Rhabdomyolysis in diabetic emergencies

Rhabdomyolysis (RM) is a clinical and laboratory syndrome resulting from leakage of muscle cell contents into plasma. The increased plasma concentration of the substances released such as creatine kinase (CK) permits the clinician to diagnose this syndrome. Non-traumatic RM has occasionally been reported in patients with diabetic decompensation. We encountered about 44 cases of RM in 265 diabetic emergencies (including DKA or hyperosmolar, or both) during the period from 1984-1 to 1990-6, diagnosed based on (1) serum creatine kinase (CK) > 1000 IU/l and (2) the absence of acute myocardial infarction, stroke and end-stage renal disease. On admission, those who presented with RM had significantly higher concentration of blood urine nitrogen (BUN) (83.3 +/- 5.9 vs. 58.8 +/- 2.4 mg/dl, P < 0.05), creatine (4.45 +/- 0.4 vs. 2.97 +/- 0.1 mg/dl, P < 0.05) and serum osmolarity (386.5 +/- 5.2 vs. 351.6 +/- 2.4 mOsm/kg, P < 0.05). The mortality within 1 week of diabetic emergencies (38.5% for DKA, 35.5% for HHNK) was higher in patients with RM than those without RM (9.7% for DKA, 26.7% for HHNK). There was a correlation (r = 0.49, P < 0.05) between the levels of serum creatinine and CK in patients with RM.(ABSTRACT TRUNCATED AT 250 WORDS)

Traumatic rhabdomyolysis from severe beating--experience of volume diuresis in 200 patients

Fluid loading with balanced salt solution (BSS) was carried out in 200 patients with extensive soft tissue injuries from severe beatings. Urinary volume and dipstick specific gravity testing were used to monitor renal function with administration of furosemide for persistent oliguria. Acute intrinsic renal failure (AIRF) occurred in 21 patients (10.5%) and five patients died (2.5%); two of hyperkalemia, two of sepsis and one of multiple organ failure. Significantly increased rates of AIRF and death were associated with injury-admission intervals of more than 12 hours, severe metabolic acidosis, low initial hemoglobin, heavy pigmenturia, and high serum creatine kinase (CK) levels. An increased serum creatinine/BUN ratio was noted in four of the five patients who died. An average of 7.5 L fluids was needed in non-AIRF patients to achieve adequate diuresis with a mean positive fluid balance of 4.7 L. No patient without pigmenturia developed AIRF. Balanced salt solution volume diuresis supplemented with furosemide as necessary appears to be safe and effective in preventing AIRF in soft tissue injuries sustained in beatings.

Early management and physiologic changes in crush syndrome

Crush syndrome is a predictable sequence of events following crush injury. Significant soft tissue injury predisposes the patient to multiple complications including: hypovolemia, compartment syndrome, rhabdomyolysis, electrolyte and acidbase imbalances, coagulopathy, and renal failure. This article identifies those physiologic changes and the associated critical care management of the patient. Critical care management should be aimed at minimizing further complications through accurate assessment and therapeutic interventions.

[Exertion-related disorders in body temperature regulation in 8 participants in the Dam-to-Dam run 1993]

In eight recreational runners (seven men and one woman, aged 16 to 50 years) participating in a 16 kilometer run, disturbances in thermoregulation were diagnosed. Six experienced sudden collapse without any prodromal signs, two were exhausted and had muscle spasms. Heat exhaustion was diagnosed in four runners, exertion-related hyperthermia in three and exertion-related heat stroke in one. As a complication the latter patient developed rhabdomyolysis with low grade intravascular coagulation and acute renal insufficiency. The most important therapy consists of cooling the patient, the most important preventive measures are wearing light clothing and drinking regularly during the run.

[Rhabdomyolysis in community-acquired pneumonia]

Several cases of rhabdomyolysis associated with pneumococcal pneumonia have been recently reported. However their significance have been poorly investigated. In this retrospective study, we have compared the patients admitted in ICU for acute community-acquired pneumonia with or without rhabdomyolysis (group A: CPK > or = 1,000 Ul/l and group B: CPK < 1,000 Ul/l). Among the 41 patients of the study, 12 (29%) belonged to the group A (CPK = 1,852 +/- 535 Ul/l) and 29 (71%) to group B (CPK = 190 +/- 35 Ul/l). Neither the initial severity, nor renal impairment were different in the two groups. However the mortality was significantly higher in the group A (4/12) than in group B (2/29) (P < 0.05). In this study, pneumonia is frequently associated with rhabdomyolysis, without etiologic significance. In patients with pneumonia, rhabdomyolysis seems to be a bad prognostic indice unrelated with renal impairment.

Exercise-induced muscle damage

Muscular overuse is associated with structural damage of the contractile elements and reflected in delayed onset muscle soreness (DOMS). Mechanical stress is supposed to be the major contributing factor for inducing muscle damage. The initial damage is followed by an inflammatory response and eventually by regeneration. Calcium is assumed to play an important role in triggering the inflammatory changes. Biopsy data in man indicate that the inflammatory changes in humans do not parallel the soreness ratings, leaving the delayed onset of muscle soreness unexplained. It is a well known phenomenon that one bout of eccentric exercise has a long lasting protective effect against damage induced by a second bout of exercise. Experimental evidence suggests that this adaptation can partly be attributed to an increase in connective tissue. Plasma CK activity has widely been used as a marker for the amount of muscle damage. It has been shown that gender differences in exercise-induced CK release are caused by sex hormones dependent differences in sarcolemmal permeability. Plasma CK activity does not necessarily reflect the amount of structural damage.

[Neuromuscular disorders of the extremities after heroin-induced rhabdomyolysis]

We describe four patients with neuromuscular deficiencies after heroin-induced rhabdomyolysis. Such deficiencies have a good prognosis, but all our patients continued to have sequelae. In an emergency situation one should always consider fasciotomy for acute compartment syndromes. Two of our patients developed a Volkmann's ischemic contracture after acute compartment syndromes. The other two had deficiencies from compression neuropathies. We observed functional restitution over a period of one to two years. Physiotherapy and orthopaedic aids are important in the rehabilitation of these patients. However, the main problem is still their drug addiction.

Rhabdomyolysis: a comprehensive guide

Rhabdomyolysis is a clinical syndrome that results from the release of skeletal muscle cell contents, specifically myoglobin, into the plasma. While the precise pathogenesis of rhabdomyolysis is not clearly understood, rhabdomyolysis has been implicated as a major cause of acute renal failure. This article will serve as a comprehensive guide for nephrology nurses. A partial review of the literature, pathophysiology/etiologic factors, diagnosis, clinical presentation, and nursing interventions/treatment will be provided.

Glycerol-induced augmentation of sensitivity to endotoxin in rats

Combined sepsis and rhabdomyolysis result in a mortality rate much higher than that caused by each process alone. An analogous rat model is obtained by simultaneous i.p. administration of a nonlethal dose of lipopolysaccharide (LPS 0.025 mg/100 g) and a nonlethal i.m. injection of glycerol (1 ml/100 g). The aim of this study was to determine the factors contributing to the high mortality rate in this rat model. The factors examined include: Dehydration, plasma volume expansion, 'immunization' to glycerol, induction of LPS tolerance and the effect of free radicals formed in this model. Neither dehydration nor volume expansion affected mortality. 'Immunization' with glycerol was also not effective. In contradistinction, tolerance to LPS achieved by a daily injection with gradual increasing doses of LPS (from 0.05 mg/100 g to 1 mg/100 g) for 6 days reduced the mortality rate by 60% (P < 0.001). Moreover, decreasing free radical activity using the natural antioxidant (NAO) (5 mg/100 g) reduced mortality rates by 50%. A different antioxidant, dimethylthiourea (DMTU) (50 mg/100 g) failed to reduce mortality rates. This study suggests that the synergism between glycerol and LPS is apparently due to an increase in the rats' sensitivity to endotoxin following glycerol injection. However, endotoxin apparently does not enhance sensitivity to glycerol in the rat. The new antioxidant NAO significantly reduced the high mortality rate.

Rhabdomyolysis. A primer for the orthopaedist

Orthopaedic surgeons may be confronted with a variety of medical problems that demand recognition and treatment. These may range in severity from a mild case of rheumatoid arthritis to a life-threatening pulmonary embolism. Rhabdomyolysis is a serious problem that must be recognized early to avoid grave renal consequences. This disorder is characterized by significant muscle injury giving rise to nephrotoxic breakdown products in the bloodstream. As many as 33% of these patients will suffer acute renal failure. Many orthopaedic patients may be at high risk for rhabdomyolysis, and the orthopaedic surgeon should be familiar with its diagnosis and treatment.

Water intoxication in a schizophrenic patient with rhabdomyolysis

We report a case of water intoxication in a 54-year-old female schizophrenic patient with rhabdomyolysis. She had been admitted to a mental hospital, and treated with spiperone 6 mg daily. On August 3, 1992, the coma following a convulsion occurred. Laboratory data initially showed marked hyponatremia and hypochloremia with decreased serum potassium, and a gradual increase in serum creatine phosphokinase (CPK). The elevation in serum CPK with marked hyponatremia observed in the present patient was probably caused by excessive drinking of water. In this patient, the CPK elevation revealed the rhabdomyolysis.

Rhabdomyolysis: a review of the literature

Rhabdomyolysis (lysis of skeletal muscle cells) is a potentially lethal syndrome with a broad spectrum of clinical and biochemical findings. Myalgia, pigmenturia and elevated activity of serum creatine kinase are the common features. Fulminant rhabdomyolysis may be associated with severe metabolic disturbances and involvement of other organ systems. Cardiac arrest, compartment syndrome and acute renal failure are the major complications. The extent of the life-threatening complications of rhabdomyolysis strongly depends on early diagnosis and adequate therapy. As the repair mechanism of striated muscle functions very well, the prognosis of adequately treated rhabdomyolysis is excellent. This article reviews the present state of knowledge of clinical and biochemical diagnosis of rhabdomyolysis, the pathophysiologic background, the classification and the etiological provocative factors.

Massive myocardial calcification of right and left ventricles following acute myocarditis complicated with rhabdomyolysis-induced acute renal failure

A 26-year-old man was admitted with a high fever, oliguria, skeletal muscle weakness, and cardiogenic shock which led to a diagnosis of acute myocarditis and acute rhabdomyolysis. During treatment with hemodialysis and calcium supplementation, because of severe hypocalcemia, a massive calcification of both right and left ventricular myocardium gradually became apparent with repeated computed tomographic (CT) examinations. Technetium-99m scannings more clearly delineated the markedly accumulated calcium in the myocardium, while significant activity was not detected in other soft tissues. Histopathological examinations by myocardial biopsy revealed a large amount of fibrosis and calcium deposits, and serial CT scans showed a gradual regression of the calcium deposition, suggesting that this rare form of massive dystrophic calcification may parallel changes in the severity of myocarditis, and may be associated with abnormalities in calcium metabolism secondary to rhabdomyolysis-induced acute renal failure.

[Secondary rhabdomyolysis and acute renal failure in gastroenteritis with hypernatremic dehydration]

A child with severe gastroenteritis developed acute rhabdomyolysis combined with acute renal failure. The pathophysiological mechanisms of this clinical syndrome are not completely understood. Rhabdomyolysis is mainly due to osmotic changes on both sides of the cell membrane. The preventive and therapeutic measures consist of adequate fluid substitution, correction of electrolyte and acid-base imbalances, administration of diuretics and alkalization of the urine. Dialysis treatment may be necessary. In this particular case renal failure resolved but the child died of other organ failure.

Non-traumatic rhabdomyolysis complicating antihistamine overdose

Antihistamines are common over the counter medications which are frequently involved in overdoses. The usual clinical course is dominated by the anticholinergic affects of these agents; it includes significant autonomic and central nervous system effects and direct cardiac toxicity (1). We report a case of a suicide attempt in a young adult male where ingestion of the antihistamines diphenhydramine and doxylamine was complicated by non-traumatic rhabdomyolysis and acute renal failure.

Caffeine contractures, twitch characteristics and the threshold for Ca(2+)-induced Ca2+ release in skeletal muscle from horses with chronic intermittent rhabdomyolysis

Muscle from horses with intermittent exercise associated rhabdomyolysis was examined to determine if calcium regulation was abnormal. In vitro studies on semimembranosus muscle fibre bundles showed the time to 50 per cent relaxation of caffeine-induced contractures was shorter and the electrically elicited twitch longer in horses with exercise associated rhabdomyolysis. Substitution of strontium for calcium eliminated the difference in caffeine contracture between the normal and rhabdomyolysis horses. The threshold of calcium-induced calcium release was lower than normal in terminal cisternae-containing fractions of muscle from horses with rhabdomyolysis. Thoroughbreds with rhabdomyolysis had a shorter time to peak twitch tension than standardbreds, and normal thoroughbreds had a shorter caffeine contracture than normal standardbreds. There was no difference in fibre typing between breeds or groups. Either no histological changes or low grade to moderate degenerative myopathy was seen in muscle from horses with rhabdomyolysis. These results suggest horses with intermittent exercise associated rhabdomyolysis have abnormal calcium regulation.

Tetany and rhabdomyolysis due to surreptitious furosemide--importance of magnesium supplementation

Diuretics may induce hypokalemia, hypocalcemia and hypomagnesemia. While severe hypokalemia may cause muscle weakness, severe hypomagnesemia is associated with muscle spasms and tetany which cannot be corrected by potassium and calcium supplementation alone (1,2). Surreptitious diuretic ingestion has been described, mainly in women who are concerned that they are obese or edematous. Symptomatic hypokalemia has been reported in such patients (3-7) and in one case hypocalcemia was observed (8), but the effects of magnesium depletion were not noted in these patients.

Neuroleptic malignant syndrome-like state in a patient with Down syndrome and basal ganglia calcification

We report a case of rhabdomyolysis in a 13-year-old Down syndrome patient with progressive quadriplegia, choreoathetosis and dystonia. Cranial CT demonstrated bilateral basal ganglia calcification. He experienced the sudden onset of high fever, cloudiness of consciousness, muscle rigidity and severe opisthotonus. The diagnosis was made on the basis of the marked increases in serum creatine kinase and myoglobin. There was remarkable elevation of 5-hydroxyindoleacetic acid, homovanillic acid and methoxy-hydroxyphenyl glycol in the cerebrospinal fluid during hyperpyrexia. This case exhibited almost all the diagnostic criteria of the neuroleptic malignant syndrome. It was suggested that abnormalities of monoamines in the central nervous system may be related to the pathologic etiology of this state and rhabdomyolysis.

[Prevention of acute renal failure in muscular injuries]

Rhabdomyolysis may be caused by sustained, continuous pressure to skeletal muscle. The syndrome is characterized by hypovolemia, hyperkalemia and release of excessive amounts of myoglobin to the circulation. If untreated, the syndrome becomes complicated by potentially fatal acute renal failure. Two case reports are presented which illustrate the importance of early and aggressive fluid substitution where forced alkaline diuresis seemed to prevent life threatening renal complications.

Psychotropic drug-related rhabdomyolysis

OBJECTIVE

The objective of this review is to discuss the pathophysiology and potential etiologies of rhabdomyolysis in psychiatric patients, with an emphasis on psychotropic drug-induced rhabdomyolysis.

DATA SOURCES

References were obtained through an on-line search of MEDLINE, using English-language and human literature only.

STUDY SELECTION

Because the topic is a potential drug-induced adverse effect, no controlled studies are available. Most of the literature are case reports and series of case reports.

DATA EXTRACTION

The quality of case reports was assessed using the Food and Drug Administration guidelines for assessing the causality of a potential adverse drug reaction.

DATA SYNTHESIS

The results of this review are based on qualitative data and indicate that rhabdomyolysis in psychiatric patients can be from multiple etiologies, including agitation, dehydration, and intramuscular injections, as well as an adverse effect of psychotropic medications. Although the deficiencies of this type of data are recognized, it is the only type of data often available to assess the etiology and causality of an uncommon adverse event.

CONCLUSIONS

Rhabdomyolysis in psychiatric patients can be caused by many factors, both drug- and non-drug-related. Rhabdomyolysis is more likely to occur when patients are faced with a combination of risk factors. When combinations of factors are present (e.g., aggression and restraints, intramuscular injections, and extrapyramidal effects), or when muscle trauma from an individual factor is sufficiently traumatic, muscle necrosis may occur to the point that rhabdomyolysis ensues.

Effects of changes in plasma volume on fatal rhabdomyolysis in the rat induced by glycerol injections

Rhabdomyolysis can be fatal in both experimental animals and man, but very little is known of the factors causing increased mortality in rhabdomyolysis. The aims of this study were to create an animal model of fatal rhabdomyolysis in rats by a glycerol injection into the leg muscle, and to elucidate some of the factors affecting mortality as a result of rhabdomyolysis formation. In this study, two factors which can result in increased mortality in rats as a result of glycerol injection, were examined. These factors include varying doses of 50% glycerol (0.5-2 ml/100 g) and various stages of dehydration prior to glycerol injection. Dehydration was induced by 1: chronic dehydration, in which the rats underwent water deprivation for a period of 24 to 72 hours prior to injection of glycerol; 2: acute dehydration, by the induction of either diuresis, by injecting sucrose (200-600 mg/100 g) to the femoral vein, or hemorrhage (0.7-2.1 ml/100 g). The results demonstrate that the mortality rate in rats increased in all three models of dehydration as the dose of glycerol injected to the rats increased (above a dose of 0.75 ml/100 g) and as the extent of dehydration increased. Use of a blood substitute before or after glycerol injection in order to compensate for the loss of body fluids did not increase the survival rate of the glycerol-injected rats. In contradistinction, rats treated with non-lethal doses of glycerol exhibited substantial resistance to a second lethal dose of glycerol, injected two weeks following the first injection.