Acute renal failure due to muscle necrosis in carbon-monoxide poisoning

Sciatic neuropathy and rhabdomyolysis after carbon monoxide intoxication: A case report

RATIONALE

Peripheral neuropathy is a rare complication of carbon monoxide intoxication. Peripheral neuropathy following carbon monoxide intoxication is known to completely recover within a few months.

PATIENT CONCERNS

A 40-year-old man complained of motor weakness and hypoesthesia of the right lower extremity with swelling of his right thigh after carbon monoxide intoxication resulting from a suicide attempt.

DIAGNOSES

Following nerve conduction and electromyographic studies, the patient was diagnosed with sciatic neuropathy with severe axonopathy. Clinical and laboratory findings led to a diagnosis of rhabdomyolysis.

INTERVENTIONS

The patient was treated conservatively for rhabdomyolysis and underwent comprehensive rehabilitation for sciatic neuropathy during hospitalization.

OUTCOMES

After discharge, he underwent serial follow-up tests with nerve conduction and electromyographic studies, which showed prolonged persistence of sciatic neuropathy; however, he showed significant improvement at his 26-month post-discharge follow-up.

LESSON

Patients presenting with peripheral neuropathy secondary to carbon monoxide intoxication may show variable recovery periods; however, a favorable prognosis can be expected regardless of the concomitant occurrence of rhabdomyolysis and/or compartment syndrome.

Carbon monoxide poisoning with severe myonecrosis and acute renal failure

A case of carbon monoxide (CO) poisoning with severe myonecrosis and acute renal failure (ARF) is presented with extremely high values of CPK but with preservation of myocardial tissue. A discussion of the broad effects of CO intoxication is undertaken with a review of the pertinent literature. Diagnostic and therapeutic mainstays are presented with some pitfalls and alternatives to their implementation. Computed tomography of affected muscles is presented as an alternative to muscle biopsy, and a unique modality of noninvasive diagnosis of myonecrosis.

Rhabdomyolysis and acute renal failure following carbon monoxide poisoning: two case reports with muscle histopathology and enzyme activities

Two patients with carbon monoxide poisoning are presented, both of whom suffered rhabdomyolysis complicated by acute renal failure. One patient, an attempted suicide, developed a compartment syndrome of the right thigh that required fasciotomy and recovered after a period of hemofiltration and hemodialysis. Muscle biopsy appearances were consistent with partial muscle infarction. The other patient, rescued from a smoke filled room, exhibited raised creatine kinase but no evidence of muscle swelling. He developed anuric renal failure and adult respiratory distress syndrome and died despite maximum intensive care. Muscle biopsy showed early evidence of muscle necrosis. In both cases there was a marked reduction of enzyme activities in the muscle biopsy consistent with metabolic derangement. Although there was a clinical compartment syndrome in the first case, there was no muscle swelling at the time of biopsy or subsequently in the second case. A direct toxic effect of carbon monoxide may thus have been an important mechanism contributing to the muscle necrosis in the second case, although local ischemia may have been an exacerbating factor in the first case.

Neurological manifestation of carbon monoxide poisoning

The clinical signs and post-mortem findings in a case of carbon monoxide poisoning are described, and correlated with the computer tomographic (CT) scan appearances. The value of serial CT scanning as a diagnostic tool is highlighted.

Cocaine intoxication: hyperpyrexia, rhabdomyolysis and acute renal failure

Cocaine has become the recreational drug of abuse of the eighties. The prevalence of cocaine has been manifesting increases in intoxications and poisonings. Acute overdoses have been associated with hyperthermia, agitation, paranoid ideation, status epilepticus, ventricular fibrillation, ventricular tachycardia, myocardial infarction, coma, and death. This is the first reported case of cocaine intoxication resulting in severe hyperthermia, bizarre behavior, rhabdomyolysis, and acute renal failure. Treatment consisted of cooling via iced intravenous fluids, nasogastric lavage with ice water, and benzodiazepine sedation. To our knowledge, there is no case report which supports the allusions that cocaine intoxication may cause rhabdomyolysis and acute renal failure.

Cutaneous blisters and carbon monoxide poisoning

We present the cases of three patients with skin blisters following carbon monoxide (CO) poisoning. Their blisters appeared to be related to the severity of the poisoning (HbCO levels of more than 40%). Two of the three patients died despite aggressive initial 100% surface oxygen followed by hyperbaric oxygen therapy. The pathophysiology of this type of blister remains unresolved. It could result from pressure necrosis alone or from a combination of pressure necrosis and direct CO inhibition of tissue oxidative enzymes. Although skin involvement as a result of CO poisoning is less frequently reported today than in the past (perhaps because of misidentified burns or because of more aggressive resuscitation and treatment protocols), the physician should recognize that such blisters may signal severe CO poisoning.

Myoglobinuria: presentation of personal cases and review of the literature

The presence of myoglobin in the urine is a symptom of rhabdomyolysis occurring in many muscular affections. Muscle tissue from seven patients who had presented one of more episodes of myoglobinuria has been studied by histological, histochemical, and biochemical methods. Three cases belonging to the same family and an additional one revealed a muscular CPT deficiency. Two of those cases were females. In two other cases a toxic etiology was suggested, one due to heroin and the other to associated fenfluramine and phenformin. In the last case the origin of rhabdomyolysis was not clearly defined and viral infection, drug intolerance or electrolytic imbalance were proposed. The cases are discussed in the light of the literature and the possible etiopathogenetic mechanisms are reviewed.

Acute muscle necrosis after chronic overdosage of phenformin and fenfluramine

A case of acute muscle necrosis with probable myoglobinuria is presented. The patient had been taking excessive doses of phenformin and fenfluramine, and a toxic etiology is suggested. Muscle necrosis is tentatively attributed either to the combined effect of these drugs on some underlying biochemical abnormality of muscle or to a defect of oxygen utilization secondary to myoglobin alterations.

Myoglobin: methods and diagnostic uses

Myoglobin is the oxygen-binding protein characteristic of skeletal and cardiac muscle. With muscle disease or dysfunction, myoglobin may enter the circulation, and after renal clearance, it may also appear in the urine. Therefore, the presence of myoglobinemia and myoglobinuria may serve as indicators of the presence and severity of muscle disease. With newly developed methods of detection, myoglobinemia and myoglobinuria are now recognized as complications of trauma, ischemia, surgery, states of exertion and stress, metabolic abnormalities, inherited enzyme disorders, toxin and drug actions, and inflammatory states. Infarction of the heart muscle also can be detected by myoglobin assay. Persistent myoglobinuric states may be complicated by renal failure and electrolyte imbalance. The diagnosis of myoglobinemia and myoglobinuria can be now confirmed with the use of immunoassay techniques. Although not yet widely available, they offer the possibility of the specificity and sensitivity needed for clinical use.

Muscle necrosis and acute renal failure in carbon monoxide poisoning

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Ischaemic contracture of muscle associated with carbon monoxide and barbiturate poisoning

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