Diabetes and rhabdomyolysis. A rare complication of a common disease

Non-traumatic and non-drug-induced rhabdomyolysis

Rhabdomyolysis (RM), a fortunately rare disease of the striated muscle cells, is a complication of non-traumatic (congenital (glycogen storage disease, discrete mitochondrial myopathies and various muscular dystrophies) or acquired (alcoholic myopathy, systemic diseases, arterial occlusion, viral illness or bacterial sepsis)) and traumatic conditions. Additionally, RM can occur in some individuals under specific circumstances such as toxic substance use and illicit drug abuse. Lipid-lowering drugs in particular are capable of causing RM. This comprehensive review will focus on non-traumatic and non-drug-induced RM. Moreover, the pathology of RM, its clinical manifestation and biochemical effects, and finally its management will be discussed.

Validation of Predicting Hyperglycemic Crisis Death Score: A Risk Stratification Tool for Appropriate Disposition of Hyperglycemic Crisis Patients from the Emergency Department

CONTEXT

Predicting hyperglycemic crisis death (PHD) score is a simple, rapid tool with six independent mortality predictors to calculate 30-day mortality and appropriately dispose patients to Intensive Care Unit (ICU) or ward.

AIMS

This study aimed at validating the efficiency of PHD score as a decision rule for prognosticating 30-day mortality and classifying hyperglycemic crisis patients for appropriate disposition from the emergency department (ED).

MATERIALS AND METHODS

This is a prospective, observational study done in the ED of a teaching hospital over 14 months. All patients aged >18 years and who met the criteria of hyperglycemic crisis were enrolled. Thirty-day mortality of six independent predictors was the primary end point. Using PHD, risk scores were calculated and patients were disposed as per physician's clinical judgment. Finally, the treating physician's decision and PHD score disposition were compared and the efficiency of PHD in predicting 30-day mortality was analyzed. Multiple logistic regression models were used for analysis. Receiver operating characteristic curve was drawn, and area under the curve along with sensitivity, specificity, positive predictive value, and negative predictive value was analyzed. P < 0.05 was considered statistically significant.

RESULTS

A total of 133 patients were included. On applying PHD score, 69, 39, and 25 patients were in the low-, intermediate-, and high-risk groups, respectively, with a mortality rate of 5.8%, 20.5%, and 56%, respectively. On comparing physician disposition with PHD score, an increasing mortality was noticed in ICU, and PHD showed equal weight in risk stratification and appropriate disposition of patients.

CONCLUSION

In adult patients with hyperglycemic crisis, PHD score is validated as a straightforward, prompt tool for predicting 30-day mortality and aids in disposition. The mortality rate in the PHD score Model II was similar to the physician's clinical decision.

Non-traumatic rhabdomyolysis and diabetes

The present clinical report describes the case of a spontaneously resolving rhabdomyolysis episode in a type 1 diabetic patient, who presented with multiple risk factors of this muscle complication, including uncontrolled brittle diabetes with sequences of hyper- and hypoglycaemic episodes in the same day, caloric restriction and intensive exercise. It should be borne in mind that rhabdomyolysis is not particularly rare in diabetes and can be severe. To raise clinicians' awareness of a possible rhabdomyolysis diagnosis, the various clinical conditions that are likely to lead to this complication in diabetic patients are also reviewed here.

Hyperosmolar hyperglycemic non ketotic coma and rhabdomyolysis; an uncommon clinical encounter

Rhabdomyolysis is usually attributed to trauma. However there is an association of rhabdomyolysis with hyperosmolar states. Recognition of this association will enable better management of the patient and reduce the burden on the care taker by preventing the onset of complications that can prove fatal. It is also important to realise that hyperosmolar coma can be the presenting complaint of a diabetic seeking medical attention for the first time.

Pediatric diabetic ketoacidosis and hyperglycemic hyperosmolar state

Diabetic ketoacidosis is an important complication of diabetes in children and is the most frequent diabetes-related cause of death in childhood. The pathophysiology of this condition can be viewed as an exaggeration of the normal physiologic mechanisms responsible for maintaining an adequate fuel supply to the brain and other tissues during periods of fasting and physiologic stress. The optimal therapy has been a subject of controversy, particularly because the most frequent serious complication of diabetic ketoacidosis-cerebral edema-and the relationship of this complication to treatment are incompletely understood. In this article, the author reviews the pathophysiology of diabetic ketoacidosis and its complications and presents an evidence-based approach to the management of this condition.

A case of fulminant type 1 diabetes with transiently positive anti-GAD antibodies

A subtype of idiopathic type 1 diabetes with a rapid onset and no diabetes-related antibodies has been recently advocated as non-autoimmune fulminant type 1 diabetes. However, it is not definite yet that this subtype is always caused by non-autoimmune mechanism. A 48-year-old man was admitted to our hospital because of high plasma glucose and renal insufficiency. Laboratory findings were as follows: plasma glucose 1052 mg/dL, urinary ketone bodies (+/-), arterial blood pH 7.44, bicarbonate 23.8 mmol/L, base excess 0.3 mmol/L, plasma osmolality 342 mOsm/L, serum creatinine 2.1 mg/dL, blood urea nitrogen 69.7 mg/dL, and serum creatine kinase 1024 IU/L, giving a diagnosis of acute renal failure secondary to rhabdomyolysis associated with diabetes. Urinary C-peptide reactivity was 4.7 microg/day. The level of HbAlc was 7.0%, not so high as compared to that of plasma glucose, indicating an aggravation of diabetes within the recent short period. Antibodies to islet cell antigen, IA-2 and insulin were negative, while those to glutamic acid decarboxylase (GAD) were positive at 13.1 U/mL, which were negative half a year and two years and a half later. Serum amylase level was within normal range at admission, increased to 380 IU/L and normalized in 4 to 5 weeks as serum creatinine lowered. These data are compatible to the diagnosis of fulminant type 1 diabetes. However, the present case is different from others in positive antibodies to GAD at admission that turned to be negative subsequently. Considering our results and others together, further investigations are necessary to clarify whether all cases of fulminant type 1 diabetes are non-autoimmune or some of them are caused by autoimmune mechanism.

Rhabdomyolysis in diabetic ketoacidosis

Rhabdomyolysis is a potentially lethal disorder, characterized by elevated serum concentrations of creatine kinase (CK) due to skeletal muscle injury. In this paper a patient with diabetic ketoacidosis (DKA) is reported who developed rhabdomyolysis (maximum CK level, 37,700 U/L; normal, < 170 U/L), anemia (6.2 g/dL) and thrombocytopenia (16,000/microL). This combination of rhabdomyolysis with anemia and thrombocytopenia has not yet been reported in DKA. The pathogenic mechanism leading to rhabdomyolysis in DKA remains unsettled. From the literature it seems that those patients who develop rhabdomyolysis have very high glucose levels and a high osmolality on admission. Low phosphate levels can play a role as well. The etiology of anemia and thrombocytopenia in our patient remains obscure. Intravascular hemolysis could not be demonstrated but intramedullar hemolysis, due to osmolar shift or hypophosphatemia, cannot be excluded. A review of the literature data revealed that rhabdomyolysis is not so uncommon in DKA. However, to obtain incidence data in children, prospective studies are necessary.

[Acute rhabdomyolysis after spinal anesthesia for knee arthroscopy]

We report an observation of acute rhabdomyolysis of gluteus maximum muscles occurring in a non-obese patient installed in supine position that underwent knee arthroscopy under spinal anaesthesia. The patient had insulin-dependent diabetes melitus with documented microangiopathy. The interest of this observation resides in the occurrence of the syndrome after a short period of time (one hour) of installation in the supine position in a patient that did not have any of the generally described risk factors of rhabdomyolysis.

Acute renal failure due to rhabdomyolysis in diabetic patients

We report a 32-year-old Black man, admitted to the ICU with coma and severe metabolic disturbances due to diabetic ketoacidosis. During the admission, rhabdomyolysis and acute renal failure (ARF) were diagnosed. After metabolic control and gradual decrease of creatine kinase levels, he presented a progressive improvement of renal function. We emphasize nontraumatic rhabdomyolysis as a poorly recognized pathogenetic factor for ARF in diabetic ketoacidosis and suggest that a better understanding of its mechanisms and an early application of protective measures is necessary.