Unexplained Rhabdomyolysis and Hepatic Renal Dysfunction: A Case of Bongkrekic Acid Poisoning.

Bongkrekic acid (BA) is a lipotoxin that can cause fatal food poisoning. Severe BA poisoning can rapidly progress from liver and kidney damage to multiple organ failure and is rarely manifested as persistent hypoglycemia and rhabdomyolysis. It has a high mortality rate and poor prognosis. However, clinical data on patients with foodborne BA poisoning are limited. The aim of this study is to summarize the characteristics of patients with BA poisoning, provide reference for early diagnosis and treatment, and improve the survival rate and prognosis of patients with BA poisoning.

The Significance of Rhabdomyolysis Secondary to Hypothyroidism.

Rhabdomyolysis is a rare but serious complication of hypothyroidism, typically associated with precipitating factors such as medication interactions, strenuous exercise, and illicit drug use. We present a unique case of rhabdomyolysis in an 89-year-old female due to severe hypothyroidism without identifiable precipitating factors. Laboratory results revealed markedly elevated creatine kinase (CK) levels and acute kidney injury (AKI). The diagnosis was confirmed by critically elevated thyroid-stimulating hormone (TSH) and low free thyroxine (FT4) levels. Prompt initiation of levothyroxine supplementation and fluid resuscitation led to clinical improvement and downward trend in creatinine and CK levels. This case highlights the importance of considering hypothyroidism in the differential diagnosis of rhabdomyolysis and the need for timely T4 supplementation and supportive care to prevent severe complications.

Recurrent rhabdomyolysis caused by palmitoyltransferase II (CPT-2) deficiency but complete normal acylcarnitine profile: A patient presentation and review of the literature.

Recurrent rhabdomyolysis, marked by skeletal muscle breakdown, can stem from various causes, including genetic disorders. We detail a patient of a 22-year-old male with carnitine palmitoyltransferase II (CPT-2) deficiency manifesting recurrent rhabdomyolysis despite normal acylcarnitine profiles. Whole-genome sequencing identified two CPT2 gene variants: c.338C > T and c.482G > A, confirming the diagnosis. We conducted a case report and a comprehensive literature review encompassing 262 articles related to CPT-2 deficiency available on PubMed. The review detailed 245 cases across various forms, including lethal neonatal, severe infantile hepatocardiomuscular, and myopathic forms. The study highlighted the variability and complexity of CPT-2 deficiency phenotypes, emphasizing correlations between variants and phenotypes as well as gender distribution. Although the CPT-2 deficiency genotype does not entirely predict phenotype severity, it remains informative for most patients, assisting in assessing the severity linked to each genetic variant. The results of our study offer crucial insights into evaluating the severity associated with individual genetic variants. Notably, our patient displayed normal acylcarnitine profiles between illness episodes, indicating possible profile abnormalities only during active disease states. We propose the collection of additional blood samples for acylcarnitine analysis during episodes of rhabdomyolysis without delay in all patients presenting with rhabdomyolysis of unknown cause as a crucial diagnostic strategy. This approach may unveil unexpected underlying diseases, enabling early and accurate diagnoses.

High Altitude Liver Failure: An Infrequent Trigger.

How to cite this article: Srinivasan A, Prusty BSK. High Altitude Liver Failure: An Infrequent Trigger. Indian J Crit Care Med 2024;28(10):988.

Exercise-Associated Hyponatremic Encephalopathy, Rhabdomyolysis, and Acute Kidney Injury While Hiking in the Grand Canyon.

We present an unusual case of concomitant exercise-associated hyponatremic encephalopathy (EAHE), exertional rhabdomyolysis (ER), and acute kidney injury (AKI) in a Grand Canyon hiker. Our case patient, an adult 41-year-old male, consumed an excessive amount of water during his descent into the Canyon during hot weather. The next day, he was unable to hike out due to severe leg pain and disorientation, and ultimately evacuated by helicopter, having a grand mal seizure in flight. Despite having no serum sodium level, medics administered an intravenous (IV) bolus of 3% hypertonic saline (HTS) before transporting him to the hospital. There, he was diagnosed with EAHE (serum sodium, 114 mmol⋅L-1), ER, bilateral compartment syndromes, and mild AKI. The life-threatening EAHE was immediately corrected with more IV HTS, the limb-threatening compartment syndromes by surgical fasciotomies, and eventually, the AKI by oral and IV fluids. This case demonstrates the seriousness of overconsumption of water, as well as the potential complications of muscle damage when a deconditioned person does prolonged, strenuous exercise. Furthermore, it also illustrates the importance of considering EAHE within the differential diagnosis for acute alterations in level of consciousness. Lastly, it shows the importance to prioritize patient treatments for conditions that are an immediate threat to life or limb.

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

Background: Currently, there remains substantial controversy in research regarding whether the concomitant use of colchicine and statins increases the occurrence of rhabdomyolysis, warranting further substantiation. Objective: This study aimed to identify the likelihood drug-drug interactions (DDIs) for the co-administration of colchicine and statins resulting in rhabdomyolysis. Methods: A disproportionality analysis was conducted by using data sourced from the US Food and Drug Administration Adverse Event Reporting System (FAERS) to detect rhabdomyolysis signals associated with the combined use of colchicine and statins. The association between (colchicine/statins/colchicine and statins) and rhabdomyolysis were evaluated using information component (IC). DDI signals were calculated based on the Ω shrinkage measure and Bayesian confidence propagation neural network (BCPNN) method. Furthermore, stratification was performed based on colchicine and individual statins agents. Results: In total, 11,119 reports of rhabdomyolysis were identified in the FAERS database, 255 (2.29%) involved both colchicine and statins. Our analysis showed potential DDI signals of rhabdomyolysis (Ω025 = 1.17) among individuals concurrent use of colchicine and statins. Moreover, further drug-specific analysis suggests DDI signals in the colchicine-atorvastatin pair (Ω025 = 1.12), and colchicine-rosuvastatin pair (Ω025 = 1.05), along with a higher proportion of rhabdomyolysis (IC025 = 5.20) and (IC025 = 4.26), respectively. Conclusion: The findings suggest that concomitant use of colchicine and statins may increase the risk of rhabdomyolysis, particularly when combined with atorvastatin or rosuvastatin. Therefore, healthcare professionals should pay special attention to life-threatening AE such as rhabdomyolysis, when co-prescribing colchicine statins.

Rhabdomyolysis and Pigment Nephropathy - An Uncommon Manifestation of Eucalyptus Oil Consumption.

Eucalyptus oil consumption is well known to cause adverse effects on central nervous system like seizures, ataxia and unconsciousness. No antidote is available and treatment is largely supportive. We report a case of rhabdomyolysis with pigment cast nephropathy and acute kidney injury in a young female following eucalyptus oil consumption and its successful management.

Postanesthetic rhabdomyolysis in 7 warmblood horses.

OBJECTIVE: To describe the clinical findings, outcomes, and muscle histopathology in warmblood horses that developed severe rhabdomyolysis in the perianesthetic period despite remaining stable while under general anesthesia. ANIMALS: 7 warmblood horses, 6 geldings and 1 mare, with a median age of 9 years (range, 4 to 18 years) and median weight of 615 kg (range, 550 to 703 kg). Records from the Valberg Neuromuscular Diagnostic Laboratory and Michigan State University were reviewed (2016 to 2023) to identify warmbloods with postanesthetic myopathy (PAM). CLINICAL PRESENTATION: Warmblood horses with no history of myopathy developed PAM after remaining stable while under general anesthesia. Five of 7 horses were in regular work prior to anesthesia, and activity level was unknown in 2 horses. Time to standing in recovery was prolonged, 3 horses were euthanized due to persistent recumbency, and rhabdomyolysis recurred in 4 horses 5 to 11 days after anesthesia, with 1 surviving. Horses had muscle stiffness, pain, and sweating and struggled to remain standing. As PAM developed, serum creatine kinase activity and lactate concentrations (12 ± 7 mmol/L; n = 5) were markedly increased. RESULTS: At necropsy, histopathology revealed complete glycogen depletion (5 of 7), acute myodegeneration (6 of 7), and chronic active myodegeneration of representative skeletal muscle samples. A semimembranosus biopsy obtained 14 days after anesthesia from the survivor had rare glycogen-depleted fibers. CLINICAL RELEVANCE: Warmblood horses are susceptible to fatal PAM characterized by acute myodegeneration, lactic acidosis, and muscle glycogen depletion that occurs up to 11 days after anesthesia. In horses with delayed recovery after anesthesia, monitoring for 2 weeks after anesthesia, including assessment of serum creatine kinase activity and blood lactate, could potentially improve outcomes.

Real-world analysis of levetiracetam-associated rhabdomyolysis: insights from the FDA adverse event reporting system.

BACKGROUND: Levetiracetam, a widely prescribed antiseizure medication, is recognized for its broad-spectrum efficacy, good tolerability, and minimal drug interactions. This study examines the association between levetiracetam and rhabdomyolysis, utilizing real-world data from the FDA Adverse Event Reporting System (FAERS) database to further elucidate its safety profile. METHODS: This study extracted adverse events related to levetiracetam from the FAERS database (Q1 2013 to Q1 2024). Four types of disproportionality analysis identified rhabdomyolysis as a significant adverse even. Logistic regression assessed risk factors, including gender, age, and severity. A Gaussian Mixture Model analyzed the time-to-onset distribution of rhabdomyolysis, while the impact of concomitant medications on its risk was evaluated using Reporting Odds Ratio (ROR). RESULTS: Levetiracetam significantly increased rhabdomyolysis risk (ROR = 13.5). Males showed a higher incidence (OR = 2.60). Most adverse events occurred within the first 30 days, with a bimodal onset distribution. Co-administration of antibiotics, antipsychotics, and PPIs elevated the risk while other antiseizure medications did not. CONCLUSION: This study found a significant association between levetiracetam and the risk of rhabdomyolysis, highlighting the need for increased clinical vigilance in this patient population. Future research should focus on elucidating the underlying mechanisms and optimizing clinical guidelines.

Paving the way ahead: protocol optimization of mouse models in crush syndrome related acute kidney injury research.

Backgrounds: Crush syndrome (CS) is the leading cause of death after earthquakes, second only to direct trauma. Acute kidney injury (AKI) is the most severe complication of CS. Research based on the CS-AKI mouse model and kidney function assessment by glomerular filtration rate (GFR) helps to elucidate the pathogenesis of CS-AKI, which contributes to effective treatment measures. Methods: Mice were modeled by the multi-channel small animal crushing platform. We set up different CS-AKI modeling parameters by applying different crushing weights (0.5 kg, 1.0 kg, 1.5 kg), crushing durations (6 h, 12 h, 16 h), and decompression durations (6 h, 12 h, 24 h). The GFR, serum creatinine (SCr), blood urea nitrogen (BUN), kidney tissue Kim-1 mRNA and Ngal mRNA expression levels, and HE staining were examined to evaluate the results of different protocols. Results: The results showed that with the crushing weight increased, the kidney function assessment's gold standard GFR significantly decreased, and the levels of SCr and BUN increased. Meanwhile, the longer crushing durations found a higher extension of inflammatory cell infiltration in the kidney. The degree of kidney injury continued to worsen with the duration of decompression, indicating severe damage after reperfusion, which was associated with tubular injury and a sustained elevation of the inflammatory state. Conclusion: We successfully constructed CS-AKI mouse models with different severities under the above parameters. Applying 1.5 kg for 16 h and then decompressing for 24 h induced severe AKI. These findings provide clues for further exploration of the mechanism and treatment of traumatic AKI.

Carnitine Palmitoyltransferase II (CPT2) Deficiency: An Overlooked and Elusive Cause of Acute Kidney Injury.

Carnitine palmitoyltransferase II (CPT2) deficiency is a rare inherited disorder affecting fatty acid metabolism. This enzymatic defect presents with a broad clinical spectrum, from severe neonatal forms that can be fatal, to milder myopathic variants characterized by myalgia and recurrent myoglobinuria in adolescence and adulthood. Herein, we report the case of a male patient who developed exertional rhabdomyolysis and acute kidney injury due to CPT2 deficiency. This case underscores the importance of considering genetic disorders in the differential diagnosis of patients presenting with recurrent exercise intolerance and metabolic crises. Early recognition and diagnosis enable prompt implementation of dietary and lifestyle modifications aimed at mitigating potential complications such as renal impairment. Moreover, timely diagnosis allows for genetic counseling of affected individuals and their families.

Colorectal Carcinoma and Gluteal Abscesses in the Background of a Gait Disturbance Presentation.

Introduction: Profuse diarrhea and abdominal discomfort are well-documented symptoms of patients with known colorectal cancer. It is much less common for these patients to present with a chief complaint of gait disturbance and rhabdomyolysis. We present a case of incidentally discovered colorectal carcinoma in a patient who was initially evaluated for progressive weakness and recurrent falls. Case Presentation: A 51-year-old man was admitted to our department for management of rhabdomyolysis in the setting of progressive lower extremity weakness and mechanical falls. He developed abdominal discomfort and bowel changes during his admission, and after further investigation, he was found to have a rectal polyp positive for invasive adenocarcinoma, as well as multiple gluteal abscesses. Workup for metastasis, mutations, and oncogenic biomarkers was unremarkable. Conclusion: This case is a demonstration of a medically complex patient presentation compounded by multifactorial processes. Future providers may take note that an initial absence of classic gastrointestinal (GI) symptoms does not necessarily rule out underlying GI cancer. Instead, the initial presentation of colorectal adenocarcinoma may manifest with paraneoplastic versus incidental progressive proximal limb weakness prior to GI symptoms such as diarrhea. Additionally, our report demonstrates a case of possible paraneoplastic gluteal abscesses, which may have further contributed to the patient's gait disturbance. However, it is unclear as to whether our patient's various symptoms were directly linked to one another, or if they were incidental co-presentations.

Fatal poisoning by dietary supplements accompanied by massive rhabdomyolysis and multiple organ failure. / Smiertelne zatrucie suplementami diety przebiegajace z masywna rabdomioliza i niewydolnoscia wielonarzadowa.

Obesity epidemic and prevailing standards of desired body shape encourage society to use weight loss aids. Thermogenics, which are dietary supplements aimed at increasing energy expenditure, are particularly gaining popularity. These preparations can be easily purchased without prescription and have a complex composition, which means they can interact with numerous substances. The article describes the case of a 31-year-old female patient who, in a suicide attempt, ingested significant amounts of the dietary supplements 'Blue Magic' and 'Purim'. Both supplements contain, among other ingredients: caffeine, yohimbine, reserpine, and synephrine. The patient developed multiple organ failure, which led to her death on the second day of hospitalization. Poisoning by dietary supplements, due to their diverse composition and the lack of correlation between the content and the composition declared by the manufacturer, can pose a significant threat to the health and life of consumers.

Perioperative Rhabdomyolysis in Obese Individuals Undergoing Bariatric Surgery: Current Status.

One potential complication in bariatric surgery is rhabdomyolysis, which is a condition involving muscle tissue damage that can significantly impact a patient's health. The causes of rhabdomyolysis can be broadly classified into two major categories: traumatic and non-traumatic. Early investigations into the development of intraoperative rhabdomyolysis in bariatric surgery identified the main risk factors as tissue compression-primarily affecting the lower extremities, gluteal muscles, and lumbar region-as well as prolonged periods of immobilization. Clinically, rhabdomyolysis is typically suspected when a patient presents with muscle pain, weakness, and potentially dark urine or even anuria. However, the most reliable biomarker for rhabdomyolysis is elevated serum creatine kinase levels. The primary goal in managing hydration is to correct intravascular volume depletion, with solutions such as Lactated Ringer's or 0.9% saline being appropriate options for resuscitation. Perioperative diagnosis of rhabdomyolysis poses a significant challenge for anesthesiologists, requiring a high degree of clinical suspicion, particularly in bariatric patients. In this vulnerable population, prevention is crucial. The success of treatment depends on its early initiation; however, there are still significant limitations in the therapies available to prevent renal injury secondary to rhabdomyolysis.

Clinical and pathological findings of Africanized bee (Apis mellifera) envenomation in horses.

Africanized crossbred bees (Apis mellifera) originated in Brazil in 1957, and since then, the number of accidents involving humans and animals has significantly increased. Although they are considered clinical emergencies, there are few reports describing the clinical and pathological aspects of bee envenomation in horses. In this context, this report aims to describe the clinical and pathological features of bee toxicity after massive bee envenomation in three horses. The horses were referred to the veterinary hospital the day following the attack, and after clinical and laboratory examination, they presented with vascular, muscular, pulmonary, hepatic, and renal impairment. Even after the initiation of therapy immediately upon admission, the clinical condition of the two horses worsened, and they died within two days of hospitalization, with pathological analysis confirming the previously observed clinical alterations of generalized vasculopathy, liver degeneration, pulmonary edema, and renal tubular necrosis. Many cases of massive bee envenomation have been documented in both humans and animals, particularly in dogs. Understanding the mechanism of action of apitoxin, its effects on various tissues, and the ideal therapy for each patient has proven crucial for improving survival rates.

Osimertinib-Induced Myositis in a Patient With Metastatic Non-small Cell Lung Cancer With Epidermal Growth Factor Receptor Mutation.

Osimertinib is a third-generation tyrosine kinase inhibitor (TKI) that has emerged as a standard treatment in non-small cell lung cancer (NSCLC) with epidermal growth factor receptor (EGFR) mutation. While it is generally well tolerated, milder side effects of diarrhea, cytopenia, and cutaneous rashes are common. Osimertinib-induced myositis and rhabdomyolysis are exceedingly rare, and only a few cases have been documented in the literature to date. In this report, we present a case of a 59-year-old female with metastatic NSCLC who experienced myalgia following the initiation of osimertinib. Blood work revealed elevated creatine kinase (CK), serum creatinine (Cr), alanine aminotransferase (ALT), and aspartate aminotransferase (AST). Initially, her myalgia improved, and lab work normalized after drug discontinuation and supportive care. However, rechallenge with a 50% dose resulted in recurrence of symptoms and elevated serum CK, Cr, ALT, and AST. MRI findings suggested diffuse inflammation and a muscle biopsy revealed necrotizing myopathy. Symptoms ameliorated upon complete cessation of the drug and use of steroids. This case highlights the importance of recognizing this rare adverse effect of osimertinib and a guide for managing these associated symptoms.

An acute life-threatening episode of rhabdomyolysis, renal failure, altered mental status and hyperammonemia in an adult with 3-methylcrotonyl-CoA carboxylase deficiency.

3-methylcrotonyl-CoA carboxylase (3-MCC) deficiency is an autosomal recessive disorder of leucine metabolism. Since 3-MCC deficiency is thought to be a benign condition, a few newborn screening programs discontinued to screen this condition. We report a case of a 24-year-old previously healthy male patient who developed generalized rhabdomyolysis, weakness, respiratory and renal failure, acute pancreatitis, hyperammonemia, and altered consciousness after strenuous exercise. Diagnosis of 3-MCC was made based on increased plasma C5OH carnitine, urine 3-methylcrotonylglycine, and 3-hydroxyisovalerate, and later whole genome sequencing study confirmed the diagnosis. Low plasma carnitine and high creatine kinase (CK) levels were again noted after two months of poor compliance with carnitine therapy. Since 3-MCC deficiency is often incidentally diagnosed in asymptomatic mothers through positive newborn screening in the newborns and most positive newborn screening cases have benign clinical outcomes, 3-MCC deficiency has been considered a benign condition. Observation of a life-threatening episode triggered by strenuous exercise and recurrent occurrence of low carnitine and high CK without carnitine supplementation may support 3-MCC deficiency to be the condition covered by the newborn screen since carnitine supplementation likely prevents an episode that can be life-threatening. Asymptomatic adults with 3-MCC deficiency may benefit from periodic evaluation of plasma carnitine levels.

McArdle's Disease: A Differential Diagnosis of Metabolic Myopathies.

McArdle's disease, also known as glycogen storage disease type V or McArdle syndrome, is a pure muscle myopathy with an autosomal recessive inheritance pattern. It is caused by mutations in the gene that encodes muscle phosphorylase. Symptoms typically begin in late adolescence or early adulthood, presenting as exercise intolerance. This review focuses on the diagnosis of McArdle's disease, initially manifesting as a clinical picture of rhabdomyolysis in an 18-year-old male patient with a history of minor thalassemia who had been followed in pediatric consultation since age three for failure to thrive. After excluding common causes such as alcohol consumption, drug use, traumatic muscle compression, and other conditions, the diagnosis of McArdle's disease was considered. The diagnosis was supported by laboratory tests showing myoglobinuria and elevated creatine kinase levels, as well as the absence of increased serum lactate following ischemic exercise. Genetic testing confirmed the presence of mutations in the PYGM gene, corroborating the diagnosis. Treatment includes administering a diet rich in slow-absorbing carbohydrates, regular low-intensity physical exercise, and, in some cases, supplementation with vitamin B6 and creatine. The prognosis is generally favorable with proper disease management, although vigorous exercise should be avoided to prevent complications such as severe muscle injury and rhabdomyolysis. Although McArdle's disease is a rare condition, it is likely underdiagnosed. Ideally, it should be considered in the differential diagnosis of rhabdomyolysis in all patients with symptoms of exercise intolerance and/or recurrent myoglobinuria.

Rhabdomyolysis-related acute kidney injury in patients with COVID-19.

BACKGROUND: Viral and bacterial infections may be complicated by rhabdomyolysis, which has a spectrum of clinical presentations ranging from asymptomatic laboratory abnormalities to life-threatening conditions such as renal failure. Direct viral injury as well as inflammatory responses may cause rhabdomyolysis in the course of coronavirus disease 2019 (COVID-19). When presented with acute kidney injury (AKI), rhabdomyolysis may be related to higher morbidity and mortality. AIM: To compare rhabdomyolysis-related AKI with other AKIs during COVID-19. METHODS: A total of 115 patients with COVID-19 who had AKI were evaluated retrospectively. Fifteen patients had a definite diagnosis of rhabdomyolysis (i.e., creatine kinase levels increased to > 5 times the upper normal range with a concomitant increase in transaminases and lactate dehydrogenase). These patients were aged 61.0 ± 19.1 years and their baseline creatinine levels were 0.87 ± 0.13 mg/dL. Patients were treated according to national COVID-19 treatment guidelines. They were compared with patients with COVID-19 who had AKI due to other reasons. RESULTS: For patients with rhabdomyolysis, creatinine reached 2.47 ± 1.17 mg/dL during follow-up in hospital. Of these patients, 13.3% had AKI upon hospital admission, and 86.4% developed AKI during hospital follow-up. Their peak C-reactive protein reached as high as 253.2 ± 80.6 mg/L and was higher than in patients with AKI due to other reasons (P < 0.01). Peak ferritin and procalcitonin levels were also higher for patients with rhabdomyolysis (P = 0.02 and P = 0.002, respectively). The mortality of patients with rhabdomyolysis was calculated as 73.3%, which was higher than in other patients with AKI (18.1%) (P = 0.001). CONCLUSION: Rhabdomyolysis was present in 13.0% of the patients who had AKI during COVID-19 infection. Rhabdomyolysis-related AKI is more proinflammatory and has a more mortal clinical course.