Adult-onset carnitine palmitoyl transferase II (CPT II) deficiency presenting with rhabdomyolysis and acute kidney injury

Metabolic myopathies are among the treatable causes of rhabdomyolysis and myoglobinuria. Carnitine palmitoyl transferase 2 (CPT II) deficiency is one of the most common causes of recurrent myoglobinuria in adults. It is an inherited disorder of fatty acid oxidation pathway, commonly associated with elevated acylcarnitine levels. In this case report, we present a 49-year-old male patient who developed acute kidney injury after rhabdomyolysis and was thus diagnosed with CPT2 deficiency after his first episode of rhabdomyolysis. Inborn errors of metabolism should be kept in mind in patients with rhabdomyolysis. Acylcarnitine profile may be normal in CPT II deficiency, even during an acute attack, and molecular genetic diagnostics should be applied if there is high index of clinical suspicion.

[Carnitin-Palmitoyl Transferase type 2 deficiency: a rare cause of acute renal failure due to rhabdomyolysis]

Fatty acid oxidation disorders are inborn errors of metabolism. One of the possible alterations involves the failure of the carnitin-based transport of long-chain fatty acids into the mitochondria, necessary for muscle metabolism in case of prolonged physical exertion. Three kinds of Carnitin-Palmitoyl Transferase type 2 (CPT2) deficiency have been described: a myopathic form, a severe infantile form and a neonatal form. The clinical picture is characterized by recurrent attacks of rhabdomyolysis, muscular pains and fatigue, secondary to a prolonged physical exercise and sometimes aggravated by intercurrent events. Rhabdomyolysis episodes are associated with a significant increase in creatine phosphokinase and myoglobinuria and may result in acute renal failure. Patients are usually asymptomatic during intercurrent periods. When acute renal failure from rhabdomyolysis arises after intense physical activity, it is therefore necessary to also investigate the presence of metabolic myopathies due to enzymatic deficiency.

An unusual case of gross myoglobinuria in a child following Russell's viper (Daboia russelii) envenomation

Overt myoglobinuria associated with myotoxicity is a classic feature of sea snake envenomation. Russell's viper bites usually result in coagulopathy, neurotoxicity and nephrotoxicity but rarely myotoxicity has been reported, especially in the Sri Lankan variety (Daboia russelii). All those studies have demonstrated mild degree myotoxicity with microscopic level myoglobinuria. We report what is probably the first case of gross myoglobinuria in a child following a Russell's viper bite with biochemical evidence of significant myotoxicity well beyond the levels that have been previously reported.

Heroin addiction and renal disease

In this paper, renal involvement secondary to other medical complications of heroin addiction is discussed. We review 12 published studies totalling 102 heroin addicts with renal disease. Of these, in only 40 patients could other discernible causes of renal disease be excluded. The existence of 40 reported cases of renal disease from a population of more than half a million is insufficient data upon which to postulate the existence of a type of renal disease unique to heroin addicts.

Clinical features and new molecular findings in muscle phosphofructokinase deficiency (GSD type VII)

Muscle phosphofructokinase (PFKM) deficiency, a rare disorder of glycogen metabolism also known as glycogen storage disease type VII (GSDVII), is characterized by exercise intolerance, myalgias, cramps and episodic myoglobinuria associated with compensated hemolytic anaemia and hyperuricemia. We studied five patients with PFKM deficiency coming from different Italian regions. All probands showed exercise intolerance, hyperCKemia, cramps and myoglobinuria. One patient had a mild hypertrophic cardiomyopathy. Biochemical studies revealed residual PFK activity ranging from 1 to 5%. Molecular genetic analysis identified four novel mutations in the PFKM gene. In our series of patients, clinical and laboratory features were similar in all but one patient, who had an unusual phenotype characterized by 25 ears disease history, high CK levels, hypertrophic cardiomyopathy with paroxysmal atrial fibrillation without fixed muscle weakness.

[Treatment for crush syndrome of extremities with antioxidants]

OBJECTIVE

To study the clinical therapeutic effect of antioxidants assistant treatment of extremities crush syndrome (CS)in order to find new therapy.

METHODS

Twenty-one male patients (aged from 24 to 48 years, mean 36 years) were treated with the next antioxidants in early stage: (1) 20% Mannitol 250 ml intravenous drip in 30 minutes (one time per 6 to 8 h). (2) Sodium aescinate 20 mg, Salvia Miltiorrhiza 20 ml were dissolved respectively in isotonic saline or 5% glucose 200 ml and dripped by intravenous drip (50 to 60 drips per minute). The drugs were used for 5 to 7 days (one time per day). Basifying urine, keeping the nagative liquid banlance and electrolyte banlance, preventing infection and hold out treatment were done. When the pressure of muscular osteofascial compartment was more than 30 mmHg, deep fasia was cut to decompress timely and the above-mentioned drugs were continuously applied for patients.

RESULTS

Myoglobin urine of 21 cases died out after 2 to 3 days, of them, 13 cases were performed to decompress. After open decompression, 2 cases suffered from amputation because of long time of ischemia, 2 cases took place slight dysfunction of lower limbs, one hand had ischemia muscular contracture in 1 case and one foot down-vertical in 1 case. After followed-up of 8 months to 1 year, according to the function standard, the result were excellent in 8 cases, good in 7 cases, fair in 2 cases, poor in 4 cases. The excellent and good rate was about 71.4% (15/21).

CONCLUSION

After extremities crushed for long time, application of antioxidents as early as possible can decrease significantly the incidence and invalidity rate of CS.

Successful transplantation of kidneys from a donor with myoglobinuric acute renal failure

The shortage of donor organs is reflected in the growing number of patients on the waiting list for kidney transplantation worldwide. It seems to be sensible to expand the scarce donor pool by the cautious use of extended donor criteria. Kidneys from a 21-year-old deceased donor road traffic accident victim who suffered acute renal failure (ARF) due to myolysis were transplanted. Both transplantations were successful after an initial period of delayed graft function. Therefore, kidneys from deceased donors with ARF should not be excluded for transplantation in general.

High Body Mass Index in Muscular Patients and Flank Position Are Risk Factors for Rhabdomyolysis: Case Report after Laparoscopic Live-Donor Nephrectomy

BACKGROUND AND PURPOSE

Rhabdomyolysis is well known after traumatic crush injuries or ischemia involving muscles. Postoperatively, it most likely is secondary to surgical positioning and patient muscle mass. We report a case after laparoscopic live-donor nephrectomy.

CASE REPORT

A muscular 35-year-old man underwent elective left laparoscopic live-donor nephrectomy in a 70 degrees flank position with four ports. He was in the right-side lying position with hip flexion (flank position) for approximately 4 hours. A kidney bridge had been placed between the iliac crest and the rib cage. Postoperatively, the patient had light-pinkish urine and low urine output. There was marked induration of the buttocks and significant pedal and scrotal edema. With judicious use of alkalinization and diuretics, the patient did not require dialysis, and renal function returned to base level by postoperative day 20. The recipient of the kidney had a normal postoperative course.

CONCLUSION

Rhabdomyolysis is a syndrome of muscle necrosis and release of intracellular components into the circulation. Acute renal failure secondary to myoglobinuria is a common complication. We currently use little flexion of the table during donor nephrectomy and bring the table to a neutral position immediately after kidney retrieval. Postoperatively, one needs a high index of suspicion for rhabdomyolysis to avoid or at least promptly recognize this rare but potentially serious condition after any operation lasting >or=4 hours.

[Acute renal failure following convulsion-induced myoglobinuria]

A 75-year-old female with history of putamenal hemorrhage 8 years earlier was admitted to our hospital with generalized convulsion lasting 40 minutes. Convulsion responded quickly to intravenous administration of diazepam, but deep coma persisted thereafter. Although renal function had normalized before this episode, urinary output was immediately estimated to be limited. Drip-infusion of Ringer's solution and the combined administration of furosemide and mannitol were started. The laboratory values 6 hours after admission demonstrated extremely elevated GOT, GPT, CPK, BUN and Cr levels, suggesting rhabdomyolysis. Urinalysis confirmed myoglobinuria. Despite massive diuretic therapy, renal dysfunction did not improve and she died on hospital day 4. The treatment outcome was probably influenced by her general condition of dehydration and acidosis at admission, as well as muscle damage caused by convulsion. Myoglobinuria can induce life-threatening renal failure, and may be caused by convulsion.

Muscle cell injury, haemolysis and dark urine in children with falciparum malaria in Papua New Guinea

During a prospective study of red cell variants and severe malaria in children, a surprising observation was the occurrence of dark urine. Children were grouped according to urine findings: 22 had dark urine that contained a haem protein (Group I), 93 had urine of normal colour that contained a haem protein (Group II) and 236 had normal urine (Group III). To investigate the cause of dark urine, haemolysis and muscle cell injury were assessed. Intravascular haemolysis was greater in Group I than in Groups II and III. However, anaemia was more severe in Group III and is likely to have resulted mainly from extravascular haemolysis. Median plasma myoglobin concentrations were greater in Groups I and II than Group III (P = 0.00060). Plasma myoglobin was greater in children with cerebral malaria, hyperlactataemia and those who died but was not associated with acidosis. Urine myoglobin was greater in Group I than Groups II and III (P = 0.00054). It is likely that both haemoglobin and myoglobin contributed to dark urine. The association between muscle cell injury and coma suggests sequestration of parasitized red cells as a common underlying pathology. In malaria, hyperlactataemia may result directly from breakdown of muscle protein as well as tissue hypoxia.

The prevalence of false-positive cardiac troponin I in ED patients with rhabdomyolysis

OBJECTIVE

Cardiac troponin I (cTnI) is considered the most specific marker of cardiac muscle injury. We encountered several patients with rhabdomyolysis and elevated cTnI, although they did not otherwise have evidence of cardiac injury. We determined the prevalence of false-positive cTnI in emergency department (ED) patients with rhabdomyolysis.

METHODS

We conducted a retrospective cohort study of ED patients admitted with a diagnosis of rhabdomyolysis. Patients were included in the study if they had a serum creatine kinase (CK) of 1000 U/L or greater and at least one serum cTnI determination. Patients with positive cTnI were considered true positives if they had either electrocardiography (EKG) or echocardiography abnormalities; false positives if both the EKG and the echocardiography were considered normal; or indeterminate if they did not have both an EKG and an echocardiogram. The primary outcome of the study was the prevalence of false-positive cTnI. Secondary outcomes included risk stratification by cocaine use, myoglobinuria, and renal failure and correlation of peak CK and troponin levels.

RESULTS

One hundred nine patients were included in the final analysis; 55 (50%) patients had a positive cTnI. Of the 55 patients with positive cTnI, 32 (58%) were true positives, 18 (33%) were false positives, and 5 (9%) were indeterminate. The prevalence of false-positive cTnI was 17% (18/109, 95% confidence interval 0.10-0.25). There was no association between false-positive cTnI and cocaine use, renal failure, or myoglobinuria. There was poor correlation between peak CK and peak cTnI levels (r = -.08, 95% confidence interval -0.34 to 0.19).

CONCLUSION

The prevalence of false-positive cTnI in ED patients with rhabdomyolysis is 17%.

Oral alkalinizing solution as a potential prophylaxis against myoglobinuric acute renal failure: preliminary data from healthy volunteers

BACKGROUND

Acute renal failure (ARF) secondary to crush injury is one of the leading causes of hospitalization and death in survivors of massive disasters. The standard therapy for crush injury, intravenous (i.v.) hydration and alkalinization of urine, is often not feasible after a mass disaster; therefore, oral rehydration and urinary alkalinization may be a useful substitute.

METHODS

We developed and evaluated an oral alkalinizing solution (OAS) to induce alkaline diuresis. We enrolled 12 volunteer Iranian Army recruits (mean age 19.4+/-0.8 years) who drank an average of 650 ml of OAS for 12 h. We checked the volume and pH of their urine every hour, and measured venous blood gas and electrolytes at 6, 12 and 15 h.

RESULTS

All subjects tolerated the OAS without adverse events, and had active diuresis (>200 ml/h) after an average of 3.0+/-0.7 h. Their urine became alkaline (pH>7.0) within an average of 3.25+/-0.8 h. There were no significant electrolyte abnormalities.

CONCLUSIONS

OAS seems to be a safe and promising means of inducing alkaline diuresis. It may be a feasible alternative to i.v. hydration to prevent ARF secondary to crush injuries in the context of mass disasters where i.v. hydration is not possible. A dose of 10 ml/kg/h may be the correct amount to induce alkaline diuresis within the first 12 h after crush injuries. The use of OAS for this purpose should be evaluated further.

Muscle carnitine palmitoyltransferase II deficiency: clinical and molecular genetic features and diagnostic aspects

Muscle carnitine palmitoyltransferase (CPT) II deficiency is an autosomal recessive disorder of fatty acid oxidation characterized by attacks of myalgia and myoglobinuria. This review summarizes the clinical features of this disease, analyzing data of 28 patients with biochemically and genetically confirmed CPT II deficiency. The review shows that exercise-induced myalgia is the most frequent symptom, whereas myoglobinuria, known as the clinical hallmark, is missing in 21% of the patients. Typically, myalgia starts in childhood, whereas attacks with myoglobinuria mostly emerge in adolescence or early adulthood. However, there are also patients with only myalgia, patients with attacks triggered by factors other than exercise, and patients with late-onset disease. Molecular or biochemical analysis is necessary for diagnosis, since no myopathologic hallmark exists. For screening patients, analysis of not only the common S113L mutation but also the P50H and Q413fs-F448L mutations is recommended. The phenotype of muscle CPT II deficiency might be influenced by the underlying mutation, and patients with a truncating mutation on 1 allele might be affected more severely.

[Nation-wide survey on muscle glycogen storage disease (MGSDs) and comparison with our experiences in diagnosis of MGSDs]

To clarify the actual frequency of each type of muscle glycogen storage diseases (MGSDs) in Japan, we performed nation-wide survey in 2001. We compared the results with our diagnostic experiences at Hamamatu City Medical Center for Developmental Medicine. The majority (approximately 80%) of the MGSDs consisted of type II, V and III in Japan. In our experiences, most of the patients were diagnosed by the assays of glycolytic enzyme activities using biopsied skeletal muscles. However, the biochemical diagnoses of MGSDs type II, III, IV, and IX can be made using blood samples. Additionally, common genetic mutation (708/709 delTTC) of myophosphorylase gene has been found approximately in 50% of the Japanese patients with MGSDs type V. Therefore, approximately 70% of the MGSDs may be diagnosed by biochemical and genetic analysis using blood samples. Additional survey on McArdle's disease showed that the onset of muscle symptoms in McArdle's disease were variable, however, fixed muscular symptoms such as muscle weakness and muscle atrophy were present in 45% of patients.

[Myoglobinuric acute renal failure secondary to convulsion]

Myoglobinuric acute renal failure secondary to convulsion.

Alpha-sarcoglycan deficiency featuring exercise intolerance and myoglobinuria

An 8-year-old boy was referred for recent onset of easy fatigue. He showed hyperCKemia and mild scapular winging. Muscle biopsy on the quadriceps muscle demonstrated slight fibre size variability. Dystrophin was normally distributed, carnitine palmitoyl transferase and glycolytic enzymes had normal activities. In the following years the patient developed exercise intolerance and myoglobinuria. Immunohistochemistry showed marked reduction of alpha-sarcoglycan, confirmed by Western blotting. Molecular analysis revealed compound heterozygosity with Arg284Cys and Glu137Lys substitutions, corresponding to nucleotide changes C850 T and G409 A in the gene. At present the patient, 20 years old, shows mild proximal weakness with prominent involvement of the paraspinal muscles, dorsal kyphosis and lumbar hyperlordosis. Exercise intolerance and myoglobinuria, already described in Becker muscular dystrophy, should be also considered among the possible presentations of sarcoglycan deficiencies.

Rhabdomyolysis following status asthmaticus

A 15-year-old Chinese boy developed rhabdomyolysis with myoglobinuria and marked elevation of serum creatine phosphokinase following a prolonged and severe attack of asthma. He recovered after vigorous hydration and supportive treatment. Clinicians should be aware of this potentially fatal, albeit rare, complication of status asthmaticus.

Myoglobinuria: evaluation of methods in the clinical diagnosis acute renal failure

Patients with red--brown urine which may be a sign of myoglobinuria, can develop acute renal failure. We assayed serum creatinine, blood urea nitrogen (BUN) and creatine kinase activity in a total of 33 patients of equal groups, A (automobile accident), B (trauma) and C (undergoing rhabdomyolysis). In addition we tested 132 urine samples for the presence of myoglobin using a dipstick assay. Only five patients in group A showed any sign of myoglobinuria with increased creatine kinase activity upto 7 times the normal value but their serum creatinine level and BUN were within the normal range. In contrast, all 22 patients in group B and C showed myoglobinuria and above normal concentrations of serum creatinine and BUN, with significantly increased (p < 0.0001) creatine kinase activity upto 150 times the normal range. Four of the most seriously ill patients in group C developed acute renal failure. Supplementation of routine determinations of serum creatinine and BUN and serum creatine kinase activity with a rapid test for myoglobinuria provides an extra indication of impending renal dysfunction. It may be beneficial in the emergency management of these patients.

Absence of myoglobinuria in acute psychotic patients with marked elevation in serum creatine phosphokinase level

Elevated levels of serum creatine phosphokinase, muscular type (CK(MM)) are caused primarily by diseased muscle fiber. Acute psychoses are often associated with a marked increase in serum CK(MM) levels, though the reason remains obscure. Since striated muscle damage is also associated with pigmenturia and myoglobinuria, we sought to determine whether the markedly high serum CK level of acute psychosis reflects skeletal muscle damage by evaluating urinary myoglobin in affected patients. Baseline serum CK was measured on admission in 713 consecutive acute psychotic inpatients (BPRS> or =40). Those showing a serum CK levels above 1000 IU/l on the first 2 days of hospitalization underwent urine collection for myoglobin testing. Patients with physical trauma or medical conditions known to cause CKemia were excluded. Twenty-five patients were eligible for the study. In no case did myoglobinuria or pigmenturia accompany the marked CKemia. There is an unexpected dissociation between the robust increase in the serum CK(MM) levels and the absence of myoglobinuria in acute psychosis. Our negative finding may indicate that the serum CK threshold for myoglobinuria is very high (above 10000 IU/l). Alternatively, psychosis-associated CKemia may be related to an unknown, nontraumatic, pathophysiological mechanism(s).