Hyperbaric oxygen therapy as treatment for bilateral arm compartment syndrome after CrossFit: case report and literature review.

INTRODUCTION: CrossFit is a physical fitness program characterized by high-intensity workouts that can be associated with serious injury. Acute compartment syndrome in the upper limbs is a rare occurrence. It may occur after intense physical exercise, and its usual treatment is surgical. Hyperbaric oxygen therapy is a treatment described as adjunctive in cases of compartmental syndrome. PRESENTATION: We describe the case of a CrossFit practitioner who, after intense training, developed progressive symptoms of rhabdomyolysis and acute bilateral arm compartment syndrome, who was successfully treated with hyperbaric oxygen therapy and required no fasciotomy as surgical treatment. CONCLUSIONS: Acute compartment syndrome in the arms after intense physical exercise is a rare occurrence that should be suspected by practitioners of physical activity experiencing intense, disproportionate and progressive pain. In the case presented, hyperbaric oxygen therapy was successfully used in the treatment of the disorder, with satisfactory progress, and without the need for a surgical fasciotomy as therapy.

Risk Factors for Collegiate Swimmers Hospitalized With Exertional Rhabdomyolysis.

OBJECTIVE: To identify midseason risk factors for symptomatic exertional rhabdomyolysis (sER) in swimmers after a novel upper body workout. DESIGN: Retrospective (1) survey and (2) analyses of observational laboratory data conducted over a 16-week training period, 2 months before sER. SETTING: Midwest University. PARTICIPANTS: Thirty-four collegiate swimmers. INDEPENDENT VARIABLES: (1) Motivation, symptoms, and supplements for survey variables. (2) Changes (midseason minus preseason) in body composition, blood pressure (BP), urinary measures, and protein shake ingestion for laboratory variables. MAIN OUTCOME MEASURES: Swimmers were categorized in hospitalized (H), treated and released from hospital (RH), and nonhospitalized (NH) groups for analyses. RESULTS: (1) Six swimmers were in the H group (17.6%; 3 male/3 female) and 7 in the RH group (20.6%; 3 male/4 female). Nonsignificant trend toward H swimmers relating more upper body soreness (≥9/10) than RH (8/10) and NH (6/10) swimmers (P > 0.05) while reporting "felt bad and workout went poorly" (P = 0.009). H and RH swimmers reported more arm locking during the workout (P = 0.04) and brown urine after arm competition compared with NH-group swimmers (P = 0.03). (2) Increases in right systolic (P = 0.01) and left diastolic (P = 0.02) BP, with trends toward decreased left arm lean mass (P = 0.06) in H compared with RH and NH swimmers. Female H swimmers had more acidic urine (pH = 5.50 vs 6.9; P = 0.004), less volume, and higher specific gravity than RH + NH swimmers. All H swimmers regularly ingested protein shakes after workouts. CONCLUSIONS: Risk factors for sER included exceptional motivation, extreme soreness, increased resting BP, acidic urine (females), and regular ingestion of protein shakes.

Exercise-induced rhabdomyolysis - a patient series. / Treningsindusert rabdomyolyse ­ en pasientserie.

BACKGROUND: No guidelines are available for the treatment and follow up of exercise-induced rhabdomyolysis. The purpose of this study was to describe the treatment, complications and follow-up of patients with exercise-induced rhabdomyolysis at Diakonhjemmet Hospital. MATERIAL AND METHOD: A retrospective observational study from 2011 up to and including 2015 of patients with exercise-induced rhabdomyolysis ≥ 18 years and with creatine kinase > 5 000 IU/l. RESULTS: We registered a total of 42 patients and obtained informed consent from 31. Twenty were treated as inpatients with a median hospitalisation time of 2.5 (1­6) days. Median creatine kinase was 36 797 (17 172­53 548) IU/l upon admission and 16 051 (11 845­26 505) IU/l at discharge. Median intravenous fluid volume was 6 000 (1 000­27 700) ml. Eleven patients underwent urinary alkalinisation. None developed severe kidney injury or other serious complications such as electrolyte imbalance, compartment syndrome or disseminated intravascular coagulation, either during hospitalisation or in the course of the study period. INTERPRETATION: Healthy persons with exercise-induced rhabdomyolysis have a very low risk of complications. Our patients are treated as outpatients or considered for discharge with creatine kinase < 40 000 IU/l measured at least three days after their workout, and if they have no risk factors or other complications.

Severe rhabdomyolysis secondary to adenovirus infection: case report and literature review.

A 38-year-old male presented with renal failure in the setting of a flu-like illness. Urinalysis showed myoglobinuria and granular casts. His serum creatine phosphokinase was markedly elevated. He was diagnosed with rhabdomyolysis and was volume resuscitated with normal saline and bicarbonate-containing fluid. Workup included a respiratory viral panel which was positive for adenovirus. Other causes such as trauma, seizure, and intoxicants were excluded. He developed progressive renal failure necessitating hemodialysis. After ~ 4 weeks he recovered renal function and dialysis was discontinued. Viral-induced myopathy should be suspected in patients who present with rhabdomyolysis.

An increase in the number of admitted patients with exercise-induced rhabdomyolysis. / Økning i antall pasienter med treningsindusert rabdomyolyse?

BACKGROUND: Rhabdomyolysis may lead to serious complications, and treatment is both time-consuming and costly. The condition can be caused by many factors, including intense exercise. The purpose of this study was to investigate whether the number of hospitalisations due to exercise-induced rhabdomyolysis has changed in recent years. We describe the disease course in hospitalised patients, and compare disease course in individuals with exercise-induced rhabdomyolysis and rhabdomyolysis due to other causes. MATERIAL AND METHOD: The study is a systematic review of medical records from Akershus University Hospital for the years 2008 and 2011 ­ 14. All hospitalised patients with diagnostic codes M62.8, M62.9 and T79.6 and creatine kinase levels > 5 000 IU/l were included. The cause of the rhabdomyolysis was recorded in addition to patient characteristics and the results of various laboratory tests. RESULTS: Of 161 patients who were hospitalised with rhabdomyolysis during the study period, 44 cases (27 %) were classified as exercise-induced. In 2008 there were no admissions due to exercise-induced rhabdomyolysis; in 2011 and 2012 there were six and four admissions respectively, while in 2014 there were 22. This gives an estimated incidence of 0.8/100 000 in 2012 and 4.6/100 000 in 2014. Strength-training was the cause of hospitalisation in 35 patients (80 % of the exercise-induced cases). Three patients (7 % of the exercise-induced cases) had transient stage 1 kidney injury, but there were no cases with stage 2 or stage 3 injury. By comparison, 52 % of patients with rhabdomyolysis due to another cause had kidney injury, of which 28 % was stage 2 or 3. INTERPRETATION: The number of persons hospitalised with exercise-induced rhabdomyolysis has increased four-fold from 2011 to 2014, possibly due to changes in exercise habits in the population. None of the patients with exercise-induced rhabdomyolysis had serological signs of kidney injury upon hospital discharge.

Creatinine as predictor value of mortality and acute kidney injury in rhabdomyolysis.

BACKGROUND: Rhabdomyolysis (RB) is a syndrome characterised by decomposition of skeletal muscle that could be life threatening, so the identification of biomarkers of its severity could help us in its treatment. Creatine kinase (CK) is usually taken as a reference in patients with RB in order to stratify prognosis, however that is not probably the most effective parameter. AIMS: The present study was designed to analyse the specific features and mortality of patients with RB and the relation between creatinine, CK and mortality. METHODS: Retrospective cohort analysis among patients admitted to San Pedro Hospital in Logroño (Spain) with RB (CK levels higher than 2000 U/L) diagnosed since 1 January 2009 until 31 December 2; 013 522 patients with RB patients diagnosed of RB were collected. The aetiology and the analytical feature (creatinine, CK, calcium, phosphorus, pH and bicarbonate), as well as 30-year mortality, were investigated. RESULTS: Among the 522 patients, there were 138 deaths. Four patients required renal replacement therapy. The most common cause of RB was trauma (29%). Infectious aetiology had the highest mortality (41.2%). The median CK was 3451 u/L (interquartile range 3348), and the mean creatinine at admission was 132.6 umol/L (±110.5). Initial CK levels do not have predictive ability on mortality or renal dysfunction in contrast to initial creatinine values. Each state of acute kidney injury (AKI) increased mortality compared with those who have not presented this renal dysfunction (P < 0.0001). Age, calcium, phosphorus, bicarbonate and pH are associated with AKI. CONCLUSION: Despite being a diagnostic marker for RB, initial CK levels do not predict mortality. However, creatinine initial levels are related to progression to acute renal injury and mortality at 30 days.

Urinalysis is an inadequate screen for rhabdomyolysis.

STUDY OBJECTIVES: Hematuria by urine dipstick with absent red blood cells (RBCs) on microscopy is indicative of rhabdomyolysis. We determined the sensitivity of this classic urinalysis (UA) finding in the diagnosis of rhabdomyolysis. METHODS: We conducted a retrospective electronic medical record review of patients with a primary or secondary diagnosis of rhabdomyolysis with a creatine phosphokinase (CPK) greater than 1000 IU/L and a UA within the first 24 hours. Data were collected using a standardized data form, and a blinded panel of 3 emergency medicine physicians reviewed selected cases. Sensitivity and 95% confidence intervals (CIs) were calculated for detection of rhabdomyolysis by UA. RESULTS: During the study period, 1796 patients were diagnosed with rhabdomyolysis, of whom 228 met inclusion criteria. The mean peak CPK was 27509 IU/L. One hundred ninety-five (86%) had a urine dip-positive for blood. However, only 94 patients (41%) had a positive urine dip and negative microscopic hematuria, resulting in a sensitivity of 41% (95% CI, 35%-47%). In a subset of 66 patients (29%) with more severe rhabdomyolysis (initial CPK, ≥10000 IU/L; mean CPK, 53365 IU/L), UA had a sensitivity of 55% (95% CI, 43%-67%). Broadening the definition of negative microscopy from 0 to 3 RBCs to less than 10 RBCs only increased the sensitivity to 79% (95% CI, 73%-83%). CONCLUSIONS: The combination of a positive urine dip for blood and negative microscopy is an insensitive test for rhabdomyolysis, and the absence of this finding should not be used to exclude the diagnosis.

Creatine kinase levels during preseason camp in National Collegiate Athletic Association Division I football athletes.

OBJECTIVE: To investigate mean creatine kinase (CK) levels in National Collegiate Athletic Association (NCAA) Division I football athletes and the relationship between mean CK levels and demographic variables. DESIGN: Observational cohort. SETTING: NCAA Division I football program. PARTICIPANTS: NCAA Division I football athletes. INTERVENTIONS: Blood and urine samples were obtained from 32 athletes on the first (time 1), third (time 2), and seventh (time 3) days of football camp. MAIN OUTCOME MEASURES: Mean CK levels. The hypotheses were formulated before the data were collected. RESULTS: All urine samples tested negative for blood. Mean CK levels were 284.7 U/L at time 1, 1299.8 U/L at time 2, and 1562.4 U/L at time 3. The increases in means were statistically significant (P < 0.005 for all pairwise comparisons). Most demographic variables were not related to mean CK levels. The number of days in the precamp conditioning program was negatively associated with mean CK levels (P = 0.0284). CONCLUSIONS: Mean CK levels in NCAA Division I football athletes during camp were higher than the serological criteria for rhabdomyolysis commonly used in clinical practice. More data are needed to assess if the number of days of participation in precamp conditioning is related to lower CK levels in NCAA Division I football athletes during camp.

[Renoprotective effects of statins under the conditions of acute renal failure, caused by rhabdomyolysis].

The experiment on white rats was targeted at the examination of influence of statins (atorvastatin, lovastatin, simvastatin) under the conditions of acute renal failure, caused by rhabdomyolysis. Renoprotective effects of statins were demonstrated by reduction of hyperazotemia and proteinuria and improvement of renal excretory function, which correlated with antioxidant properties of drugs.

A cluster of exertional rhabdomyolysis affecting a Division I Football team.

OBJECTIVE: To identify risk factors for exertional rhabdomyolysis (ER) among collegiate football athletes. We hypothesized that a back squat workout triggered ER in some players, and that the risk of ER was altered by players' characteristics or other exposures. DESIGN: Case report and case-control study. SETTING: National Collegiate Athletic Association Division I Football Program and an academic medical center. PARTICIPANTS: National Collegiate Athletic Association Division I football players. INDEPENDENT VARIABLES: Characteristics, performance during the implicated workout, and exposures of players. MAIN OUTCOME MEASURES: Exertional rhabdomyolysis was the primary outcome; the hypotheses were formulated before data were collected. RESULTS: Initial serum creatine kinase and creatinine values ranged from 96,987 to 331,044 U/L and from 1.0 to 3.4 mg/dL, respectively. The risk of ER increased as the time and number of sets needed to complete 100 back squats increased [odds ratio (OR), 1.11; 95% confidence interval (CI), 1.03-1.19; P = 0.0051 and OR, 1.33; 95% CI, 1.09-1.63; P = 0.0056, respectively]. Affected players were significantly more likely than unaffected players to report that they went to muscle failure (P = 0.006), did not think they could complete the workout (P = 0.02), and performed extra squats (P = 0.02) during the back squat assignment. For athletes playing skilled or semiskilled positions, the risk of ER increased as the percent body weight lifted increased [OR (corresponding to a 10% increase), 1.77; 95% CI, 1.06-2.94; P = 0.0292]. Drinking protein shakes after the implicated workout was associated with a decreased risk (OR, 0.70; 95% CI, 0.51-0.96; P = 0.0284); the odds decreased about 30% per shake. CONCLUSIONS: Percent body weight lifted, the number of sets, and time needed to complete 100 back squats were significantly associated with increased risk of ER. Affected athletes were more likely to report going to muscle failure, thinking they could complete the workout, and performing extra squats during the back squat assignment. Consuming protein shakes after the implicated workout was associated with a decreased risk. Clinicians, athletes, and athletic program staff must know risk factors for ER and early symptoms of ER.

[Rhabdomyolysis related to physical activity in young subjects].

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

Severe falciparum malaria with dengue coinfection complicated by rhabdomyolysis and acute kidney injury: an unusual case with myoglobinemia, myoglobinuria but normal serum creatine kinase.

BACKGROUND: Acute kidney injury (AKI) is a complication of severe malaria, and rhabdomyolysis with myoglobinuria is an uncommon cause. We report an unusual case of severe falciparum malaria with dengue coinfection complicated by AKI due to myoglobinemia and myoglobinuria while maintaining a normal creatine kinase (CK). CASE PRESENTATION: A 49-year old Indonesian man presented with fever, chills, and rigors with generalized myalgia and was diagnosed with falciparum malaria based on a positive blood smear. This was complicated by rhabdomyolysis with raised serum and urine myoglobin but normal CK. Despite rapid clearance of the parasitemia with intravenous artesunate and aggressive hydration maintaining good urine output, his myoglobinuria and acidosis worsened, progressing to uremia requiring renal replacement therapy. High-flux hemodiafiltration effectively cleared his serum and urine myoglobin with recovery of renal function. Further evaluation revealed evidence of dengue coinfection and past infection with murine typhus. CONCLUSION: In patients with severe falciparum malaria, the absence of raised CK alone does not exclude a diagnosis of rhabdomyolysis. Raised serum and urine myoglobin levels could lead to AKI and should be monitored. In the event of myoglobin-induced AKI requiring dialysis, clinicians may consider using high-flux hemodiafiltration instead of conventional hemodialysis for more effective myoglobin removal. In Southeast Asia, potential endemic coinfections that can also cause or worsen rhabdomyolysis, such as dengue, rickettsiosis and leptospirosis, should be considered.

Ischemic electrocardiographic changes and elevated troponin from severe heatstroke in an adolescent.

BACKGROUND: Heatstroke can result in significant diffuse tissue derangement, which can result in multiple organ system dysfunction. The heart can equally be affected and ischemia and infarction may occur. OBJECTIVE: This study aimed to present the potential complications from heatstroke to the myocardium. CASE: A case of a 15-year-old adolescent boy who collapsed after playing football in a hot summer day was found to be hyperthermic and poorly perfused. He had ischemic electrocardiographic changes and elevated cardiac enzymes but with normal coronary arteries. CONCLUSIONS: Heatstroke can lead to morbidity and mortality. Tissue damage during heatstroke is believed to result from uncoupling during oxidative phosphorylation. It is important to realize that heart damage can occur from heatstroke and that appropriate diagnostic and therapeutic measures are required for a good outcome.

Role of dipstick in detection of haeme pigment due to rhabdomyolysis in victims of Bam earthquake.

Avoiding life-threatening complications of rhabdomyolysis depends on early diagnosis and prompt management. The aim of this study was to evaluate the role of urinary dipstick test in the detection of haeme pigment in patients who were at risk of acute renal failure (ARF) due to rhabdomyolysis after suffering injury in the Bam earthquake. Serum creatine phosphokinase (CPK) level was used as the gold standard for prediction of ARF. ARF developed in 8 (10%) of 79 patients studied. We found no significant differences in the sensitivity, specificity and accuracy of dipstick urine and serum CPK tests for identifying patients who were at risk of ARF. However, dipstick urine test is an easy test that can be performed quickly at an earthquake site.

Capture-induced exertional rhabdomyolysis in the Shortfin Mako Shark, Isurus oxyrinchus.

BACKGROUND: Shortfin Mako sharks (Isurus oxyrinchus) are top-order predators in oceanic food chains. They are captured worldwide by commercial and recreational fisheries, but little is known about the effects that fishing has on the homeostasis and longevity of these animals. OBJECTIVE: This study aimed to assess the health of Shortfin Mako sharks captured by recreational fishers off eastern Australia. METHODS: Twenty-four sharks were captured, and their gender, length, weight, reproductive maturity, and stage were recorded. After blood and urine collection, serum analytes were quantified using standard biochemical methods, whereas urine was analyzed using semi-quantitative reagent strips, microscopic examination, centrifugation, and ammonium sulfate precipitation tests. RESULTS: Six Makos presented with red-brown urine. The means of notable serum analytes were as follows: sodium 276 mmol/L, potassium 15.6 mmol/L, inorganic phosphate 10.6 mmol/L, magnesium 3.3 mmol/L, urea 325 mmol/L, creatinine 52 µmol/L, AST 2806 U/L, CK 240938 U/L, lactate 44.4 mmol/L, osmolarity 1160 mmol/L, and pH 7.13. These analytes differed from the respective sand tiger shark reference interval, which was used as a proxy for Makos. The red-brown urine was due to myoglobin and had a mean pH of 5.76 that, when combined with red-brown casts, led to a diagnosis of fishing-induced exertional rhabdomyolysis that occurred secondary to lactic acidosis, hypoxia, and hypovolemia. It was further exacerbated by hyperkalemia and acute renal failure, serious complications that often lead to mortality. CONCLUSIONS: Practitioners caring for sharks and rays should consider collecting urine from free-living or aquarium animals when they are captured for examination and/or treatment, particularly at times with maximal seawater temperatures.

A systematic review on the definition of rhabdomyolysis.

BACKGROUND: Rhabdomyolysis (RML) is an interdisciplinary condition due to muscle cell injury followed by the release of cell components into circulation. Etiology of RML has a broad range; a serious complication is acute kidney injury (AKI). Despite its high relevance, there is no established formal definition for RML. OBJECTIVES: A systematic review, focusing on RML definition, providing a recommendation for clinicians. METHOD: Systematic literature research in PubMed and Embase (1968-07/2018). RESULTS: The database research presented 8136 articles in PubMed and 2151 in Embase. After screening, 614 papers were retained for statistical analysis. A retrospective study was the most used design (44%). A definition of RML was stated in 231 studies (37.6%), including a precise creatine kinase level (CK) cut-off most frequently (67.1%). In 53/231 (22.9%) studies the CK cut-off was > 5 × upper limit of normal (ULN), and in 64/231 (27.7%) studies > 1000 IU/L. Further components of definitions were elevated CK without specific thresholds, and clinical symptoms. Exclusion criteria referring to the definition of RML were established in 113 studies, including myocardial, renal, cerebral and neuromuscular characteristics. CONCLUSION: At present, we recommend a clinical syndrome of acute muscle weakness, myalgia, and muscle swelling combined with a CK cut-off value of > 1000 IU/L/ or CK > 5 × ULN for the standard definition of a mild RML. Additionally measured myoglobinuria and AKI indicate a severe type of RML. Exclusion criteria as well as the chronological sequence need to be considered for a conclusive RML definition.