Rhabdomyolysis: a review of clinical presentation, etiology, diagnosis, and management

Trends in Pediatric Rhabdomyolysis and Associated Renal Failure: A 10-Year Population-Based Study

OBJECTIVES

Rhabdomyolysis in children is a highly variable condition with presentations ranging from myalgias to more severe complications like acute renal failure. We sought to explore demographics and incidence of pediatric rhabdomyolysis hospitalizations and rates of associated renal failure, as our current understanding is limited.

METHODS

This was a retrospective analysis using the Healthcare Cost and Utilization Project Kids' Inpatient Database to identify children hospitalized with a primary diagnosis of rhabdomyolysis. Data were analyzed for demographic characteristics, as well as geographic and temporal trends. Multivariable logistic regression was used to identify characteristics associated with rhabdomyolysis-associated acute renal failure.

RESULTS

From 2006 to 2016, there were 8599 hospitalized children with a primary diagnosis of rhabdomyolysis. Overall, hospitalizations for pediatric rhabdomyolysis are increasing over time, with geographic peaks in the South and Northeast regions, and seasonal peaks in March and August. Though renal morbidity was diagnosed in 8.5% of children requiring hospitalization for rhabdomyolysis, very few of these patients required renal replacement therapy (0.41%), and death was rare (0.03%). Characteristics associated with renal failure included male sex, age greater than 15 years, and non-Hispanic Black race.

CONCLUSIONS

Though renal failure occurs at a significant rate in children hospitalized with rhabdomyolysis, severe complications, including death, are rare. The number of children hospitalized with rhabdomyolysis varies by geographic region and month of the year. Future studies are needed to explore etiologies of rhabdomyolysis and laboratory values that predict higher risk of morbidity and mortality in children with rhabdomyolysis.

Compromised mitochondrial quality control triggers lipin1-related rhabdomyolysis

LPIN1 mutations are responsible for inherited recurrent rhabdomyolysis, a life-threatening condition with no efficient therapeutic intervention. Here, we conduct a bedside-to-bench-and-back investigation to study the pathophysiology of lipin1 deficiency. We find that lipin1-deficient myoblasts exhibit a reduction in phosphatidylinositol-3-phosphate close to autophagosomes and late endosomes that prevents the recruitment of the GTPase Armus, locks Rab7 in the active state, inhibits vesicle clearance by fusion with lysosomes, and alters their positioning and function. Oxidized mitochondrial DNA accumulates in late endosomes, where it activates Toll-like receptor 9 (TLR9) and triggers inflammatory signaling and caspase-dependent myolysis. Hydroxychloroquine blocks TLR9 activation by mitochondrial DNA in vitro and may attenuate flares of rhabdomyolysis in 6 patients treated. We suggest a critical role for defective clearance of oxidized mitochondrial DNA that activates TLR9-restricted inflammation in lipin1-related rhabdomyolysis. Interventions blocking TLR9 activation or inflammation can improve patient care in vivo.

A rare case of hypokalaemia and hypophosphataemia secondary to geophagia

We report a case of severe hypokalaemia and moderate hypophosphataemia from clay ingestion. A 60-year-old woman presented with flaccid paralysis. Investigations revealed a serum potassium level of 1.8 mmol/L, phosphate level of 0.56 mmol/L and creatine kinase level of 30 747 IU/L. She had marked proximal and distal muscle weakness due to severe hypokalaemia and concurrent hypophosphataemia, which likely contributed to the onset of rhabdomyolysis. The patient subsequently admitted to significant pica, most likely secondary to an associated iron deficiency. We conclude that the ingested clay acted as a potassium and phosphate binder. Although we did not investigate the content of the clay in this case, it has been reported that clay can bind potassium in vitro and is rich in minerals such as aluminium that could play a role in the binding of phosphate, although the exact mechanism remains unclear. The patient recovered fully and outpatient follow-up at 6 months and again at 40 months confirmed no electrolyte abnormality, myopathy nor any further geophagia.

Polymyxin B-induced rhabdomyolysis: A case report

RATIONALE

Polymyxin B has been used to treat extensively drug-resistant gram-negative bacteria and shown a better antibacterial effect in the clinic at present. Meanwhile, polymyxin B is associated with several adverse effects. However, there is a lack of awareness that polymyxin B can cause rhabdomyolysis. In this study, we firstly report a case of polymyxin B-induced rhabdomyolysis during antiinfection therapy.

PATIENT CONCERNS

A 70-year-old woman suffering from rheumatic heart disease underwent aortic and mitral valve replacement at our institute. Subsequently, she developed bacteremia and pneumonia caused by extensively drug resistance-acinetobacter baumannii. Polymyxin B was administered for 5 days. During treatment, the patient complained of muscle pain and limb weakness, and her serum creatine phosphokinase and myoglobin levels rose.

DIAGNOSIS

The clinical symptoms and laboratory examination confirmed rhabdomyolysis, and polymyxin B-induced rhabdomyolysis was considered.

INTERVENTION

We ceased polymyxin B treatment and monitored the patient daily.

OUTCOMES

Serum creatine phosphokinase levels returned to normal, myoglobin levels decreased, and muscle pain was significantly alleviated after cessation of polymyxin B. We identified this as a case of polymyxin B-induced rhabdomyolysis.

LESSONS

Here, we report the first reported case of rhabdomyolysis induced by polymyxin B administration. The awareness of rare adverse reaction helps ensure the clinical safety of polymyxin B treatment.

Minor Blunt Injury-induced Rhabdomyolysis from a Road Traffic Accident in Nigeria

Rhabdomyolysis, though not a common complication of minor blunt trauma, may result in life-threatening acute kidney injury (AKI). Here is illustrated a case of a young male who sustained minor blunt injuries in a road traffic accident, which he overlooked and presented with features of severe AKI. The patient is a 24-year-old male, who presented with progressive weakness, difficulty in walking, and features of uremia, 14 days after he sustained minor blunt injuries and lacerations in a road traffic accident. Evaluation showed elevated serum creatine kinase, serum myoglobin, and severe azotemia. He was commenced on hemodialysis. He was also commenced on antibiotics, analgesic, and 5% dextrose/saline. He had three sessions of hemodialysis on alternate days. His condition improved remarkably after the first session of dialysis. He was discharged after 18 days on admission. Follow-up in the clinic showed a normal renal function. This case report shows rhabdomyolysis from minor blunt injuries sustained in a road traffic accident and complicated by severe AKI. The patient almost recovered full renal function with management.

[Clinical features and laboratory data analysis of Aeromonas bacteremia with hematological diseases]

目的

分析患有血液系统疾病患者气单胞菌血流感染的临床及实验室特征，为该类患者气单胞菌感染的防治提供依据。

方法

回顾性分析中国医学科学院血液病医院2014年1月至2018年12月5年发生气单胞菌血症的血液系统疾病患者，收集患者临床感染特征、菌株耐药性、发生季节、治疗及转归情况等相关信息。

结果

共42例血液病患者发生气单胞菌血流感染，其中39例（92.9%）血流感染发生于粒细胞缺乏（粒缺）期，平均发热时间为4（1~27）d，22例（52.4%）患者症状仅为发热，6例（14.3%）伴消化道症状（腹痛、腹泻、恶心、上消化道出血），8例（19.0%）伴肺部感染，13例（31.0%）伴皮肤软组织感染。7例（16.7%）患者死亡，且均伴皮肤软组织感染。气单胞菌对碳青霉烯类抗菌药物的耐药率为68.3%~70.7%，而对头孢菌素类、喹诺酮类及氨基糖苷类抗菌药物的耐药率均小于10%。

结论

血液系统疾病合并气单胞菌血流感染主要发生在粒缺期，主要以发热为主，当伴有皮肤软组织感染时死亡率高。抗菌药物选择应依据药敏结果，避免使用碳青霉烯类抗菌药物。

Rhabdomyolysis in organic acidemia patients manifesting with metabolic decompensation

Several metabolic disorders are related to rhabdomyolysis, but their association with methylmalonic acidemia (MMA) and propionic acidemia (PA) is unclear. Eleven patients with MMA and four patients with PA were treated and/or followed up in Kumamoto University Hospital between January 2009 and December 2018. Three patients with MMA and one patient with PA developed rhabdomyolysis at 1-2 weeks after onset of metabolic crisis. Cases 1 and 4 initially developed rhabdomyolysis after withdrawal from continuous hemodiafiltration (CHDF), and cases 2 and 3 developed rhabdomyolysis at the time of onset and had recurrent rhabdomyolysis during the recovery phase after withdrawal from CHDF. Mitochondrial dysfunction is associated with rhabdomyolysis. The rhabdomyolysis in patients with MMA and PA may have been attributed to a defect in energy production because of a secondary mitochondrial disorder. Therefore, physicians should closely follow patients with MMA and PA, especially after withdrawal of hemodialysis therapy, and provide supportive care for their mitochondrial function.

A Healthy Toddler With Fever and Lethargy

A 21-month-old previously healthy girl presented to the emergency department initially with fever, rhinorrhea, and poor oral intake. She was subsequently discharged from the hospital on amoxicillin for treatment of acute otitis media but presented hours later on the same day with continued poor oral intake, decreased urine output, and lethargy. The patient was afebrile on examination without a focal source of infection or evidence of meningismus, but she was lethargic and minimally responsive to pain and had reduced strength in the upper and lower extremities. Initial laboratory analysis revealed leukocytosis with a neutrophil predominance and bandemia, hyponatremia, mild hyperkalemia, hyperglycemia, elevated transaminases, a mild metabolic acidosis, glucosuria, ketonuria, and hematuria. Follow-up tests, based on the history and results of the initial tests, were sent and led to a surprising diagnosis.

Evaluating the Effect of Vitamin C on Myocardial Angiogenesis Under Oxidative Stress Induced by Exhaustive Exercise in Rat

Background: The main purpose of the present study was to assess the effects of exhaustive swimming with the consumption of a vitamin C supplement on indices of myocardial oxidative stress and gene expression related to angiogenesis. Methods: Wistar rats were randomly divided into six groups of normal (C), 100 and 200 mg/kg of vitamin C, (VC100 and VC200), exercise with 100 and 200 mg/kg of vitamin C (Ex+VC100 and Ex+VC200) and exercise without treatment (Ex). Finally, the serum activity of serum creatine phosphokinase (CK) and lactate dehydrogenase (LDH) and heart tissue oxidant/antioxidant parameters, besides gene expression of Vascular endothelial growth factor-B (VEGF-B), angiopoietin 1 (ANGPT-1) and matrix metalloproteinases 2 (MMP-2) was measured. Results: Significant increase in LDH level was seen in group Ex which was remarkably attenuated in group Ex+VC200 (p<0.001). The tissue oxidative stress was observed in group Ex where daily intake of vitamin C could remarkably regulate this property (p<0.01). Vitamin C could ameliorate significant upper gene expression of VEGF-B and MMP-2 remarkably (p<0.05). Conclusion: Oxidative condition in myocardial besides over expression of MMP-2, could be concluded as a detrimental condition resulting from exhaustive swimming that continued by the proteolytic release of CK and LDH from the muscle. Upper gene expression of VEGF-B and MMP-2 besides no changes of ANGPT-1 can be concluded as an early stage of angiogenesis. All these events were somehow attenuated by vitamin C which confirmed its beneficial effects as an antioxidant and the role of oxidation properties in the regulation of angiogenesis.

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.

Rhabdomyolysis and coeliac disease: A causal or casual association? A case report and review of literature

BACKGROUND

Rhabdomyolysis is a rare, potentially life-threatening condition, caused by multiple disorders. The association with Coeliac Disease (CD) has been rarely reported and in these cases muscular damage was imputed to hypokalemia. Herein we describe a new case of severe rhabdomyolysis in a child subsequently diagnosed as affected by CD, and review previous reports.

CASE PRESENTATION

A 3-year-old boy was referred for diarrhea, brown urine, muscular pain/weakness, and no history of muscular trauma. At entry, laboratory tests showed elevated levels of creatine kinase (CK) (x100 unv) and aspartate aminotransferase (AST) (x10 unv), alanine aminotrasferase (ALT) (x5 unv); electrolytes were within the reference range. Twenty-four hours after admission serum CK peaked 115,000 U/L and transaminases increased up to 30 times unv. Hyperhydration treatment was started with renal function monitoring. Urine output decreased little, while serum creatinine and urea nitrogen stayed within the reference range. Serum potassium levels went down to 2.8 mEq/L at day 3, in spite of supplementation. The patient completely recovered at day 16. Main metabolic causes of rhabdomyolysis were ruled out by appropriate tests. Because of rarely reported cases of CD/rhabdomyolysis, anti-tissue transglutaminase (tTG) antibodies were measured and found positive (IgA 34 U/mL, unv <9). HLA typing was DQA1 05:02, DQB1 03:02. As jejunal biopsy showed patchy villous atrophy, gluten free diet (GFD) was prescribed. One year after starting GFD, histology was normal.

REVIEW OF LITERATURE

Literature (search engines: PUB MED and GOOGLE SCHOLAR) from 1980 to 2016 retrieved 8 cases (age range: 12 to 75 years old) previously described.

CONCLUSION

The present case suggests to check for CD in children with severe rhabdomyolysis. Because severe rhabdomyolysis itself may elevate the serum potassium levels, hypokalemia might go unrecognized as the cause of muscular damage.

Rhabdomyolysis in a Tertiary PICU: A 10-Year Study

OBJECTIVES

Rhabdomyolysis is a disorder of muscle breakdown. The aim of this study was to describe the epidemiology of rhabdomyolysis in children admitted to a PICU and to assess the relationship between peak creatinine kinase and mortality.

DESIGN

Retrospective cohort study in children admitted to the PICU with rhabdomyolysis between January 1, 2005, and December 31, 2014. Demographic, clinical, and outcome data were recorded. Outcomes were analyzed by level of peak creatinine kinase value (0-10,000, 10,001-50,000, > 50,000IU/L). Long-term renal outcomes were reported for PICU survivors.

SETTING

A single-centre academic tertiary PICU.

PATIENTS

Children admitted to the PICU with serum creatinine kinase level greater than 1,000 IU/L.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

There were 182 children with rhabdomyolysis. The median peak creatinine kinase value was 3,583 IU/L (1,554-9,608). The primary diagnostic categories included sepsis, trauma, and cardiac arrest. Mortality for peak creatinine kinase values 0-10,000, 10,001-50,000, and > 50,000 IU/L were 24/138 (17%), 6/28 (21%), and 3/16 (19%), respectively (p = 0.87). Children with a peak creatinine kinase greater than 10,000 IU/L had a longer duration of mechanical ventilation and ICU length of stay than children with peak creatinine kinase less than 10,000. Renal replacement therapy was administered in 29/182 (16%). There was longer duration of mechanical ventilation (273 [141-548] vs. 73 [17-206] hr [p < 0.001]) and ICU length of stay (334 [147-618] vs. 100 [37-232] hr (p < 0.001)] in children receiving renal replacement therapy. Continuous veno-venous hemofiltration was the most common modality 23/29 (79%). Only one child required renal replacement therapy postintensive care stay, and adverse long-term renal outcomes were uncommon.

CONCLUSIONS

In children with rhabdomyolysis requiring intensive care, peak creatinine kinase was not associated with mortality but is associated with greater use of intensive care resources. Chronic kidney disease is an uncommon sequelae of rhabdomyolysis in children requiring intensive care.

Severe Rhabdomyolysis Associated With RSV

Severe rhabdomyolysis is associated with morbidity and mortality. We report on a previously well male who developed severe rhabdomyolysis, sepsis, and multi-organ failure. The patient made a complete recovery. Extensive microbiological testing was only positive for RSV, making this the first reported case of adult RSV-related rhabdomyolysis in the literature.

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.

A Case of Exertional Rhabdomyolysis: When Exertion Exceeds Capacity

The purpose of this article is to present a discussion of a young adult patient with exertional rhabdomyolysis. Rhabdomyolysis is the process of muscle tissue destruction and damage to the cell membrane, with subsequent release of the intracellular myocyte contents into the systemic circulation. This leads to the potential for the life-threatening systemic complications of electrolyte abnormalities, cardiac dysrhythmias, acute kidney injury, compartment syndrome, and disseminated intravascular coagulopathy. Rhabdomyolysis as a syndrome can be difficult to recognize and diagnose in the emergency care setting due to the fact that there are many etiologies and variations in symptomatology. The emergency care provider must have an astute knowledge base of this disease process and consider this pathology in the differential diagnosis of any patient at risk to achieve optimum patient outcomes and reduce morbidity and mortality.

[Acute renal failure caused by rhabdomyolysis in children: a clinical analysis of 26 cases]

OBJECTIVE

To investigate the clinical features and prognosis of acute renal failure (ARF) caused by rhabdomyolysis (RM) in children.

METHODS

A retrospective analysis was performed for the clinical data, laboratory examination, and prognosis of 26 RM children with ARF.

RESULTS

The causes for all 26 RM children with ARF were non-traumatic diseases, and the three most common causes were infection (69%), diabetes (12%), and metabolic disease (8%). In the RM children with ARF, the five most frequent clinical manifestations were fever (69%), multiple organ dysfunction syndrome (69%), convulsion (46%), oliguria or anuria (35%), and tea-colored urine (27%). All 26 children had a serum creatine kinase (CK) level of >1 000 IU/L, among whom 26 had increased aspartate aminotransferase, 25 had increased alanine aminotransferase, 25 had increased creatine kinase isoenzyme, and 23 had increased lactate dehydrogenase. Serum myoglobin (Mb) was measured in 22 children and was found to increase in all these children. The mean time for CK to decrease to below 1 000 IU/L was 10±5 d. There was no significant difference in the time to CK recovery between the 10 children who were treated with conventional treatment as well as continuous venous-venous hemofiltration and those who were not treated with blood purification (P>0.05). Of all 26 RM children with ARF, 7 were withdrawn from the treatment, and 19 had normal renal function after treatment.

CONCLUSIONS

ARF and multiple organ dysfunction syndrome are major complications in RM children. The major primary disease for RM children with ARF is infectious disease. CK is the major marker for the diagnosis of RM. Early diagnosis and appropriate treatment may reverse ARF and improve prognosis.

Primary Myoglobinuria: Differentiate Myoglobinuria from Hemoglobinuria

Myoglobin is dark red colour heme containing protein, stored in muscle. Change in permeability of myolemma causes myoglobin leak in plasma, which is cleared by kidney swiftly. Differentiating myoglobinuria from hemoglobinuria is important. Clinicians concern over myoglobinuria is to protect the patient from acute renal disease. We present a case of primary myoglobinuria, its clinical symptoms, diagnosis and treatment.

Rhabdomyolysis in Dak-Bum devotees: A case series

INTRODUCTION

India is a land of culture and heritage always known for its rituals. The devotees offer their prayers in the form of fasting, sacrifices and many other difficult ways to please Almighty! While doing so they often endanger their lives. Rhabdomyolysis, in a particular group of devotees of Bihar/Jharkhand known as Dak-Bum, is a life-threatening clinical entity which occurs in these devotees who travel a long distance in a short period in a fasting state. Rhabdomyolysis detected by myoglobinuria can lead to acute kidney injury and mortality.

AIM

To study and identify cases of rhabdomyolysis in devotees (Dak-Bum) and the role of early diagnosis and management.

MATERIALS AND METHODS

The study was conducted at Ruban Emergency Hospital Patna from August 2010 to August 2013 over 27 patients - 26 males and 1 female of age group 22-34 years. They presented with major symptoms such as dehydration, tender swollen calf muscles and myoglobinuria. The patients were admitted over a period of 2-3 weeks time in a single year (nine patients in 2010, five patients in 2011 and seven patients in 2012 and six patients in 2013). The study was restricted to the month of August every year, as this ritual occurs in a particular season. Inclusion criteria were all previously healthy devotees. The study period was from admission till discharge with daily follow-up of each patient.

RESULTS

Rhabdomyolysis developed in 27 Dak-Bum devotees and all had acute renal failure at the time of admission. RIFLE criteria-Stage F (failure) and acute kidney injury network criteria (3^rd stage). However, recovery was good due to early intervention in the form of haemodialysis and forced alkaline diuresis by soda bicarbonate infusion.

CONCLUSION

Rhabdomyolysis developing in Dak-Bum devotees because of travelling a long distance in a short period, could be managed well due of early diagnosis, timely referral, haemodialysis and forced alkaline diuresis.

Vitamin D3 Reduces Tissue Damage and Oxidative Stress Caused by Exhaustive Exercise

Exhaustive exercise results in inflammation and oxidative stress, which can damage tissue. Previous studies have shown that vitamin D has both anti-inflammatory and antiperoxidative activity. Therefore, we aimed to test if vitamin D could reduce the damage caused by exhaustive exercise. Rats were randomized to one of four groups: control, vitamin D, exercise, and vitamin D+exercise. Exercised rats received an intravenous injection of vitamin D (1 ng/mL) or normal saline after exhaustive exercise. Blood pressure, heart rate, and blood samples were collected for biochemical testing. Histological examination and immunohistochemical (IHC) analyses were performed on lungs and kidneys after the animals were sacrificed. In comparison to the exercise group, blood markers of skeletal muscle damage, creatine kinase and lactate dehydrogenase, were significantly (P < 0.05) lower in the vitamin D+exercise group. The exercise group also had more severe tissue injury scores in the lungs (average of 2.4 ± 0.71) and kidneys (average of 3.3 ± 0.6) than the vitamin D-treated exercise group did (1.08 ± 0.57 and 1.16 ± 0.55). IHC staining showed that vitamin D reduced the oxidative product 4-Hydroxynonenal in exercised animals from 20.6% to 13.8% in the lungs and from 29.4% to 16.7% in the kidneys. In summary, postexercise intravenous injection of vitamin D can reduce the peroxidation induced by exhaustive exercise and ameliorate tissue damage, particularly in the kidneys and lungs.

Postinfectious Rhabdomyolysis in a 5-Year-Old Boy: When to Look a Little Deeper

We report on a 5-year-old boy with recurrent severe postinfectious rhabdomyolysis who, after systematic stepwise evaluation, was found to have the adult form of carnitine palmityl transferase II (CPT II) deficiency directly by blood mutation analysis. Timely diagnosis of CPT II deficiency in this case prevented further potentially devastating episodes of rhabdomyolysis by avoiding triggering factors.

CONCLUSION

Although most cases of rhabdomyolysis are nonrecurrent and benign, a metabolic myopathy, such as CPT II deficiency, should be suspected in children with episodic muscle necrosis and paroxysmal myoglobinuria.

Acute rhabdomyolysis and inflammation

Rhabdomyolysis results from the rapid breakdown of skeletal muscle fibers, which leads to leakage of potentially toxic cellular content into the systemic circulation. Acquired causes by direct injury to the sarcolemma are most frequent. The inherited causes are: i) metabolic with failure of energy production, including mitochondrial fatty acid ß-oxidation defects, LPIN1 mutations, inborn errors of glycogenolysis and glycolysis, more rarely mitochondrial respiratory chain deficiency, purine defects and peroxysomal α-methyl-acyl-CoA-racemase defect (AMACR), ii) structural causes with muscle dystrophies and myopathies, iii) calcium pump disorder with RYR1 gene mutations, iv) inflammatory causes with myositis. Irrespective of the cause of rhabdomyolysis, the pathology follows a common pathway, either by the direct injury to sarcolemma by increased intracellular calcium concentration (acquired causes) or by the failure of energy production (inherited causes), which leads to fiber necrosis. Rhabdomyolysis are frequently precipitated by febrile illness or exercise. These conditions are associated with two events, elevated temperature and high circulating levels of pro-inflammatory mediators such as cytokines and chemokines. To illustrate these points in the context of energy metabolism, protein thermolability and the potential benefits of arginine therapy, we focus on a rare cause of rhabdomyolysis, aldolase A deficiency. In addition, our studies on lipin-1 (LPIN1) deficiency raise the possibility that several diseases involved in rhabdomyolysis implicate pro-inflammatory cytokines and may even represent primarily pro-inflammatory diseases. Thus, not only thermolability of mutant proteins critical for muscle function, but also pro-inflammatory cytokines per se, may lead to metabolic decompensation and rhabdomyolysis.

Rare complications of pediatric diabetic ketoacidosis

The incidence of type 1 diabetes (T1D) among youth is steadily increasing across the world. Up to a third of pediatric patients with T1D present with diabetic ketoacidosis, a diagnosis that continues to be the leading cause of death in this population. Cerebral edema is the most common rare complication of diabetic ketoacidosis in children. Accordingly, treatment and outcome measures of cerebral edema are vastly researched and the pathophysiology is recently the subject of much debate. Nevertheless, cerebral edema is not the only sequela of diabetic ketoacidosis that warrants close monitoring. The medical literature details various other complications in children with diabetic ketoacidosis, including hypercoagulability leading to stroke and deep vein thrombosis, rhabdomyolysis, pulmonary and gastrointestinal complications, and long-term memory dysfunction. We review the pathophysiology, reported cases, management, and outcomes of each of these rare complications in children. As the incidence of T1D continues to rise, practitioners will care for an increasing number of pediatric patients with diabetic ketoacidosis and should be aware of the various systems that may be affected in both the acute and chronic setting.

Rhabdomyolysis: review of the literature

Rhabdomyolysis is a serious and potentially life threatening condition. Although consensus criteria for rhabdomyolysis is lacking, a reasonable definition is elevation of serum creatine kinase activity of at least 10 times the upper limit of normal followed by a rapid decrease of the sCK level to (near) normal values. The clinical presentation can vary widely, classical features are myalgia, weakness and pigmenturia. However, this classic triad is seen in less than 10% of patients. Acute renal failure due to acute tubular necrosis as a result of mechanical obstruction by myoglobin is the most common complication, in particular if sCK is >16.000 IU/l, which may be as high as 100,000 IU/l. Mortality rate is approximately 10% and significantly higher in patients with acute renal failure. Timely recognition of rhabdomyolysis is key for treatment. In the acute phase, treatment should be aimed at preserving renal function, resolving compartment syndrome, restoring metabolic derangements, and volume replacement. Most patients experience only one episode of rhabdomyolysis, mostly by substance abuse, medication, trauma or epileptic seizures. In case of recurrent rhabdomyolysis, a history of exercise intolerance or a positive family history for neuromuscular disorders, further investigations are needed to identify the underlying, often genetic, disorder. We propose a diagnostic algorithm for use in clinical practice.

Elevation of creatine kinase is associated with worse outcomes in 2009 pH1N1 influenza A infection

BACKGROUND

Current medical knowledge lacks specific information regarding creatine kinase (CK) elevation in influenza A pH1N1 (2009) infection.

OBJECTIVES

Primary endpoints were correlation between CK at intensive care unit (ICU) admission and ICU mortality. Secondary endpoints were ICU length of stay (LOS), mechanical ventilation (MV), and requirement of renal replacement techniques (RRT).

MATERIALS AND METHODS

A prospective multicenter register included all adults admitted for severe acute respiratory insufficiency (SARI) with confirmed pH1N1 in 148 ICUs. Clinical data including demographics, comorbidities, laboratory information, organ involvement, and prognostic data were registered. Post hoc classification of subjects was determined according to CK level. Data are expressed as median (interquartile range).

RESULTS

Five hundred and five (505) patients were evaluable. Global ICU mortality was 17.8 % without documented differences between breakpoints. CK ≥500 UI/L was documented in 23.8 % of ICU admissions, being associated with greater renal dysfunction: acute kidney injury (AKI) was more frequent (26.1 versus 17.1 %, p < 0.05) and twofold requirement of RRT [11 versus 5.6 %, p < 0.05; odds ratio (OR) = 2.09 (95 % confidence interval [CI] 1.01-4.32)]. Increase of CK ≥1,000 UI/L was associated with two or more quadrant involvement on chest X-ray (63.2 versus 40.2 %, p < 0.01) and increased intubation risk (73.9 versus 56.7 %, p = 0.07) and duration of mechanical ventilation (median 15 days versus 11 days, p < 0.01). As a result, CK ≥1,000 UI/L was associated with 5 extra days of ICU and hospital LOS.

CONCLUSIONS

CK is a biomarker of severity in pH1N1 infection. Elevation of CK was associated with more complications and increased ICU LOS and healthcare resources.

Adolescent with Rhabdomyolysis due to Undiagnosed Hypothyroidism

Exercise-induced rhabdomyolysis has been described in military recruits, trained athletes and daily runners. Statin use, quail ingestion, infection by Epstein-Barr virus (EBV), and hypothyroidism, though rare, are risk factors for the development of rhabdomyolysis. We describe the case of a 15-year-old female who presented with myalgias, weakness, and pigmenturia following marching band practice. Laboratory tests confirmed an elevated creatine kinase (CK) level as well as a profound hypothyroid state. Muscle biopsy revealed severe muscle necrosis and myositis. Treatment with levothyroxine resulted in obtaining an euthyroid state and regain of muscle strength as well as decrease in CK levels. Although rare, hypothyroidism should be considered as a potential cause of rhabdomyolysis in pediatric patients undergoing a myopathy workup.

Mechanism-based therapeutic approaches to rhabdomyolysis-induced renal failure

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.

Late-onset rhabdomyolysis in burn patients in the intensive care unit

Rhabdomyolysis (RML), defined as creatine phosphokinase (CPK) >1000 U/L, is relatively common immediately after a significant burn. Late-onset RML, occurring a week or more after a burn, is less well understood and recognised. All patients admitted to the Intensive Care Unit (ICU) following an acute burn between May 2006 and December 2009 were retrospectively identified. Patients with CPK>1000 U/L a week or more after their burn had a detailed notes review. Seventy-six patients were admitted during 43 months. Late-onset RML was demonstrated in 7/76 (9%) patients. They had a similar pattern of normal or mildly raised CPK on admission that resolved over the following days, but suddenly increased sharply to over 1000 U/L, a week or more after their burn, usually around day ten. A severe late-onset RML occurred in 5/76 (7%) patients, with a CPK rise of over 5000 U/L, and all required haemodialysis. Potential triggering factors for late-onset RML include sepsis, nephrotoxic drugs and hypophosphataemia. It is important to consider measuring CPK in all patients with the above complications, even after it has previously been observed to be normal, in order to initiate early treatment.

Exercise-induced rhabdomyolysis and transient loss of deambulation as outset of partial carnitine palmityl transferase II deficiency

We report the case of a 13-year-old boy with an abrupt onset of leg pain and muscle weakness, incapability of deambulation and a laboratory picture of exercise-induced acute rhabdomyolysis. Intravenous hyperhydration and forced diuresis were adopted to avoid renal complications. No evidence of articular or residual muscular damage was appreciated in the short-term. The recurrence of rhabdomyolysis required a muscular biopsy showing a disturbance of fatty acid β-oxidation pathway.

Extreme hypernatremia combined with rhabdomyolysis and acute renal failure

Rhabdomyolysis is a life-threatening condition that involves muscle cell destruction. Among its etiologies, severe hypernatremia is a less common cause. We report a teenage girl with congenital central hypoventilation syndrome and hypothalamus dysfunction syndrome who presented with extreme hypernatremia (sodium, 211 mmol/L) with rhabdomyolysis (creatine kinase, 32,850 U/L) and acute renal failure (creatinine, 6.1 mg/dL) following gastroenteritis with 7-kg weight loss. Rhabdomyolysis subsequently led to acute renal failure and hyperkalemia. Acute hemodialysis was initiated on hospital day 3 for hyperkalemia. This resulted in a 13 mmol/L fall in serum sodium in 3 hours despite using a 156 mmol/L sodium bath, but without the development of cerebral edema or neurological defect. This report highlights an unusual cause of rhabdomyolysis in children and the experience of managing such a difficult clinical situation.

[A case of rhabdomyolysis during hospitalization for acute hepatitis A]

A 29-year-old man was admitted to hospital with fever, myalgia, and sore throat. Initial laboratory findings were compatible with acute hepatitis; he was positive for the serologic marker for acute hepatitis A. On the 3rd day of admission, in spite of normalization of body temperature and a reduction in serum liver enzyme levels, serum levels of creatinine phosphokinase had increased up to 16,949 U/L. The patient recovered with supportive therapy and was discharged on the 12th day. We report a case of acute hepatitis A complicated by rhabdomyolysis during hospitalization.

Novel inhibitors of human organic cation/carnitine transporter (hOCTN2) via computational modeling and in vitro testing

PURPOSE

The objective was to elucidate the inhibition requirements of the human organic cation/carnitine transporter (hOCTN2).

METHODS

Twenty-seven drugs were screened initially for their potential to inhibit uptake of L-carnitine into a stably transfected hOCTN2-MDCK cell monolayer. A HipHop common features pharmacophore was developed and used to search a drug database. Fifty-three drugs, including some not predicted to be inhibitors, were selected and screened in vitro.

RESULTS

A common features pharmacophore was derived from initial screening data and consisted of three hydrophobic features and a positive ionizable feature. Among the 33 tested drugs that were predicted to map to the pharmacophore, 27 inhibited hOCTN2 in vitro (40% or less L-carnitine uptake from 2.5 microM L-carnitine solution in presence of 500 microM drug, compared to L-carnitine uptake without drug present). Hence, the pharmacophore accurately prioritized compounds for testing. K(i) measurements showed low micromolar inhibitors belonged to diverse therapeutic classes of drugs, including many not previously known to inhibit hOCTN2. Compounds were more likely to cause rhabdomyolysis if the C(max)/K(i) ratio was higher than 0.0025.

CONCLUSION

A combined pharmacophore and in vitro approach found new, structurally diverse inhibitors for hOCTN2 that may possibly cause clinical significant toxicity such as rhabdomyolysis.