Rhabdomyolysis: an evaluation of 475 hospitalized patients

Clinical features of Haff disease and myositis after the consumption of boiled brackish water crayfish: a retrospective study of 96 cases at a single centre

The present study describes the difference in clinical features between the patients with Haff disease and crayfish-related myositis (CRM) after crayfish consumption. This was a single-centre, retrospective analysis at the Emergency Department of the Drum Tower Hospital of Nanjing University School of Medicine from July to August of 2016. The baseline information came from the Electronic Medical Record System at the institution. Totally 96 patients were included, of whom 52 patients were confirmed to have Haff disease and 44 patients were CRM. The illness predominately occurs in summer and most of them (55/96) are female. The primary clinical features are myalgia, muscle allodynia and back and body pain. Statistical differences in the baseline CK, CK-MB, myoglobin, and the WBC count exist between the Haff disease and CRM groups (P < 0.05). The serum levels of CK and CK-MB increase in the second (a median time 29.2 ± 7.4 h) or third day (a median time 54.8 ± 9.3 h) of disease course, and then rapidly decreased to normal levels, while the levels of myoglobin peak at the admission (a median time 7.7 ± 6.4 h) and became normal after admission. There were no fatalities or complications during this study. All 96 patients recovered in a week. Of them, 75 were followed-up within 1 month and none had recurrence. The Haff disease and CRM after boiled crayfish consumption reflect a different severity of muscle injury, and reveal similar clinical characteristics and most of the laboratory values. The overall prognosis of both is good.

Exertional and CrossFit-Induced Rhabdomyolysis

Few publications of exercise-induced rhabomyolysis currently exist in the medical literature besides case reports. However, this condition can be severe, resulting in hospitalization and IV fluid administration to prevent serious sequelae. This report describes a case of exercise-induced rhabdomyolysis caused by a CrossFit workout. A 31-year-old female presented with 2 days of bilateral upper extremity pain and soreness, which began 2 days after she completed a CrossFit workout. Workup revealed an elevated creatine phosphokinase (CPK) of 18 441 U/L, consistent with exercise-induced rhabdomyolysis, and elevated liver function tests and elevated D-dimer, although her renal function was normal. She was hospitalized for 2 days and treated with IV fluids. This case report demonstrates that CrossFit exercises can lead to rhabdomyolysis, highlighting a condition that may be underdiagnosed and underreported.

How to do it: investigate exertional rhabdomyolysis (or not)

Rhabdomyolysis is the combination of symptoms (myalgia, weakness and muscle swelling) and a substantial rise in serum creatine kinase (CK) >50 000 IU/L; there are many causes, but here we specifically address exertional rhabdomyolysis. The consequences of this condition can be severe, including acute kidney injury and requirement for higher level care with organ support. Most patients have ‘physiological’ exertional rhabdomyolysis with no underlying disease; they do not need investigation and should be advised to return to normal activities in a graded fashion. Rarely, exertional rhabdomyolysis may be the initial presentation of underlying muscle disease, and we review how to identify this much smaller group of patients, who do require investigation.

Detecting Toxic Myopathies as Medication Side Effect

The goal of this article is to provide physiatrists, neurologists, and neuromuscular medicine physicians a framework that can be easily used in the process of evaluating, identifying, and treating patients with toxic myopathies. This review attempts to classify these rare but potentially deadly conditions in clinical patterns and distinguishes the cellular mechanisms in which the offending agents tend to impact the structure and function of myocytes.

Seizures, Systemic Inflammatory Response, and Rhabdomyolysis Associated With Laboratory-Confirmed 2C-I and 25-I Exposure

The 2C drugs are hallucinogenic phenethylamines. They and their n-benzyloxymethyl analogs have become popular as "legal highs," and significant toxicity has been attributed to their use. We report on a case of seizures, systemic inflammatory response, and rhabdomyolysis associated with laboratory-confirmed 4-iodo-2,5-dimethoxyphenethylamine and 4-iodo-2,5-dimethoxy-N-(2-methoxybenzyl) phenethylamine exposure. A 17-year-old male teenager developed seizures after taking "2 strips of acid." The seizures resolved with midazolam, but he became apneic and was intubated. His head computed tomography was unremarkable. Initial creatinine level was 1.5 mg/dL, with a creatine kinase of 112 U/L. His urine immunoassay drug screen was negative. He was extubated within 12 hours but had elevated temperatures for 48 hours. He was treated with antibiotics, but no source of infection was identified. His creatinine level peaked at 2.46 mg/dL. His creatine kinase peaked 72 hours later at 14579 U/L. He was treated with intravenous fluids and did not require renal replacement therapy. He recovered fully and was discharged after 5 days. Serum and urine samples were tested using liquid chromatography time-of-flight mass spectrometry. We detected 4-iodo-2,5-dimethoxyphenethylamine and 4-iodo-2,5-dimethoxy-N-(2-methoxybenzyl) phenethylamine in both serum and urine. No other substances were detected. The 2C drugs and their n-benzyloxymethyl analogs are potent serotonergic agents. Their use has been associated with multiple adverse effects including seizures, rhabdomyolysis, and death. They should be considered in differential diagnosis for drug-induced seizures and as a cause for systemic inflammatory response. This case highlights the significant toxicity seen with these compounds.

Usefulness of delta neutrophil index for early prediction of overt disseminated intravascular coagulopathy in patients with venomous snakebite

Objective

Clinically, consumptive coagulopathy, such as disseminated intravascular coagulopathy (DIC), is the most important among the common venomous snakebite complications owing to the serious hemorrhage risk associated with this condition. We evaluated the predictive value of the delta neutrophil index (DNI)-a new indicator for immature granulocytes-for DIC diagnosis.

Methods

This retrospective observational study consecutively assessed adult patients with venomous snakebites for over 51 months. Patients were categorized into the no DIC and DIC groups. DNI values were measured within 24 hours after snakebite.

Results

Thirty patients (26.3%) developed DIC. The DIC group had significantly higher median initial DNI than the no DIC group (0% vs. 0.2%, P&lt;0.001). When the DIC group was divided into early and late groups (within and over 24 hours after snakebite, respectively), the DNI of the former was significantly higher than that of the latter and no DIC group. The late DIC group had significantly higher DNI than the no DIC group. Furthermore, DNI positively correlated with the DIC score (r=0.548, P&lt;0.001). The initial DNI (odds ratio, 4.449; 95% confidence interval, 1.738 to 11.388; P=0.002) was an early DIC predictor. The area under the curve based on the initial DNI's receiver operating characteristic curve was 0.724.

Conclusion

DNI values were significantly higher in the DIC group. Additionally, DNI was an early predictor of DIC development in patients with venomous snakebites in the emergency department.

Serum myoglobin, creatine kinase, and cell-free DNA in endurance sled dogs and sled dogs with clinical rhabdomyolysis

OBJECTIVE

To evaluate whether cell-free DNA (cfDNA) concentrations are increased in dogs with exertional rhabdomyolysis and whether concentrations are correlated with serum myoglobin concentration and creatine kinase activity.

DESIGN

Observational cohort study.

SETTING

Yukon Quest 1,000-mile International Sled Dog Race 2015.

ANIMALS

Twelve normal competitive sled dogs; 5 dogs with rhabdomyolysis.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Blood was collected from all confirmed cases of exertional rhabdomyolysis and compared to the winning team at the midrace point. Results indicate that median cfDNA did not increase, but decreased by the race finish (prerace = 314.2 ng/mL versus midrace = 283.7 ng/mL versus postrace = 249.5 ng/mL). There were no rises in median cfDNA in dogs with rhabdomyolysis (255 ng/mL) negating its potential utility as a measure of acute skeletal muscle compromise. In contrast, myoglobin concentration and creatine kinase activity at the midrace point for normal dogs were significantly lower than dogs with rhabdomyolysis. Values for myoglobin and creatine kinase were strongly positively correlated (R = 0.91).

CONCLUSIONS

cfDNA is not a useful biomarker for exertional rhabdomyolysis in contrast to myoglobin and creatine kinase. Further evaluation of timing and clinical signs suggests that exertional rhabdomyolysis occurs early in endurance activities. Among the dogs with rhabdomyolysis, the dog that demonstrated clinical signs had the highest serum creatine kinase activity and myoglobin concentration.

Rhabdomyolysis following status epilepticus with hyperuricemia: A case report and literature review

RATIONALE

Rhabdomyolysis owing to status epilepticus (SE) can be life-threating, with acute kidney injury (AKI) the most serious complication; therefore, early recognition of the risk factors is important. Hyperuricemia after epileptic seizures has been reported, and severe hyperuricemia can lead to acute renal function damage.

PATIENT CONCERNS

We present the case of a 21-year-old man hospitalized for SE, who had especially high level of blood uric acid (UA) at initial presentation.

DIAGNOSIS

The patient was diagnosed with rhabdomyolysis due to SE.

INTERVENTIONS

The patient was treated with hydration and bicarbonate therapy. But he developed acute kidney failure (AKF) and hemodialysis was performed.

OUTCOMES

After hemodialysis, his symptoms disappeared and laboratory data returned to normal.

LESSONS

Hyperuricemia after SE might indicate severe muscle damage or reduced clearance of metabolites, and could be a risk factor for kidney dysfunction, especially with rhabdomyolysis. To our knowledge, this is the first report of rhabdomyolysis following SE with hyperuricemia.

Risk factors for delayed-onset rhabdomyolysis in doxylamine succinate intoxication patients

Background and Objectives:

Patients who overdose on doxylamine, hypnotic agent, usually exhibit good outcomes, but some experience serious complications. Some patients who present with normal creatinine phosphokinase levels in the emergency department later develop rhabdomyolysis during observation. We investigated factors associated with delayed-onset rhabdomyolysis in patients with doxylamine overdoses.

Methods:

Our investigation period was between 1 January 2011 and 29 February 2016. The initial blood samples were obtained for arterial blood gas analysis and measurements of the levels of electrolytes, creatinine phosphokinase, blood urea nitrogen, creatinine, aspartate aminotransferase, alanine aminotransferase, and lactate dehydrogenase. Urine analyses including pH and occult blood analyses were performed. Follow-up samples were obtained at 6 and 12 h after admission. Delayed-onset rhabdomyolysis was defined by a follow-up serum creatinine phosphokinase level greater than fivefold the upper limit of normal (>1000 IU/L). Comparisons of categorical variables between groups were performed using either the χ2 or Fisher exact tests. Continuous variables were compared between groups using the Mann–Whitney U test.

Results:

A total of 337 patients were enrolled. The large amount of ingested doxylamine (odds ratio = 7.002), tachycardia (odds ratio = 2.809), low arterial blood gas analysis pH (odds ratio = 2.267), and presence of occult blood in the urine (odds ratio = 2.048) were significant associated with delayed-onset rhabdomyolysis.

Conclusion:

Laboratory follow-up examinations were required for patients, ingested more than 18 mg/kg doxylamine poisoning, who had pulses exceeding 120 beats/min, had arterial blood gas analysis pH values below 7.3 on blood and urine testing, and/or exhibited the presence of occult blood in the urine, even if the initial creatinine phosphokinase level was normal.

Clinics in diagnostic imaging (179). Severe rhabdomyolysis complicated by myonecrosis

A 32-year-old man presented to the emergency department with severe right lower limb pain and swelling of three days' duration. He had multiple prior admissions for recurrent seizures and suicide attempts. Markedly elevated serum creatine kinase levels and urine myoglobinuria were consistent with a diagnosis of rhabdomyolysis. Initial magnetic resonance imaging of the right lower limb revealed diffuse muscle oedema and features of myositis in the gluteal muscles and the adductor, anterior and posterior compartments of the thigh. Follow-up magnetic resonance imaging performed 11 days later showed interval development of areas of myonecrosis and haemorrhage. The causes, clinical presentation and imaging features of rhabdomyolysis are discussed.

Treatment of exertional rhabdomyolysis in athletes: a systematic review

BACKGROUND

Exertional rhabdomyolysis (ER) is the breakdown of skeletal muscle tissue following intense physical activity that results in impairment of the cell membrane, which allows intracellular contents to be released into the bloodstream. Signs and symptoms include myalgia, myoglobinuria and increased creatine kinase (CK) levels. Athletes are vulnerable to this condition due to their increased level of physical activity. The severity and effects of this condition vary between individuals; however, all athletes are at risk of significant muscle damage, renal failure and perhaps death if not recognized and treated quickly. Effective methods for treatment and return to activity following this condition should be established.

OBJECTIVES

The objective of this review was to identify effective treatment methods associated with ER in athletes.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

Adult and adolescent patients (15 years of age and older) in the athletic population who have been diagnosed with ER.

TYPES OF INTERVENTIONS

Fluid resuscitation/replacement or other treatment methods that aim to improve CK levels and decrease myoglobinuria and treat ER.

TYPES OF STUDIES

Due to the absence of randomized control trials, the quantitative component of the review considered descriptive studies, case series and individual case reports for inclusion.

OUTCOMES

PRIMARY OUTCOMES

CK and myoglobinuria levels.

SECONDARY OUTCOMES

length of hospital stay; length of time from diagnosis to premorbid levels of physical activity.

SEARCH STRATEGY

A comprehensive search of the following databases with no date limitation was conducted: CINAHL, PubMed, ProQuest, Embase, SPORTDiscus and Physical Education Index. Results were limited to those available in English.

METHODOLOGICAL QUALITY

Two independent reviewers evaluated the retrieved articles for methodological quality using the standardized critical appraisal instrument from the Joanna Briggs Institute Meta-Analysis of Statistics and Review Instruments.

DATA EXTRACTION

Data were extracted from the articles by two independent reviewers using the standardized Joanna Briggs Institute extraction tool.

DATA SYNTHESIS

Narrative and tabular synthesis.

RESULTS

Fourteen studies with a combined total of 53 participants were included. Aggressive intravenous (IV) fluid resuscitation was found to be the most commonly utilized treatment method for decreasing CK levels and resolving myoglobinuria. The addition of compounds within the IV fluid varied between studies.

CONCLUSION

Due to the types of included studies and variation in reported treatment methods and outcomes for ER among athletes, effectiveness of treatment could not be determined. The limited evidence available indicates that IV fluid replacement, specifically normal saline, is the most commonly reported treatment for decreasing CK levels and myoglobinuria following ER. It appears that normal saline may be combined with other compounds including sodium bicarbonate, sodium chloride or potassium chloride to achieve reduction of CK levels and myoglobinuria. Clinically, early IV fluid replacement appears to be delivered at a rate of approximately 400 ml/hour, with adjustments ranging between 200 and 1000 ml/hour, depending on severity and volume states. Hospitalization time varies, depending on severity of condition, and return to activity is widely inconsistent among the athletic population.

Severe rhabdomyolysis induced by quetiapine and mirtazapine in a French military soldier

Rhabdomyolysis is a potential complication of psychotropic drugs use and may potentially lead to life-threatening complications, such as an acute renal failure. We describe the case of a 40-year-old military soldier suffering from post-traumatic stress disorder was admitted for an adaptation of his treatment. Mirtazapine was introduced and quetiapine increased. Two days later, the patient presented with severe rhabdomyolysis syndrome. Mirtazapine administration was paused and intravenous hydration commenced. Shortly after the creatine kinase levels decreased enabling mirtazapine to be reintroduced without complication. It is our opinion that 5-hydroxytryptamine 2a serotonergic receptors inhibition (related to mirtazapine and quetiapine) associated with muscle training was responsible for inducing rhabdomyolysis. This must be kept in mind when psychotropic medications are adjusted, especially in an athletic population such as military.

Combined Therapy with Extracorporeal Shock Wave and Adipose-Derived Mesenchymal Stem Cells Remarkably Improved Acute Ischemia-Reperfusion Injury of Quadriceps Muscle

Extracorporeal shock wave (ECSW) and adipose-derived mesenchymal stem cells (ADMSCs) have been recognized to have capacities of anti-inflammation and angiogenesis. We tested the hypothesis that ECSW and ADMSC therapy could attenuate ischemia-reperfusion- (IR-) induced thigh injury (femoral artery tightened for 6 h then the tightness was relieved) in rats. Adult male SD rats (n = 30) were divided into group 1 (sham-control), group 2 (IR), group 3 (IR + ECSW/120 impulses at 0.12 mJ/mm² given at 3 h/24 h/72 h after IR), group 4 (allogenic ADMSC/1.2 × 10⁶ cell intramuscular and 1.2 × 10⁶ cell intravenous injections 3 h after IR procedure), and group 5 (ECSW + ADMSC). At day 7 after the IR procedure, the left quadriceps muscle was harvested for studies. At 18 h after the IR procedure, serum myoglobin/creatine phosphokinase (CPK) levels were highest in group 2, lowest in group 1, and with intermediate values significantly progressively reduced in groups 3 to 5 (all p < 0.0001). By day 5 after IR, the mechanical paw-withdrawal threshold displayed an opposite pattern of CPK (all p < 0.0001). The protein expressions of inflammatory, oxidative-stress, apoptotic, fibrotic, DNA-damaged, and mitochondrial-damaged biomarkers and cellular expressions of inflammatory and DNA-damaged biomarkers exhibited an identical pattern of CPK among the five groups (all p < 0.0001). The microscopic findings of endothelial-cell biomarkers and number of arterioles expressed an opposite pattern of CPK, and the angiogenesis marker was significantly progressively increased from groups 1 to 5, whereas the histopathology showed that muscle-damaged/fibrosis/collagen-deposition areas exhibited an identical pattern of CPK among the five groups (all p < 0.0001). In conclusion, ECSW-ADMSC therapy is superior to either one applied individually for protecting against IR-induced thigh injury.

Acute kidney injury in pediatric patients with rhabdomyolysis

Purpose

This study aimed to evaluate the clinical findings in pediatric rhabdomyolysis and the predictive factors for acute kidney injury (AKI) in Korean children.

Methods

Medical records of 39 Korean children, who were newly diagnosed with rhabdomyolysis from January 2008 to December 2015, were retrospectively analyzed. The diagnosis was made from the medical history, elevated serum creatinine kinase level >1,000 IU/L, and plasma myoglobin level >150 ng/mL. Patients with muscular dystrophy and myocardial infarction were excluded.

Results

The median patient age at diagnosis was 14.0 years (range, 3–18 years), and the male to female ratio was 2.5. The most common presenting symptom was myalgia (n=25, 64.1%), and 14 patients (35.9%) had rhabdomyolysis-induced AKI. Eighteen patients (46.2%) had underlying diseases, such as epilepsy and psychotic disorders. Ten of these patients showed rhabdomyolysis-induced AKI. The common causes of rhabdomyolysis were infection (n=12, 30.7%), exercise (n=9, 23.1%), and trauma (n=8, 20.5%). There was no difference in the distribution of etiology between AKI and non-AKI groups. Five patients in the AKI group showed complete recovery of renal function after stopping renal replacement therapy. The median length of hospitalization was 7.0 days, and no mortality was reported. Compared with the non-AKI group, the AKI group showed higher levels of peak creatinine kinase and myoglobin, without statistical significance.

Conclusion

The clinical characteristics of pediatric rhabdomyolysis differ from those observed in adult patients. Children with underlying diseases are more vulnerable to rhabdomyolysis-induced AKI. AKI more likely develops in the presence of a high degree of albuminuria.

Rhabdomyolysis Following Colonoscopy: A Case Report

We experienced a case of 1 patient who died from rhabdomyolysis-related complications after colonoscopy. A 60-year-old man had undergone an ‘uncomplicated’ colonoscopic polypectomy. Approximately 10 hours following this procedure, the patient complained of increasing left abdominal pain. His computed tomography image showed free gas, but his operative findings revealed no macroscopic perforation or abscess formation. Eight hours after the operation, the patient presented with myoglobulinuria, and we diagnosed the condition to be rhabdomyolysis. Based on this case, we recommend that rhabdomyolysis be added to the list of complications following a colonoscopic procedure. Moreover, for prevention and early treatment, endoscopists should be attentive to the risk factors and signs/symptoms of rhabdomyolysis.

The Study of Rhabdomyolysis in the Elderly: An Epidemiological Study and Single Center Experience

Rhabdomyolysis is a syndrome caused by injury to skeletal muscle. There is limited data of rhabdomyolysis in the elderly. The objective of this study is to investigate demographic data, etiologies, laboratory values, prognostic factors, and mortality of rhabdomyolysis in the geriatric population. A 4-years retrospective chart review study was conducted. Our inclusion criteria were age above 65 years and creatinine kinase level excess five times of normal upper limit. Among 167 patients, 47.3% were male. The median age at diagnosis was 80.11 (66-101) years. The duration of follow up in the study ranged from 0 to 48 months. Fall (with or without immobilization) was the most frequent cause of rhabdomyolysis in 56.9%. The mean baseline glomerular filtration rate (GFR), GFR at diagnosis, and peak decline in GFR was 76.94, 48.96, and 54.41 cc/min respectively. The mean CK at diagnosis and peak CK was 5097.22 and 6320.07. There were 45 deaths (21%) over the span of 4 years. Multivariate analysis demonstrated that number of medications pre-admission (Meds No.), peak decline in GFR, and acute kidney injury (AKI) are independent predictors for overall survival for rhabdomyolysis in the elderly. To our knowledge, this is the first epidemiological study of rhabdomyolysis in the elderly. Falls (with and without immobilization) were the most common etiology. Meds No. (>8), peak decline in GFR (<30 cc/min), and evidence of AKI are associated with shorter overall survival and can serve as potential independent prognostic markers for rhabdomyolysis in elderly patients.

Hyperkalemia in electrical burns: A retrospective study in Colombia

INTRODUCTION

Classically, hyperkalemia has been regarded as a complication in patients with electrical burns. The etiology of hyperkalemia includes metabolic acidosis, destruction of red blood cells, rhabdomyolysis and the development of renal failure. The purpose of this study was to determine the prevalence of hyperkalemia within the first 24h after electrical burn injury and to evaluate the possible association of serum potassium concentration with cutaneous burn size (%TBSA) and serum creatine phosphokinase (CPK) concentration.

METHODS

A retrospective, cross-sectional study was conducted, based on review of medical records of adult patients hospitalized in the first 24h post electrical injury. Serum potassium (K⁺) levels were divided into low, normal, and high groups, with breakpoints at 3.5mmol/L and 5.0mmol/L and normal 3.6-4.9mmol/L. To assess potential differences according to the time elapsed between the time of the injury and the sampling time, data were grouped as follows: t1: samples obtained in the first 6h post-injury; t2: samples taken at 6-12h; t3: samples taken at 12-24h.

RESULTS

336 patients were studied. The median age was 32 years old (IQR: 25-43). 95.2% of patients were men. Low and normal values of K⁺ were observed in 13.7% and 85.1%, respectively. The prevalence of hyperkalemia was only 1.2%, and was not related to previously-administered medications or to simple blood gas pH value during admission. CPK>10,000IU/L was observed in 22.6%. No association was found between the serum potassium concentration and either %TBSA burned or the highest CPK value.

CONCLUSIONS

First, patients admitted to our burn unit with electrical injury accompanied by significant skin and muscle injury rarely exhibit hyperkalemia. Secondly, the presence of hyperkalemia is independent of the severity of rhabdomyolysis or the extent of the burn.

Massive Rhabdomyolysis; A Rare Cause of Hepatocellular Dysfunction

BACKGROUND Rhabdomyolysis syndrome is a rare surgical complication. It is infrequently reported in prolonged operations under lateral decubitus position. This syndrome mainly impacts kidney function and electrolytes levels; liver is another organ that is uncommonly affected. CASE REPORT A 54-year-old male underwent a partial hepatectomy in the supine position, the procedure lasted three hours. After five days of uneventful recovery from surgery, he was readmitted to the hospital with rhabdomyolysis syndrome involving his lower limbs. No predisposing factors other than surgery could be identified. Based on blood tests, the only affected organ was the liver. Upon aggressive hydration, the creatinine kinase, hepatic enzymes, bilirubin levels, and prothrombin time were normalized. The patient regained normal physical strength over the next few weeks. CONCLUSIONS Liver dysfunction secondary to rhabdomyolysis is rare but should be considered when other causes are excluded. Prothrombin time, bilirubin levels and albumin levels may help to identify concomitant liver damage. Rhabdomyolysis is rarely reported in liver resection surgeries.

Rhabdomyolysis and acute kidney injury: creatine kinase as a prognostic marker and validation of the McMahon Score in a 10-year cohort: A retrospective observational evaluation

BACKGROUND

High-volume fluid resuscitation and the administration of sodium bicarbonate and diuretics have a theoretical renoprotective role in patients at high risk of acute kidney injury (AKI) following rhabdomyolysis. Abnormally elevated creatine kinase has previously been used as a biological marker for the identification of patients at high risk of AKI following rhabdomyolysis.

OBJECTIVE

To assess the sensitivity and specificity of plasma creatine kinase (admission and peak values) for the prediction of AKI requiring renal replacement therapy (RRT) or of death in patients with confirmed rhabdomyolysis. To compare the diagnostic performance of creatine kinase with the McMahon score.

DESIGN

Retrospective observational study. Data collection included McMahon and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores; daily creatine kinase; daily creatinine and electrolytes; ICU length of stay and mortality.

SETTING

Neurosciences and Trauma Critical Care Unit (Cambridge, UK).

PATIENTS

In total, 232 adults with confirmed rhabdomyolysis (creatine kinase > 1000 Ul) admitted to Neurosciences and Trauma Critical Care Unit between 2002 and 2012.

MAIN OUTCOME MEASURES

AKI, RRT and mortality.

RESULTS

Forty-five (19%) patients developed AKI and 29 (12.5%) patients required RRT. Mortality was significantly higher in patients who developed AKI (62 vs. 18%, P < 0.001). Average creatine kinase on admission was 5009 (range 69-157 860) Ul. Creatine kinase peaked between the day of admission and day 3 in 91% of cases. PEAK creatine kinase of at least 5000 Ul is 55% specific and 83% sensitive for the prediction of AKI requiring RRT. A McMahon Score of at least 6 calculated on admission is 68% specific and 86% sensitive for RRT.

CONCLUSIONS

Creatine kinase is not a specific or early predictor of AKI in patients with rhabdomyolysis. Although a PEAK creatine kinase of at least 5000 Ul has sensitivity acceptable for screening purposes, this is often a delayed finding. A McMahon score of at least 6 calculated on admission allows for a more sensitive, specific and timely identification of patients who may benefit from high-volume fluid resuscitation.

Clinical, laboratory, and hemostatic findings in cats with naturally occurring sepsis

OBJECTIVE To characterize clinical and laboratory findings in cats with naturally occurring sepsis, emphasizing hemostasis-related findings, and evaluate these variables for associations with patient outcomes. DESIGN Prospective, observational, clinical study. ANIMALS 31 cats with sepsis and 33 healthy control cats. PROCEDURES Data collected included history; clinical signs; results of hematologic, serum biochemical, and hemostatic tests; diagnosis; and outcome (survival vs death during hospitalization or ≤ 30 days after hospital discharge). Differences between cats with and without sepsis and associations between variables of interest and death were analyzed statistically. RESULTS The sepsis group included cats with pyothorax (n = 10), septic peritonitis (7), panleukopenia virus infection (5), bite wounds (5), abscesses and diffuse cellulitis (3), and pyometra (1). Common clinical abnormalities included dehydration (21 cats), lethargy (21), anorexia (18), pale mucous membranes (15), and dullness (15). Numerous clinicopathologic abnormalities were identified in cats with sepsis; novel findings included metarubricytosis, hypertriglyceridemia, and high circulating muscle enzyme activities. Median activated partial thromboplastin time and plasma D-dimer concentrations were significantly higher, and total protein C and antithrombin activities were significantly lower, in the sepsis group than in healthy control cats. Disseminated intravascular coagulopathy was uncommon (4/22 [18%] cats with sepsis). None of the clinicopathologic abnormalities were significantly associated with death on multivariate analysis. CONCLUSIONS AND CLINICAL RELEVANCE Cats with sepsis had multiple hematologic, biochemical, and hemostatic abnormalities on hospital admission, including several findings suggestive of hemostatic derangement. Additional research including larger numbers of cats is needed to further investigate these findings and explore associations with outcome.

Rhabdomyolysis with different etiologies in childhood

AIM

To investigate different etiologies and management of the rhabdomyolysis in children.

METHODS

Eight pediatric rhabdomyolysis cases who applied to the Dokuz Eylul University Faculty of Medicine Department of Pediatric Nephrology with different etiologies between January 2004 and January 2012 were evaluated in terms of age, gender, admission symptoms, physical examination findings, factors provoking rhabdomyolysis, number of rhabdomyolysis attacks, laboratory results, family history and the final diagnosis received after the treatment.

RESULTS

Average diagnosis ages of eight cases were 129 (24-192) ± 75.5 mo and five of them were girls. All of them had applied with the complaint of muscle pain, calf pain, and dark color urination. Infection (pneumonia) and excessive physical activity were the most important provocative factors and excessive licorice consumption was observed in one case. In 5 cases, acute kidney injury was determined and two cases needed hemodialysis. As a result of the further examinations; the cases had received diagnoses of rhabdomyolysis associated with mycoplasma pneumoniae, sepsis associated rhabdomyolysis, licorice-induced hypokalemic rhabdomyolysis, carnitine palmitoyltransferase II deficiency, very long-chain acyl-CoA dehydrogenase deficiency, congenital muscular dystrophy and idiopathic paroxysmal rhabdomyolysis (Meyer-Betz syndrome).

CONCLUSION

It is important to distinguish the sporadic and recurrent rhabdomyolysis cases from each other. Recurrent rhabdomyolysis cases should follow up more regardful and attentive.

Clinical and laboratory findings of rhabdomyolysis in opioid overdose patients in the intensive care unit of a poisoning center in 2014 in Iran

OBJECTIVES

The aim of this study was to investigate the clinical and demographic characteristics and some laboratory findings of hospitalized patients with acute opioid toxicity and rhabdomyolysis.

METHODS

This cross-sectional study investigated 354 patients hospitalized at Baharloo Hospital in Tehran in 2014 with acute illicit drug toxicity. Data were collected using an investigator-made checklist. The collected data (such as mortality rate, demographic data, and renal function tests, as well as serum biochemical findings) were analyzed by descriptive statistics and the chi-square test.

RESULTS

A total of 354 patients were admitted to the hospital in 2014 with acute illicit drug toxicity, including 291 males and 63 females. The total number of patients with rhabdomyolysis was 76 (21.5% of the total), of whom 69 (90.8%) were male and 7 (9.2%) were female. Most cases of rhabdomyolysis were associated with methadone abuse, followed by opium abuse. Rhabdomyolysis was most common in those 20-29 and 30-39 years old, with methadone and opium the most commonly abused illicit drugs. The mean blood urea level was 3.8±1.0 mg/dL, and the mean serum potassium and sodium levels were 3.8±0.3 mg/dL and 140.4±4.0 mg/dL, respectively. Five patients, all of whom were male, passed away due to severe renal failure (6.5%).

CONCLUSIONS

Toxicity caused by opioids is associated with clinical complications and laboratory disorders, such as electrolyte disorders, which can lead to lethal or life-threatening results in some cases. Abnormal laboratory test findings should be identified in patients with opioid toxicity in order to initiate efficient treatment.

Outcomes of exertional rhabdomyolysis following high-intensity resistance training

BACKGROUND

High-intensity resistance training (HIRT) programmes are increasingly popular amongst personal trainers and those attending gymnasiums. We report the experience of exertional rhabdomyolysis (ER) at two tertiary hospitals in Melbourne, Australia.

AIMS

To compare the clinical outcomes of ER with other causes of rhabdomyolysis.

METHODS

Retrospective cross-sectional study of patients presenting with a serum creatine kinase (CK) of greater than 25 000 units/L from 1 September 2013 to 31 August 2014 at two tertiary referral hospitals in Melbourne, Australia. Records were examined to identify care measures implemented during hospital stay, clinical outcomes during admission and on subsequent follow up.

RESULTS

Thirty four cases of rhabdomyolysis with a CK of greater than 25 000 units/L (normal range: 20-180 units/L) were identified during the 12-month study period. Twelve of the 34 cases (35%) had ER with 10 of 12 related to HIRT. No acute kidney injury, intensive care admission or death were seen among those with ER. All cases were managed conservatively, with 11 admitted and 9 receiving intravenous fluids only. In contrast, patients with rhabdomyolysis from other causes experienced significantly higher rates of intensive care admission (64%, P = 0.0002), acute kidney injury (82%, P = 0.0001) and death (27%, P = 0.069).

CONCLUSION

ER resulting from HIRT appears to have a benign course compared with rhabdomyolysis of other aetiologies in patients with a serum CK greater than 25 000 units/L. Conservative management of ER appears to be adequate, although this requires confirmation in future prospective studies.

The usefulness of diffusion-weighted magnetic resonance imaging performed in the acute phase as an early predictor of delayed neuropsychiatric sequelae in acute carbon monoxide poisoning

Delayed onset of neuropsychiatric symptoms after apparent recovery from acute carbon monoxide (CO) poisoning has been described as delayed neuropsychiatric sequelae (DNS). No previous study has determined whether early use of diffusion-weighted magnetic resonance imaging (DWI) can predict which patients will develop DNS in the acute CO poisoning. This retrospective observational study was performed on adult patients with acute CO poisoning consecutively treated over a 17-month period. All included patients with acute CO poisoning underwent DWI to evaluate brain injury within 72 h after CO exposure. DWI was evaluated as follows: (1) presence of pathology, (2) number of pathologies, (3) asymmetry, and (4) location of pathology. Patients were divided into two groups. The DNS group was composed of patients with delayed sequelae, while the non-DNS group included patients with no sequelae. A total of 102 patients with acute CO poisoning were finally enrolled in this study. DNS developed in 10 patients (9.8%). Between the DNS group and the non-DNS group, presence of pathology on DWI and initial Glasgow Coma Scale (GCS) showed significant difference. There was also a statistical difference between the non-DNS group and DNS group in terms of CO exposure time, troponin I, rhabdomyolysis, acute kidney injury, and pneumonia. The presence of pathology in DWI and initial GCS (cutoff: <12) at the emergency department served as an early predictors of DNS.

Febrile rhabdomyolysis of unknown origin in refugees coming from West Africa through the Mediterranean

OBJECTIVES

Cases of undiagnosed severe febrile rhabdomyolysis in refugees coming from West Africa, mainly from Nigeria, has been observed since May 2014. The aim of this study was to describe this phenomenon.

METHODS

This was a multicentre retrospective observational study of cases of febrile rhabdomyolysis reported from May 2014 to December 2016 in 12 Italian centres.

RESULTS

A total of 48 cases were observed, mainly in young males. The mean time interval between the day of departure from Libya and symptom onset was 26.2 days. An average 8.3 further days elapsed before medical care was sought. All patients were hospitalized with fever and very intense muscle aches. Creatine phosphokinase, aspartate aminotransferase, and lactate dehydrogenase values were abnormal in all cases. The rhabdomyolysis was ascribed to an infective agent in 16 (33.3%) cases. In the remaining cases, the aetiology was undefined. Four out of seven patients tested had sickle cell trait. No alcohol abuse or drug intake was reported, apart from a single reported case of khat ingestion.

CONCLUSIONS

The long incubation period does not support a mechanical cause of rhabdomyolysis. Furthermore, viral infections such as those caused by coxsackievirus are rarely associated with such a severe clinical presentation. It is hypothesized that other predisposing conditions like genetic factors, unknown infections, or unreported non-conventional remedies may be involved. Targeted surveillance of rhabdomyolysis cases is warranted.

Severe asymptomatic rhabdomyolysis complicating a mycoplasma pneumonia

Rhabdomyolysis is a very rare and serious extrapulmonary manifestation of a Mycoplasma pneumoniae infection. We describe a case of a 47-year-old male patient who presented with progressive dyspnoea, hypoxaemia and cough during the last 3 days. He had no relevant muscular complaints but was diagnosed with severe rhabdomyolysis for which he was treated with hyperhydration. Molecular diagnostics confirmed M. pneumoniae as the causative agent and our patient was successfully treated with doxycycline.Only a few cases of rhabdomyolysis complicating a M. pneumoniae infection have been described, mostly in infants. In this case, typical suggestive complaints of rhabdomyolysis were absent suggesting that the complication might be underdiagnosed.

Rhabdomyolysis in an HIV cohort: epidemiology, causes and outcomes

Background

The Literature on rhabdomyolysis in the HIV-positive population is sparse and limited. We aimed to explore the incidence, patient characteristics, etiologies and outcomes of rhabdomyolysis in a cohort of HIV-positive patients identified through the Johns Hopkins HIV clinical registry between June 1992 and April 2014.

Methods

A retrospective analysis of 362 HIV-positive patients with non-cardiac CK elevation ≥1000 IU/L was performed. Both inpatients and outpatients were included. Incidence rate and potential etiologies for rhabdomyolysis were ascertained. The development of acute kidney injury (AKI, defined as doubling of serum creatinine), need for dialysis, and death in the setting of rhabdomyolysis were determined. Logistic regression was used to evaluate the association of peak CK level with the development of AKI.

Results

Three hundred sixty two cases of rhabdomyolysis were identified in a cohort of 7079 patients with a 38,382 person years follow-up time. The incidence rate was nine cases per 1000 person-years (95% CI: 8.5–10.5). Infection was the most common etiology followed by compression injury and drug/alcohol use. One-third of cases had multiple potential etiologies. AKI developed in 46% of cases; 20% of which required dialysis. Thirteen percent died during follow-up. After adjustment, AKI was associated with higher CK (OR 2.05 for each 1-log increase in CK [95% CI: 1.40–2.99]), infection (OR 5.48 [95% CI 2.65–11.31]) and higher HIV viral load (OR 1.22 per 1-log increase [95% CI: 1.03–1.45]).

Conclusion

Rhabdomyolysis in the HIV-positive population has many possible causes and is frequently multifactorial. HIV-positive individuals with rhabdomyolysis have a high risk of AKI and mortality.

The clinical significance of technetium-99m methylene diphosphonate bone scintigraphy findings in patients with rhabdomyolysis

OBJECTIVE

This study evaluated the relationship between bone scintigraphy finding and clinical factors and assessed the prognostic value of bone scintigraphy finding in patients with rhabdomyolysis.

PATIENTS AND METHODS

We retrospectively enrolled 143 patients with rhabdomyolysis who had undergone bone scintigraphy. Bone scintigraphy was classified into three groups: no or equivocal soft tissue uptake, a localized uptake, and a diffuse uptake. The relationship of bone scintigraphy findings with clinical factors was evaluated. Multiple logistic regression analysis was performed to identify the risk factors for acute renal failure (ARF) and renal replacement therapy (RRT).

RESULTS

Of 143 patients, 52 (36.4%) experienced ARF and 12 (8.4%) required RRT. Among cases caused by exercise, 83.7% showed localized soft tissue uptake. Diffuse soft tissue uptake was only shown among the patients with rhabdomyolysis caused by drug and toxin. Patients with localized or diffuse soft tissue uptake had higher levels of serum creatine kinase, myoglobin, aspartate aminotransferase, alanine aminotransferase, and lactate dehydrogenase compared with patients with no or equivocal uptake (P<0.05). Multiple logistic regression analysis showed that age, female sex, and serum phosphate level were associated with a risk for ARF and only serum creatinine level was associated with a risk for RRT (P<0.05). Bone scintigraphy findings failed to show significance for predicting ARF and RRT (P>0.05).

CONCLUSION

Soft tissue uptake on bone scintigraphy in patients with rhabdomyolysis was related to etiologies and showed limited value for predicting ARF and RRT.

Exceptionally High Creatine Kinase (CK) Levels in Multicausal and Complicated Rhabdomyolysis: A Case Report

Patient: Male, 36

Final Diagnosis: Rhabdomyolysis induced acute renal failure

Symptoms: Diarrhea • generalized weakness

Medication: —

Clinical Procedure: Hemodialysis • intubation

Specialty: Critical Care Medicine

Absence of anti-HMG-CoA reductase autoantibodies in severe self-limited statin-related myopathy

INTRODUCTION

Patients with self-limited statin-related myopathy improve spontaneously when statins are stopped. In contrast, patients with statin-associated autoimmune myopathy have autoantibodies recognizing 3-hydroxy-3-methyl-glutaryl-coenzyme A reductase (HMGCR) and usually require immunosuppressive therapy to control their disease. On initial presentation, it can sometimes be difficult to distinguish between these 2 diseases, as both present with muscle pain, weakness, and elevated serum creatine kinase (CK) levels. The goal of this study was to determine whether patients with severe self-limited statin-related myopathy also make anti-HMGCR autoantibodies.

METHODS

We screened 101 subjects with severe self-limited cerivastatin-related myopathy for anti-HMGCR autoantibodies.

RESULTS

No patient with severe self-limited cerivastatin-related myopathy had anti-HMGCR autoantibodies.

CONCLUSION

Anti-HMGCR autoantibody testing can be used to help differentiate whether a patient has self-limited myopathy due to cerivastatin or autoimmune statin-associated myopathy; these findings may apply to other statins as well. Muscle Nerve 54: 142-144, 2016.

Characteristics of Creatine Kinase Elevation in Trauma Patients and Predictors of Acute Kidney Injury

INTRODUCTION

Rhabdomyolysis in general trauma patients is a cause of acute kidney injury. However, there are limited data on prevalence, risk factors and the dynamics of creatine kinase (CK) as a surrogate marker for rhabdomyolysis.

AIM

This study aimed to examine the characteristics of CK elevation in general trauma patients and identify the risk factors of acute kidney injury (AKI).

METHOD

A retrospective study of trauma patients at Songklanagarind Hospital from January 2009 to August 2014 using CK, clinical characteristics and trauma severity as predictors and AKI as defined by the Acute Kidney Injury Network, 2005 criteria as the outcomes.

RESULTS

Of the 372 patients included in the study, the prevalence of rhabdomyolysis was 40.3%, the mean injury severity score (ISS) was 19.5 and 7% had AKI. The CK level peaked at 40 hours after admission with a rate change of 50.98 U/L/h. An initial mean arterial pressure < 65 mmHg, ISS ≥ 25 and CK elevation > 1,000 U/L/h were independently associated with AKI.

CONCLUSION

Traumatic rhabdomyolysis resulting in AKI occurs in patients with a high peak CK with an increasing rate of change and a high ISS. These parameters could identify patients who needed close monitoring of CK and renal function.

Magnetic resonance imaging of painful swollen legs in the emergency department: a pictorial essay

Patients presenting with a painful swollen leg are not infrequently encountered at the emergency department and can pose a diagnostic dilemma for attending physicians. The potential causes of leg pain and swelling include trauma, infection, inflammation, and neurogenic, vascular, and iatrogenic conditions; with magnetic resonance imaging (MRI) being an important tool in evaluation. We describe the MRI features of various conditions causing painful swollen legs. We also discuss the differential diagnosis and the useful clinical and laboratory findings that radiologists should be aware of, in order to arrive at an accurate diagnosis.

Multimodality imaging findings in rhabdomyolysis and a brief review of differential diagnoses

Rhabdomyolysis has traditionally been a clinical diagnosis with healthcare providers utilizing historical context, physical exam, and laboratory data to arrive at a diagnosis. However, there are myriad imaging findings that may be corroborative and support the presumptive diagnosis. This paper seeks to review imaging findings associated with rhabdomyolysis using different modalities including radiography, sonography, computed tomography (CT), magnetic resonance imaging (MRI), and bone scintigraphy.

A systematic review of sex and age factors in neuroleptic malignant syndrome diagnosis frequency

OBJECTIVE

To examine sex and age distributions in neuroleptic malignant syndrome (NMS) patients based on a systematic literature review.

METHOD

EMBASE and PubMed databases were searched to identify any observation of NMS published from January 1, 1998 through November 1, 2014 that was accessible and interpretable (using language translation software). Redundant and equivocal reports were excluded. Sex ratio and age distributions were examined using standard graphical techniques and measures of association.

RESULTS

Twenty-eight independent sex ratio estimates were included. Males predominated in most (75%) estimates with an overall median sex ratio of 1.47 (95% CI, 1.20-1.80). NMS incidence peaked at age 20-25 years and declined steadily thereafter, with males consistently outnumbering females at all but the oldest age intervals.

CONCLUSION

NMS patients are 50% more likely to be males, and NMS is most likely to occur in young adulthood.

Erythropoietin protects against rhabdomyolysis-induced acute kidney injury by modulating macrophage polarization

Erythropoietin (EPO) is a well-known hormone that is clinically used for the treatment of anemia. Very recently, an increasing body of evidence showed that EPO could still regulate bioactivities of macrophages. However, the details about the immunomodulatory effect of EPO on macrophages are not fully delineated, particularly in the setting of renal damages. Therefore, in the present study, we determined whether EPO could exert an impact on the dynamics of macrophages in a well-established model of rhabdomyolysis-induced acute kidney injury and explored the potential mechanisms. EPO was found to ameliorate kidney injuries by reducing macrophages recruitment and promoting phenotype switch toward M2 macrophages in vivo. It was also confirmed that EPO could directly suppress pro-inflammatory responses of M1 macrophages and promote M2 marker expression in vitro. Data indicated the possible involvement of Jak2/STAT3/STAT6 pathway in the augmentation of EPO on M2 polarization. These results improved the understanding of the immunoregulatory capacity of EPO on macrophages, which might optimize the therapeutic modalities of EPO.

Abiraterone-induced rhabdomyolysis resulting in acute kidney injury: A case report and review of the literature

Abiraterone, a CYP17 inhibitor, blocks androgen biosynthesis in multiple tissue types. In combination with prednisone, it is approved as a first-line treatment for metastatic castration-resistant prostate cancer. We present a case of rhabdomyolysis associated with abiraterone therapy resulting in acute on chronic kidney injury in a patient with metastatic castration-resistant prostate cancer. Strict monitoring should be employed in patients started on abiraterone who have additional risk factors for developing rhabdomyolysis.

Serum neuron-specific enolase as an early predictor of delayed neuropsychiatric sequelae in patients with acute carbon monoxide poisoning

Delayed onset of neuropsychiatric symptoms after apparent recovery from acute carbon monoxide (CO) poisoning has been described as delayed neuropsychiatric sequelae (DNS). To date, there have been no studies on the utility of serum neuron-specific enolase (NSE), a marker of neuronal cell damage, as a predictive marker of DNS in acute CO poisoning. This retrospective observational study was performed on adult patients with acute CO poisoning consecutively treated over a 9-month period. Serum NSE was measured after emergency department arrival, and patients were divided into two groups. The DNS group comprised patients with delayed sequelae, while the non-DNS group included patients with none of these sequelae. A total of 98 patients with acute CO poisoning were enrolled in this study. DNS developed in eight patients. The median NSE value was significantly higher in the DNS group than in the non-DNS group. There was a statistical difference between the non-DNS group and the DNS group in terms of CO exposure time, Glasgow Coma Scale (GCS), loss of consciousness, creatinine kinase, and troponin I. GCS and NSE were the early predictors of development of DNS. The area under the curve according to the receiver operating characteristic curves of GCS, serum NSE, and GCS combined with serum NSE were 0.922, 0.836, and 0.969, respectively. In conclusion, initial GCS and NSE served as early predictors of development of DNS. Also, NSE might be a useful additional parameter that could improve the prediction accuracy of initial GCS.

Unveiling the Metabolic Changes on Muscle Cell Metabolism Underlying p-Phenylenediamine Toxicity

Rhabdomyolysis is a disorder characterized by acute damage of the sarcolemma of the skeletal muscle leading to release of potentially toxic muscle cell components into the circulation, most notably creatine phosphokinase (CK) and myoglobulin, and is frequently accompanied by myoglobinuria. In the present work, we evaluated the toxicity of p-phenylenediamine (PPD), a main component of hair dyes which is reported to induce rhabdomyolysis. We studied the metabolic effect of this compound in vivo with Wistar rats and in vitro with C2C12 muscle cells. To this aim we have combined multi-omic experimental measurements with computational approaches using model-driven methods. The integrative study presented here has unveiled the metabolic disorders associated to PPD exposure that may underlay the aberrant metabolism observed in rhabdomyolys disease. Animals treated with lower doses of PPD (10 and 20 mg/kg) showed depressed activity and myoglobinuria after 10 h of treatment. We measured the serum levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and creatine kinase (CK) in rats after 24, 48, and 72 h of PPD exposure. At all times, treatment with PPD at higher doses (40 and 60 mg/kg) showed an increase of AST and ALT, and also an increase of lactate dehydrogenase (LDH) and CK after 24 h. Blood packed cell volume and hemoglobin levels, as well as organs weight at 48 and 72 h, were also measured. No significant differences were observed in these parameters under any condition. PPD induce cell cycle arrest in S phase and apoptosis (40% or early apoptotic cells) on mus musculus mouse C2C12 cells after 24 h of treatment. Incubation of mus musculus mouse C2C12 cells with [1,2-¹³C₂]-glucose during 24 h, subsequent quantification of ¹³C isotopologues distribution in key metabolites of glucose metabolic network and a computational fluxomic analysis using in-house developed software (Isodyn) showed that PPD is inhibiting glycolysis, non-oxidative pentose phosphate pathway, glycogen turnover, and ATPAse reaction leading to a reduction in ATP synthesis. These findings unveil the glucose metabolism collapse, which is consistent with a decrease in cell viability observed in PPD-treated C2C12 cells and with the myoglubinuria and other effects observed in Wistar Rats treated with PPD. These findings shed new light on muscle dysfunction associated to PPD exposure, opening new avenues for cost-effective therapies in Rhabdomyolysis disease.