Clinical spectrum of rhabdomyolysis presented to pediatric emergency department

Rhabdomyolysis: A Rare Presentation of Hashimoto Thyroiditis in an Adolescent Boy and Review of the Literature

INTRODUCTION

Hypothyroidism-induced rhabdomyolysis without precipitating factors is extremely rare, particularly in pediatric patients. We describe a previously healthy adolescent boy who came to our institution with vague symptoms and was found to have rhabdomyolysis secondary to hypothyroidism due to Hashimoto thyroiditis. We also summarize previously published cases in children and adolescents.

CASE PRESENTATION

A 16-year-old boy presented to the emergency department at Riley Hospital for Children with a 2-week history of bilateral eye and lip swelling, fatigue, and slowing of speech initially attributed to angioedema. His laboratory studies were significant for acute kidney injury secondary to rhabdomyolysis. Additional evaluation revealed profound primary hypothyroidism and positive TPO antibodies. Although his free T4 was undetectable, his TSH was only 32.2 mcU/mL. He received IV hydration and thyroid replacement, and his symptoms improved after several months of treatment.

DISCUSSION

Rhabdomyolysis without any risk factors is very rare, especially in children. Our patient was not on any medications, had no family history of neuromuscular disorders, and no history of trauma, infection, or strenuous exercise. The reason behind the disproportionately mild elevation of TSH in the setting of an undetectable free T4 is unclear.

CONCLUSION

It is important for clinicians to be aware that rhabdomyolysis may be a presenting sign of severe hypothyroidism, as delay in diagnosis and treatment can be detrimental.

Paediatric rhabdomyolysis: A UK centre's 10-year retrospective experience

AIMS

To describe the aetiologies of paediatric rhabdomyolysis and explore the medium-term renal consequences.

METHODS

Retrospective, single-centre review of children with rhabdomyolysis.

RESULTS

Two hundred and thirty-two children met inclusion criteria for the analysis. Mean age at presentation was 8.4 (SD ± 5.5) years. The commonest aetiology was infection (28%), with viral myositis making up the clear majority (75%). Trauma was identified as a cause in 18% of children, seizures in 10% and immune-mediated mechanisms in 8%. Acute kidney injury (AKI) was present in 32% of the cases overall. Children with AKI tended to be younger, with higher peak creatine kinase (CK) and active urinary sediment on urinalysis at presentation. AKI and the need for renal replacement therapy (RRT) were associated with a prolonged hospital stay (15 (interquartile range, IQR 6.5-33) vs. 2 (IQR 0-7) days). A total of 18 children and young people required RRT, with a mean duration of 7.1 ± 4.3 days. Those who received RRT were more likely to have abnormalities on urinalysis at presentation (46% vs. 5%). Over the period of the study, 9% of children died and 2% met criteria for a diagnosis of chronic kidney disease.

CONCLUSIONS

This large paediatric rhabdomyolysis case series provides new and unique insights into the condition. Our results highlight the common aetiologies and provide evidence of good renal recovery overall, even in the most severely affected cases. Abnormalities of urinalysis appear to be important in predicting the development of AKI and the need for RRT.

Case report: Rhabdomyolysis in children in acute and chronic disease-a challenging condition in pediatric emergency medicine

Rhabdomyolysis is a challenging condition in pediatric emergency departments (PED): It ranges from asymptomatic illness with isolated elevation of creatine kinase (CK) levels to a life-threatening condition associated with extreme elevations in CK, electrolyte imbalances, circulatory failure (CF), acute kidney injury (AKI), and multi-organ disease. Most common causes of rhabdomyolysis are viral myositis and trauma, hereditary metabolic myopathies must be considered when facing rhabdomyolysis in early childhood. We report two cases of severe rhabdomyolysis with CF in our PED, thereby summarizing first-line management of rhabdomyolysis.

Prevalence and Mortality of Post-traumatic Acute Kidney Injury in Children; a Systematic Review and Meta-analysis

Introduction

Numerous studies on acute kidney injury (AKI) following trauma have been performed, and acceptable findings have been reported in the adult population. The present meta-analysis summarizes the studies performed on the pediatric population to evaluate the prevalence of AKI following trauma in this population.

Method

The Medline, Embase, Scopus and Web of Sciences databases were searched for articles published until the July, 31, 2021. Two independent reviewers screened observational studies performed on children with physical trauma and AKI related to it. The interested outcomes were the prevalence and mortality of trauma-related AKI in traumatized children.

Results

Data of 9 articles were included in the present meta-analysis. The prevalence of trauma-related AKI varied between 0% and 30.30% among included studies. Pooled analysis showed that the prevalence of trauma-related AKI was 9.86% (95% CI: 8.02 to 11.84%). The prevalence of AKI after exertional rhabdomyolysis, direct physical trauma, and earthquake related injuries was 0%, 12.64% and 24.60%, respectively. There was a significant relationship between the prevalence of AKI and trauma etiology (p = 0.038). Moreover, the occurrence of AKI in children with trauma was associated with an increased risk of mortality (OR = 5.55; 95% CI: 2.14 to 13.93).

Conclusion

The findings of the present study showed that 9.86% of children develop AKI following trauma, which may increase their risk of death by about 5.5 times. Nevertheless, since none of the studies had adjusted their analyzes for potential confounders, caution should be exercised in interpreting the relationship between trauma-related AKI and mortality.

Motor Vehicle Collision and Acute Kidney Injury in Children

OBJECTIVE

Our study aimed to determine the prevalence of acute kidney injury (AKI) in pediatric patients who sustained trauma due to motor vehicle collision (MVC) and identify factors associated with its development.

METHODS

We retrospectively reviewed the clinical information and laboratory tests of pediatric patients who were admitted because of MVC from January 2014 to April 2021. The occurrence of AKI was our primary outcome, which was defined by the Kidney Disease Improving Global Outcomes criteria. A serum creatine kinase (CK) level of 1000 IU/L or greater was defined as rhabdomyolysis.

RESULTS

Sixty-four patients (median age, 9.6 years) were included in the study. Twenty three of the patients (35.9%) developed AKI: stage 1 AKI in 18 (78.3%) and stage 2 AKI in 5 (21.7%) patients. Acute kidney injury patients had higher injury severity scores (no AKI: 5.0; stage 1 AKI: 10.5; stage 2 AKI: 26.0). Rhabdomyolysis was present in 21.1% of the patients and was associated with the overall AKI risk (odds ratio [OR], 7.3; 95% confidence interval [CI], 1.6-32.6) and stage 2 AKI (OR, 15.0; 95% CI, 1.4-163.2). Blood tests from AKI patients showed lower serum bicarbonate and base excess, higher leukocyte and CK levels on admission, and a higher peak CK in the first 72 hours of admission. Intubation in emergency department (OR, 11.1; 95% CI, 1.2-102.1) and surgical interventions (OR, 3.2; 95% CI, 1.0-9.8) were associated with AKI. Acute kidney injury patients required longer stay in pediatric intensive care unit (median 1.0 vs 2.3 days, P < 0.001) and hospital (median 4.1 vs 7.0 days, P = 0.010).

CONCLUSIONS

Approximately one third of pediatric patients who sustained trauma from MVC developed AKI. Initial blood results, including higher CK and leukocyte count, and lower bicarbonate and base excess, were associated with the development of AKI. Rhabdomyolysis occurred in approximately one fifth of the patients and was significantly associated with AKI.

Dexmethylphenidate-Induced Rhabdomyolysis by Interaction With Aromatase Inhibitor

Rhabdomyolysis secondary to prescription drug-drug interactions can be an overlooked life-threatening emergency. Amphetamines and similar substances have been associated with muscle lysis secondary to increased sympathetic activity that can cause myotoxicity, hyperthermia, and increased muscular activity. Anabolic steroids may also be a predisposing factor in developing rhabdomyolysis. A high index of suspicion for drug-induced rhabdomyolysis in a patient presenting with atraumatic extremity pain can facilitate rapid diagnosis and treatment. We present a case of drug-induced rhabdomyolysis likely secondary to a previously unreported medication interaction.

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.

Acute kidney injury in pediatric non-traumatic rhabdomyolysis

BACKGROUND

Our study aimed to determine the prevalence of acute kidney injury (AKI) in pediatric non-traumatic rhabdomyolysis, and to identify factors associated with its development.

METHODS

Clinical information and laboratory tests of children with rhabdomyolysis who were admitted between 2009 and 2018 were reviewed retrospectively. Rhabdomyolysis was defined by a peak serum creatine kinase (CK) level > 1000 IU/L within the first 72 h of admission. The primary outcome was the occurrence of AKI within the first 7 days of admission, which was determined by the KDIGO criteria.

RESULTS

A total of 54 patients with a median age of 7.8 years old were included. Ten (18.5%) patients developed AKI. AKI was relatively rare in children with viral myositis (2.6%), whereas all patients with rhabdomyolysis related to seizure or irritability/dystonia developed AKI. Patients with AKI had higher white cell count (10.6 vs. 4.5 × 10⁹/L) and lower serum bicarbonate (19.4 vs. 25.5 mmol/L) on admission, with higher peak serum CK (23,086.0 vs. 3959.5 IU/L). The AKI group was more likely to present with positive urine results (myoglobinuria, dipstick heme or protein ≥ 2+). Peak serum CK had a good discriminatory power for stage 2-3 AKI (AUC 0.930, p = 0.005), with an optimal cut-off of 15,000 IU/L identified from the ROC analysis.

CONCLUSIONS

The overall prevalence of AKI in pediatric non-traumatic rhabdomyolysis was 18.5%. Positive urine tests (myoglobinuria, dipstick heme or protein ≥ 2+), high white cell count, lower serum bicarbonate on admission, and high peak serum CK were associated with development of AKI.

RYR1-related rhabdomyolysis: a spectrum of hypermetabolic states due to ryanodine receptor dysfunction

Variants in the ryanodine receptor-1 gene (RYR1) have been associated with a wide range of neuromuscular conditions, including various congenital myopathies and malignant hyperthermia (MH). More recently, a number of RYR1 variants, mostly MH-associated, have been demonstrated to contribute to rhabdomyolysis events not directly related to anesthesia in otherwise healthy individuals. This review focuses on RYR1-related rhabdomyolysis, in the context of several clinical presentations (i.e., exertional rhabdomyolysis, exertional heat illnesses and MH), and conditions involving a similar hypermetabolic state, in which RYR1 variants may be present (i.e., neuroleptic malignant syndrome and serotonin syndrome). The variety of triggers that can evoke rhabdomyolysis, on their own or in combination, as well as the number of potentially associated complications, illustrates that this is a condition relevant to several medical disciplines. External triggers include but are not limited to strenuous physical exercise, especially if unaccustomed or performed under challenging environmental conditions (e.g., high ambient temperature or humidity), alcohol/illicit drugs, prescription medication (in particular statins, other anti-lipid agents, antipsychotics and antidepressants) infection, or heat. Amongst all patients presenting with rhabdomyolysis, a genetic susceptibility is present in a proportion, with RYR1 being one of the most common genetic causes. Clinical clues for a genetic susceptibility include recurrent rhabdomyolysis, creatine kinase (CK) levels above 50 times the upper limit of normal, hyperCKemia lasting for 8 weeks or longer, drug/medication doses insufficient to explain the rhabdomyolysis event, and a positive family history. For the treatment or prevention of RYR1-related rhabdomyolysis, the RYR1 antagonist dantrolene can be administered, both in the acute phase, or prophylactically in patients with a history of muscle cramps and/or recurrent rhabdomyolysis events. Aside from dantrolene, several other drugs are being investigated for their potential therapeutic use in RYR1-related disorders. These findings offer further therapeutic perspectives for humans, suggesting an important area for future research.

Acute Kidney Injury Among Children Admitted With Viral Rhabdomyolysis

BACKGROUND

Infectious etiologies cause a large portion of pediatric rhabdomyolysis. Among pediatric patients with rhabdomyolysis, it is unknown who will develop acute kidney injury (AKI). We sought to test the hypothesis that a viral etiology would be associated with less AKI in children admitted with rhabdomyolysis than a nonviral etiology.

METHODS

In this single-center retrospective cohort study, patients <21 years of age admitted with acute rhabdomyolysis from May 1, 2010, through December 31, 2018, were studied. The primary outcome was development of AKI, defined by using the Kidney Disease: Improving Global Outcomes guidelines. The primary predictor was identification of viral infection by laboratory testing or clinical diagnosis. Covariates included age, sex, race, insurance provider, presence of proteinuria and myoglobinuria, and initial creatinine kinase and serum urea nitrogen. Routine statistics and multivariable logistic modeling were performed via SAS 9.4 (SAS Institute, Inc, Cary, NC).

RESULTS

In total, 319 pediatric patients with rhabdomyolysis were studied. The median age was 13 years. Patients were predominately male (69.9%), non-Hispanic Black (55.2%), and publicly insured (45.1%). We found no difference in the rates of AKI in those with a viral diagnosis versus those without a viral diagnosis (30 of 77 [39.0%] vs 111 of 234 [47.4%]; P = .19). Multivariable analysis revealed that viral diagnosis was not associated with the development of AKI. Patients ≥13 years of age, male patients, and those with proteinuria and elevated serum urea nitrogen on admission had increased odds of developing AKI.

CONCLUSIONS

In our study, viral rhabdomyolysis did not have lower rates of AKI compared with nonviral etiologies of AKI; therefore, providers should consider continued caution in these patients.

The Epidemiology and Management of Pediatric AKI in Asia

Because of the lack of early recognition and referral, the incidence of pediatric acute kidney injury (AKI) in Asia still is underestimated. Although each diagnostic criteria has its own merits, the Kidney Disease Improving Global Outcomes classification now is widely accepted. In Asia, the spectrum of pediatric AKI is wide-ranging, from pediatric AKI in highly sophisticated tertiary-care pediatric intensive care units in resource-rich regions due to advanced procedures such as transplantation, cardiac surgery, and other hospital-acquired causes, to primary care preventable causes, such as infectious diseases, snakebite, and so forth in rural parts of the developing world. The development and application of novel biomarkers, concepts such as the Renal Angina Index and advanced renal replacement therapy have revolutionized the era of treating AKI, but the cost and feasibility are the key determinants, especially in rural areas. In view of availability and expenses, peritoneal dialysis should be the first choice in less-developed areas, however, because of various barriers, it still needs more effort. Effective educational steps to both medical carers and families are needed urgently.

Utility of Automated Feeding Data to Detect Social Instability in a Captive Breeding Colony of Rhesus Macaques (Macaca mulatta): A Case Study of Intrafamily Aggression

Some captive breeding colonies of rhesus macaques live in large outdoor multimale, multifemale social groups. These groups are composed of several matrilineal families, governed by a clear female dominance hierarchy. Aggression within the same or between different matrilineal families due to social instability can result in trauma and mortality. Therefore, a primary management goal is to detect emerging social unrest before the onset of significant fighting and wounding. Accordingly, groups are monitored routinely for changes in dominance and alliance relations as well as for increases in trauma frequency and severity. Decreased food intake is a normal physiologic response to acute stress; therefore, inappetence in key animals or groups of monkeys might be used as an indicator of increased social stress and emerging instability. An incident of intrafamily aggression occurred recently in a breeding group at our facility and resulted in considerable fighting. Because this compound was equipped with an automated feeding system that tracks the caloric intake of individual animals, we retrospectively analyzed feeding data to determine whether significant reduction in caloric consumption occurred prior to the onset of aggression, compared with baseline values. Neither the entire group nor individual families showed any significant differences in total caloric intake between baseline and previous 24 h values; however, the affected family exhibited a 20% reduction in total caloric during the 24 h prior to the aggression. Most notably, the deposed subfamily showed a marked 58% reduction in caloric intake during the prior 24 h, whereas remaining subfamilies showed no significant changes in intake. High-ranking animals of the group, including the α female, β female, and α male, similarly exhibited marked decreases in caloric intake during that period. These findings indicate that automated feeders can assist management staff with monitoring social stability in breeding colonies of rhesus macaque.

Clinical Features of Acute Rhabdomyolysis in 55 Pediatric Patients

Objective: This study was designed to compare the clinical manifestations, laboratory tests, etiology, and prognosis of children with acute rhabdomyolysis (RM) at various ages. This study was designed to analyze the risk factors for acute kidney injury (AKI) in children with RM and to identify the role of neuromuscular and autoimmune disease in children with RM. Methods: Clinical data for 55 children with RM were collected and statistically analyzed. Patients were stratified to an infant group (G1) (age <1 year), preschool group (G2) (age 1-6 year), school-age group (G3) (age 7-11 year), and an adolescent group (G4) (age 12-16 year). Results: The top three clinical manifestations were dark urine (52.7%), myalgia (38.2%), and fever (23.8%). Patients in G1 had fever (71.4%), vomiting (77.8%), and urinalysis abnormalities (14.3%), without triad clinical manifestations. Fifty percent of patients in G4 group had myalgia; 70.8% had dark urine; 75% had abnormal urine tests. The most common cause in each age group was as follows: sepsis (57.1%) in G1; hereditary neuromuscular diseases (44.4%) in G2; immune diseases (40%) in G3; strenuous exercise (50%) in G4. Logistic regression analysis shown that AKI was not corelated with age, gender, or peak creatine phosphokinase. AKI was, however, associated with presence of an electrolyte disorder. Conclusion: The clinical manifestations and laboratory findings in infants with acute RM are not typical and need to be taken seriously. The presence of an electrolyte disorder is a risk factor for AKI in children with RM. The most common pathogenesis of RM varies among age groups. Congenital hereditary metabolic disease and immune diseases should not be ignored as a cause of RM in children.

Rhabdomyolysis in Children: Three Exotic Presentations from Suriname

We describe three clinical cases of Surinamese children with rhabdomyolysis with diverse clinical presentation and course. The first patient had rhabdomyolysis because of toxins caused by multiple beestings and developed acute kidney injury. The other two patients had rhabdomyolysis following acute infection with chikungunya and influenza A/H1N1 virus. These cases emphasize that the diverse etiology of rhabdomyolysis should be considered in children in tropical settings.

Rhabdomyolysis: Patterns, Circumstances, and Outcomes of Patients Presenting to the Emergency Department

Background

Exertional rhabdomyolysis is a condition resulting from skeletal muscle damage and release of intracellular toxins into the systemic circulation as a consequence of extreme physical effort. With increasing numbers of people partaking in high-intensity workouts, we hypothesized that the rate of presentation of exertional rhabdomyolysis was also increasing.

Methods

All presentations to the Princess Alexandra Hospital emergency department in Brisbane, Australia between March 2005 and December 2016 were identified from the electronic medical record. Records of patients with a serum creatine kinase value >1,000 U/L or a urinary myoglobin >5 mg/L were extracted for determination of whether the rhabdomyolysis was attributable to physical exertion.

Results

From a total of 1,957 rhabdomyolysis cases, 89 patients (70.8% male) were identified as having exertional rhabdomyolysis. The frequency of presentation increased from 0.28/10,000 presentations in 2005 to 3.5/10,000 in 2015. Gym-induced exertional rhabdomyolysis was the primary subcategory (53.9%) for these cases, and manual labor was the second most common subcategory (15.7%).

Conclusion

This study provides evidence for increasing instances of exertional rhabdomyolysis in the Brisbane, Australia metropolitan area and adds to the current knowledge about those who develop exertional rhabdomyolysis. Future studies are warranted to investigate if similar trends are being seen in other regions and to identify the circumstances leading to the presentation. Such knowledge would be valuable for devising strategies to prevent and mitigate injury.

Acute kidney injury in pediatric patients with rhabdomyolysis

Purpose

This study aimed to evaluate the clinical findings in pediatric rhabdomyolysis and the predictive factors for acute kidney injury (AKI) in Korean children.

Methods

Medical records of 39 Korean children, who were newly diagnosed with rhabdomyolysis from January 2008 to December 2015, were retrospectively analyzed. The diagnosis was made from the medical history, elevated serum creatinine kinase level >1,000 IU/L, and plasma myoglobin level >150 ng/mL. Patients with muscular dystrophy and myocardial infarction were excluded.

Results

The median patient age at diagnosis was 14.0 years (range, 3–18 years), and the male to female ratio was 2.5. The most common presenting symptom was myalgia (n=25, 64.1%), and 14 patients (35.9%) had rhabdomyolysis-induced AKI. Eighteen patients (46.2%) had underlying diseases, such as epilepsy and psychotic disorders. Ten of these patients showed rhabdomyolysis-induced AKI. The common causes of rhabdomyolysis were infection (n=12, 30.7%), exercise (n=9, 23.1%), and trauma (n=8, 20.5%). There was no difference in the distribution of etiology between AKI and non-AKI groups. Five patients in the AKI group showed complete recovery of renal function after stopping renal replacement therapy. The median length of hospitalization was 7.0 days, and no mortality was reported. Compared with the non-AKI group, the AKI group showed higher levels of peak creatinine kinase and myoglobin, without statistical significance.

Conclusion

The clinical characteristics of pediatric rhabdomyolysis differ from those observed in adult patients. Children with underlying diseases are more vulnerable to rhabdomyolysis-induced AKI. AKI more likely develops in the presence of a high degree of albuminuria.

Illegal immigration: the puzzling role of several risk factors for rhabdomyolysis

A 14-year-old boy presented with low-grade fever, widespread myalgia and difficulty in walking and standing 2 days after the undocumented trip which brought him from western Africa to Italy. His serum creatine phosphokinase was markedly elevated. He was diagnosed with rhabdomyolysis and was volume-restored with normal saline and bicarbonate-containing fluid. Anamnesis revealed illegal, not well-specified, forced consumption in his fatherland, and very bad conditions of the trip (prolonged immobility, dehydration, hypothermia). Workup included a respiratory microbiological panel which was positive for Chlamydia pneumoniae Other microbiological agents were excluded. After 3 weeks, he recovered complete motility. Undocumented immigrants may present several risk factors for rhabdomyolysis that give to this group of individuals a higher risk of developing this disorder.

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.

Assessment of acute motor deficit in the pediatric emergency room

OBJECTIVES

This review article aimed to present a clinical approach, emphasizing the diagnostic investigation, to children and adolescents who present in the emergency room with acute-onset muscle weakness.

SOURCES

A systematic search was performed in PubMed database during April and May 2017, using the following search terms in various combinations: "acute," "weakness," "motor deficit," "flaccid paralysis," "child," "pediatric," and "emergency". The articles chosen for this review were published over the past ten years, from 1997 through 2017. This study assessed the pediatric age range, from 0 to 18 years.

SUMMARY OF THE DATA

Acute motor deficit is a fairly common presentation in the pediatric emergency room. Patients may be categorized as having localized or diffuse motor impairment, and a precise description of clinical features is essential in order to allow a complete differential diagnosis. The two most common causes of acute flaccid paralysis in the pediatric emergency room are Guillain-Barré syndrome and transverse myelitis; notwithstanding, other etiologies should be considered, such as acute disseminated encephalomyelitis, infectious myelitis, myasthenia gravis, stroke, alternating hemiplegia of childhood, periodic paralyses, brainstem encephalitis, and functional muscle weakness. Algorithms for acute localized or diffuse weakness investigation in the emergency setting are also presented.

CONCLUSIONS

The clinical skills to obtain a complete history and to perform a detailed physical examination are emphasized. An organized, logical, and stepwise diagnostic and therapeutic management is essential to eventually restore patient's well-being and full health.

Seven-Digit Creatine Kinase in Acute Rhabdomyolysis in a Child

Rhabdomyolysis is an acute life-threatening condition that can occur in childhood secondary to many causes. The authors report the case of a 3-year-old male child who presented with acute rhabdomyolysis. The peak plasma creatine kinase level was extremely high. The 2 main causes of rhabdomyolysis in childhood are viral myositis and trauma, which can sometimes lead to acute renal failure. The highest creatine kinase levels reported in the literature so far was a 6-digit level in 2014 case report. In this study, the authors report the case of a 7-digit creatine kinase level in a child secondary to viral myositis who did not require renal dialysis.

Beyond muscle destruction: a systematic review of rhabdomyolysis for clinical practice

Background

Rhabdomyolysis is a clinical syndrome that comprises destruction of skeletal muscle with outflow of intracellular muscle content into the bloodstream. There is a great heterogeneity in the literature regarding definition, epidemiology, and treatment. The aim of this systematic literature review was to summarize the current state of knowledge regarding the epidemiologic data, definition, and management of rhabdomyolysis.

Methods

A systematic search was conducted using the keywords “rhabdomyolysis” and “crush syndrome” covering all articles from January 2006 to December 2015 in three databases (MEDLINE, SCOPUS, and ScienceDirect). The search was divided into two steps: first, all articles that included data regarding definition, pathophysiology, and diagnosis were identified, excluding only case reports; then articles of original research with humans that reported epidemiological data (e.g., risk factors, common etiologies, and mortality) or treatment of rhabdomyolysis were identified. Information was summarized and organized based on these topics.

Results

The search generated 5632 articles. After screening titles and abstracts, 164 articles were retrieved and read: 56 articles met the final inclusion criteria; 23 were reviews (narrative or systematic); 16 were original articles containing epidemiological data; and six contained treatment specifications for patients with rhabdomyolysis.

Conclusion

Most studies defined rhabdomyolysis based on creatine kinase values five times above the upper limit of normal. Etiologies differ among the adult and pediatric populations and no randomized controlled trials have been done to compare intravenous fluid therapy alone versus intravenous fluid therapy with bicarbonate and/or mannitol.

Diagnostic evaluation of rhabdomyolysis

Rhabdomyolysis is characterized by severe acute muscle injury resulting in muscle pain, weakness, and/or swelling with release of myofiber contents into the bloodstream. Symptoms develop over hours to days after an inciting factor and may be associated with dark pigmentation of the urine. Serum creatine kinase and urine myoglobin levels are markedly elevated. Clinical examination, history, laboratory studies, muscle biopsy, and genetic testing are useful tools for diagnosis of rhabdomyolysis, and they can help differentiate acquired from inherited causes of rhabdomyolysis. Acquired causes include substance abuse, medication or toxic exposures, electrolyte abnormalities, endocrine disturbances, and autoimmune myopathies. Inherited predisposition to rhabdomyolysis can occur with disorders of glycogen metabolism, fatty acid β-oxidation, and mitochondrial oxidative phosphorylation. Less common inherited causes of rhabdomyolysis include structural myopathies, channelopathies, and sickle-cell disease. This review focuses on the differentiation of acquired and inherited causes of rhabdomyolysis and proposes a practical diagnostic algorithm. Muscle Nerve 51: 793-810, 2015.