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Amin T, Nassar M, Abosheaishaa H, Ali A, Zirkiyeva M, Lopez R. A Case of Diabetic Ketoacidosis Presented With Severe Rhabdomyolysis-Induced Acute Kidney Injury. Cureus 2023; 15:e38042. [PMID: 37228554 PMCID: PMC10206602 DOI: 10.7759/cureus.38042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2023] [Indexed: 05/27/2023] Open
Abstract
We present a patient who presented with diabetic ketoacidosis and severe rhabdomyolysis-induced acute kidney injury. The patient developed generalized edema, nausea, and vomiting, and his kidney function deteriorated, necessitating renal replacement therapy, despite the successful treatment of his initial conditions. A comprehensive evaluation was conducted to determine the underlying cause of the severe rhabdomyolysis, including autoimmune myopathies, viral infections, and metabolic disorders. A muscle biopsy revealed necrosis and myophagocytosis but no significant inflammation or myositis. The patient's clinical and laboratory results improved with appropriate treatment, including temporary dialysis and erythropoietin therapy, and he was discharged to continue his rehabilitation with home health care.
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Affiliation(s)
- Toka Amin
- Internal Medicine, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, New York, USA
| | - Mahmoud Nassar
- Internal Medicine, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, New York, USA
| | - Hazem Abosheaishaa
- Internal Medicine, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, New York, USA
- Gastroenterology, Cairo University, Cairo, EGY
| | - Amr Ali
- Pathology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, USA
| | - Milana Zirkiyeva
- Internal Medicine, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, New York, USA
| | - Ricardo Lopez
- Internal Medicine, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, New York, USA
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Rana M, Cuttin K, Berry GT, Torres A. Paroxysmal hyperthermia, dysautonomia and rhabdomyolysis in a patient with Lesch-Nyhan syndrome. JIMD Rep 2021; 62:30-34. [PMID: 34765395 PMCID: PMC8574172 DOI: 10.1002/jmd2.12249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 07/24/2021] [Accepted: 08/12/2021] [Indexed: 11/22/2022] Open
Abstract
Lesch-Nyhan syndrome is an x-linked genetic disorder of purine metabolism that results in the overproduction of uric acid and neurologic deficits manifesting as intellectual disability, dystonia, other movement disorders and self-mutilation. We describe a 12-year-old patient with a history of Lesch-Nyhan syndrome, G6PD deficiency and central diabetes insipidus and multiple admissions for fever, acute kidney injury and transaminitis in the setting of rhabdomyolysis. The patient's temperature dysregulation and dysautonomia is likely attributable to abnormal neurotransmitter release, particularly that of dopamine, in the central nervous system. Our patient presented similarly to that of a patient with neuroleptic malignant syndrome (NMS), with symptoms including altered mental status, fever, dysautonomia and renal failure, and laboratory findings including elevated serum creatinine kinase, leukocytosis, transaminitis, hypernatremia and metabolic acidosis. Similar to NMS, disruption of dopamine neurotransmission results in dysregulated sympathetic activity and hyperthermia.
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Affiliation(s)
- Mandeep Rana
- Department of Pediatrics, Division of Pediatric NeurologyBoston University School of Medicine, Boston Medical CenterBostonMassachusettsUSA
| | - Karen Cuttin
- Department of Pediatrics, Division of Pediatric NeurologyBoston University School of Medicine, Boston Medical CenterBostonMassachusettsUSA
| | - Gerard T. Berry
- Department of Pediatrics, Division of Genetics and GenomicsBoston Children's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Alcy Torres
- Department of Pediatrics, Division of Pediatric NeurologyBoston University School of Medicine, Boston Medical CenterBostonMassachusettsUSA
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Bihari S, Prakash S, Dixon DL, Cavallaro E, Bersten AD. Induced hypernatremia in patients with moderate-to-severe ARDS: a randomized controlled study. Intensive Care Med Exp 2021; 9:33. [PMID: 34219190 PMCID: PMC8255097 DOI: 10.1186/s40635-021-00399-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 06/06/2021] [Indexed: 12/15/2022] Open
Abstract
Background Induced hypernatremia and hyperosmolarity is protective in animal models of lung injury. We hypothesized that increasing and maintaining plasma sodium between 145 and 150 mmol/l in patients with moderate-to-severe ARDS would be safe and will reduce lung injury. This was a prospective randomized feasibility study in moderate-to-severe ARDS, comparing standard care with intravenous hypertonic saline to achieve and maintain plasma sodium between 145 and 150 mmol/l for 7 days (HTS group). Both groups of patients were managed with lung protective ventilation and conservative fluid management. The primary outcome was 1-point reduction in lung injury score (LIS) or successful extubation by day 7. Results Forty patients were randomized with 20 in each group. Baseline characteristics of severity of illness were well balanced. Patients in the HTS group had higher plasma sodium levels during the first 7 days after randomization when compared with the control group (p = 0.04). Seventy five percent (15/20) of patients in the HTS group were extubated or had ≥ 1-point reduction in LIS compared with 35% (7/20) in the control group (p = 0.02). There was also a decrease in length of mechanical ventilation and hospital length of stay in the HTS group. Conclusion We have shown clinical improvement in patients with moderate-to-severe ARDS following induced hypernatremia, suggesting that administration of hypertonic saline is a safe and feasible intervention in patients with moderate-to-severe ARDS. This suggests progress to a phase II study. Clinical Trial Registration Australian and New Zealand Clinical Trials Registry (ACTRN12615001282572) Supplementary Information The online version contains supplementary material available at 10.1186/s40635-021-00399-3.
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Affiliation(s)
- Shailesh Bihari
- Department of ICCU, Flinders Medical Centre, Bedford Park, SA, 5042, Australia. .,College of Medicine and Public Health, Flinders University, Adelaide, SA, 5001, Australia.
| | - Shivesh Prakash
- Department of ICCU, Flinders Medical Centre, Bedford Park, SA, 5042, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, SA, 5001, Australia
| | - Dani L Dixon
- Department of ICCU, Flinders Medical Centre, Bedford Park, SA, 5042, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, SA, 5001, Australia
| | - Elena Cavallaro
- College of Medicine and Public Health, Flinders University, Adelaide, SA, 5001, Australia
| | - Andrew D Bersten
- Department of ICCU, Flinders Medical Centre, Bedford Park, SA, 5042, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, SA, 5001, Australia
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Abstract
Elder abuse and neglect are highly prevalent but woefully underdetected and underreported. The presentation is rarely clear and requires the piecing together of clues that create a mosaic of the full picture. More research needed to better characterize findings that, when identified, can contribute to certainty in cases of suspected abuse. Medical and laboratory data can be helpful in the successful determination of abuse and neglect.
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Affiliation(s)
- Veronica M LoFaso
- New York Presbyterian Hospital, Weill Cornell Medical College, Box 39, 525 East 68th Street, New York, NY 10065, USA.
| | - Tony Rosen
- New York Presbyterian Hospital, Weill Cornell Medical College, Box 39, 525 East 68th Street, New York, NY 10065, USA
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Bihari S, Peake SL, Bailey M, Pilcher D, Prakash S, Bersten A. Admission high serum sodium is not associated with increased intensive care unit mortality risk in respiratory patients. J Crit Care 2014; 29:948-54. [PMID: 25041993 DOI: 10.1016/j.jcrc.2014.06.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Revised: 04/14/2014] [Accepted: 06/12/2014] [Indexed: 11/20/2022]
Abstract
BACKGROUND Because increased serum osmolarity may be lung protective, we hypothesized that increased mortality associated with increased serum sodium would be ameliorated in critically ill patients with an acute respiratory diagnosis. METHODS Data collected within the first 24 hours of intensive care unit (ICU) admission were accessed using ANZICS CORE database. From January 2000 to December 2010, 436,209 patients were assessed. Predefined subgroups including patients with acute respiratory diagnoses were examined. The effect of serum sodium on ICU mortality was assessed with analysis adjusted for illness severity and year of admission. Results are presented as odds ratio (95% confidence interval) referenced against a serum sodium range of 135 to 144.9 mmol/L. RESULTS Overall ICU mortality was increased at each extreme of dysnatremia (U-shaped relationship). A similar trend was found in various subgroups, with the exception of patients with respiratory diagnoses where ICU mortality was not influenced by high serum sodium (odds ratio, 1.3 [0.7-1.2]) and was different from other patient groups (P<.01). Any adverse associations with hypernatremia in respiratory patients were confined to those with arterial pressure of oxygen (PaO2)/fraction of inspired oxygen (Fio2) ratios of greater than 200. CONCLUSION High admission serum sodium is associated with increased odds for ICU death, except in respiratory patients.
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Affiliation(s)
- Shailesh Bihari
- Department of Critical Care Medicine, Flinders University, Bedford Park, South Australia, Australia; Department of Intensive Care Medicine, Flinders Medical Centre, Bedford Park, South Australia, Australia.
| | - Sandra L Peake
- School of Medicine, University of Adelaide, Adelaide, South Australia, Australia; ANZIC Research Centre, Monash University, Melbourne, Australia; Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Adelaide, Australia.
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia.
| | - David Pilcher
- ANZIC Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia; The Alfred Hospital, Melbourne, Australia; Australia New Zealand Intensive Care Society (ANZICS), Clinical Outcomes and Resource Evaluation (CORE) Centre, Melbourne, Australia.
| | - Shivesh Prakash
- Department of Intensive Care Medicine, Flinders Medical Centre, Bedford Park, South Australia, Australia.
| | - Andrew Bersten
- Department of Critical Care Medicine, Flinders University, Bedford Park, South Australia, Australia; Department of Intensive Care Medicine, Flinders Medical Centre, Bedford Park, South Australia, Australia.
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Lindner G, Funk GC. Hypernatremia in critically ill patients. J Crit Care 2013; 28:216.e11-20. [DOI: 10.1016/j.jcrc.2012.05.001] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Revised: 04/12/2012] [Accepted: 05/09/2012] [Indexed: 02/07/2023]
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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: 76] [Impact Index Per Article: 5.8] [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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Lindner G, Funk GC, Schwarz C, Kneidinger N, Kaider A, Schneeweiss B, Kramer L, Druml W. Hypernatremia in the Critically Ill Is an Independent Risk Factor for Mortality. Am J Kidney Dis 2007; 50:952-7. [PMID: 18037096 DOI: 10.1053/j.ajkd.2007.08.016] [Citation(s) in RCA: 187] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2007] [Accepted: 08/27/2007] [Indexed: 12/25/2022]
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Affiliation(s)
- Jason P Denman
- Department of Internal Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD
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Zantut-Wittmann DE, Garmes HM, Panzan AD, Lima MDO, Baptista MTM. Severe rhabdomyolysis due to adipsic hypernatremia after craniopharyngioma surgery. ACTA ACUST UNITED AC 2007; 51:1175-9. [DOI: 10.1590/s0004-27302007000700023] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2007] [Accepted: 08/06/2007] [Indexed: 11/22/2022]
Abstract
The association of diabetes insipidus and adipsia after craniopharyngioma surgery has high morbidity. Hypernatremia can be caused by adipsia and be aggravated by diabetes insipidus. Rhabdomyolysis rarely occurs. DASE REPORT: This is the first report of a diabetic patient with craniopharyngioma who developed diabetes insipidus and adipsia after surgery, evolving with severe hypernatremia that caused considerable rhabdomyolysis. CONCLUSION: The importance of the evaluation of muscle integrity when under hypernatremic states is pointed out. Although adipsia may have a simple solution through volunteer water ingestion, serious consequences such as repeated severe hypernatremia episodes and intense rhabdomyolysis with high morbidity could occur, if adipsia is not diagnosed.
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Ettinger JEMTM, de Souza CAM, Santos-Filho PV, Azaro E, Mello CAB, Fahel E, Batista PBP. Rhabdomyolysis: diagnosis and treatment in bariatric surgery. Obes Surg 2007; 17:525-32. [PMID: 17608266 DOI: 10.1007/s11695-007-9091-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Rhabdomyolysis (RML) and subsequent acute renal failure can be serious problems following bariatric operations. Early diagnosis and treatment are important to avoid the complications of RML. METHODS This review was achieved by searching the key words: Rhabdomyolysis, diagnosis, treatment and bariatric surgery. We included prospective, retrospective, case reports and review articles. RESULTS RML diagnosis can be done by: signs and symptoms, physical evaluation, laboratory findings and imaging examinations. Muscle weakness, myalgia, decubitus ulcer, proteinuria and myoglobinuria are the more mentioned findings. Elevation of CPK levels is the most sensitive diagnostic evidence of RML. Treatment is geared toward preserving renal function by avoiding dehydration, hypovolemia, tubular obstruction, aciduria, and free radical release. Early recognition allows the administration of fluids, bicarbonate, and mannitol. CONCLUSION Prophylactic measures and early diagnosis and treatment of rhabdomyolysis in bariatric surgery are imperative to prevent the potential fatal complications of this condition.
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Affiliation(s)
- João E M T M Ettinger
- Postgraduate Course of Medicine and Human Health, Escola Bahiana de Medicina, Department of Surgery, Hospital São Rafael (HSR) and Hospital Cidade, Bahia, Brazil.
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Hoorn EJ, de Vogel S, Zietse R. Insulin resistance in an 18-year-old patient with Down syndrome presenting with hyperglycaemic coma, hypernatraemia and rhabdomyolysis. J Intern Med 2005; 258:285-8. [PMID: 16115304 DOI: 10.1111/j.1365-2796.2005.01541.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- E J Hoorn
- Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
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Abstract
Rhabdomyolysis is a relatively common condition that may occur intermittently in chronic and inflammatory myopathy, muscular dystrophy, and metabolic myopathy. Rhabdomyolysis can also present acutely in otherwise healthy individuals. The list of etiologies for acute muscle cell lysis is enormous, with new causes described yearly. Series on acute pediatric rhabdomyolysis have not yet been published. This article describes a retrospective review of children admitted to the authors' institution during an 8-year period in whom rhabdomyolysis was recognized as a complication during their hospital stay. Patients with intermittent or relapsing rhabdomyolysis were excluded. Nineteen children were identified. Trauma (five cases), nonketotic hyperosmolar coma (two cases), viral myositis (two cases), dystonia (two cases), and malignant hyperthermia-related conditions (two cases) were the most common causes of rhabdomyolysis. Acute renal failure was the most frequent complication, occurring in 42% of cases. The mean age of renal failure patients was 13.9 years, compared to 8 years for non-renal failure children. Careful assessment of the initial urinalysis would have suggested a diagnosis of rhabdomyolysis in 9 of 16 patients tested.
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Affiliation(s)
- N Watemberg
- Child Neurology Division, Medical College of Virginia, Richmond, USA.
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Abstract
beta 2 microglobulin is a potentially amyloidogenic low molecular weight protein. Increased serum levels are seen in renal diseases that decrease glomerular filtration and/or tubular reabsorption, dialysis patients, chronic inflammatory diseases, and certain malignancies. Various aspects of beta 2 microglobulin metabolism and its accumulation in the kidney are addressed.
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Marcus EL, Rudensky B, Sonnenblick M. Occult elevation of CK as a manifestation of rhabdomyolysis in the elderly. J Am Geriatr Soc 1992; 40:454-6. [PMID: 1634696 DOI: 10.1111/j.1532-5415.1992.tb02010.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To evaluate the incidence, etiology and clinical course of rhabdomyolysis in hospitalized elderly patients. DESIGN Retrospective case series. SETTING Acute geriatric department of a university-affiliated teaching hospital. PATIENTS Twenty-three patients who fulfilled our criteria of rhabdomyolysis. Criteria for inclusion were the finding of elevated serum creatine kinase of five-fold or greater above the upper reference limit and greater than 97% MM isoenzyme. RESULTS In a 3-year period 23 patients out of 2,870 admissions fulfilled the criteria for rhabdomyolysis, an incidence rate of 0.8%. Diseases or insults associated with rhabdomyolysis were, in order of frequency, acute immobilization, infectious disease, cerebrovascular accident, hyperosmolar state, hyponatremia, hypernatremia, hypothermia, and a fall. Twenty-two patients recovered from the acute illness; one patient died from respiratory failure. Seventeen patients had renal failure (serum creatinine greater than 180 mumol/L), none necessitating dialysis. Serum creatinine always declined following recovery. CONCLUSION Elevation of CK with few other clinical features of rhabdomyolysis is common in admissions to a geriatric service. It is due to complete immobilization resulting from acute illness. Renal failure is mild and reversible, and the prognosis for recovery is excellent.
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Affiliation(s)
- E L Marcus
- Geriatrics Department, Shaare Zedek Medical Center, Jerusalem, Israel
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