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Al Bizri L, Do A, Ouellette DR. Extreme Elevation of Creatine Kinase in a Young Male Patient With Recurrent Rhabdomyolysis. Cureus 2022; 14:e24817. [PMID: 35686273 PMCID: PMC9170544 DOI: 10.7759/cureus.24817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2022] [Indexed: 12/02/2022] Open
Abstract
Rhabdomyolysis is a common cause of admission to the intensive care unit. However, recurrent rhabdomyolysis remains a rare encounter for intensivists and presents a challenge in terms of identifying its etiology. Considerations of metabolic myopathies as a culprit remain underexplored. We present a case of a patient with recurrent rhabdomyolysis with extreme elevation of creatine kinase.
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2
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Guo Q, Lin H, Lin J. Chlorpheniramine poisoning as a potential cause of rhabdomyolysis: A case report and literature review. Am J Emerg Med 2022; 57:236.e1-236.e3. [DOI: 10.1016/j.ajem.2022.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 03/21/2022] [Accepted: 04/07/2022] [Indexed: 10/18/2022] Open
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3
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Samura M, Hirose N, Kurata T, Takada K, Nagumo F, Koshioka S, Ishii J, Uchida M, Inoue J, Enoki Y, Taguchi K, Higashita R, Kunika N, Tanikawa K, Matsumoto K. Identification of Risk Factors for Daptomycin-Associated Creatine Phosphokinase Elevation and Development of a Risk Prediction Model for Incidence Probability. Open Forum Infect Dis 2021; 8:ofab568. [PMID: 34888403 PMCID: PMC8651170 DOI: 10.1093/ofid/ofab568] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 11/09/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND In this study, we investigated the risk factors for daptomycin-associated creatine phosphokinase (CPK) elevation and established a risk score for CPK elevation. METHODS Patients who received daptomycin at our hospital were classified into the non-elevated or elevated CPK group based on their peak CPK levels during daptomycin therapy. Univariable and multivariable analyses were performed, and a risk score and prediction model for the incidence probability of CPK elevation were calculated based on logistic regression analysis. RESULTS The non-elevated and elevated CPK groups included 181 and 17 patients, respectively. Logistic regression analysis revealed that concomitant statin use (odds ratio [OR], 4.45 [95% confidence interval {CI}, 1.40-14.47]; risk score 4), concomitant antihistamine use (OR, 5.66 [95% CI, 1.58-20.75]; risk score 4), and trough concentration (Cmin) between 20 and <30 µg/mL (OR, 14.48 [95% CI, 2.90-87.13]; risk score 5) and ≥30.0 µg/mL (OR, 24.64 [95% CI, 3.21-204.53]; risk score 5) were risk factors for daptomycin-associated CPK elevation. The predicted incidence probabilities of CPK elevation were <10% (low risk), 10%-<25% (moderate risk), and ≥25% (high risk) with total risk scores of ≤4, 5-6, and ≥8, respectively. The risk prediction model exhibited a good fit (area under the receiver operating characteristic curve, 0.85 [95% CI, .74-.95]). CONCLUSIONS These results suggested that concomitant use of statins with antihistamines and Cmin ≥20 µg/mL were risk factors for daptomycin-associated CPK elevation. Our prediction model might aid in reducing the incidence of daptomycin-associated CPK elevation.
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Affiliation(s)
- Masaru Samura
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Tokyo, Japan
- Department of Pharmacy, Yokohama General Hospital, Kanagawa, Japan
| | - Naoki Hirose
- Department of Pharmacy, Yokohama General Hospital, Kanagawa, Japan
| | - Takenori Kurata
- Department of Pharmacy, Yokohama General Hospital, Kanagawa, Japan
| | - Keisuke Takada
- Department of Pharmacy, Yokohama General Hospital, Kanagawa, Japan
| | - Fumio Nagumo
- Department of Pharmacy, Yokohama General Hospital, Kanagawa, Japan
| | - Sakura Koshioka
- Department of Pharmacy, Yokohama General Hospital, Kanagawa, Japan
| | - Junichi Ishii
- Department of Pharmacy, Yokohama General Hospital, Kanagawa, Japan
| | - Masaki Uchida
- Department of Pharmacy, Yokohama General Hospital, Kanagawa, Japan
| | - Junki Inoue
- Department of Pharmacy, Yokohama General Hospital, Kanagawa, Japan
| | - Yuki Enoki
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Kazuaki Taguchi
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Ryuji Higashita
- Wound Care Center, Yokohama General Hospital, Kanagawa, Japan
| | - Norifumi Kunika
- Internal Medicine, Yokohama General Hospital, Kanagawa, Japan
| | - Koji Tanikawa
- Department of Pharmacy, Yokohama General Hospital, Kanagawa, Japan
| | - Kazuaki Matsumoto
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Tokyo, Japan
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4
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Hughes AR, Lin A, Hendrickson RG. Clinical and patient characteristics associated with severe outcome in diphenhydramine toxicity. Clin Toxicol (Phila) 2021; 59:918-925. [PMID: 33666139 DOI: 10.1080/15563650.2021.1891244] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Diphenhydramine is frequently misused and ingested recreationally for its antihistaminergic and antimuscarinic effects and is often involved in both serious and fatal poisonings, either in isolation or in combination with other xenobiotics. OBJECTIVE This analysis sought to determine which patient and encounter characteristics were associated with severe outcome after diphenhydramine overdose. METHODS This is an analysis of the multi-center ToxIC registry (2010-2016). Descriptive analysis of all cases with diphenhydramine listed as the "primary agent" contributing to toxicity were included. Analysis sought to determine which patient and encounter characteristics were associated with severe outcome, defined as occurrence of seizure, ventricular dysrhythmia, or intubation. To determine which patient and encounter characteristics were individually associated with severe outcome, we performed chi-square tests. Fisher's exact tests were used in the case of sparse data. We also performed multivariable logistic regression to further determine independent risk factors for severe outcome in diphenhydramine overdose. RESULTS Eight hundred and sixty-three cases remained after exclusion with 15.6% (n = 135) of all patients having one or more severe outcome. The most common severe outcome was seizures which occurred in 98 (11.6%) of all ingestions. Females comprised 59.1% (n = 510) of all ingestions. Most ingestions were intentional (86.0%, n = 742) with the most common known reason for an intentional ingestion being self-harm, accounting for 37.5% (n = 324) of all ingestions. Self-harm ingestions and ingestions in males were more commonly associated with intubation. When examining outcomes by age, there were no significant differences overall or in any individual outcome except intubation in which children 0-12 were less likely to be intubated as compared to teens and adults. Signs and symptoms most strongly associated with a severe outcome included acidemia (pH < 7.2), QRS prolongation (QRS > 120 ms), and elevated anion gap (AG > 20). DISCUSSION Acidemia, QRS prolongation, and elevated anion gap are associated with severe outcomes in diphenhydramine toxicity. Further research is warranted to determine their predictive characteristics.
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Affiliation(s)
- Adrienne R Hughes
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, USA.,Oregon Poison Center, Portland, OR, USA
| | - Amber Lin
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Robert G Hendrickson
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, USA.,Oregon Poison Center, Portland, OR, USA
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5
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Skryabin VY, Zastrozhin M, Sychev DA. Olanzapine-Associated Rhabdomyolysis: A Case Report. Cureus 2021; 13:e12568. [PMID: 33564555 PMCID: PMC7863024 DOI: 10.7759/cureus.12568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
This paper presents the case of a 20-year-old patient with a suspected diagnosis of paranoid schizophrenia. He was prescribed oral olanzapine at a dose of 10 mg per day, and the treatment was associated with rhabdomyolysis (serum creatine kinase = 9,725 U/L on day four of the therapy). On suspicion of its contribution to rhabdomyolysis, olanzapine was immediately withdrawn. Pharmacogenetic testing demonstrated that the patient’s CYP2D6 genotype was *4/*4 (1846G>A, rs3892097). Based on these results, the patient was switched to trifluoperazine, a medication that is not metabolized by the CYP2D6 isoenzyme. Subsequently, the patient recovered well and was discharged without any nephrological sequelae. The presented case demonstrates that pharmacogenetic‐guided personalization of treatment may allow selecting the best medication and determining the right dosage, resulting in the reduced risk of adverse drug reactions and pharmacoresistance.
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Affiliation(s)
- Valentin Y Skryabin
- Department No. 2, Moscow Research and Practical Centre on Addictions, Moscow, RUS
| | - Michael Zastrozhin
- Laboratory of Genetics and Fundamental Studies, Moscow Research and Practical Centre on Addictions, Moscow, RUS
| | - Dmitry A Sychev
- Clinical Pharmacology and Therapy Department, Russian Medical Academy of Continuous Professional Education of the Ministry of Health of the Russian Federation, Moscow, RUS
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6
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Ali Z, Khan M, Ullah W, Kpehor AA, Cheema MA. QT interval prolongation and rhabdomyolysis associated with diphenhydramine toxicity: a case report. J Community Hosp Intern Med Perspect 2020; 10:151-153. [PMID: 32850053 PMCID: PMC7425623 DOI: 10.1080/20009666.2020.1749511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Diphenhydramine is a widely available, over-the-counter medication used for allergies and as a sleeping aid. When used in prescription doses, it is generally safe. Overdose of the medication has been associated with dangerous and life-threatening outcomes. Our case describes diphenhydramine toxicity manifesting with two rare but potentially life-threatening complications, rhabdomyolysis, and QT prolongation. Laboratory testing for diphenhydramine levels are not widely available. We recommend a high degree of suspicion for these complications when evaluating patients with diphenhydramine overdose, to adequately manage and prevent untoward outcomes.
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Affiliation(s)
- Zain Ali
- Internal Medicine, Abington Memorial Hospital, Abington, PA, USA
| | - Mariya Khan
- Civil Hospital, Dow University of Health Sciences, Karachi, Pakistan
| | - Waqas Ullah
- Internal Medicine, Abington Memorial Hospital, Abington, PA, USA
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7
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Saadi R, Bohnenberger K. Physostigmine for Antimuscarinic Toxicity. J Emerg Nurs 2020; 46:126-128. [PMID: 31918808 DOI: 10.1016/j.jen.2019.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 08/21/2019] [Accepted: 09/09/2019] [Indexed: 11/29/2022]
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8
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Dare RK, Tewell C, Harris B, Wright PW, Van Driest SL, Farber-Eger E, Nelson GE, Talbot TR. Effect of Statin Coadministration on the Risk of Daptomycin-Associated Myopathy. Clin Infect Dis 2018; 67:1356-1363. [PMID: 29668884 PMCID: PMC6186852 DOI: 10.1093/cid/ciy287] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 04/14/2018] [Indexed: 01/13/2023] Open
Abstract
Background Daptomycin-associated myopathy has been identified in 2%-14% of patients, and rhabdomyolysis is a known adverse effect. Although risk factors for daptomycin-associated myopathy are poorly defined, creatine phosphokinase (CPK) monitoring and temporary discontinuation of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, or "statins," has been recommended. Methods We conducted a single-center, retrospective, matched case-control risk factor analysis in adult and pediatric patients from 2004 to 2015. Patients in whom myopathy (defined as CPK values above the upper limit of normal) developed during daptomycin treatment were matched 1:1 to no-myopathy controls with at least the same duration of therapy. Risk factors independently associated with myopathy were determined using multivariable conditional logistic regression. Secondary analysis was performed in patients with rhabdomyolysis, defined as CPK values ≥10 times the upper limit of normal. Results Of 3042 patients reviewed, 128 (4.2%) were identified as having daptomycin-associated myopathy, 25 (0.8%) of whom had rhabdomyolysis; 121 (95%) of the 128 were adults, and the mean duration of therapy before CPK elevation was 16.7 days (range, 1-58 days). In multivariate analysis, deep abscess treatment (odds ratio, 2.80; P = .03), antihistamine coadministration (3.50; P = .03), and statin coadministration (2.60; P = .03) were independent risk factors for myopathy. Obesity (odds ratio, 3.28; P = .03) and statin coadministration (4.67; P = .03) were found to be independent risk factors for rhabdomyolysis, and older age was associated with reduced risk (0.97; P = .05). Conclusions Statin coadministration with daptomycin was independently associated with myopathy and rhabdomyolysis. This is the first study to provide strong evidence supporting this association. During coadministration, we recommend twice-weekly CPK monitoring and consideration of withholding statins.
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Affiliation(s)
- Ryan K Dare
- Division of Infectious Diseases, Department of Medicine, University of Arkansas for Medical Sciences, Little Rock
| | | | - Bryan Harris
- Division of Infectious Diseases, Department of Medicine, Nashville, Tennessee
| | - Patty W Wright
- Division of Infectious Diseases, Department of Medicine, Nashville, Tennessee
| | - Sara L Van Driest
- Division of General Pediatrics, Department of Pediatrics, Nashville, Tennessee
- Division of Clinical Pharmacology, Department of Medicine, Nashville, Tennessee
| | - Eric Farber-Eger
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - George E Nelson
- Division of Infectious Diseases, Department of Medicine, Nashville, Tennessee
| | - Thomas R Talbot
- Division of Infectious Diseases, Department of Medicine, Nashville, Tennessee
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9
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Lee YF, Mao WC, Tai YM, Chang HA, Kao YC, Huang SY, Tzeng NS. Delayed-onset rhabdomyolysis related to olanzapine: a case report. Singapore Med J 2016; 57:279. [PMID: 27212263 DOI: 10.11622/smedj.2016094] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Yen-Feng Lee
- Department of Psychiatry, Tri-Service General Hospital - Beitou Branch, National Defense Medical Center, Taipei, Taiwan ROC.,Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan ROC
| | - Wei-Chung Mao
- Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan ROC
| | - Yueh-Ming Tai
- Department of Psychiatry, Tri-Service General Hospital - Beitou Branch, National Defense Medical Center, Taipei, Taiwan ROC.,Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan ROC
| | - Hsin-An Chang
- Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan ROC.,Student Counseling Center, National Defense Medical Center, Taipei, Taiwan ROC
| | - Yu-Chen Kao
- Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan ROC.,Department of Psychiatry, Tri-Service General Hospital - Songshan Branch, National Defense Medical Center, Taipei, Taiwan ROC.
| | - San-Yuan Huang
- Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan ROC
| | - Nian-Sheng Tzeng
- Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan ROC.,Student Counseling Center, National Defense Medical Center, Taipei, Taiwan ROC
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10
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Garnier R, Blanc-Brisset I, Langrand J, Villa A. Toxicité aiguë de la doxylamine. Revue bibliographique. TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2016. [DOI: 10.1016/j.toxac.2016.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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11
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Oritani S, Michiue T, Chen JH, Tani N, Ishikawa T. Biodistribution of diphenhydramine in reproductive organs in an overdose case. Hum Cell 2016; 30:106-116. [PMID: 27838883 DOI: 10.1007/s13577-016-0151-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 10/26/2016] [Indexed: 10/20/2022]
Abstract
Motion sickness medications such as Travelmin® prescribed in Japan include diphenhydramine (DPH), dyphylline, diphenidol, and/or caffeine. Herein, we report a patient who died due to rhabdomyolysis after ingesting a DPH containing motion sickness medication. A Japanese male in his 30 s reported missing after going out for a drive early in the morning was found dead in his car in the evening of the same day. An autopsy showed moderate edema, congestion, and several petechiae in both lungs. The brain was congested and edematous with no atherosclerosis of cerebral arteries. The prostate and both testes were slightly edematous. Gastric contents included approximately 15 mL of dark-brown fluid without tablets or food residue. Toxicological examination showed that blood DPH levels in all tissues were between 4.90 and 7.27 μg/mL, which represented toxic to lethal levels. DPH (μg/mL) levels were approximately 3-9 times higher in the prostate (73.42) and testes (left, 28.23; right, 30.09) than those in all regions of the brain (range 7.75-12.33). Blood dyphylline, diphenidol and caffeine levels in reproductive organs reached high, but not toxic levels. In conclusion, DPH, dyphylline, diphenidol, and caffeine levels were higher in reproductive organs such as the prostate and testes than in the central nervous system and heart. As we determined in this case, motion sickness medications might accumulate in reproductive organs. Thus, further examination of tissue biodistribution of DPH, dyphylline, diphenidol, and caffeine is necessary to assess their potential long-term effects in these sites.
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Affiliation(s)
- Shigeki Oritani
- Department of Legal Medicine, Osaka City University Medical School, Asahi-machi 1-4-3, Abeno, Osaka, 545-8585, Japan
| | - Tomomi Michiue
- Department of Legal Medicine, Osaka City University Medical School, Asahi-machi 1-4-3, Abeno, Osaka, 545-8585, Japan.,Forensic Autopsy Section, Medico-legal Consultation and Postmortem Investigation Support Center, c/o Department of Legal Medicine, Osaka City University Medical School, Asahi-machi 1-4-3, Abeno, Osaka, 545-8585, Japan
| | - Jian-Hua Chen
- Department of Legal Medicine, Osaka City University Medical School, Asahi-machi 1-4-3, Abeno, Osaka, 545-8585, Japan.,Forensic Autopsy Section, Medico-legal Consultation and Postmortem Investigation Support Center, c/o Department of Legal Medicine, Osaka City University Medical School, Asahi-machi 1-4-3, Abeno, Osaka, 545-8585, Japan
| | - Naoto Tani
- Department of Legal Medicine, Osaka City University Medical School, Asahi-machi 1-4-3, Abeno, Osaka, 545-8585, Japan.,Forensic Autopsy Section, Medico-legal Consultation and Postmortem Investigation Support Center, c/o Department of Legal Medicine, Osaka City University Medical School, Asahi-machi 1-4-3, Abeno, Osaka, 545-8585, Japan
| | - Takaki Ishikawa
- Department of Legal Medicine, Osaka City University Medical School, Asahi-machi 1-4-3, Abeno, Osaka, 545-8585, Japan. .,Forensic Autopsy Section, Medico-legal Consultation and Postmortem Investigation Support Center, c/o Department of Legal Medicine, Osaka City University Medical School, Asahi-machi 1-4-3, Abeno, Osaka, 545-8585, Japan.
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12
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Ely MR, Romero SA, Sieck DC, Mangum JE, Luttrell MJ, Halliwill JR. A single dose of histamine-receptor antagonists before downhill running alters markers of muscle damage and delayed-onset muscle soreness. J Appl Physiol (1985) 2016; 122:631-641. [PMID: 27493198 DOI: 10.1152/japplphysiol.00518.2016] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 07/13/2016] [Accepted: 07/28/2016] [Indexed: 11/22/2022] Open
Abstract
Histamine contributes to elevations in skeletal muscle blood flow following exercise, which raises the possibility that histamine is an important mediator of the inflammatory response to exercise. We examined the influence of antihistamines on postexercise blood flow, inflammation, muscle damage, and delayed-onset muscle soreness (DOMS) in a model of moderate exercise-induced muscle damage. Subjects consumed either a combination of fexofenadine and ranitidine (blockade, n = 12) or nothing (control, n = 12) before 45 min of downhill running (-10% grade). Blood flow to the leg was measured before and throughout 120 min of exercise recovery. Markers of inflammation, muscle damage, and DOMS were obtained before and at 0, 6, 12, 24, 48, and 72 h postexercise. At 60 min postexercise, blood flow was reduced ~29% with blockade compared with control (P < 0.05). Markers of inflammation were elevated after exercise (TNF-ɑ, IL-6), but did not differ between control and blockade. Creatine kinase concentrations peaked 12 h after exercise, and the overall response was greater with blockade (18.3 ± 3.2 kU·l-1·h-1) compared with control (11.6 ± 2.0 kU·l-1·h-1; P < 0.05). Reductions in muscle strength in control (-19.3 ± 4.3% at 24 h) were greater than blockade (-7.8 ± 4.8%; P < 0.05) and corresponded with greater perceptions of pain/discomfort in control compared with blockade. In conclusion, histamine-receptor blockade reduced postexercise blood flow, had no effect on the pattern of inflammatory markers, increased serum creatine kinase concentrations, attenuated muscle strength loss, and reduced pain perception following muscle-damaging exercise.NEW & NOTEWORTHY Histamine appears to be intimately involved with skeletal muscle during and following exercise. Blocking histamine's actions during muscle-damaging exercise, via common over-the-counter antihistamines, resulted in increased serum creatine kinase, an indirect marker of muscle damage. Paradoxically, blocking histamine's actions attenuated muscle strength loss and reduced perceptions of muscle pain for 72 h following muscle-damaging exercise. These results indicate that exercise-induced histamine release may have a broad impact on protecting muscle from exercise-induced damage.
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Affiliation(s)
- Matthew R Ely
- Department of Human Physiology, University of Oregon, Eugene, Oregon
| | - Steven A Romero
- Department of Human Physiology, University of Oregon, Eugene, Oregon
| | - Dylan C Sieck
- Department of Human Physiology, University of Oregon, Eugene, Oregon
| | - Joshua E Mangum
- Department of Human Physiology, University of Oregon, Eugene, Oregon
| | | | - John R Halliwill
- Department of Human Physiology, University of Oregon, Eugene, Oregon
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Abstract
BACKGROUND Rhabdomyolysis is a condition that is characterised by the breakdown of skeletal muscle tissue and leakage of intracellular myocyte contents into circulating blood. Rhabdomyolysis can lead to acute kidney injury (AKI) and is a potentially life-threatening condition. Studies have indicated that continuous renal replacement therapy (CRRT) may provide benefits for people with rhabdomyolysis by removing potentially damaging myoglobin and stabilising haemodynamic and metabolic status. OBJECTIVES We aimed to: i) assess the efficacy of CRRT in removing myoglobin; ii) investigate the influence of CRRT on mortality and kidney-related outcomes; and iii) evaluate the safety of CRRT for the treatment of people with rhabdomyolysis. SEARCH METHODS We searched the Cochrane Renal Group's Specialised Register to 6 January 2014 through contact with the Trials' Search Co-ordinator using search terms relevant to this review. We also searched China National Knowledge Infrastructure (from 1 January 1979 to 16 April 2013) and the Chinese Clinical Trials Register (to 16 April 2013). SELECTION CRITERIA All randomised controlled trials (RCTs) and quasi-RCTs that investigated clinical outcomes of CRRT for people with rhabdomyolysis were included. DATA COLLECTION AND ANALYSIS Two authors independently assessed studies for inclusion and extracted data. We derived risk ratios (RR) for dichotomous data and mean differences (MD) for continuous data with 95% confidence intervals (CI). Methodological risk of bias was assessed using the Cochrane risk of bias tool. MAIN RESULTS Of the three included studies (101 participants), one evaluated continuous arteriovenous haemodialysis and two investigated continuous venovenous haemofiltration; all included conventional therapy as control.We found significant decreases in myoglobin in patients among whom CRRT therapy was initiated on days four, eight, and 10 (day 4: MD -11.00 (μg/L), 95% CI -20.65 to -1.35; Day 8: MD -23.00 (μg/L), 95% CI -30.92 to -15.08; day 10: MD -341.87 (μg/L), 95% CI -626.15 to -57.59) compared with those who underwent conventional therapy.Although CRRT was associated with improved serum creatinine, blood urea nitrogen, and potassium levels; reduced duration of the oliguria phase; and was associated with reduced time in hospital, no significant differences were found in mortality rates compared with conventional therapy (RR 0.17, 95% CI 0.02 to 1.37). The included studies did not report on long-term outcomes or prevention of AKI.Overall, we found that study quality was suboptimal: blinding and randomisation allocation were not reported by any of the included studies, leading to the possibility of selection, performance and detection bias. AUTHORS' CONCLUSIONS Although CRRT may provide some benefits for people with rhabdomyolysis, the poor methodological quality of the included studies and lack of data relating to clinically important outcomes limited our findings about the effectiveness of CRRT for people with rhabdomyolysis.There was insufficient evidence to discern any likely benefits of CRRT over conventional therapy for people with rhabdomyolysis and prevention of rhabdomyolysis-induced AKI.
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Affiliation(s)
- Xiaoxi Zeng
- West China Hospital, Sichuan UniversityDepartment of Nephrology37 Guo Xue XiangChengduSichuanChina610041
| | - Ling Zhang
- West China Hospital, Sichuan UniversityDepartment of Nephrology37 Guo Xue XiangChengduSichuanChina610041
| | - Taixiang Wu
- West China Hospital, Sichuan UniversityChinese Clinical Trial Registry, Chinese Ethics Committee of Registering Clinical TrialsNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Ping Fu
- West China Hospital, Sichuan UniversityDepartment of Nephrology37 Guo Xue XiangChengduSichuanChina610041
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14
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Vearrier D, Curtis JA. Case files of the medical toxicology fellowship at Drexel University. Rhabdomyolysis and compartment syndrome following acute diphenhydramine overdose. J Med Toxicol 2011; 7:213-9. [PMID: 21656083 DOI: 10.1007/s13181-011-0157-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Affiliation(s)
- David Vearrier
- Division of Medical Toxicology, Department of Emergency Medicine, Drexel University College of Medicine, Philadelphia, PA 19102, USA.
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15
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Boutaud O, Roberts LJ. Mechanism-based therapeutic approaches to rhabdomyolysis-induced renal failure. Free Radic Biol Med 2011; 51:1062-7. [PMID: 21034813 PMCID: PMC3116013 DOI: 10.1016/j.freeradbiomed.2010.10.704] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2010] [Revised: 10/18/2010] [Accepted: 10/19/2010] [Indexed: 10/18/2022]
Abstract
Rhabdomyolysis-induced renal failure represents up to 15% of all cases of acute renal failure. Many studies over the past 4 decades have demonstrated that accumulation of myoglobin in the kidney is central in the mechanism leading to kidney injury. However, some discussion exists regarding the mechanism mediating this oxidant injury. Although the free-iron-catalyzed Fenton reaction has been proposed to explain the tissue injury, more recent evidence strongly suggests that the main cause of oxidant injury is myoglobin redox cycling and generation of oxidized lipids. These molecules can propagate tissue injury and cause renal vasoconstriction, two of the three main conditions associated with acute renal failure. This review presents the evidence supporting the two mechanisms of oxidative injury, describes the central role of myoglobin redox cycling in the pathology of renal failure associated with rhabdomyolysis, and discusses the value of therapeutic interventions aiming at inhibiting myoglobin redox cycling for the treatment of rhabdomyolysis-induced renal failure.
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Affiliation(s)
- Olivier Boutaud
- Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
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Martínez Sánchez L, Velasco Rodríguez J, Panzino Occhiuzzo F, Simó Nebot M, García Algar O, Luaces Cubells C. Detección de fenciclidina en el cribado toxicológico en orina: un falso positivo peligroso. An Pediatr (Barc) 2011; 74:418-9. [DOI: 10.1016/j.anpedi.2011.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2010] [Revised: 01/25/2011] [Accepted: 01/26/2011] [Indexed: 10/18/2022] Open
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Zeng X, Fu P. Continuous renal replacement therapy (CRRT) for rhabdomyolysis. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2010. [DOI: 10.1002/14651858.cd008566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Blackford MG, Fitzgibbon JJ, Reed MD. Assessment of serum creatine kinase among adolescent patients following jimsonweed (Datura stramonium) and moonflower (Datura inoxia) ingestions: a review of 11 cases. Clin Toxicol (Phila) 2010; 48:431-4. [PMID: 20524835 DOI: 10.3109/15563651003772946] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Datura stramonium (DS) (jimsonweed) is well known for its abuse potential for hallucinogenic effects and Datura inoxia (DI) (moonflower) has been abused for similar effects. To our knowledge, only one case report describes rhabdomyolysis in association with DS or DI ingestion. CASE IDENTIFICATION AND DETAILS Patient hospital charts were retrospectively screened from January 1, 2002 to December 31, 2007 to identify patients with qualifying ICD-9 codes for toxic plant ingestions. We report on 11 patient cases of DS/DI ingestions in which serum creatine kinase (CK) concentrations were monitored. These admissions occurred at our hospital over a 6-year period. Serum CK concentrations ranged from 72 to 70,230 U/L. Only three patients had serum CK concentrations greater than 1,000 U/L. One patient with a peak concentration of 70,230 U/L and a positive myoglobinuria was diagnosed with rhabdomyolysis. DISCUSSION Based on our review of the literature and these cases, it is possible that serum CK concentrations may be elevated more frequently than previously realized. The clinical significance of this abnormal laboratory value is uncertain with the majority of patients remaining asymptomatic without any clinical evidence of rhabdomyolysis.
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Affiliation(s)
- Martha G Blackford
- Divisions of Clinical Pharmacology and Toxicology and the Rebecca D. Considine Clinical Research Institute, Children's Hospital Medical Center of Akron, Akron, OH, USA
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Syed H, Som S, Khan N, Faltas W. Doxylamine toxicity: seizure, rhabdomyolysis and false positive urine drug screen for methadone. BMJ Case Rep 2009; 2009:bcr09.2008.0879. [PMID: 21686586 DOI: 10.1136/bcr.09.2008.0879] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The present report highlights the possible adverse effects of doxylamine, a common over the counter sleep aid. Doxylamine is an antihistamine that at toxic doses can cause anticholinergic effects, including seizures, rhabdomyolysis and death. The following case describes a patient with doxylamine toxicity who presented with seizure and confusion. Our patient was managed symptomatically, and remained otherwise stable throughout his hospitalisation. This case is atypical in terms of a delayed rhabdomyolysis and a false positive urine drug screen test for methadone. There is evidence that doxylamine at toxic levels can lead to false positives for methadone and phencyclidine testing using immunoassay-based urine drug screen kits. Urine drug screen testing on patients who are hospitalised is typically performed using immunoassays. However, in certain cases confirmatory secondary testing may be required. Doxylamine is prone to abuse and knowledge of the clinical presentation of its toxicity and the management of acute overdose can be life-saving.
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Affiliation(s)
- Husnain Syed
- Trinitas Hospital, Internal Medicine, 225 Williamson Ave, Elizabeth, New Jersey, 07207, USA
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Scharman EJ, Erdman AR, Wax PM, Chyka PA, Caravati EM, Nelson LS, Manoguerra AS, Christianson G, Olson KR, Woolf AD, Keyes DC, Booze LL, Troutman WG. Diphenhydramine and dimenhydrinate poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila) 2006; 44:205-23. [PMID: 16749537 DOI: 10.1080/15563650600585920] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
In 2003, there were 28,092 human exposures to diphenhydramine reported to poison centers in the US. A related drug, dimenhydrinate, is a less frequent cause of poisonings. Between January 2000 and June 2004, there were 2,534 reported dimenhydrinate ingestions in children less than 6 years of age. An evidence-based expert consensus process was used to create this guideline. Relevant articles were abstracted by a trained physician researcher. The first draft was created by the primary author. The entire panel discussed and refined the guideline before distribution to secondary reviewers for comment. The panel then made changes based on the secondary review comments. The objective of this guideline is to assist poison center personnel in the appropriate out-of-hospital triage and initial management of patients with a suspected ingestion of diphenhydramine or dimenhydrinate, or a dermal exposure to diphenhydramine. This guideline is based on an assessment of current scientific and clinical information. The expert consensus panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and the health professionals providing care, considering all of the circumstances involved. This guideline does not substitute for clinical judgment. The panel's recommendations for dermal or oral exposures to diphenhydramine or oral exposures to dimenhydrinate follow. The grade of recommendation is in parentheses: 1) All patients with suicidal intent, intentional abuse, or in cases in which a malicious intent is suspected (e.g., child abuse or neglect) should be referred to an emergency department (Grade D). 2) In patients without evidence of self-harm, abuse, or malicious intent, poison center personnel should elicit additional information including the time of the ingestion or dermal exposure, determination of the precise dose ingested, and the presence of co-ingestants (Grade D). 3) Patients experiencing any changes in behavior other than mild drowsiness or mild stimulation should be referred to an emergency department. Examples of moderate to severe symptoms that warrant referral include agitation, staring spells, inconsolable crying, hallucinations, abnormal muscle movements, loss of consciousness, seizures, or respiratory depression (Grade D). 4) For patients referred to the emergency department, transportation via ambulance should be considered based on several factors including the condition of the patient and the length of time it will take the patient to arrive at the emergency department (Grade D). 5) If the patient has no symptoms, and more than 4 hours have elapsed between the time of diphenhydramine ingestion and the call to the poison center, referral to an emergency department is not recommended. For dermal exposures to diphenhydramine, if the patient has no symptoms and it has been more than 8 hours since the diphenhydramine was thoroughly removed from the skin, referral to an emergency department is not recommended (Grade D). 6) Patients with acute ingestions of less than a toxic dose of diphenhydramine, or chronic exposures to diphenhydramine and no or mild symptoms, can be observed at home with instructions to call the poison center back if symptoms develop or worsen. The poison center should consider making a follow-up call at approximately 4 hours after ingestion (Grade D). 7) Children less than 6 years of age who ingest at least 7.5 mg/kg of diphenhydramine should be referred to an emergency department (Grade D). 8) Patients 6 years of age and older who ingest at least 7.5 mg/kg or 300 mg of diphenhydramine (whichever is less), should be referred to an emergency department (Grade D). 9) If the patient has no symptoms, and more than 6 hours have elapsed between the time of dimenhydrinate ingestion and the call to the poison center, referral to an emergency department is not recommended (Grade D). 10) Patients with acute ingestions of less than a toxic dose of dimenhydrinate, or chronic exposures to dimenhydrinate and no or mild symptoms, can be observed at home with instructions to call the poison center back if symptoms develop or worsen. The poison center should consider making a follow-up call at approximately 6 hours after ingestion (Grade D). 11) Children less than 6 years of age ingesting at least 7.5 mg/kg of dimenhydrinate should be referred to an emergency department (Grade D). 12) Patients 6 years of age and older ingesting at least 7.5 mg/kg or 300 mg of dimenhydrinate (whichever is less), should be referred to an emergency department for evaluation (Grade D). 13) Following oral exposures of diphenhydramine or dimenhydrinate, do not induce emesis. Because of the potential for diphenhydramine or dimenhydrinate to cause loss of consciousness or seizures, activated charcoal should not be administered en route to an emergency department (Grade D). 14) For chronic dermal exposures of diphenhydramine, skin decontamination (with water or soap and water) should be attempted prior to transporting a patient to an emergency department unless moderate to severe symptoms are already present. In this circumstance, transportation should not be delayed, and EMS personnel should attempt skin decontamination en route to the emergency department (Grade D). 15) Intravenous sodium bicarbonate may be administered by EMS personnel if QRS widening (QRS >0.10 msec) is present and if authorized by EMS medical direction (Grade D). 16) Physostigmine should be reserved for administration in a hospital (Grade D). 17) Benzodiazepines may be administered by EMS personnel if agitation or seizures are present, and if authorized by EMS medical direction (Grade D).
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