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.

Value and Use of Urinalysis for Myoglobinuria.

CONTEXT.­: Urine myoglobin testing is primarily indicated for diagnosis and risk assessment of kidney injury in patients with rhabdomyolysis. However, its utility is limited by a lack of rapid and reliable results. Myoglobin reacts positively for blood by urine dipstick, which can serve as an indicator of myoglobinuria. OBJECTIVE.­: To evaluate the performance and value of blood and red cell measurements by urinalysis as a surrogate test for myoglobinuria in routine clinical practice. DESIGN.­: This study is a retrospective observational study involving analysis of hemoglobin and red blood cell results by urinalysis in patients tested for urine myoglobin. RESULTS.­: A total of 13 139 urine myoglobin results from 88 Veterans Affairs facilities during a 15-year period ending in October 2014 were evaluated. Among methods used by each laboratory, qualitative urine myoglobin tests declined from 25 of 53 (47.1%) in 2000 to 5 of 77 (6.4%) in 2013. Of 7311 tests (55.6%) performed by quantitative methods with concomitant urinalysis, 3915 (53.5%) showed negative to trace blood results, of which myoglobin was 1000 µg/L or greater in 17 (0.4%). Among 1875 (25.5%) with 3+ (large) blood results, urine myoglobin was ≥1000 µg/L in 273 of 1533 (17.8%) with hematuria (≥5 red blood cells per microliter) and 109 of 342 (31.9%) without hematuria. CONCLUSIONS.­: Urinalysis results reliably predicted the absence of myoglobinuria and could be used to avert overtesting for urine myoglobin while also providing useful diagnostic information when urine myoglobin test results are not immediately available.

Acute Kidney Injury Secondary to Rhabdomyolysis: A Rare Presentation of Chikungunya Fever.

Chikungunya fever is an arthropod-borne viral illness characterised by high grade fever and incapacitating arthralgias. It is considered benign; however, in the recent outbreaks, several complications have been reported worldwide. We report a case of male patient with Chikungunya fever, possibly contracted from infected mosquitoes endemic in Karachi, Pakistan. The clinical presentation included fever, myalgias and anuria. Investigations revealed renal failure and significantly raised creatinine phosphokinase (CPK), suggesting rhabdomyolysis to be the cause of acute kidney injury (AKI). Rhabdomyolysisis likely occurred due to virus-induced myositis; a rare presentation of Chikungunya fever. The patient gradually recovered from renal failure following supportive care and renal replacement therapy.

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.

Cluster of exertional rhabdomyolysis in three young women.

Three young women, aged 18-24 years, presented to general practice with signs and symptoms of exertional rhabdomyolysis in 2016. All attended the same gym and had undertaken an intensive physical workout. Presenting symptoms were severe muscle pain and swelling, significantly reduced range of motion in affected muscles and, in two cases, dark-coloured urine. One case had presented to the out-of-hours service 4 months previously with similar symptoms but rhabdomyolysis was not considered, although retrospective history taking suggests that was the likely diagnosis. All three women were admitted to hospital, treated with intravenous fluids and discharged between 1 and 6 days later. All made a full recovery with no renal sequelae. The cases were questioned about potential risk factors, and the only commonality was unaccustomed strenuous exercise.

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.

Clinico-pathological findings in a striped dolphin (Stenella coeruleoalba) affected by rhabdomyolysis and myoglobinuric nephrosis (capture myopathy).

A striped dolphin (Stenella coeruleoalba) calf stranded alive because of a Salter-Harris fracture type 1 of a caudal vertebra and remained in a provisional rehabilitation facility for 3 days where the fracture stabilization was attempted, but he died the day after bandaging. Serum and urine samples were collected during hospitalization (days 1, 2 and 3 serum and day 2 urine). Serum analysis showed increased urea, alanine transaminase, aspartate transaminase, and serum amyloid A values, while creatinine was below the lower limit. Urine analysis showed urinary protein-to-creatinine ratio of 5.3 with glomerular proteinuria. Postmortem analyses demonstrated a severe rhabdomyolysis and myoglobinuric nephrosis, suggestive of capture myopathy syndrome. We report, for the first time, the clinico-pathological changes during this condition in a striped dolphin.

An ignored cause of red urine in children: rhabdomyolysis due to carnitine palmitoyltransferase II (CPT-II) deficiency.

Carnitine palmitoyltransferase II (CPT-II) deficiency is an autosomal recessively inherited disorder involving the ß-oxidation of long-chain fatty acids, which leads to rhabdomyolysis and subsequent acute renal failure. The clinical phenotype varies from a severe infantile form to a milder muscle form. Here, we report a 9-year-old boy referred to our hospital for the investigation of hematuria with a 2-day history of dark urine and malaise. As no erythrocytes in the microscopic examination of the urine and hemoglobinuria were present, myoglobinuria due to rhabdomyolysis was the most probable cause of dark urine. After excluding the other causes of rhabdomyolysis, with the help of metabolic investigations, the patient was suspected to have CPT-II deficiency, the most common cause of metabolic rhabdomyolysis. Our aim in presenting this case is to emphasize considering rhabdomyolysis in the differential diagnosis of dark urine in order to prevent recurrent rhabdomyolysis and renal injury.

A Klebsiella pneumoniae liver abscess presenting with myasthenia and tea-colored urine: A case report and review of 77 cases of bacterial rhabdomyolysis.

RATIONALE: Rhabdomyolysis is a well-known syndrome in clinical practice, although rhabdomyolysis caused by a liver abscess is rarely reported and the patient may lack symptoms that are associated with a primary site of infection. Early recognition of this possibility is needed to avoid diagnostic delay and facilitate treatment. We report the case of a 71-year-old woman with a Klebsiella pneumoniae (KP) pyogenic liver abscess who presented with myasthenia and tea-colored urine and also review the 77 reported cases of bacterial rhabdomyolysis. PATIENT CONCERNS: The patient was 71 years old and presenting with a 7-day history of myasthenia and a 3-day history of tea-colored urine, but without fever or abdominal pain. DIAGNOSES: Laboratory testing in our case revealed rhabdomyolysis, and blood culture revealed KP. Abdominal ultrasonography revealed a hypoechoic enclosed mass, and computed tomography (CT) revealed an enclosed low-density mass (8.3 × 6.6 × 6.1 cm). The main diagnoses were a pyogenic liver abscess with rhabdomyolysis. INTERVENTIONS: Empirically intravenous piperacillin-sulbactam and intravenous potassium treatment, as well as fluid infusions and other supportive treatments were provided after admission. After the diagnosis was confirmed and susceptibility test results were available, we adjusted the antibiotics to cefoperazone and sulbactam, which were maintained for 6 weeks. OUTCOMES: The patient's symptoms relieved and the abnormal laboratory parameters corrected. Follow-up abdominal ultrasonography at 24 months after her discharge revealed that the abscess had disappeared. LESSONS: Early recognition and careful consideration of the underlying cause of rhabdomyolysis are critical to improving the patient's prognosis. Thus, physicians should carefully consider the underlying cause in elderly patients who present with rhabdomyolysis, as they may lack symptoms of a primary infection.

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.

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.

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.

Rhabdomyolysis and exercise-associated hyponatremia in ultra-bikers and ultra-runners.

BACKGROUND: Exercise-associated hyponatremia (EAH), rhabdomyolysis and renal failure appear to be a unique problem in ultra-endurance racers. METHODS: We investigated the combined occurrence of EAH and rhabdomyolysis in seven different ultra-endurance races and disciplines (i.e. multi-stage mountain biking, 24-h mountain biking, 24-h ultra-running and 100-km ultra-running). RESULTS: Two (15.4%) ultra-runners (man and woman) from hyponatremic ultra-athletes (n = 13) and four (4%) ultra-runners (four men) from the normonatremic group (n = 100) showed rhabdomyolysis following elevated blood creatine kinase (CK) levels > 10,000 U/L without the development of renal failure and the necessity of a medical treatment. Post-race creatine kinase, plasma and urine creatinine significantly increased, while plasma [Na(+)] and creatine clearance decreased in hyponatremic and normonatremic athletes, respectively. The percentage increase of CK was higher in the hyponatremic compared to the normonatremic group (P < 0.05). Post-race CK levels were higher in ultra-runners compared to mountain bikers (P < 0.01), in faster normonatremic (P < 0.05) and older and more experienced hyponatremic ultra-athletes (P < 0.05). In all finishers, pre-race plasma [K(+)] was related to post-race CK (P < 0.05). CONCLUSIONS: Hyponatremic ultra-athletes tended to develop exercise-induced rhabdomyolysis more frequently than normonatremic ultra-athletes. Ultra-runners tended to develop rhabdomyolysis more frequently than mountain bikers. We found no association between post-race plasma [Na(+)] and CK concentration in both hypo- and normonatremic ultra-athletes.