A crack addict with extremely high creatine kinase levels

Acute rhabdomyolysis and renal failure in HIV-infected patients: risk factors, presentation, and pathophysiology

Rhabdomyolysis is a common cause of acute renal failure and may be related to a variety of predisposing factors. This entity has been increasingly recognized in HIV-infected individuals and is an important cause of morbidity and mortality. We present a series of seven HIV-positive patients admitted with rhabdomyolysis over a 5-year period; three developed acute renal failure. Infections and substance abuse were the most common risk factors identified; an average of three predisposing factors was present in each case. All patients showed resolution of creatinine phosphokinase (CPK) elevation and serum creatinine returned to the normal range in the three patients who developed renal insufficiency; however, all patients required prolonged hospitalization and one patient died of sepsis. The pathophysiological mechanisms of muscle injury in our patients are reviewed and their bearing on prognosis discussed. It is concluded that clinicians should have a high index of suspicion for the development of rhabdomyolysis in HIV-infected patients with a combination of noncompliance with medical therapy and/or substance abuse and acute infection. With comprehensive supportive care, the prognosis of acute rhabdomyolysis in this population may be reasonably good.

Cocaine-associated rhabdomyolysis and excited delirium: different stages of the same syndrome

Previous case reports indicate that cocaine-associated rhabdomyolysis and excited delirium share many similar features, suggesting that they may be different stages of the same syndrome. We tested this hypothesis by comparing data from 150 cases of cocaine-associated rhabdomyolysis reported in the medical literature with data from an autopsy registry for 58 victims of fatal excited delirium and 125 victims of fatal acute cocaine toxicity. Patients with rhabdomyolysis are similar to victims of fatal excited delirium with regard to age; gender; race; route of cocaine administration; the experiencing of excitement, delirium, and hyperthermia; and the absence of seizures. Compared with victims of fatal acute cocaine toxicity, patients with rhabdomyolysis are different with regard to each of these variables. Compared with victims of fatal acute cocaine toxicity, both victims of rhabdomyolysis and fatal excited delirium are more likely to be black, male, and younger; to have administered cocaine by smoking or injection; and to have experienced excitement, delirium, and hyperthermia; they are also less likely to have had seizures. Because cocaine-associated rhabdomyolysis and excited delirium have similar clinical features and risk factors, occur in similar populations of drug users, and can be explained by the same pathophysiologic processes, we conclude that they are different stages of the same syndrome. It appears that this syndrome is caused by changes in dopamine processing induced by chronic and intense use of cocaine rather than by the acute toxic effects of the drug.

Severe rhabdomyolysis with renal failure after intranasal cocaine use

A case of acute renal failure due to rhabdomyolysis in a patient who used cocaine on a daily basis is presented. In contrast to many prior reports of renal failure occurring with cocaine-associated rhabdomyolysis, our patient did not use intravenous cocaine and did not have any evidence of trauma, seizure, hypotension, hyperthermia, hyperactivity, or coma. His creatine phosphokinase peaked at 448,000 U/liter. He was treated initially with forced diuresis and i.v. furosemide, but he became oliguric, developed pulmonary edema, and required hemodialysis. He recovered fully after 3 weeks of dialysis. The literature is reviewed in an attempt to delineate a rational approach to evaluating cocaine users at risk for rhabdomyolysis.

Rhabdomyolysis and hyperthermia after cocaine abuse: a variant of the neuroleptic malignant syndrome?

Rhabomyolysis with myoglobinuria has been added relatively recently to the neurologic complications associated with the increased use of cocaine and the introduction of its alkaloid form (crack). This retrospective study reports our experience with 14 patients who presented with rhabdomyolysis after cocaine use in a municipal hospital over a 3-year period. Seven patients used "crack", 2 intravenous and 3 nasal insufflation. All patients but one had hyperthermia, 11 altered mental status, 8 tachycardia, and 4 muscle rigidity. Nine developed renal failure; 3 of these patients died. Two other patients died of cardiorespiratory arrest. Cocaine-related rhabdomyolysis has a high mortality. The observed association with hyperthermia and other central neurologic features resembles the neuroleptic malignant syndrome. Since chronic cocaine use may alter the availability of dopamine either through transmitter depletion or decrease in the number of dopamine receptors, a common pathogenetic mechanism is possible. However, other mechanisms, which are not mutually exclusive but rather frequently overlapping, may play an important role. These include agitation, hyperthermia, adrenergic overstimulation leading to vasoconstriction and ischemia or calcium release from the sarcoplasmic reticulum resulting in increased entry into the muscle cell leading to cell death; in addition, cocaine has direct toxic effect on the muscles.