Nontraumatic rhabdomyolysis with short-term alcohol intoxication - a case report

When Vaping Isn't Actually Safer: A Death From Toxic Alcohol Contaminated Vape Juice

ABSTRACT

Vape juice is a diluent for e-cigarette active ingredients, nicotine or tetrahydrocannabinol (THC). Lack of strict regulation in vape juice production is a concern as ingredients and their concentrations may vary widely from the labeling.A 43-year-old woman was transported via ambulance to the hospital after ingesting homemade vape juice, presenting unresponsive with decerebrate posturing. She reportedly made a tincture combining a vape juice purchased online (containing "ethylene glycol") and THC for "endometriosis-related pain relief." Laboratory evaluation revealed anion gap metabolic acidosis, elevated serum lactate, and high serum osmolality. Urine fluoresced under Wood's lamp, and fomepizole was administered as an ethylene glycol antidote, but she expired the following afternoon. Clinical serum toxicology results returned after death revealed 235 mg/dL of methanol, and no ethylene glycol.Autopsy findings included ischemic changes of the gastrointestinal tract and cerebral edema with herniation. Postmortem toxicology performed on hospital admission blood revealed methanol (220 mg/dL), propylene glycol (59 mg/dL), Δ-9 THC and metabolites, and medications administered during hospitalization. The medical examiner determined the cause of death to be methanol and propylene glycol toxicity.To our knowledge, this is the first report of accidental death from ingestion of vape juice contaminated with toxic alcohol.

Breast cancer, alcohol, and phosphate toxicity

Alcohol consumption is associated with an increased risk of breast cancer, even at low alcohol intake levels, but public awareness of the breast cancer risk associated with alcohol intake is low. Furthermore, the causative mechanisms underlying alcohol's association with breast cancer are unknown. The present theoretical paper uses a modified grounded theory method to review the research literature and propose that alcohol's association with breast cancer is mediated by phosphate toxicity, the accumulation of excess inorganic phosphate in body tissue. Serum levels of inorganic phosphate are regulated through a network of hormones released from the bone, kidneys, parathyroid glands, and intestines. Alcohol burdens renal function, which may disturb the regulation of inorganic phosphate, impair phosphate excretion, and increase phosphate toxicity. In addition to causing cellular dehydration, alcohol is an etiologic factor in nontraumatic rhabdomyolysis, which ruptures cell membranes and releases inorganic phosphate into the serum, leading to hyperphosphatemia. Phosphate toxicity is also associated with tumorigenesis, as high levels of inorganic phosphate within the tumor microenvironment activate cell signaling pathways and promote cancer cell growth. Furthermore, phosphate toxicity potentially links cancer and kidney disease in onco-nephrology. Insights into the mediating role of phosphate toxicity may lead to future research and interventions that raise public health awareness of breast cancer risk and alcohol consumption.

Elevated creatinine kinase levels amongst Dutch adolescents with acute alcohol intoxication

This study aims to explore the prevalence of creatinine kinase elevation amongst a sample of Dutch adolescents admitted for acute alcohol intoxication. The data on all admitted adolescents < 18 years old with acute alcohol intoxication between 2008 and 2021 were collected from a Dutch major district general hospital, Reinier de Graaf Gasthuis, in Delft. Overall, 495 adolescents who were treated for symptoms of acute alcohol intoxication during this period were included in the study. When evaluating the blood samples of the included patients, elevated creatinine kinase levels were found in 60% of the cases, with a mean of 254 U/I (normal value ≤ 145 U/I). A confirmed diagnosis of rhabdomyolysis (increase in CK > fivefold the upper limit of normal) was present in 4.4% of cases. Moreover, using a linear regression this study found that a higher blood alcohol concentration was associated with higher creatinine kinase levels, when adjusted for positive drug screenings amongst the adolescents with acute alcohol intoxication (p = 0.027; β = 66.88; 95% CI 7.68 - 126.08).    Conclusions: This is the first study focusing on how acute alcohol intoxication affects adolescents' muscle tissue. The results could potentially help to prevent alcohol use within the sports world. It could also aid understanding of how acute alcohol intoxication influences the breakdown of adolescents' muscle tissue. What is Known: • Alcohol, alongside pharmaceutical agents and illicit drugs, is a significant cause of rhabdomyolysis (increase in creatinine kinase > fivefold the upper limit of normal). • Creatinine kinase elevation in alcohol intoxicated patients may be as a result of direct "muscular" toxicity" (myotoxicity) or from prolonged immobilization and ischemic compression induced by coma. What is New: • Our retrospective cohort study is a pioneer in addressing the effect of acute alcohol intoxication amongst adolescents (< 18 years) upon muscle tissue (creatinine kinase level) within a large population. When evaluating the blood samples of the included population, elevated creatinine kinase levels were found in 60% of the cases, with a mean of 254 U/I (normal value ≤ 145 U/I). • There is an association between alcohol intoxication and elevated creatinine kinase levels amongst adolescents. Future research is needed to further understand the pathophysiology and causality of this interaction.

[Myorenal syndrome in forensic practice: molecular aspects of etiology and pathogenesis]

The objective of the study is to analyze the publications on biochemical aspects of myorenal syndrome (crush-syndrome) pathogenesis. Factors of trauma and other etiologies significant in terms of forensic practice that cause muscle tissue destruction are presented. Molecular processes in rhabdomyolysis and subsequent renal damage, the establishment of the sequence of which is important for forensic medicine, are outlined. The study results will improve our understanding of the of myorenal syndrome pathophysiology, its biochemical features, and optimize methods for its forensic diagnosis.

A Rare Complication of Rhabdomyolysis: Peripheral Neuropathy

Rhabdomyolysis is a complex medical condition characterized by muscle necrosis and the release of intracellular components into the circulation. Although its most common cause is a direct traumatic injury, it can result from non-traumatic factors as well, including infection, toxins, and drugs. Serum creatine phosphokinase (CPK) levels are usually elevated in this condition and they correlate with the severity of the muscle damage (the higher the CPK peak, the greater the magnitude of muscle damage), although lower levels of CPK do not necessarily rule it out. The common complications associated with rhabdomyolysis include acute kidney injury, compartment syndrome, and, in rare cases, peripheral neuropathy. In this report, we present a case of a young patient, with a history of alcohol abuse, who presented with bilateral numbness of the feet post-immobilization and was subsequently found to have severe rhabdomyolysis.

Rhabdomyolysis in drug-related deaths

Background

This study aims to detect myoglobin staining in the cases in which were suspected that intoxication was the cause of death.

Materials and method

This study selected the drug-related death cases including those with toxic blood levels of substances. These drug-related death cases were classified into two groups: (1) suggestive of intoxication death group and (2) other causes of death group which was control group. The kidneys of all these cases were immunohistochemically stained with the myoglobin antibody for rhabdomyolysis diagnosis.

Results

There were 50 drug-related deaths separated into 28 study cases and 22 control cases. The positive myoglobin stain was found in 17 cases (60.7%) in the study group and 5 cases (22.7%) in the control group. The difference between two groups was statistically significant (p = 0.007).

Conclusions

Myoglobin detection in kidney by immunohistochemistry should be done to help for confirming the cause of deaths in these drug-related death cases.

Nebulized ivermectin for COVID-19 and other respiratory diseases, a proof of concept, dose-ranging study in rats

Ivermectin is a widely used antiparasitic drug with known efficacy against several single-strain RNA viruses. Recent data shows significant reduction of SARS-CoV-2 replication in vitro by ivermectin concentrations not achievable with safe doses orally. Inhaled therapy has been used with success for other antiparasitics. An ethanol-based ivermectin formulation was administered once to 14 rats using a nebulizer capable of delivering particles with alveolar deposition. Rats were randomly assigned into three target dosing groups, lower dose (80-90 mg/kg), higher dose (110-140 mg/kg) or ethanol vehicle only. A toxicology profile including behavioral and weight monitoring, full blood count, biochemistry, necropsy and histological examination of the lungs was conducted. The pharmacokinetic profile of ivermectin in plasma and lungs was determined in all animals. There were no relevant changes in behavior or body weight. There was a delayed elevation in muscle enzymes compatible with rhabdomyolysis, that was also seen in the control group and has been attributed to the ethanol dose which was up to 11 g/kg in some animals. There were no histological anomalies in the lungs of any rat. Male animals received a higher ivermectin dose adjusted by adipose weight and reached higher plasma concentrations than females in the same dosing group (mean Cmax 86.2 ng/ml vs. 26.2 ng/ml in the lower dose group and 152 ng/ml vs. 51.8 ng/ml in the higher dose group). All subjects had detectable ivermectin concentrations in the lungs at seven days post intervention, up to 524.3 ng/g for high-dose male and 27.3 ng/g for low-dose females. nebulized ivermectin can reach pharmacodynamic concentrations in the lung tissue of rats, additional experiments are required to assess the safety of this formulation in larger animals.

Binge alcohol consumption leading to hypokalemic rhabdomyolysis

A 43-year-old man presented with acute onset rapidly progressive weakness in all four limbs (proximal greater than distal), following an episode of binge alcohol ingestion, and was admitted for evaluation and management. There was a history of decreased urine output since 2 days with dark-coloured urine. He was found to have severe hypokalemia and renal dysfunction. Serum creatine kinase was significantly high, and further investigation revealed significantly elevated serum and urine myoglobin levels suggestive of rhabdomyolysis, which was secondary to severe hypokalemia. Following supplementation with intravenous and oral potassium and supportive care, the weakness improved significantly, and he was subsequently discharged. This case describes severe hypokalemia, resulting in rhabdomyolysis and generalised lower motor neuron weakness, in a setting of binge alcohol ingestion, which is an entity rarely described in literature.

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

Evaluation of Acute Alcohol Intoxication as the Primary Cause of Death: A Diagnostic Challenge for Forensic Pathologists

Deaths caused by acute alcohol intoxication (AAI) remain a major public health issue. This study is retrospective and descriptive: an 8-year case analysis of deaths due to AAI in Maryland. Study showed that of 150 AAI deaths, the death rate among Hispanics (10.41/100,000 population) was significantly higher than all the non-Hispanics combined (1.88/100,000 population). The majority of individuals were young adults, overweight, and binge drinkers. The obese group showed significantly lower mean heart and peripheral blood alcohol concentration (BAC) (0.36%, 0.37%) than the normal weight group (0.45%, 0.42%). Based on the PBAC and urine AC ratio, 49.6% deaths likely occurred close to peak phase, followed by postabsorptive phase (31.6%) and absorptive phase (18.8%). Our results indicate that forensic pathologists should evaluate postmortem BAC in the light of individual's age, drinking history, body weight, possible phase of alcohol intoxication, and other autopsy findings when certifying AAI as primary cause of death.

Spinning Out of Control: A 19-Year-Old Female with Spinning-Related Exertional Thigh Compartment Syndrome

Thigh compartment syndrome (TCS) is a rare condition caused by high pressures within the fascial compartments of the thigh, impeding capillary flow and leading to decreased perfusion, tissue hypoxia, and necrosis. TCS is most frequently associated with trauma and anticoagulation but has also rarely been associated with exercise-related injury. We present the case of a 19-year-old female who reported painful swelling in her thighs and darkening of her urine after participating in a spinning class. On physical examination, the patient was found to have tight, painful thigh compartments with extreme tenderness on passive motion. Labs revealed a marked elevation of creatine kinase and leukocytosis. The patient was diagnosed with TCS and underwent emergent decompression fasciotomy and aggressive IV fluids for protection against myoglobinuria. Due to high clinical suspicion, prompt diagnosis, and early surgery, the patient experienced excellent recovery without functional deficits. 

Non-cardiogenic pulmonary edema, rhabdomyolysis and myocardial injury following heroin inhalation: a case report

BACKGROUND

Heroin use by non-injecting routes of administration (snorting, swallowing, "chasing the dragon") is considered to be safer but is not risk-free for fatal overdose or serious side effects. We report the case of an adolescent who was transferred unconscious to the emergency department after heroin inhalation. Description of the case: A 17-year-old male was transferred to the emergency department unconscious (Glasgow coma scale: 6/15) after heroin inhalation. He was treated with non-rebreather mask and intravenous infusion of naloxone with gradual improvement of consciousness and arterial blood gasses. The chest computed tomography showed signs of acute respiratory distress syndrome. Laboratory exams on the second day of hospitalization showed elevated creatine kinase (CK) and troponin-I levels while his electrocardiography (ECG) showed J-point elevation in V1, V2, and V3 precordial leads. On the second day of hospitalization the pulmonary infiltrates were not present in his chest X-ray while on the eighth day, troponin-I and CK levels were normalized without dynamic ECG changes and the patient was discharged uneventfully.

CONCLUSION

Heroin inhalation may cause severe complications, such as non-cardiogenic pulmonary edema, rhabdomyolysis or myocardial injury. Hippokratia 2016, 20(1): 84-87.

Rhabdomyolysis induced AKI via the regulation of endoplasmic reticulum stress and oxidative stress in PTECs

Mechanism for the role of ER stress and oxidative stress activation in rhabdomyolysis-associated AKI.