnormalities was formed. Muscular biopsies were declined due to the rapid clinical improvement of the dog. A follow-up showed the progressive decline of CK activity to normal values and clinical remission of signs. A diagnosis of rhabdomyolysis was concluded based on clinical signs, consistent CK activity elevations and the response to supportive treatment for rhabdomyolysis, despite the absence of myoglobinuria and EMG abnormalities. Rhabdomyolysis should not be excluded based on the lack of EMG abnormalities or myoglobinuria in dogs.

Acute carbon monoxide poisoning as a cause of rhabdomyolysis in a case of flame burn

Carbon monoxide (CO) poisoning typically occurs from inhalation of CO at excessive levels. Rhabdomyolsis is not an uncommon complication following acute CO poisoning, yet there are very few reported cases in the literature. It is characterised by rapid breakdown of skeletal muscles and release of its contents into the circulation, leading to acute kidney injury (AKI). Early diagnosis and treatment are crucial to avoid anticipated morbidity and mortality. We are presenting a case of a woman in her 40s with 28% flame burn in a closed space. The patient developed CO poisoning, which led to rhabdomyolysis as evidenced by clinical manifestations and laboratory findings (creatine kinase had reached an unmeasurable level). The patient developed AKI and was successfully managed in our ICU. Here, we are highlighting the importance of considering CO poisoning as one of the potential causes of rhabdomyolysis in burn victim.