Rhabdomyolysis secondary to a weight-loss prescription.

We present a case of a case of a man in his 70s on multiple medications (including treatment of ischemic heart disease and diabetes who developed significant rhabdomyolysis, complicated by acute kidney injury (AKI) and encephalopathy, while using a compounded medication for weight loss. The patient was admitted to the intensive care unit and progressed favourably after haemodialysis and supportive care. Information regarding the ingestion of weight-loss drugs was unknown at the time of admission and was only discovered after resolution of encephalopathy, raising the possibility of toxin-associated rhabdomyolysis. This case emphasises the need for a thorough clinical history and scrutiny of the safety of weight-loss prescriptions, including preparations that comprise a combination of drugs and supplements that may adversely interact with chronic medications, especially in polymedicated patients.

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.

Acute Compartment Syndrome and Rhabdomyolysis Caused by a Single Electrical Muscle Stimulation in a 46-Year-Old Female Professional Athlete With Fibromyalgia, Chronic Fatigue Syndrome, and Myofascial Disorder: A Case Report.

ABSTRACT: Electrical muscle stimulation (EMS) training has been recognized as an effective modality for improving body composition, enhancing body strength, and facilitating injury recovery. However, individuals who are new to EMS training and those with certain chronic diseases should exercise caution due to the increased risk of rhabdomyolysis. This case report describes the occurrence of rhabdomyolysis and gluteal compartment syndrome following a single session of EMS training in a 46-year-old Caucasian female professional athlete. The patient was successfully managed with intensive intravenous fluid therapy and sodium bicarbonate supplementation, along with close monitoring of electrolytes and renal function. Electrical muscle stimulation training poses an increased risk of severe complications in individuals with chronic diseases and myopathy. Therefore, careful subject selection is required for EMS training in individuals with chronic diseases and myopathy to prevent common side effects. For individuals trying EMS training for the first time, it is recommended to avoid high-frequency EMS exercises.

Clearance of NT-proBNP and Procalcitonin during Continuous Venovenous Hemodialysis with the Medium Cutoff Filter in Patients with Rhabdomyolysis-Associated Early Acute Kidney Injury.

INTRODUCTION: In polytrauma patients with AKI continuous venovenous hemodialysis (CVVHD) with medium cutoff membrane filters is commonly adopted to increase the removal of both myoglobin and inflammatory mediators, but its impact on increasing molecular weight markers of inflammation and cardiac damage is debated. METHODS: Twelve critically ill patients with rhabdomyolysis (4 burns and 8 polytrauma patients) and early AKI requiring CVVHD with EMIc2 filter were tested for 72 h on serum and effluent levels for NT-proBNP, procalcitonin (PCT), myoglobin, C-reactive protein (CRP), alpha1-glycoprotein, albumin, and total protein. RESULTS: The sieving coefficients (SCs) for proBNP and myoglobin were as higher as 0.5 at the start, decreased to 0.3 at the 2nd h, and then slowly declined to the final value of 0.25 and 0.20 at the 72nd h, respectively. PCT showed a negligible SC at the 1st h, a peak of 0.4 at the 12th h, and a final value of 0.3. SCs for albumin, alpha1-glycoprotein, and total protein were negligible. A similar trend was observed for the clearances (17-25 mL/min for proBNP and myoglobin; 12 mL/for PCT; <2 mL/min for albumin, alpha1-glycoprotein, and total protein). No correlation was found between systemic determinations and filter clearances of proBNP, PCT, and myoglobin. Net fluid loss/hour during CVVHD positively correlated with systemic myoglobin for all patients and NT-proBNP in the burn patients. CONCLUSION: CVVHD with EMiC2 filter showed low clearances for NT-proBNP and procalcitonin. CVVHD did not significantly affect the serum levels of these biomarkers, which could be adopted in the clinical management of early CVVHD patients.

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.

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.

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.

Sportmedizinische Beratung nach akuter Rhabdomyolyse bei erblicher Myopathie ­ eine herausfordernde Leistungsdiagnostik.

INTRODUCTION: Increased serum creatinine kinase after physical activity is well known and there is currently no cut-off value. We present the systematic diagnosis after rhabdomyolysis in a rare cause. HISTORY: A 36-year-old soldier developed acute kidney failure due to rhabdomyolysis after intense physical exertion. FINDINGS AND DIAGNOSIS: Sporty habitus, CK elevation and highly normal kidney values. Massive CK increase after step loading on the bicycle ergometer. We stopped further physical stress and initiated diagnostics. THERAPY AND COURSE: The genetic diagnosis found a hereditary myopathy of the lipid metabolism (VLCAD deficiency). We used individualized performance analysis to determine the safe load limit. In the ordinary athletic testing of these performance limits, no excessive CK activation could be determined. CONCLUSION: Recurrent rhabdomyolyses characterize the late onset of VLCAD, which can occur after intense physical activity, periods of fasting or dehydration. Patients can continue physical exercise safely after determining the individual tolerance.

Acute rhabdomyolysis in hepatitis-associated aplastic anemia patient undergoing allogeneic hematopoietic stem-cell transplantation: case report and literature review.

BACKGROUND: Hepatitis-associated aplastic anemia (HAAA) is a specific type of aplastic anemia, and hematopoietic stem-cell transplantation (HSCT) is recommended as the first-line. Acute rhabdomyolysis (AR) during hematopoietic stem-cell transplantation (HSCT) is a rare, serious complication, with only 10 cases reported in the world so far. CASE PRESENTATION: Herein, we present a case of AR developing during HLA-haploidentical HSCT in a 55-year-old man who suffered from HAAA. On day 7 after stem cell transfusion, the patient reported a muscle pull in thigh and complained of muscle swelling, pain and change in urine color. Despite the timely diagnosis (based on the levels of myoglobin and creatine kinase, and muscle MRI findings, etc.) and rapid hydration and alkalization, the situation progressed dramatically, and the patient died of multi-organ failure during the preparation for continuous renal replacement therapy (CRRT). Five days after his death, the whole-exome sequencing result confirmed that the patient had a germline missense mutation in SCN4A I 1545 V and ACTN3 R577X. CONCLUSION: AR is a rare but threatening complication during HSCT, especially in cases with kidney dysfunction. The creatine kinase level may not truly and completely reflect the severity and prognosis for cases with localized lesion. We suggest that genetic analysis should be performed for better understanding the pathological changes of AR during HSCT, especially for patients with bone marrow failure.

A Rare Pediatric Case of Severe Rhabdomyolysis Owing to Dual Infection.

AIM: We aimed to report a severe and rare pediatric rhabdomyolysis case associated with a dual viral infection. CASE: A 13 year-old, healthy girl presented with the complaints of fever, abdominal pain, weakness and dark-colored urine. She was diagnosed with rhabdomyolysis based on clinical signs and laboratory findings. The diagnosis was confirmed by serological tests and real-time polymerase chain reaction for Epstein-Barr virus (EBV) and cytomegalovirus (CMV), respectively. Other potential genetic, metabolic and infectious causes were evaluated meticulously but no evidence was found. This case is also important as it is the first reported case to our knowledge on rhabdomyolysis associated with EBV and CMV co-infection in children. CONCLUSION: The presented case experienced tetraplegia due to the severe muscular damage and muscle power returned to normal range after 3 months. This suggests that EBV and CMV may have exert synergistic effects leading to more severe inflammation and degeneration.

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.

Management of rhabdomyolysis: A practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: The treatment of rhabdomyolysis remains controversial. Although there is no question that any associated compartment syndrome needs to be identified and released, debate persists regarding the benefit of further therapy including aggressive intravenous fluid resuscitation (IVFR), urine alkalization with bicarbonate, and the use of mannitol. The goal of this practice management guideline was to evaluate the effects of bicarbonate, mannitol, and aggressive intravenous fluids on patients with rhabdomyolysis. METHODS: A systematic review and meta-analysis comparing treatments in patients with rhabdomyolysis was performed. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was applied to assess the quality of evidence and to create evidence-based recommendations regarding the use of bicarbonate, mannitol, and aggressive IVFR in patients with rhabdomyolysis. RESULTS: A total of 12 studies were identified for analysis. On quantitative analysis, IVFR decreased the incidence of acute renal failure (ARF) and need for dialysis in patients with rhabdomyolysis. Neither bicarbonate nor mannitol administration improved the incidence of acute renal failure and need for dialysis in patients with rhabdomyolysis. Quality of evidence was deemed to be very low, with the vast majority of the literature being retrospective studies. CONCLUSION: In patients with rhabdomyolysis, we conditionally recommend for aggressive IVFR to improve outcomes of ARF and lessen the need for dialysis. We conditionally recommend against treatment with bicarbonate or mannitol in patients with rhabdomyolysis.

Successful Treatment of Capture Myopathy and Satellite Transmitter Injury in an Atlantic Yellow-nosed Albatross (Thalassarche chlororhynchos).

An Atlantic yellow-nosed albatross (Thalassarche chlororhynchos) was found on shore 3 days after having been captured at sea by researchers. It presented very lethargic, moderately dehydrated, and in poor body condition. It was mildly hypothermic, with moderate pediculosis, and dark malodorous feces with yellow urates. The bird had a 48-g satellite transmitter attached with a backpack-style chest harness, which caused an ulcerative lesion on the interscapular area. The bird was severely anemic (packed cell volume, 18%), and plasma chemistry results were suggestive of a severe rhabdomyolysis (aspartate transaminase, 3620 U/L; creatine kinase, 100 400 U/L). We hypothesized that capture myopathy occurred because of a combination of capture stress and prolonged physical restraint by researchers, stress associated with repeated attempts by the bird to remove the satellite-transmitter harness, and a lengthy road transport to the rehabilitation center. A treatment protocol, which relied on a combination of aggressive fluid therapy, selenium, vitamins E and B12, and multivitamin supplementation, was administered after the initial physical assessment of the albatross. Isoflurane inhalation anesthesia was used to minimize stress associated with the performed medical procedures (eg, physical examination, removal of the satellite transmitter harness, blood collection, and wound management). Measures were adopted while the bird was hospitalized to reduce stress (eg, quiet and comfortable environment with visual barriers and restricting handling of the patient to experienced staff). Clinical and hematological monitoring was used to assess the patient's condition as the bird gradually recovered while hospitalized. The albatross was successfully released 28 days after the initial presentation, suggesting that the medical protocol employed in this case may be useful for the treatment of capture myopathy in albatrosses and other birds.

Complicated peripartum course in a patient with very long-chain acyl-coenzyme A dehydrogenase (VLCAD) deficiency.

Very long-chain acyl-coenzyme A (CoA) dehydrogenase (VLCAD) deficiency is an autosomal recessive fatty acid oxidation disorder characterized by rhabdomyolysis, hypoglycemia and cardiomyopathy. The general treatment approach in adult patients is based on the prevention of catabolism. High carbohydrate, low fat diet and supplementation of medium-chain triglycerides are essential in the treatment. There is little experience with pregnancy follow-up in this patient group. We present a complicated peripartum course and successful management in a patient with VLCAD deficiency. Although high-dose glucose infusion was initiated, creatine kinase levels significantly increased in the immediate postpartum period, but the patient remained asymptomatic and rhabdomyolysis resolved rapidly after increasing the glucose infusion rate.

Acute viral myositis: profound rhabdomyolysis without acute kidney injury.

BACKGROUND: Acute viral myositis (AVM) may be triggered by influenza A/B, enteroviruses and other viruses. Severe complications including rhabdomyolysis regularly lead to acute kidney injury (AKI). The aim of this short report was to discuss management and differential diagnosis of massive creatine kinase (CK) elevation. PATIENT, MATERIAL AND METHODS: Herein, we report on a 19-year-old Austrian male of African descent with a history of respiratory tract infections and whole-body pain. He further developed acute viral myositis and massive CK elevation up to 440,000 IU/L but without any signs of AKI. A literature search relating AVM, management and differential diagnosis of rhabdomyolysis was conducted in PubMed and UptoDate. RESULTS: A full panel of serological and autoimmune blood work-up including testing for human immunodeficiency virus (HIV), hepatitis, influenza A/B, Epstein-Barr virus (EBV), antinuclear antibodies (ANA) and autoantibodies against various extractable nuclear antigens (ENA) did not reveal evidence for viral originators or autoimmune diseases. This case indicates that in acute viral myositis associated with extreme CK elevation (>400,000 IU/L) AKI might be completely absent. Potential causes for this clinical phenotype, differential diagnosis and management are discussed.

Rhabdomyolysis and complement-once again, epithelial cells take center stage.

Rhabdomyolysis is frequently associated with kidney injury. Unfortunately, there are no specific treatments for this condition, and patient care primarily consists of supportive measures. In this edition of Kidney International, Boudhabhay et al. demonstrate that myoglobin released from injured skeletal muscle cells triggers tubulointerstitial complement activation. In a mouse model of the disease, interventions that scavenged free heme or that prevented complement activation ameliorated kidney injury, raising the possibility that these strategies may be effective treatments for the condition.

Fulminant Bacillus cereus food poisoning with fatal multi-organ failure.

This case represents a rare fulminant course of fried-rice associated food poisoning in an immunocompetent person due to pre-formed exotoxin produced by Bacillus cereus, with severe manifestations of sepsis, including multi-organ (hepatic, renal, cardiac, respiratory and neurological) failure, shock, metabolic acidosis, rhabdomyolysis and coagulopathy. Despite maximal supportive measures (continuous renal replacement therapy, plasmapheresis, N-acetylcysteine infusion and blood products, and broad-spectrum antimicrobials) and input from a multidisciplinary team (consisting of infectious diseases, intensive care, gastroenterology, surgery, toxicology, immunology and haematology), mortality resulted. This case is the first to use whole genome sequencing techniques to confirm the toxigenic potential of B. cereus It has important implications for food preparation and storage, particularly given its occurrence in home isolation during the COVID-19 pandemic.

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.