Psychotropic drug-related rhabdomyolysis

From quail to earthquakes and human conflict: a historical perspective of rhabdomyolysis

Rhabdomyolysis is a common cause of acute kidney injury, featuring muscle pain, weakness and dark urine and concurrent laboratory evidence of elevated muscle enzymes and myoglobinuria. Rhabdomyolysis is often seen in elderly and frail patients following prolonged immobilization, for example after a fall, but a variety of other causes are also well-described. What is unknown to most physicians dealing with such patients is the fascinating history of rhabdomyolysis. Cases of probable rhabdomyolysis have been reported since biblical times and during antiquity, often in the context of poisoning. Equally interesting is the link between rhabdomyolysis and armed conflict during the 20th century. Salient discoveries regarding the pathophysiology, diagnosis and treatment were made during the two world wars and in their aftermath. 'Haff disease', a form of rhabdomyolysis first described in 1920, has fascinated scientists and physicians alike, but the marine toxin causing it remains enigmatic even today. As a specialty, we have also learned a lot about the disease from 20th-century earthquakes, and networks of international help and cooperation have emerged. Finally, rhabdomyolysis has been described as a sequel to torture and similar forms of violence. Clinicians should be aware that rhabdomyolysis and the development of renal medicine are deeply intertwined with human history.

Psychosis and severe rhabdomyolysis associated with synthetic cannabinoid use: A case report

BACKGROUND

Synthetic cannabinoid (SC) or "spice" refers to a variety of herbal/chemical mixtures, which mimic the effects of marijuana. They are generally marked as "herbal incense" and best known by the brand names of "K2," "spice," "aroma," "Mr. Nice Guy" and "dream." Little data are available on the psychopathological and physical effects of SC.

CASE DESCRIPTION

We reported on a 23-year-old man without prior psychiatric history who developed acute psychosis and severe rhabdomyolysis (creatine phosphokinase [CPK]: 44,300 UI/L) associated with "Mr. Nice Guy" consumption. To our knowledge, this is the first case report of severe rhabdomyolysis associated with SC use in the U.S.

CONCLUSIONS

Physicians should be aware of the possibility of new-onset psychotic symptoms and rhabdomyolysis in patients that use SC.

[Rhabdomyolysis in a Bipolar Adolescent. Analysis of Associated Factors]

OBJECTIVE

To describe a case of rhabdomyolysis associated with the use of quetiapine and lamotrigine in an adolescent treated for bipolar disorder.

METHOD

Description of the clinical case, analysis of the associated factors and a non-systematic review of the relevant literature.

RESULTS

An 18 year old male, with bipolar disorder and treated pharmacologically with quetiapine and lamotrigine, after two weeks of physical activity presents with rhabdomyolysis. Quetiapine and exercise have been associated with rhabdomyolysis. The mediator mechanism of this association has not been found, although it has been established that there is neuromuscular dysfunction and an increase in sarcomere permeability.

CONCLUSIONS

This clinical case allowed the complex interaction between antipsychotic agents and increased physical activity to be observed in a psychiatric adolescent patient, as well as the appearance of a potentially lethal medical complication.

Rhabdomyolysis after correction of hyponatremia in psychogenic polydipsia possibly complicated by ziprasidone

OBJECTIVE

To report a case of rhabdomyolysis related to correction of hyponatremia secondary to psychogenic polydipsia, possibly complicated by the use of ziprasidone.

CASE SUMMARY

A 50-year-old white man treated for 3 weeks with ziprasidone 40 mg twice daily for chronic paranoid schizophrenia was admitted to the intensive care unit after a witnessed generalized seizure. Marked hypotonic hyponatremia was present secondary to psychogenic polydipsia. After correction of hyponatremia with intravenous NaCl 0.9%, he developed a substantial elevation in the creatine kinase level without any evidence of muscle trauma, stiffness, or swelling or any signs of neuroleptic malignant syndrome. Renal failure or compartment syndrome did not complicate the clinical picture.

DISCUSSION

It is well known that severe hyponatremia can cause neurologic complications such as stupor, seizures, and even coma. Hyponatremia from water intoxication (n = 28) and its correction with intravenous fluids (n = 2) may cause non-neurologic complications such as rhabdomyolysis. An explanation may lie within the calcium-sodium exchange mechanism across the skeletal myocyte or the failure of cell volume regulation secondary to extracellular hypo-osmolality. Neuroleptic medications have been linked to the development of rhabdomyolysis, with antipsychotics being the primary offenders. As of August 2005, there has been only one reported case of rhabdomyolysis related to correction of hyponatremia complicated by an atypical antipsychotic (clozapine). It is possible that ziprasidone, like clozapine, may enhance muscle cell permeability leading to rhabdomyolysis under similar conditions.

CONCLUSIONS

Psychiatric patients treated with atypical antipsychotic medications should be closely monitored for rhabdomyolysis during correction of hyponatremia, thus permitting prompt therapy to limit its complications.

Rhabdomyolysis secondary to a drug interaction between simvastatin and clarithromycin

OBJECTIVE

To report a case of rhabdomyolysis resulting from concomitant use of clarithromycin and simvastatin.

CASE SUMMARY

A 64-year-old African-American man was admitted to the hospital for worsening renal failure, elevated creatine phosphokinase, diffuse muscle pain, and severe muscle weakness. About three weeks prior to admission, the patient was started on clarithromycin for sinusitis. The patient had been receiving simvastatin for approximately six months. He was treated aggressively with intravenous hydration, sodium bicarbonate, and hemodialysis. A muscle biopsy revealed necrotizing myopathy secondary to a toxin. The patient continued to receive intermittent hemodialysis until his death from infectious complications that occurred three months after admission. There were several factors that could have increased his risk for developing rhabdomyolysis, including chronic renal failure.

DISCUSSION

Clarithromycin is a potent inhibitor of CYP3A4, the major enzyme responsible for simvastatin metabolism. The concomitant administration of macrolide antibiotics and other hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase inhibitors have resulted in previous reports of rhabdomyolysis. Other factors may increase the risk of this drug interaction, including the administration of other medications that are associated with myopathy, underlying renal insufficiency, and administration of high doses of HMG-CoA reductase inhibitors.

CONCLUSIONS

Macrolide antibiotics inhibit the metabolism of HMG-CoA reductase inhibitors that are metabolized by CYP3A4 (i.e., atorvastatin, cerivastatin, lovastatin, simvastatin). This interaction may result in myopathy and rhabdomyolysis, particularly in patients with renal insufficiency or those who are concurrently taking medications associated with myopathy.

Laboratory findings in acute schizophrenia. Relevance to medical management on emergency admission

This study documents the prevalence of abnormal laboratory findings in schizophrenic patients who were admitted, because of acute disease, to a psychiatric intensive care unit in Japan. Patient laboratory data were evaluated retrospectively prior to treatment. Of 259 male acute schizophrenic patients (ICD-10: F2 group), nearly 10% were dehydrated, 33% had hypokalemia and leukocytosis, and 66% showed elevated serum muscle enzymes. This prevalence was statistically significant compared with that of psychiatric outpatients (F1 group). In addition, these medical problems in the F2 group were as frequent as those in the F1 group, i.e., alcohol and/or psychoactive substance abusers (ICD-10), although the problems in the F2 group occurred less often than in the F1 group. Current medication, obvious complications, or the presence of alcohol and/or psychoactive substance abuse in the F2 group were not major causes of these results. The medical problems significantly improved after 8 hours of fluid therapy. These findings strongly suggest the significance of medical management for acute schizophrenic patients on emergency admission as well as for alcohol and/or psychoactive substance abusers.

Rhabdomyolysis associated with naltrexone

OBJECTIVE

To report a possible association between naltrexone therapy and the development of rhabdomyolysis in one patient.

CASE SUMMARY

A 28-year-old white man in good physical health was started on naltrexone 50 mg/d for inpatient treatment of alcohol dependence and depression. A routine serum chemistry panel obtained on day 9 of naltrexone therapy showed marked new elevations in creatine kinase and aspartate aminotransferase. The patient remained asymptomatic and did not develop renal insufficiency. The serum enzyme concentrations returned to normal within eight days of naltrexone discontinuation.

DISCUSSION

Rhabdomyolysis has not been previously reported to occur in patients during treatment with naltrexone. Alcoholism may result in a reversible acute muscle syndrome, but our patient did not fit the appropriate clinical profile for such a syndrome. Additionally, the other prescribed medications could not be implicated as possible causative agents.

CONCLUSIONS

This case report illustrates a possible association between naltrexone therapy and rhabdomyolysis.

Rhabdomyolysis leading to acute renal failure following administration of neuroleptic medication

The case of a 48-year-old man who developed rhabdomyolysis, without the features of neuroleptic malignant syndrome, following the administration of neuroleptics is described. Possible mechanisms for this development, and methods of detection, are discussed.

Seizures, ventricular tachycardia, and rhabdomyolysis as a result of ingestion of venlafaxine and lamotrigine

Few cases of overdoses have been described involving venlafaxine, lamotrigine, or a combination of the two agents. We describe a combined venlafaxine and lamotrigine ingestion in a patient presenting with a seizure, ventricular tachycardia, and rhabdomyolysis. We conclude that patients with overdoses that involve venlafaxine can exhibit severe cardiac effects in addition to seizures, especially if venlafaxine is combined with other agents.

Atypical Neuroleptic Malignant Syndrome Presenting as Rhabdomyolysis, Altered Consciousness, and Leukocytosis

Objective:

To provide a clinically accurate description of an atypical form of neuroleptic malignant syndrome (NMS) induced by perphenazine, to underline the importance of early diagnosis of this atypical form of NMS, and to stimulate discussion of possible mechanisms of this adverse drug event.

Case Summary:

A 61-year-old man had received perphenazine for 5 years for treatment of schizophrenia. He presented with progressive muscle rigidity, difficulty walking, and lower back pain. He was found to be disoriented and confused with tardive dyskinesia and muscle weakness. The patient was afebrile and normotensive. Clinical workup and laboratory test results were consistent with a diagnosis of rhabdomyolysis. The patient was treated with rehydration and sodium bicarbonate. Perphenazine therapy was discontinued and the symptoms resolved within 3 days.

Discussion:

Rhabdomyolysis has been reported in patients receiving psychotropic drugs, but the frequency of the occurrence is not known. The most frequent cause of rhabdomyolysis in psychiatric patients is NMS; however, this patient had only part of the classical picture of NMS. Other cases of atypical presentation are reviewed.

Conclusions:

Muscle injury in the presence of psychotropic drugs can manifest in many different ways. This suggests a complex mechanism of injury, involving central mechanisms as well as direct injury to the muscle.

Rhabdomyolysis due to hereditary torsion dystonia

Following an acute dystonic crisis, a 6-year-old boy with hereditary torsion dystonia developed rhabdomyolysis. To our knowledge, hereditary torsion dystonia has never been reported as a cause of rhabdomyolysis. Early diagnosis and treatment of rhabdomyolysis should be considered in children with severe dystonia in order to prevent renal failure.