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.

Acute lumbar paraspinal compartment syndrome after radical cystectomy

Lumbar paraspinal compartment syndrome (LPCS) is a rare diagnosis, seen in patients chronically after repeated lumbar trauma or acutely in a postoperative setting. Only a dozen cases are documented worldwide, and to date no clinical guidelines exist for the diagnosis nor the treatment.We describe the case of a 44-year-old man with excruciating lower back pain following a radical cystectomy. The postoperative laboratory values were compatible with acute rhabdomyolysis. The lumbar spine MRI showed necrosis of lumbosacral paraspinal muscles, making the diagnosis of acute LPCS. After seeking advice from different specialists, the conservative approach was chosen with combined pain treatment and physiotherapy. The patient is currently still disabled for some tasks and needs chronic pain medication.

Kidney replacement and conservative therapies in rhabdomyolysis: a retrospective analysis

BACKGROUND

Toxic renal effects of myoglobin following rhabdomyolysis can cause acute kidney injury (AKI) with the necessity of kidney replacement therapy (KRT). Fast elimination of myoglobin seems notable to save kidney function and intensify kidney repair. Clinical data regarding efficacy of KRT in critical care patients with rhabdomyolysis and AKI are limited. This retrospective analysis aimed to identify differences between conservative therapy and different modalities of KRT regarding myoglobin elimination and clinical outcome.

METHODS

This systematic, retrospective, single-center study analyzed 328 critical care patients with rhabdomyolysis (myoglobin > 1000 µg/l). Median reduction rate of myoglobin after starting KRT was calculated and compared for different modalities. Multivariate logistic regression models were established to identify potential confounder on hospital mortality. Filter lifetime of the various extracorporeal circuits was analyzed by Kaplan-Meier curves.

RESULTS

From 328 included patients 171 required KRT. Health condition at admission of this group was more critical compared to patient with conservative therapy. Myoglobin reduction rate did not differ between the groups (KRT 49% [30.8%; 72.2%] vs. conservative treatment (CT) 61% [38.5%; 73.5%]; p = 0.082). Comparison between various extracorporeal procedures concerning mortality showed no significant differences. Hospital mortality was 55.6% among patients with KRT and 18.5% with CT (p < 0.001). Multivariate logistic regression model identified requirement for KRT (OR: 2.163; CI: 1.061-4.407); p = 0.034) and the SOFA Score (OR: 1.111; CI: 1.004-1.228; p = 0.041) as independent predictive factors for hospital mortality. When comparing specific KRT using multivariate regression, no benefit was demonstrated for any treatment modality. Life span of the extracorporeal circuit was shorter with CVVH compared to that of others (log-Rank p = 0.017).

CONCLUSIONS

This study emphasizes that AKI requiring KRT following rhabdomyolysis is accompanied by high mortality rate. Differences in myoglobin reduction rate between various KRTs could not be confirmed, but CVVH was associated with reduced filter lifetime compared to other KRTs, which enable myoglobin elimination, too.

Traumatic Rhabdomyolysis: Crush Syndrome, Compartment Syndrome, and the 'Found Down' Patient

Traumatic rhabdomyolysis is a systemic manifestation of muscle injury and can occur from various traumatic etiologies, including crush syndrome (CrshS) and compartment syndrome (CS). Although historically described in natural disaster survivors trapped under collapsed structures, the frequency of CrshS has increased in the setting of 'found down' patients from opioid overdoses. Signs and symptoms of the injured limb in CrshS may range from pressure-induced skin changes to neurologic deficits and paralysis. Although its pathophysiology differs from CS, severe injuries may lead to an associated CS. Identifying CS in a patient with CrshS can be difficult but is important to distinguish because it affects treatment. The degree of muscle damage, viability of the remaining muscular compartment, and presence of elevated compartment pressures dictate the need for surgical intervention in the form of fasciotomy. Surgical outcomes from CrshS and delayed CS result in similar high morbidity and surgical complications. This review defines and classifies the types of traumatic rhabdomyolysis and summarizes the outcomes to facilitate timely diagnosis and appropriate management for this population to reduce morbidity associated with these conditions.

Rhabdomyolysis in older adults: outcomes and prognostic factors

BACKGROUND

Rhabdomyolysis is a common condition in older adults, often associated with falls. However, prognostic factors for rhabdomyolysis have mainly been studied in middle-aged populations.

OBJECTIVE

To test the hypothesis that age influences rhabdomyolysis prognostic factors.

METHODS

This retrospective single-center observational study included all patients with a creatine kinase (CK) level greater than five times normal, admitted to Rennes University Hospital between 2013 and 2019. The primary endpoint was 30-day in-hospital mortality rate.

RESULTS

343 patients were included (median age: 75 years). The mean peak CK was 21,825 IU/L. Acute renal failure occurred in 57.7% of the cases. For patients aged 70 years and over, the main etiology was prolonged immobilization after a fall. The 30-day in-hospital mortality rate was 10.5% (23 deaths). The Charlson score, number of medications and CK and creatinine levels varied according to age. Multivariate analysis showed age to be a factor that was associated, although not proportionally, with 30-day in-hospital mortality.

CONCLUSION

Factors influencing rhabdomyolysis severity were not randomly distributed according to age. The term rhabdomyolysis encompasses various clinical realities and is associated with different mechanisms. More research is needed to better understand the physio-pathological and prognostic factors of rhabdomyolysis, especially in older adults.

Clinical outcomes of rhabdomyolysis & validation of McMahon Score for risk prediction

BACKGROUND OBJECTIVES

Rhabdomyolysis in tropics has a unique aetiology and clinical profile. The objective of this study was to determine the aetiology and clinical outcomes of rhabdomyolysis and validate the McMahon risk prediction score in affected individuals from south India.

METHODS

A retrospective study of affected individuals with rhabdomyolysis admitted to a tertiary care hospital in south India, between January 2015 and June 2020, was undertaken. In-patients who were ≥15 yr in age and had creatinine phosphokinase ≥5000 U/l were included in the study. Cardiac, stroke, chronic muscular diseases and chronic kidney disease on maintenance haemodialysis were excluded. The incidence of acute kidney injury (AKI) in this group was calculated. Other clinical outcomes determined were 28-day mortality, proportion of individuals who required renal replacement therapy (RRT), intensive care unit (ICU) admission, vasopressors, mechanical ventilation (MV), number of days on mechanical ventilator and length of stay in ICU and hospital. Validation of McMahon risk prediction score for the requirement of RRT and mortality was performed.

RESULTS

Major aetiologies identified in the 75 study participants included were infections, trauma and seizures. Twenty eight-day mortality was 24 per cent (n=18). AKI incidence was 68 per cent, out of which 43.1 per cent had RRT. AKI in all survivors became dialysis independent. Vasopressors, MV and ICU requirement were 30.7, 32 and 77.3 per cent, respectively. Receiver operator characteristic curve for RRT and mortality risk prediction based on the McMahon Score showed a sensitivity of 71.4 per cent and specificity of 77.8 per cent for a cut-off ≥7.8.

INTERPRETATION CONCLUSIONS

Rhabdomyolysis in tropics is associated with significant organ dysfunction and mortality. Although the incidence of AKI and RRT is high, the overall renal outcome is good among survivors. The wide confidence intervals for the area under curve for McMahon Score limit its predictability for RRT and mortality.

Rhabdomyolysis in a patient with end-stage renal disease and SARS-CoV-2 infection: A case report

RATIONALE

Rhabdomyolysis can be an uncommon complication of coronavirus disease 2019 (COVID-19) infection. However, the diagnosis of rhabdomyolysis could be easily missed due to its atypical clinical presentations. We present a patient with a history of end-stage renal disease (ESRD) who contracted COVID-19 and subsequently developed rhabdomyolysis. We discuss and share our experience in the management of this patient.

PATIENT CONCERNS

An 85-year-old male with ESRD undergoing routine hemodialysis was tested positive for COVID-19. The patient had clinical symptoms of fatigue, muscle pain, and difficulty walking.

DIAGNOSIS

The serum creatine kinase (CK) level was markedly elevated to 32,492.9U/L, supporting the diagnosis of rhabdomyolysis. A computed tomography scan revealed muscle injuries throughout the body, confirming the diagnosis.

INTERVENTIONS

The patient was managed through electrolyte corrections and continuous renal replacement therapy.

OUTCOMES

Repeat tests showed decreased levels of serum CK and negative severe acute respiratory syndrome coronavirus 2. His clinical symptoms, including fatigue and muscle pain, had significantly improved.

LESSONS

COVID-19 infection can cause muscle pain and fatigue, which can mask the symptoms of rhabdomyolysis. A missed diagnosis of rhabdomyolysis can be severe, especially in patients with ESRD. The serum CK level should be tested with clinical suspicion. Appropriate management, including adequate hydration and electrolyte balance, should be provided. Continuous renal replacement therapy should be considered in affected patients with renal insufficiency.

Rapid and Effective Elimination of Myoglobin with CytoSorb® Hemoadsorber in Patients with Severe Rhabdomyolysis

INTRODUCTION

Rhabdomyolysis is characterized by destruction of muscle fibers by various causes and is diagnosed by increased creatine kinase concentrations in the blood. Myoglobin released into the blood may cause acute kidney injury. In this randomized controlled study, we hypothesized that myoglobin elimination would be faster when a hemoadsorber was added to a continuous veno-venous hemodialysis (CVVHD).

METHODS

Four patients in the control group received CVVHD with a high cut-off hemofilter using high blood and dialysate flows for 48 h. Four patients in the CytoSorb group received the same treatment, but in addition, the hemoadsorber CytoSorb® was inserted in front of the hemofilter and replaced once after 24 h. Blood samples were drawn simultaneously before (pre) and after (post) the hemofilter or else the hemoadsorber, after 5 and 30 min, as well as after 2, 4, 8, and 24 h. All measurements were repeated the next day after the hemoadsorber had been renewed in the CytoSorb group. Primary outcome was the area under the curve (AUC) of the relative myoglobin concentrations as percent of baseline. To evaluate the efficacy of myoglobin removal, relative reductions in myoglobin concentrations during one passage through each device at each time point were calculated.

RESULTS

Patients in the CytoSorb group had a significantly lower AUC during the first 24 h (42 ± 10% vs. 63 ± 6%, p = 0.029) as well as during the observation period of 48 h (26 ± 7% vs. 51 ± 12%, p = 0.029). The relative reductions for myoglobin were considerably higher in the CytoSorb group compared to the control group during the first 8 h.

CONCLUSION

Myoglobin concentrations declined considerably faster when CytoSorb was added to a CVVHD. When compared to a high-cut-off hemofilter, efficacy of CytoSorb in myoglobin elimination was much better. Because of saturation after 8-12 h an exchange may be necessary.

Destructive disasters, trauma, crush syndrome, and beyond

Orthopedic injuries, especially fractures of long bones as well as multiple fractures and comminuted fractures, are very common after destructive disasters (e.g., earthquakes, wars, and hurricanes). Another frequent problem is traumatic rhabdomyolysis, which may result in crush syndrome, the second most frequent cause of death after direct traumatic impact following earthquakes. To improve outcomes, interventions should be initiated even before extrication of the victims, which include maintenance of airway patency and spine stabilization, stopping traumatic bleeding by any means, and initiating fluid resuscitation. On-site amputations have been extensively debated to liberate the victims if the release of trapped limbs is impossible. Early after the rescue, a primary survey and triage are performed, a fluid resuscitation policy is planned, complications are treated, the wounds are decontaminated, and the victim is transported to specialized hospitals. A triage and primary survey are also performed at admission to the hospitals, which are followed by a secondary survey, physical, laboratory, and imaging examinations. Washing and cleaning of the soft-tissue injuries and debridement in open, necrotic wounds are vital. Applications of fasciotomies and amputations are controversial since they are associated with both benefits and serious complications; therefore, clear indications should be defined. Crush syndrome has been described as the presence of systemic manifestations following traumatic rhabdomyolysis, the most important component of which is acute kidney injury that may contribute to fatal hyperkalemia. The overall mortality rate is around 20% in crushed patients, which underlines the importance of prevention. Treatment includes maintaining of fluid electrolyte and acid-base balance, application of dialysis, and also prevention and treatment of complications. The principles and practices in disaster medicine may differ from those applied in routine practice; therefore, organizing repeated training courses may be helpful to provide the most effective healthcare and to save as many lives as possible after mass disasters.

Clinical and Epidemiological Characteristics of Rhabdomyolysis: A Retrospective Study

Background

Rhabdomyolysis (RM) refers to a clinical syndrome in which muscle cells are damaged by various causes and the clinical manifestations are mainly muscle pain, weakness, and dark urine. Acute kidney injury (AKI) is a serious complication of RM with complex mechanisms and high mortality. Therefore, understanding the pathogenesis and clinical manifestations, early diagnosis and treatment of RM are crucial to improve its prognosis.

Method

Analysis of medical records of RM patients admitted to Tianjin Medical University General Hospital from October 2019 to October 2022. Statistical software SPSS 25.0 was used to analyze the data. The risk factors of RM-complicated AKI were analyzed by logistic regression. The receiver operating characteristic (ROC) curve was plotted, the area under the curve (AUC) was calculated, and the optimal cutoff value was determined by the Youden index. P < 0.05 indicates a statistically significant difference between the groups.

Result

Among the 71 patients, the median age of the patients was 53.0 (30.0, 71.0) years and was 2.5 times higher in men than in women. Infection was the most common etiology. History of alcohol consumption, CK, and creatinine were independent influencing factors for AKI due to RM. Logistic regression analysis showed that CK combined with creatinine had a better predictive value than the single index.

Conclusion

Our study revealed the clinical and laboratory characteristics of RM in the population attending the Tianjin Medical University General Hospital in the last three years, which is a reference for future multicenter, prospective studies.

A Lethal Combination: Legionnaires' Disease Complicated by Rhabdomyolysis, Acute Kidney Injury, and Non-Occlusive Mesenteric Ischemia

BACKGROUND Legionnaires' disease is one of the most common types of community-acquired pneumonia. It can cause acute kidney injury and also occasionally become severe enough to require continuous renal replacement therapy (CRRT). Non-occlusive mesenteric ischemia (NOMI) is a condition characterized by ischemia and necrosis of the intestinal tract without organic obstruction of the mesenteric vessels and is known to have a high mortality rate. CASE REPORT A 72-year-old man with fatigue and dyspnea was diagnosed with Legionnaires' disease after a positive result in the Legionella urinary antigen test pneumonia confirmed by chest radiography and computed tomography. He developed acute kidney injury, with anuria, rhabdomyolysis, septic shock, respiratory failure, and metabolic acidosis. We initiated treatment with antibiotics, catecholamines, mechanical ventilation, CRRT, steroid therapy, and endotoxin absorption therapy in the Intensive Care Unit. Despite ongoing CRRT, metabolic acidosis did not improve. The patient was unresponsive to treatment and died 5 days after admission. The autopsy revealed myoglobin nephropathy, multiple organ failure, and NOMI. CONCLUSIONS We report a fatal case of Legionnaires' disease complicated by rhabdomyolysis, acute kidney injury, myoglobin cast nephropathy, and NOMI. Legionella pneumonia complicated by acute kidney injury is associated with a high mortality rate. In the present case, this may have been further exacerbated by the complication of NOMI. In our clinical practice, CRRT is a treatment option for septic shock complicated by acute kidney injury. Thus, it is crucial to suspect the presence of NOMI when persistent metabolic acidosis is observed, despite continuous CRRT treatment.

Wilderness Rescue of a Hiker with Multiple Trapped Limbs by a Combined Wilderness and Urban Rescue Team Using High-Pressure Airbags

We report on the case of a 28-y-old man with both legs and left arm trapped for nearly 6 h after falling and subsequently being trapped by a boulder during a hike in the wilderness. Extrication required equipment designed for urban environments and was operated by an unconventional team of rescue professionals. The patient experienced multiple right lower-extremity orthopedic injuries, acute kidney injury secondary to rhabdomyolysis, and bilateral segmental pulmonary emboli. In this article, we detail the extrication and review the treatment guidelines for crush injuries that focus on aggressive fluid resuscitation prior to and during extrication and medication administration only if hyperkalemia presents. Wilderness rescuers should plan for the use of unconventional rescue equipment in austere prolonged rescue scenarios.

[Not Available]

We present a case report of rhabdomyolysis after intense physical activity. Tests showed increased creatine kinase compatible with rhabdomyolysis. Liver damage was suspected due to a significant elevation of aspartate transaminase (AST) and alanine transaminase (ALT). This case report discusses how an increase in AST and ALT reflects skeletal muscle damage in rhabdomyolysis instead of liver damage, especially when assessing more specific liver markers such as international normalised ratio and ϒ-glutamyl transferase, which both were within normal range in this case. This knowledge can prevent unnecessary test.

Metabolic Myopathies

PURPOSE OF REVIEW

Metabolic myopathies are disorders that affect skeletal muscle substrate oxidation. Although some drugs and hormones can affect metabolism in skeletal muscle, this review will focus on the genetic metabolic myopathies.

RECENT FINDINGS

Impairments in glycogenolysis/glycolysis (glycogen storage disease), fatty acid transport/oxidation (fatty acid oxidation defects), and mitochondrial metabolism (mitochondrial myopathies) represent most metabolic myopathies; however, they often overlap clinically with structural genetic myopathies, referred to as pseudometabolic myopathies. Although metabolic myopathies can present in the neonatal period with hypotonia, hypoglycemia, and encephalopathy, most cases present clinically in children or young adults with exercise intolerance, rhabdomyolysis, and weakness. In general, the glycogen storage diseases manifest during brief bouts of high-intensity exercise; in contrast, fatty acid oxidation defects and mitochondrial myopathies usually manifest during longer-duration endurance-type activities, often with fasting or other metabolic stressors (eg, surgery, fever). The neurologic examination is often normal between events (except in the pseudometabolic myopathies) and evaluation requires one or more of the following tests: exercise stress testing, blood (eg, creatine kinase, acylcarnitine profile, lactate, amino acids), urine (eg, organic acids, myoglobin), muscle biopsy (eg, histology, ultrastructure, enzyme testing), and targeted (specific gene) or untargeted (myopathy panels) genetic tests.

SUMMARY

Definitive identification of a specific metabolic myopathy often leads to specific interventions, including lifestyle, exercise, and nutritional modifications; cofactor treatments; accurate genetic counseling; avoidance of specific triggers; and rapid treatment of rhabdomyolysis.

The management and diagnosis of rhabdomyolysis-induced acute kidney injury: a case study

Rhabdomyolysis is characterised by a rapid dissolution of damaged or injured skeletal muscle that can be the result of a multitude of mechanisms. It can range in severity from mild to severe, leading to multi-organ failure and death. Rhabdomyolysis causes muscular cellular breakdown, which can cause fatal electrolyte imbalances and metabolic acidosis, as myoglobin, creatine phosphokinase, lactate dehydrogenase and other electrolytes move into the circulation; acute kidney injury can follow as a severe complication. This article reflects on the case of a person who was diagnosed with rhabdomyolysis and acute kidney injury after a fall at home. Understanding the underpinning mechanism of rhabdomyolysis and the associated severity of symptoms may improve early diagnosis and treatment initiation.

Russula subnigricans Poisoning Causes Severe Rhabdomyolysis That Could be Misdiagnosed as Non-ST Segment Elevation Myocardial Infarction

Mushroom poisoning and subsequently the number of patients visiting emergency rooms are increasing, as well as the proportion of fatal mushroom poisonings. Myocytic mushroom poisoning is one of the new clinical classifications. This report documents the course of a family with Russula subnigricans poisoning complicated by severe rhabdomyolysis, including a case that was misdiagnosed as myocardial infarction. A 64-y-old man visited our hospital with symptoms including substernal chest discomfort, nausea, vomiting, and myalgia, lasting for 12 h. His laboratory tests showed elevated serum high-sensitive troponin I. He was diagnosed with non-ST segment elevation myocardial infarction. After that, 2 family members who ate mushrooms together were transferred from a local emergency room with the diagnosis of rhabdomyolysis. Consequently, rhabdomyolysis due to mushroom poisoning was diagnosed. They were hospitalized in the intensive care unit. After admission, conservative management, including primary fluid resuscitation, was performed, and the patients were discharged without complications. R subnigricans poisoning was revealed after investigation and should be considered in mushroom poisoning with rhabdomyolysis. Early recognition and intensive supportive care are important for mushroom poisoning patients.

Gallic Acid Improves Therapeutic Effects of Mesenchymal Stem Cells Derived from Adipose Tissue in Acute Renal Injury Following Rhabdomyolysis Induced by Glycerol

Acute kidney injury (AKI) is identified by a progressive reduction in the glomerular filtration rate (GFR) and retention of nitrogenous waste products. Traumatic and nontraumatic rhabdomyolysis is recently considered the main cause of AKI. According to several studies, stem cell treatment is a promising therapeutic strategy for many types of disorders including AKI. The main limitation of mesenchymal stem cells (MSCs) therapy is reducing cell survival in response to oxidative stress products in injured organ areas. Gallic acid (GA) as a well-known antioxidant has been reported to confer potent-free radical scavenging and anti-inflammatory properties. Therefore, the aim of the current study was to assess the influence of MSCs and GA in acute renal injury following rhabdomyolysis induced by glycerol. A total of 70 healthy rats were divided into seven groups (10 in each group): control, AKI (glycerol, intramuscular), cell therapy (AKI + intravenous injection of mesenchymal stem cells derived from adipose tissue (AMCs), AKI + AMCs + GA (50, 100, and 200 mg/kg, intraperitoneally, 3 days a week for 3 consecutive weeks), and positive control group (the most effective dose of gallic acid). After the treatment, rats were sacrificed; blood, urine, and kidney tissues were collected; and qualitative and quantitative parameters (including blood urea nitrogen (BUN), creatine kinase (CK), lactate dehydrogenase (LDH), alkaline phosphatase (ALP), aspartate transaminase (SGOT), oxidative stress markers kidney function parameters) and histopathological indexes were assayed. Our results revealed that co-treatment of AMCs plus GA into AKI rats decreased BUN and creatinine and ameliorated kidney injury parameters after 3 weeks. Improved oxidative stress markers such as decreased MDA and increased SOD and CAT were significant in the GA + AMCs group compared to the AMCs alone in AKI rats. Also, the histopathological appearances of AKI rats including renal tubule cavity expansion and renal tubular epithelial cell edema, and interstitial inflammation, were alleviated using GA + AMCs treatment compared to the control. The obtained results of the current study documented that antioxidants could make mesenchymal stem cells more resistant to the condition in which they are supposed to be transplanted and probably improve the efficacy of stem cell therapy in AKI patients.

Rhabdomyolysis after BNT162b2 mRNA Covid-19 vaccine in an adolescent male

Pfizer-BioNTech COVID-19 (BNT162b2) conferred a high level of protection against Covid-19 with a proven short-term safety profile. Although cases of vaccine-associated myopericarditis have been reported, the existence of rhabdomyolysis without myocarditis has not yet been published.

A 16-year-old, healthy male patient, who did not use any herbal or illegal drugs before, was admitted with muscle pain that developed after the second dose of BNT162b2 vaccine. Cardiac examination and heart enzymes were normal and the patient had significantly higher creatinine kinase levels. The patient, whose enzymes returned to normal with only force hydration therapy, recovered without complications.

Reporting the side effects of the vaccine, which has a short history of application to large populations, is of vital importance in the conduct of vaccine development studies and in identifying the risky group in terms of side effects.

Hypokalemia-Induced Rhabdomyolysis in a Child with Autism Affected by the COVID-19 Pandemic

OBJECTIVE

Pediatric patients with autism spectrum disorder (ASD) often have coexisting feeding disorders. We hope to emphasize the significant implications that these feeding disorders can have on this patient population through a unique case of hypokalemia-induced rhabdomyolysis.

METHOD

We present a unique case of a 3-year-old boy with ASD and a longstanding history of food selectivity whose routine was disrupted during the COVID-19 pandemic resulting in avoidant/restrictive food intake disorder and severe undernutrition, who presented with profound hypokalemia and was subsequently found to have elevated muscle enzymes consistent with rhabdomyolysis despite only subtle complaints of difficulty walking.

RESULTS

The patient was treated with aggressive hydration, electrolyte therapy, and nasogastric tube feeds, which resulted in clinical and biochemical evidence of improvement. He was also reconnected to ASD-related care services that had lapsed during the COVID-19 pandemic.

CONCLUSION

This case exemplifies the adverse impact that feeding disorders can have on patients with ASD, particularly in the setting of stressors such as a global pandemic, and is also the first documented pediatric case of rhabdomyolysis secondary to hypokalemia from severe undernutrition. It demonstrates that physicians should have a low threshold to assess for clinical and laboratory evidence of rhabdomyolysis in patients with profound hypokalemia because symptoms of hypokalemia-induced rhabdomyolysis can often be subtle, which can delay diagnosis and thereby increase the risk for life-threatening complications from extensive muscle damage.

Management of Severe Crush Injuries in Austere Environments: A Special Operations Perspective

Crush injuries present a challenging case for medical providers and require knowledge and skill to manage the subsequent damage to multiple organ systems. In an austere environment, in which resources are limited and evacuation time is extensive, a medic must be prepared to identify trends and predict outcomes based on the mechanism of injury and patient presentation. These injuries occur in a variety of environments from motor vehicle accidents (at home or abroad) to natural disasters and building collapses. Crush injury can lead to compartment syndrome, traumatic rhabdomyolysis, arrythmias, and metabolic acidosis, especially for patients with extended treatment and extrication times. While crush syndrome occurs due to the systemic effects of the injury, the onset can be as early as 1 hour postinjury. With a comprehensive understanding of the pathophysiology, diagnosis, management, and tactical considerations, a prehospital provider can optimize patient outcomes and be prepared with the tools they have on hand for the progression of crush injury into crush syndrome.

Paint-thinner-induced Acute Kidney Injury: A Case Series and Review

Occupational health hazards contribute significantly to the morbidity and mortality of workers in factories. Toluene has become a widely abused inhaled volatile drug. The spectrum of toluene-induced renal injury includes rhabdomyolysis, myoglobinemia, distal renal tubular acidosis (RTA), acute tubular necrosis, glomerulonephritis, and interstitial nephritis. We describe two patients with paint-thinner-induced kidney injury who were affected through different routes of exposure and recovered well, with one requiring dialysis support; the second patient, who had developed Type 1 distal RTA and mild kidney injury, was managed with conservative measures. Toluene can cause acute neurological symptoms, accompanied by severe metabolic alterations, as well as organ injury and dysfunction. A common association of the development of hypokalemic paralysis and metabolic acidosis with toluene intoxication was observed. Liver injury and rhabdomyolysis are also common. Vomiting, dehydration, tubular injury, and rhabdomyolysis are all possible additional causes of acute renal failure in toluene intoxication. Type 1 distal RTA, which is characterized by an inability to lower urine pH despite acidemia, results in hyperchloremic metabolic acidosis with hypokalemia. The management of acute toluene toxicity is largely conservative, consisting of correcting the electrolytes and the acid-base balance, fluid alterations, and renal replacement therapy in severe acute kidney injury. A clinical suspicion of organ failure and prompt supportive care leads to encouraging results. Adequate protective steps for workplaces involved in the use of such substances in confined spaces include prior risk assessment, using low-toxicity chemical products, ensuring adequate ventilation, safety training, and using appropriate personal protective equipment.

Isolated rhabdomyolysis of long head of triceps mimicking upper extremity deep vein thrombosis

Rhabdomyolysis is characterised by skeletal muscle breakdown, with release of toxic intracellular contents into the circulation. A man in his 20s presented to the emergency department with acute-onset right arm swelling, with pitting oedema extending into his forearm without clear precipitant. Initial differential diagnosis was upper extremity deep vein thrombosis, however none was identified on CT venogram. Instead, rhabdomyolysis of long head of triceps was diagnosed after multidisciplinary review of the venogram by the treating vascular surgeon and radiologist. Retrospectively, added serum creatine kinase was found to be 11 587 U/L, and together with MRI of the right arm, the diagnosis was established. Given the patient's lack of comorbidities, normal renal function and reliability, he was managed conservatively as an outpatient without hospital admission for intravenous hydration. This is the only case to our knowledge of isolated long head of triceps' rhabdomyolysis reported in Australia and the second case worldwide.

Very Long-Chain Acyl-CoA Dehydrogenase Deficiency Presenting as Rhabdomyolysis

Presentation A 20 year old female attended the Emergency Department by ambulance following a collapse at a concert. On arrival she was complaining of generalised muscular pain. She had not eaten for over 12 hours and had been dancing for approximately 6 hours. The patient was known to have Very-long-chain acyl-CoA dehydrogenase deficiency (VLCAD). She had a normal exam, and normal vital signs. Diagnosis A diagnosis of rhabdomyolysis was made after her creatinine kinase (CK) was found to be >100000 units/litre (Normal range < 170U/L). Her urine was dark brown with urinalysis positive for blood. Treatment The patient was admitted to the high dependency unit, where she was treated with intravenous fluids. Her urine output and renal function were closely monitored. She made a full recovery and was discharged home four days later. Conclusion (VLCAD) is an inherited, autosomal recessive, metabolic disorder caused by mutations in the ACADVL gene. Management includes treatment of manifestation, primary prevention of manifestation, and prevention of secondary complications.

Repeatedly in Rhabdomyolysis

ABSTRACT

Repeated presentations of a rare symptom in a patient should make a physician stop and evaluate for rare conditions. This is a report of a teenager with multiple episodes of rhabdomyolysis and weakness. He was eventually diagnosed as having McArdle muscular dystrophy, or glycogen storage disease type V. His rhabdomyolysis has been severe, with a creatinine kinase level of >320,000 U/L, myoglobinuria, transaminitis, and elevated bilirubin. He has a low threshold for triggering rhabdomyolysis, such as doing an hour of aerobic exercise 2 days in a row. McArdle disease is a glycogen storage disorder in which the skeletal muscle cannot convert glycogen to glucose. Unlike other glycogen storage disorders, McArdle muscular dystrophy only affects the skeletal muscle, sparing the brain and visceral organs, leading to a vague phenotype. These patients have exercise intolerance, muscle cramps, and rhabdomyolysis. Many patients report loading with simple carbohydrates before exercise, as they have learned that this can increase their stamina. The vague symptoms can lead to decades of delay in diagnosis and significant mismanagement. Rhabdomyolysis is the most dangerous sign of McArdle disease, and it can lead to acute kidney injury, resulting in renal failure requiring dialysis in the severest cases.Rhabdomyolysis has numerous causes, but when it is recurrent, especially with seemingly insignificant triggers, one needs to develop a broader differential and pursue advanced testing. This testing can include specific exercise tests, genetic sequencing, and muscle biopsy. This case report will guide the clinician through the process of evaluating recurrent rhabdomyolysis, working through the differential diagnosis and testing options.1.

[An Unusual Case of Rhabdomyolysis]

An Unusual Case of Rhabdomyolysis Abstract. We present the case of a 52-year-old patient with accidental liquorice intoxication after consumption of liquorice tea. In the Arabic cultures the consumption of liquorice tea is very popular during Ramadan and is used to suppress thirst. In the described case this led to a severe case of pseudohyperaldosteronism. Because of the classic presentation of a hypertensive crisis, hypokalaemia and rhabdomyolysis, the patient needed intensive care. Typically, the symptoms last for up to seven days after discontinuation of liquorice and completely subside with time. The treatment consists only of supportive care.

Clinical Presentation and Management of Severe Acute Renal Failure in McArdle Disease

McArdle disease, also known as glycogen storage disease type V, is an autosomal recessive disease due to the absence of myophosphorylase activity, leading to the complete disruption of glycogen breakdown in muscles. We present a rare case of a Caucasian male, aged 26 years, who developed rhabdomyolysis-induced acute renal failure and uremic encephalopathy. Neurological examination and histopathological studies supported the diagnosis of McArdle disease. The severity of his symptoms necessitated urgent hemodialysis, upon which the patient reported improvement in status. Acute renal failure in McArdle disease usually resolves with supportive treatment and maintenance of regular physical activity. Nevertheless, in more severe cases, intensive care with urgent hemodialysis may be needed. A multidisciplinary approach is necessary for the adequate management of similar cases.

Successful orthotopic heart transplantation in CPTII deficiency

Carnitine palmitoyl transferase II (CPT II) catalyzes the release of activated long-chain fatty acids from acylcarnitines into mitochondria for subsequent fatty acid oxidation. Depending on residual enzyme activity, deficiency of this enzyme leads to a spectrum of symptoms from early onset hypoglycemia, hyperammonemia, cardiomyopathy and death to onset of recurrent rhabdomyolysis in adolescents and young adults. We present a case of successful orthotopic heart transplantation in a patient with severe infantile onset cardiomyopathy due to CPT II deficiency identified through newborn screening. Excellent cardiac function is preserved 12 years post-transplantation; however, the patient has developed intermittent episodes of hyperammonemia and rhabdomyolysis later in childhood and early adolescence readily resolved with intravenous glucose. Successful heart transplant in this patient demonstrates the feasibility of this management option in patients with even severe forms of long chain fatty acid oxidation disorders.

Rhabdomyolysis: Revisited

Rhabdomyolysis (RML) is a pathological entity characterized by symptoms of myalgia, weakness and dark urine (which is often not present) resulting in respiratory failure and altered mental status. Laboratory testing for myoglobinuria is pathognomonic but so often not present during the time of testing that serum creatine kinase should always be sent when the diagnosis is suspected. Kidney injury from RML progresses through multiform pathways resulting in acute tubular necrosis. Early treatment (ideally<6 hoursfrom onset) is needed with volume expansion of all non-overloaded patients along with avoidance of nephrotoxins. There is insufficient data to recommend any specific fluid. The mortality rate ranges from 10% to up to 50% with severe AKI, so high index of suspicion and screening should be in care plan of seriously ill patients at risk for RML.

Development and validation of a model for the early prediction of the RRT requirement in patients with rhabdomyolysis

INTRODUCTION

Rhabdomyolysis (RM) is a complex set of clinical syndromes involving the rapid dissolution of skeletal muscles. The early detection of patients who need renal replacement therapy (RRT) is very important and may aid in delivering proper care and optimizing the use of limited resources.

METHODS

Retrospective analyses of the following three databases were performed: the eICU Collaborative Research Database (eICU-CRD), the Medical Information Mart for Intensive Care III (MIMIC-III) database and electronic medical records from the First Medical Centre of the Chinese People's Liberation Army General Hospital (PLAGH). The data from the eICU-CRD and MIMIC-III datasets were merged to form the derivation cohort. The data collected from the Chinese PLAGH were used for external validation. The factors predictive of the need for RRT were selected using a LASSO regression analysis. A logistic regression was selected as the algorithm. The model was built in Python using the ML library scikit-learn. The accuracy of the model was measured by the area under the receiver operating characteristic curve (AUC). R software was used for the LASSO regression analysis, nomogram, concordance index, calibration, and decision and clinical impact curves.

RESULTS

In total, 1259 patients with RM (614 patients from eICU-CRD, 324 patients from the MIMIC-III database and 321 patients from the Chinese PLAGH) were eligible for this analysis. The rate of RRT was 15.0% (92/614) in the eICU-CRD database, 17.6% (57/324) in the MIMIC-III database and 5.6% in the Chinese PLAGH (18/321). After the LASSO regression selection, eight variables were included in the RRT prediction model. The AUC of the model in the training dataset was 0.818 (95% CI 0.78-0.87), the AUC in the test dataset was 0.794 (95% CI 0.72-0.86), and the AUC in the Chinese PLAGH dataset (external validation dataset) was 0.820 (95% CI 0.70-0.86).

CONCLUSIONS

We developed and validated a model for the early prediction of the RRT requirement among patients with RM based on 8 variables commonly measured during the first 24 h after admission. Predicting the need for RRT could help ensure appropriate treatment and facilitate the optimization of the use of medical resources.

Clinical Practice Guidelines for Exertional Rhabdomyolysis: A Military Medicine Perspective

ABSTRACT

Exertional rhabdomyolysis (ER) is an uncommon condition with a paucity of evidence-based guidance for diagnosis, management, and return to duty or play. Recently, a clinical practice guideline for diagnosis and management of ER in warfighters was updated by a team of military and civilian physicians and researchers using current scientific literature and decades of experience within the military population. The revision concentrated on challenging and controversial clinical questions with applicability to providers in the military and those in the greater sports medicine community. Specific topics addressed: 1) diagnostic criteria for ER; 2) clinical decision making for outpatient versus inpatient treatment; 3) optimal strategies for inpatient management; 4) discharge criteria; 5) identification and assessment of warfighters/athletes at risk for recurrent ER; 6) an appropriate rehabilitative plan; and finally, 7) key clinical questions warranting future research.

Rhabdomyolysis After the Use of Percussion Massage Gun: A Case Report

OBJECTIVE

Percussion massage guns are commonly used by professional athletes and nonathletes worldwide for warm-up and physical recovery; however, there are no published clinical or evidence-based reports on percussion guns regarding their benefits, indications, contraindications, and even side effects. The purpose of this case report is to describe the first case of rhabdomyolysis as a severe and potentially life-threatening illness following use of a percussion gun.

METHODS

A young Chinese woman with untreated iron deficiency anemia presented with fatigue and pain in her thigh muscles for 3 days and tea-colored urine for 1 day, after cycling and subsequently receiving percussion gun treatment by her coach for the purpose of massage and relaxing tired muscles. Muscle tenderness and multiple hematomas were found on her thighs, and her urinalysis indicated hemoglobinuria. Her serum creatine kinase was reported as "undetectably high," a hallmark of serious muscle damage leading to a diagnosis of severe rhabdomyolysis. Aggressive intravenous fluid resuscitation, urine alkalinization via intravenous alkaline solution, assessment of urine output, and maintenance of electrolyte balance were administered during hospitalization.

RESULTS

The patient's clinical presentation gradually improved with the decline of creatine kinase, and she recovered well during follow-up.

CONCLUSION

A case of severe rhabdomyolysis after percussion massage should alert caregivers, sports professionals, and the public to suspect and recognize the potentially serious adverse effects of percussion guns and to ensure that percussion massage guns be used appropriately and safely in rehabilitation therapy, especially in individuals with an underlying disease or condition. Research is needed to examine the benefits, indications, contraindications, and adverse reactions of percussion guns.

Rhabdomyolysis: evidence-based management in the emergency department

Rhabdomyolysis is a life-threatening pathological process that must be treated as early as possible to avoid potentially life-threatening sequelae. Much of the evidence that informs the management of rhabdomyolysis is retrospective research, often reported from mass disasters, and many practices that have been implemented as standard treatment are based on small studies published more than 30 years ago. This issue reviews the current literature on rhabdomyolysis and provides recommendations for each phase of care, from the prehospital setting through disposition. The evidence is examined regarding the variety of therapies that are used to manage rhabdomyolysis, the potential for recognizing a genetic predisposition for the condition, and therapeutic recommendations that improve patient outcomes.

[Rhabdomyolysis: early management]

Rhabdomyolysis is defined by myalgia, potentially painful myoedema and muscular weakness due to death of muscular fiber in the striated muscle. Frequent etiologies include physical effort, intoxication (alcohol, drugs and medication) and physical trauma. Depletion of myocyte' s adenosine triphosate (ATP) leads to an increase in intracellular calcium and myocyte death. Diagnosis relies on creatine kinase (CK) levels. The clinical spectrum of rhabdomyolysis includes an asymptomatic increased amount of CK as well as severe, life threatening complications such as acute renal failure and electrolyte disorders. Treatment is based on prevention and addressing complications.

[Rhabdomyolysis during Perioperative Period after Cardiac Surgery]

We report a case of rhabdomyolysis during a perioperative period after cardiac surgery. A 47-yearold man underwent aortic root replacement for annuloaortic ectasia under general anesthesia using sevoflurane, fentanyl, remifentanil, rocronium bromide and midazolam. On the 1st postoperative day (1 POD), his body temperature rose over 38 ℃, which continued for 3 days despite our attempt to stabilize the fever. On 4 POD, his laboratory data and hemodynamics dramatically worsened, and we commenced continuous hemodialysis filtration (CHDF) and percutaneous cardiopulmonary support system (PCPS). In addition, balloon pumping (IABP) was started on 5 POD. At the same time, we initiated dantrolene sodium hydrate infusion according to a clinical grading scale to predict malignant hyperthermia (MH) susceptibility. Serum creatine phosphokinase (CPK) increased over 350,000 U/l on the 7 POD, and dantrolene sodium hydrate was continuously infused until 9 POD. Despite dantrolene sodium infusion, CHDF, IABP and PCPS, his condition did not improve, and he died of disseminated intravascular coagulation syndrome (DIC) and sepsis on 28 POD. Computed tomography on 21 POD disclosed scattered low-density areas in the erector spinal, lliopsoas and femoral muscles, which indicated rhabdomyolysis. Histopathological examination using hematoxylin and eosin stain revealed destroyed striated-muscle fibers and swelling rhabdomyocytes. It remained unclear which drug triggered rhabdomyolysis. When MH is suspected, we should consider the use of the clinical grading scale to predict its susceptibility and start dantrolene sodium hydrate infusion.

Adult-onset Repeat Rhabdomyolysis with a Very Long-chain Acyl-CoA Dehydrogenase Deficiency Due to Compound Heterozygous ACADVL Mutations

Very long-chain acyl-CoA dehydrogenase (VLCAD) deficiency is a genetic disorder of fatty acid beta oxidation that is caused by a defect in ACADVL, which encodes VLCAD. The clinical presentation of VLCAD deficiency is heterogeneous, and either a delayed diagnosis or a misdiagnosis may sometimes occur. We herein describe a difficult-to-diagnose case of the muscle form of adult-onset VLCAD deficiency with compound heterozygous ACADVL mutations including c.790A>G (p.K264E) and c.1246G>A (p.A416T).

Protracted hyperthermia and delayed rhabdomyolysis in ecstasy toxicity: A case report

RATIONALE

Despite toxicity and unpredictable adverse effects, ecstasy use has increased in the United States. Onset of hyperpyrexia, rhabdomyolysis, disseminated intravascular coagulation (DIC), among other symptoms, occurs within hours of ingestion. Moreover, patients who experience hyperpyrexia, altered mental status, DIC, and multiorgan failure, rarely survive. This case presents a chronic ecstasy user whose symptoms would have predicted mortality. The report demonstrates a patient who experiences protracted hyperthermia, with delayed rhabdomyolysis and DIC. In addition, his peak creatine kinase (CK) of 409,440 U/L was far greater than the expected 30,000 to 100,000 U/L, being the second largest CK recorded in a survivor.

PATIENT CONCERNS

This case report presents a 20-year-old man who presented to the emergency department after experiencing a severe reaction to ecstasy. He was a chronic user who took his baseline dosage while performing at a music event. He experienced hyperpyrexia immediately (106.5°F) while becoming stiff and unresponsive. Before emergency medical service arrival, his friends placed cold compresses on the patient and rested him in an ice filled bathtub.

DIAGNOSES

Per history from patient's friends and toxicology results, the patient was diagnosed with ecstasy overdose, which evolved to include protracted hyperthermia and delayed rhabdomyolysis.

INTERVENTIONS

Due to a Glasgow coma scale score of 5, he was intubated and sedated with a propofol maintenance. Hyperpyrexia resolved (temperature dropped to 99.1°F) after start of propofol maintenance. He was extubated after 24 hours, upon which he experienced hyperthermia (101.4°F at 48 hours), delayed rhabdomyolysis, and DIC (onset at 37 hours). He remained in hyperthermia for 120 hours until carvedilol permanently returned his temperature to baseline. His plasma CK reached a peak of 409,440 U/L at 35 hours.

OUTCOMES

After primary management with intravenous fluids, the patient returned to baseline health without any consequences and was discharged after 8 days. A follow-up of 3 months postdischarge revealed no complications or disability.

LESSONS

Clinically, the case highlights how physicians should be aware of the unusual time course adverse effects of ecstasy can have. Lastly, as intensity and duration of hyperpyrexia are predictors of mortality, our case indicates maintenance of sedation with propofol and use of oral carvedilol; both are efficacious for temperature reduction in ecstasy toxicity.

Effects of fasting, feeding and exercise on plasma acylcarnitines among subjects with CPT2D, VLCADD and LCHADD/TFPD

BACKGROUND

The plasma acylcarnitine profile is frequently used as a biochemical assessment for follow-up in diagnosed patients with fatty acid oxidation disorders (FAODs). Disease specific acylcarnitine species are elevated during metabolic decompensation but there is clinical and biochemical heterogeneity among patients and limited data on the utility of an acylcarnitine profile for routine clinical monitoring.

METHODS

We evaluated plasma acylcarnitine profiles from 30 diagnosed patients with long-chain FAODs (carnitine palmitoyltransferase-2 (CPT2), very long-chain acyl-CoA dehydrogenase (VLCAD), and long-chain 3-hydroxy acyl-CoA dehydrogenase or mitochondrial trifunctional protein (LCHAD/TFP) deficiencies) collected after an overnight fast, after feeding a controlled low-fat diet, and before and after moderate exercise. Our purpose was to describe the variability in this biomarker and how various physiologic states effect the acylcarnitine concentrations in circulation.

RESULTS

Disease specific acylcarnitine species were higher after an overnight fast and decreased by approximately 60% two hours after a controlled breakfast meal. Moderate-intensity exercise increased the acylcarnitine species but it varied by diagnosis. When analyzed for a genotype/phenotype correlation, the presence of the common LCHADD mutation (c.1528G > C) was associated with higher levels of 3-hydroxyacylcarnitines than in patients with other mutations.

CONCLUSIONS

We found that feeding consistently suppressed and that moderate intensity exercise increased disease specific acylcarnitine species, but the response to exercise was highly variable across subjects and diagnoses. The clinical utility of routine plasma acylcarnitine analysis for outpatient treatment monitoring remains questionable; however, if acylcarnitine profiles are measured in the clinical setting, standardized procedures are required for sample collection to be of value.

Rhabdomyolysis as Potential Late Complication Associated with COVID-19

We describe a patient in Wuhan, China, with severe acute respiratory syndrome coronavirus 2 infection who had progressive pulmonary lesions and rhabdomyolysis with manifestations of lower limb pain and fatigue. Rapid clinical recognition of rhabdomyolysis symptoms in patients with severe acute respiratory syndrome coronavirus 2 infection can be lifesaving.

Exertional Rhabdomyolysis: A Retrospective Population-based Study

PURPOSE

This study aimed to evaluate the incidence and characteristics of exertional rhabdomyolysis (ER) in a population-based cohort.

METHODS

A retrospective cohort study was performed in Olmsted County, Minnesota, from 2003 to 2015. Incident ER cases were ascertained through the Rochester Epidemiology Project medical record linkage system through electronic searches of the International Classification of Diseases, Ninth Revision, codes and clinical note text. Population incidence rate was calculated using the corresponding Rochester Epidemiology Project census populations specific to calendar year and sex. Descriptive statistics were used.

RESULTS

Of the 430 patients, 431 cases met the inclusion criteria for rhabdomyolysis; 4.9% of cases (n = 20; males n = 18; Caucasian n = 17) were ER, with one recurrence. There were no deaths secondary to ER. The age- and sex-adjusted incidence rate of ER was 1.06 ± 0.24 (95% confidence interval = 0.59-1.52) per 100,000 person-years. Endurance activity (n = 7), manual labor (n = 5), and weight lifting (n = 4) were common causes. Complications included kidney injury (n = 5), mild electrolyte abnormalities (n = 10), elevated transaminases (n = 12), and minor electrocardiographic abnormalities (n = 4). A majority of patients were hospitalized (n = 16) for a median of 2 d, had mild abnormalities in renal and liver function and electrolytes, and were discharged without sequelae.

CONCLUSION

ER in the civilian population occurs at a much lower incidence than the military population. The most common causes were endurance exercise, manual labor, and weight lifting. The majority of cases were treated conservatively with intravenous fluid resuscitation during a brief hospital stay, and all were discharged without sequela. Only one case of recurrence occurred in this cohort, indicating the recurrence rate was low.