Idiopathic rhabdomyolysis

Rhabdomyolysis: Revisited

Rhabdomyolysis (RML) is a pathological entity characterized by symptoms of myalgia, weakness and dark urine (which is often not present) resulting in respiratory failure and altered mental status. Laboratory testing for myoglobinuria is pathognomonic but so often not present during the time of testing that serum creatine kinase should always be sent when the diagnosis is suspected. Kidney injury from RML progresses through multiform pathways resulting in acute tubular necrosis. Early treatment (ideally<6 hoursfrom onset) is needed with volume expansion of all non-overloaded patients along with avoidance of nephrotoxins. There is insufficient data to recommend any specific fluid. The mortality rate ranges from 10% to up to 50% with severe AKI, so high index of suspicion and screening should be in care plan of seriously ill patients at risk for RML.

Rhabdomyolysis-Induced Acute Renal Injury in a Schizophrenic Patient

Nowadays, schizophrenia is treated with atypical antipsychotics that can determine neuroleptic malignant syndrome or rhabdomyolysis appearance. In addition to trauma and muscular hypoxia, there are some drugs and toxins associated with rhabdomyolysis development, among which olanzapine. A case of severe rhabdomyolysis syndrome, with extremely high levels of serum creatine kinase (CK), followed by acute kidney failure, secondary to olanzapine overdose and prolonged immobilization is outlined. Continuous renal replacement therapy was performed, with a slow clearance of serum CK levels. Under supportive therapy, systemic alkalinisation with volume resuscitation and corticotherapy, patient’s general condition was improved, as well as his lower limb paresis. He followed frequent psychiatric evaluations and psychotherapies, before and after being transferred to a medical service. Rhabdomyolysis diagnosis is difficult in mild cases due to non-specific signs and symptoms, but it also has some typical manifestation, generically called “the rhabdomyolysis syndrome triad”. The treatment is usually supportive; renal replacement therapy is required in the presence of acute kidney injury unresponsive to aggressive volume resuscitation. The systemic myoglobin release is responsible for renal injury. Olanzapine muscle toxicity can lead to severe rhabdomyolysis syndrome complicated with acute kidney injury and multiple organ dysfunction syndrome. Rapid identification and aggressive therapeutic management are essential for improving patients’ outcome and prevent the occurrence of irreversible injuries.

Rhabdomyolysis: a review

Rhabdomyolysis, a syndrome of skeletal muscle breakdown with leakage of muscle contents, is frequently accompanied by myoglobinuria, and if sufficiently severe, acute renal failure with potentially life-threatening metabolic derangements may ensue. A diverse spectrum of inherited and acquired disorders affecting muscle membranes, membrane ion channels, and muscle energy supply causes rhabdomyolysis. Common final pathophysiological mechanisms among these causes of rhabdomyolysis include an uncontrolled rise in free intracellular calcium and activation of calcium-dependent proteases, which lead to destruction of myofibrils and lysosomal digestion of muscle fiber contents. Recent advances in molecular genetics and muscle enzyme histochemistry may enable a specific metabolic diagnosis in many patients with idiopathic recurrent rhabdomyolysis.

Rhabdomyolysis: a review of the literature

Rhabdomyolysis (lysis of skeletal muscle cells) is a potentially lethal syndrome with a broad spectrum of clinical and biochemical findings. Myalgia, pigmenturia and elevated activity of serum creatine kinase are the common features. Fulminant rhabdomyolysis may be associated with severe metabolic disturbances and involvement of other organ systems. Cardiac arrest, compartment syndrome and acute renal failure are the major complications. The extent of the life-threatening complications of rhabdomyolysis strongly depends on early diagnosis and adequate therapy. As the repair mechanism of striated muscle functions very well, the prognosis of adequately treated rhabdomyolysis is excellent. This article reviews the present state of knowledge of clinical and biochemical diagnosis of rhabdomyolysis, the pathophysiologic background, the classification and the etiological provocative factors.

Familial paroxysmal rhabdomyolysis: management of two cases of the non-exertional type

Familial paroxysmal rhabdomyolysis with myoglobinuria is a rare and life-threatening disease of young children, of unknown aetiology. Attacks bear no relation to exercise, are usually triggered by intercurrent infections and are often severe. The authors describe two cases and suggest plans for the prevention and management of attacks. Fasting appears to be the crucial factor precipitating attacks, but is not associated with hypoglycaemia or with a defect in lactate production, ketogenesis or fatty acid mobilisation. The fatty acid-binding protein in a muscle biopsy from one case was normal.

Acute renal failure in the neonate. Two fatal cases due to group B streptococci with rhabdomyolysis

Two cases of fatal group B streptococcal disease complicated by rhabdomyolysis in the neonate are described. They were identified by blood and cerebrospinal fluid cultures positive for group B streptococcus and by a combination of hyperkalemia, urine dipstick positive for blood without microscopic hematuria, and elevated serum muscle enzymes.

Acute abdominal rhabdomyolysis after body building exercise: is there a "rectus abdominus syndrome?"

Report of a 19-year-old man who was admitted to the hospital after vigorous exercise with signs of the "acute abdomen" syndrome. Since intestinal reasons for the complaints were excluded, a myocardial infarction was considered. However, the excessively increased serum CK levels indicated a disorder of the voluntary muscles. A biopsy taken from the rectus abdominis revealed typical features of acute rhabdomyolysis, which was obviously restricted to the rectus abdominis. Together with a somewhat later observed autopsy case of a young male with acute abdominal rhabdomyolysis, also restricted to the rectus abdominis, this case gives rise to discuss, whether there exists a "rectus abdominis syndrome" analogous to the anterior tibial syndrome.

Recurrent exertional rhabdomyolysis and stunted growth

A boy with recurrent exertional rhabdomyolysis and stunted growth is described. Fetal movements were few and the boy was small for gestational age. He always experienced easy fatigability, and he noted bouts of pigmenturia associated with episodes of considerable malaise. The change in color of the urine was caused by myoglobin. An electromyogram was myopathic. CPK rose during 60 minutes mild exercise. Prolonged moderate exercise could not be performed. Histopathological examination of muscle biopsy revealed an increase in the number of 11C fibres (20%). Electronmicroscopy revealed the wavy outline of a number of fibres and hypertrophy of sarcoplasmic reticulum elements. No cause for the stunted growth could be detected.

Acute fulminant myoglobinuric polymyositis with picornavirus-like crystals

Myoglobinuria was found in an 11 month old girl suffering from fever, dyspnoea, and muscle hypotonia. Muscle biopsy showed focal degenerative necrosis of the muscle fibres. Electronmicroscopically, picornavirus-like crystals were demonstrated in the muscle fibres. These and other findings strongly suggest that she suffered from acute myositis with myoglobinuria probably caused by Coxsackie B6 virus infection. The causal relationship of viral infection (Coxsackie, influenza, or myxo-viruses) and acute or chronic polymyositis with or without myoglobinuria is discussed.

A disorder of muscle lipid metabolism and myoglobinuria. Absence of carnitine palmityl transferase

Two brothers, 29 and 33 years of age, had recurrent myoglobinuria, renal failure and azotemia, but were otherwise normal, without apparent muscle weakness or exercise intolerance. Ischemic exercise resulted in normal lactate production. Muscle glycogen content and activities of phosphorylase and phosphofructokinase were normal. Plasma triglycerides were elevated (500 mg per deciliter) on a regular diet and rose during fasting. During a 72-hour fast, serum creatine phosphokinase rose more than 10 times, and myoglobin was detected in urine. Plasma ketone production was minimal during fasting, but prompt ketonemia ( a normal response) occurred after ingestion of medium-chain triglycerides. Carnitine palmityl transferase activity was virtually absent in crude muscle extracts and mitochondrial fractions. Lack of this enzyme impairs long-chain fatty acid utilization, reflected in increased content of plasma free fatty acids and plasma triglycerides. Depletion of ATP because of this metabolic block in muscle may account for the attacks of myoglobinuria.

Acute rhabdomyolysis ("tying-up") in standardbred horses. A morphological and biochemical study

LINDHOLM, A., H.-E. JOHANSSON & P. KJÆRSGAARD: Acute rhabdomyolysis (“tying-up”) in standardbred horses. A morphological and biochemical study. Acta vet. scand. 1974, 15, 325–339. — Morphological, biochemical and histochemical changes were studied in muscle needle biopsy specimens (gluteus medius) from 59 standardbred trotters with acute clinical symptoms of the “tying-up” disease. All horses had increased levels of serum enzymes SGOT and SCPK. The biopsy specimens were taken at various intervals after onset of clinical symptoms (1–4 hrs., 18–24 hrs. and 2–20 days). Ry light microscopy it was shown that the muscular alterations had a focal distribution and were of the hyalin degeneration type with insignificant inflammatory reaction and slight calcification. The ultrastructural changes apparently commenced with myofibrillar waving, mitochondrial and sarcotubular alterations and terminated with myofibrillar degeneration and necrosis with invasion of inflammatory cells. The inflammatory cells were ultrastructurally similar to monocytes and macrophages. The degenerative changes mainly comprised fast twitch (FT and FTH) fibres as histochemically evidenced by myofibrillar ATPase and alkaline phosphatase staining.

Riopsies from diseased muscle 1–4 hrs. after the onset of “tyingup” contained a low muscle concentration of glycogen, ATP and CP and a high concentration of lactate and glucose. Hence it is suggested that the described muscular alterations may be caused by a deranged carbohydrate metabolism caused by a local hypoxia.

It was found that the “tying-up” disease resembled idiopathic rhabdomyolysis in man and was thus designated “equine rhabdomyolysis”.

histochemistry; horse; rhabdomyolysis; skeletal muscle; “tying-up”; ultrastructure.