Rhabdomyolysis

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Contents 1 More Specific Terms 2 Etiology 3 Clinical-manifestations 4 Laboratory 5 Complications 6 Management 7 More General Terms 8 Additional Terms 9 References

More Specific Terms

• acute recurrent rhabdomyolysis; autosomal recessive acute recurrent myoglobinuria (ARARM)

Etiology

• trauma:

• crush injuries
• long lie syndrome
• prolonged surgery
• burns

• immobilization
• strenuous exercise

• especially untrained persons
• sickle cell or sickle cell trait

• heat stroke
• seizures
• inflammatory myopathy

• polymyositis/dermatomyositis
• inclusion body myositis

• alcoholic coma
• ischemia
• pharmaceutical agents

• cocaine
• fibrates: clofibrate
• HMG CoA reductase inhibitors ( statins)

• exercise &/or exertion exacerbates
• concurrent use of colchicine increases risk

• drug overdose
• antipsychotics

• neuroleptic malignant syndrome

• anesthetics

• malignant hyperthermia
• propofol

• SSRI
• zidovudine
• lithium carbonate
• antihistamines
• daptomycin
• valproic acid
• amphetamines, Ecstasy

• dietary supplements

• ephedrine
• creatine

• toxins

• multiple bee stings or wasp stings
• snake bite
• spider bite
• toxic shock syndrome
• carbon monoxide poisoning

• infections

• viral: HIV, coxsackievirus, cytomegalovirus, Epstein-Barr virus, varicella, dengue, Herpes simplex, parainfluenza virus, adenovirus, echovirus
• bacterial: Staphylococcus, Salmonella, Clostridium, Pneumococcus, Legionella, Leptospira, Coxiella burnetti ( Q fever), Rickettsia rickettsii ( Rocky Mountain spotted fever)
• malaria

• endocrinopathies

• hypothyroidism
• hyperthyroidism
• pheochromocytoma

• electrolyte abnormalities

• K+ or phosphate depletion

Clinical-manifestations

• muscle tenderness
• pressure necrosis of skin may occur
• signs of multiple trauma or crush injury may be present
• increased muscle tone

Laboratory

• marked elevation of serum creatine kinase
• elevation of serum creatinine

• decreased BUN/creatinine ratio

• serum calcium: hypocalcemia during acute phase of acute tubular necrosis ( ATN)
• hypercalcemia during the diuretic phase of ATN
• serum K+: hyperkalemia
• serum uric acid: hyperuricemia
• serum phosphate: hyperphosphatemia
• urinalysis:

• urine may be grossly positive for blood without RBC in sediment
• myoglobinuria

• elevated serum LDH, serum AST, serum ALT
• anion gap metabolic acidosis
• prolonged PT, PTT
• complete blood count: thrombocytopenia

Complications

• compartment syndrome may develop ater fluid resuscitation with worsening edema

Management

• aggressive volume expansion
• osmotic diuresis with mannitol widely used in conjunction with alkaline diuresis

• IV bicarbonate 2-3 ampules/ liter D5W to maintain urine pH > 6.5

• no convincing evidence that alkaline diuresis if more effective than saline diuresis
• continue aggressive management until urine myoglobin is negative

More General Terms

• muscular disease; myopathy

Additional Terms

• acute tubular necrosis (ATN)
• HCO3- (bicarbonate)
• mannitol (Osmitrol, Resectisol)
• myoglobinuria

References

1. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 265
2. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 598
3. Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004 Epstein M, J Am Soc Nephrol 7:1106, 1996
4. Warren JD et al, Rhabdomyolysis: a review. Muscle Nerve 2002, 1:427 PMID: [1]
5. Medical Knowledge Self Assessment Program (MKSAP) 15, American College of Physicians, Philadelphia 2009
6. National Guideline Clearinghouse Rhabdomyolysis Finnish Medical Society Duodecim ngc-guideline: [2]

rhabdomyolysis