Peer Reviewed

Case in Point

Rhabdomyolysis: 3 Cases

Authors:
Badar Zaheer, MD
Associate Professor, Emergency Department Physician, University of Illinois at Chicago College of Medicine, Chicago, Illinois

Anjella Manoharan, MS
Medical Student, University of Illinois at Chicago College of Medicine, Chicago, Illinois

Citation:
Zaheer B, Manoharan A. Rhabdomyolysis: 3 cases [published online May 8, 2019]. Consultant360.

 

The Hajj. A 26-year-old man presented with muscle cramps, muscle twitches, and muscle pain. The patient had been working as a volunteer in the pilgrimage center tents at the Hajj in Mecca, Saudi Arabia, for 3 days. On his third day of volunteering, the patient worked 2 consecutive 12-hour shifts in the hot sun without food or water.

In the health center, the patient was disoriented and did not know his date of birth. The patient also presented with nausea and vomiting. Laboratory tests revealed an elevated creatinine kinase (CK) level of 2800 U/L, an elevated blood urea nitrogen (BUN) level of 80 mg/dL, an elevated serum creatinine level of 2.6 mg/dL, and an elevated lactate level. Urinalysis results were positive for myoglobin. Results of a complete blood cell count were within normal limits.

The patient was given rapid intravenous fluids, ondansetron to control vomiting, and 1 g of intravenous acetaminophen for pain relief. He became completely alert and oriented to person, place, and time after treatment. Subsequent laboratory test results demonstrated a decrease in the CK level and an improvement in kidney function. All of the abnormal laboratory test results returned to normal ranges.

Douglas, Arizona. A 28-year-old man presented with weight loss, weakness, and fatigue. He was an undocumented migrant from Mexico who had climbed over a wall into the United States. He had traveled for 7 days on foot and had only consumed 6 or 7 bananas and little water during the journey.

In the emergency department, we observed the patient to have tea-colored urine, indicating the presence of myoglobin. Laboratory tests revealed an elevated CK level of 3000 U/L, an elevated BUN level, an elevated serum creatinine level, and an elevated lactate level.

The patient was given intravenous fluids rapidly through 2 large-bore needles. Levels of CK, BUN, creatinine, and lactate returned to normal following treatment. Results of a repeated urine test returned negative for myoglobin.

Chicago, Illinois. A 30-year-old man with obsessive compulsive disorder presented with refusal to eat for more than a week. He had been pacing in circles constantly, only stopping to sleep. He had lost 70 pounds in 2 weeks and presented with weakness.

In the hospital, dark urine was observed. Laboratory test results showed an elevated CK of 2705 U/L, an elevated BUN of 60 mg/dL, and an elevated serum creatinine of 2.1 mg/dL. Urinalysis results showed myoglobinuria.

The patient was immediately given intravenous fluids, after which repeated laboratory tests for muscle enzymes showed improvement. The CK level fell to 250 U/L, BUN improved to 30 mg/dL, and serum creatinine returned to 1.5 mg/dL.

In all 3 of these cases, the diagnosis of rhabdomyolysis was made based on the patients’ elevated CK, BUN, and serum creatinine levels. Urinalysis showed myoglobinuria in all 3 patients. The presentation of muscle pain, tea-colored urine, and/or weakness in each case also supported the diagnosis.

DISCUSSION

Rhabdomyolysis involves the breakdown of damaged skeletal muscle, which causes the leakage of intramuscular electrolytes and proteins into the circulation.1-3 According to the 2002 American College of Cardiology/American Heart Association/National Heart, Lung and Blood Institute Clinical Advisory on the Use and Safety of Statins,4 rhabdomyolysis is muscle symptoms with an elevation in CK and creatinine levels, pigment nephropathy, and usually myoglobinuria and brown urine. Rhabdomyolysis initially presents as muscle pain and weakness accompanied by dark colored urine. Laboratory findings Include a serum CK level elevated 5 to 10 times above the highest normal limits, along with elevated levels of BUN and creatinine. There may be an associated increase in liver enzymes, as well.5

There are various acquired and inherited causes of rhabdomyolysis. Some of the etiologies include trauma, extreme temperatures, strenuous exercise, infections, drugs, and structural myopathies.3 In the cases described above, the patients experienced rhabdomyolysis in different geographical areas but under similar environmental conditions.

Every year, millions of people perform the Hajj, which is a 5-day pilgrimage on foot in Mecca, Saudi Arabia. The Hajj period occurs in the summer, when temperatures can reach 43°C (110°F). Pilgrims can experience dehydration, heat stroke, or heat exhaustion due to the environmental conditions.6 One study that examined 100 patients who presented to Mecca-area hospitals during the Hajj requiring dialysis found that rhabdomyolysis was the cause of renal impairment in 68% of cases.6

The journey from Mexico to the Southwestern United States can be exhausting for migrants due to the high temperatures, extreme conditions, and traveling without food or water. One study explored the illnesses that migrants developed during their journey crossing the Arizona-Sonora border and found that rhabdomyolysis was the second most common admission diagnosis following trauma.7

In order to treat rhabdomyolysis, the first step is to identify and treat the underlying cause of the muscle injury.3 Because the most common complication of rhabdomyolysis is acute kidney injury, prompt intravenous fluid treatment is important to conserve kidney function.3 Electrolyte abnormalities, especially hyperkalemia, also should be treated.3

THE TAKEAWAY

These 3 case presentations of rhabdomyolysis in different parts of the world demonstrate the importance of obtaining a history. In these cases, the patients had experienced a lack of food and water, excessive heat, and physical exertion. When patients with a similar history present with muscle pain, tea-colored urine, and weakness, rhabdomyolysis should be in the differential diagnosis. It is important to evaluate the levels of CK, electrolytes, BUN, creatinine, lactate dehydrogenase, glomerular filtration rate, and myoglobinuria, all of which can assist in confirming a diagnosis of rhabdomyolysis.

References
  1. Bagley WH, Yang H, Shah KH. Rhabdomyolysis. Intern Emerg Med. 2007;2(3):210-218.
  2. Torres PA, Helmstetter JA, Kaye AM, Kaye AD. Rhabdomyolysis: pathogenesis, diagnosis, and treatment. Ochsner J. 2015;15(1):58-69.
  3. Chavez LO, Leon M, Einav S, Varon J. Beyond muscle destruction: a systematic review of rhabdomyolysis for clinical practice. Crit Care. 2016;20(1):135.
  4. Pasternak RC, Smith SC Jr, Bairey-Merz CN, Grundy SM, Cleeman JI, Lenfant C. ACC/AHA/NHLBI clinical advisory on the use and safety of statins. J Am Coll Cardiol. 2002;40(3):567-572.
  5. Clinical pearl: elevated liver enzymes and rhabdomyolysis. Emerg Med News. 2017;39(4):10.
  6. Nabalawi RA. Renal and electrolyte abnormalities in heat stroke during Hajj. Saudi J Intern Med. 2011;1(2):33-3
  7. Wong C, Hsu W, Carr GE. Spectrum of critical illness in undocumented border crossers. The Arizona-Mexico border experience. Ann Am Thorac Soc. 2015;12(3):410-414.