Recurrent exercise-induced rhabdomyolysis

Unusually high creatine kinase in a case of rhabdomyolysis without acute kidney injury: a case report

Background

While rhabdomyolysis frequently leads to hospital admissions, typically following trauma, recurrent occurrences are relatively rare, accounting for just 10% of cases. For young patients experiencing repetitive episodes without an apparent cause, a comprehensive investigation into the possible etiologies is crucial. Recognizing the atypical nature of recurrent rhabdomyolysis is crucial and a thorough workup encompassing evaluations for potential endocrine, inflammatory, and metabolic etiologies is recommended. Additionally, acute kidney injury is a common complication with severe rhabdomyolysis, hence early recognition and intervention is crucial.

Case Description

Herein we present a case of a 30-year-old young African American male patient with recurrent rhabdomyolysis with the highest ever reported creatine kinase (CK) to our knowledge. A notable aspect of this case is the surprising absence of acute kidney injury, despite the severity of CK elevation. We also delve into the extensive workup done for rhabdomyolysis of unclear etiology.

Conclusions

Our case underscores the importance of looking into non-traumatic factors behind recurrent rhabdomyolysis, especially in young patients. We also stress the significance of early detection and intervention, showcasing the potential to prevent acute kidney injury even in the presence of markedly elevated CK levels. Timely recognition and appropriate management can prove instrumental in mitigating the severity of complications associated with rhabdomyolysis.

Exercise testing and prescription in patients with inborn errors of muscle energy metabolism

Skeletal muscle is a dynamic organ requiring tight regulation of energy metabolism in order to provide bursts of energy for effective function. Several inborn errors of muscle energy metabolism (IEMEM) affect skeletal muscle function and therefore the ability to initiate and sustain physical activity. Exercise testing can be valuable in supporting diagnosis, however its use remains limited due to the inconsistency in data to inform its application in IEMEM populations. While exercise testing is often used in adults with IEMEM, its use in children is far more limited. Once a physiological limitation has been identified and the aetiology defined, habitual exercise can assist with improving functional capacity, with reports supporting favourable adaptations in adult patients with IEMEM. Despite the potential benefits of structured exercise programs, data in paediatric populations remain limited. This review will focus on the utilisation and limitations of exercise testing and prescription for both adults and children, in the management of McArdle Disease, long chain fatty acid oxidation disorders, and primary mitochondrial myopathies.

A Young Female With Medium-Chain Acyl-CoA Dehydrogenase Deficiency (MCADD): A Case Report

Medium-chain acyl-CoA dehydrogenase (MCAD) deficiency (MCADD) is a rare autosomal recessive inborn error of mitochondrial fatty acid oxidation. MCAD is essential for fatty acid β-oxidation during hepatic ketogenesis, which provides a major source of energy once hepatic glycogen stores are exhausted during extended fasting and periods of increased energy demand. The inability to metabolize these fatty acids results in hypoketotic hypoglycemia and the accumulation of toxic partially metabolized fatty acids. Intercurrent infection, extended fasting, excessive alcohol intake, vomiting, or diarrhea can lead to serious illness, including encephalopathy and even sudden death. Young people with MCADD are followed up on a regular basis by their metabolic disease specialist, and they are informed about risk factors as they advance through adolescence and adulthood. They should also carry along a written emergency management plan and relevant contact numbers. We describe a case of a 17-year-old female who attended her local emergency care center complaining of severe abdominal pain, vomiting, muscle ache, and poor oral intake. She was known to have MCADD; however, her emergency care plan had a date from eight years ago. She made a rapid recovery after receiving intravenous glucose and other therapies. The patient's concerns and knowledge about MCADD were not fully appreciated at the initial stage due to the rare nature of the disease. This in combination with the absence of current notes on the system, an emergency care plan dated from eight years ago, and the need to obtain specialist advice led to a slight delay in commencing specific therapy. This case report serves as a reminder of the emergency presentation of young people with MCADD, emphasizing the importance of effective communication between the patient, their parents, and the treating clinicians, obtaining the emergency care plan and recommendations, and communicating with the metabolic disease specialist.

Isolated rhabdomyolysis of long head of triceps mimicking upper extremity deep vein thrombosis

Rhabdomyolysis is characterised by skeletal muscle breakdown, with release of toxic intracellular contents into the circulation. A man in his 20s presented to the emergency department with acute-onset right arm swelling, with pitting oedema extending into his forearm without clear precipitant. Initial differential diagnosis was upper extremity deep vein thrombosis, however none was identified on CT venogram. Instead, rhabdomyolysis of long head of triceps was diagnosed after multidisciplinary review of the venogram by the treating vascular surgeon and radiologist. Retrospectively, added serum creatine kinase was found to be 11 587 U/L, and together with MRI of the right arm, the diagnosis was established. Given the patient's lack of comorbidities, normal renal function and reliability, he was managed conservatively as an outpatient without hospital admission for intravenous hydration. This is the only case to our knowledge of isolated long head of triceps' rhabdomyolysis reported in Australia and the second case worldwide.

Use of dexamethasone in idiopathic, acute pediatric rhabdomyolysis

Current rhabdomyolysis treatment guidelines vary based on the etiology and diagnosis, yet many cases evade conclusive diagnosis. In these cases, treatment options remain largely limited to fluids and supportive therapy. We present two cases of acute rhabdomyolysis diagnosed in the emergency department: a 5-year-old boy with sudden onset bilateral flank pain, and a 13-year-old boy with 2-3 days of worsening pectoral and shoulder pain. Each patient had a prior similar episode requiring hospitalization in the past. The 5-year-old had no inciting trauma or trigger, medication use, or illness. The 13-year-old previously had an upper respiratory infection during the week prior and had been strenuously exercising at the time of onset. Genetic testing results were unknown for both patients during their hospitalizations, and insurance and other barriers led to delay. Later results for the first patient revealed a heterozygous deletion in intron 19 on the LPIN1 gene interpreted as a variant of unknown significance. During their hospitalizations, both children were started on intravenous (i.v.) fluids, and creatine kinase (CK) initially trended downward, but then began to rise or plateau. After reviewing the cases, prior literature, and anecdotal evidence of benefit from corticosteroid therapy in rhabdomyolysis with our consultant metabolic physicians, dexamethasone was initiated. In both patients, dexamethasone use correlated with relief of patient symptoms, significantly decreased CK value, and our ability to discharge these patients home quickly. Our cases, discussion, and literature review all lead to the consideration of the use of dexamethasone in conjunction with standard therapy for acute rhabdomyolysis.

Body Building and Aminotransferase Elevations: A Review

In addition to liver injury, elevation of aminotransferases can be caused by strenuous exercise and use of muscle-building and weight-loss supplements. The purpose of this review is to discuss the various mechanisms of elevation of aminotransferases related to body building. A literature review was performed on clinical trials and case reports involving exercise or supplement use and their effects on aminotransferases. Normal aminotransferase levels varied according to gender, age, body mass index, and comorbidities. Strenuous exercise and weight lifting, especially in the unaccustomed, can cause elevated aminotransferases in the absence of liver damage. Supplements such as anabolic steroids, ephedra, and LipoKinetix, amongst others, have also been associated with aminotransferase elevations. The pattern of elevation of aminotransferases is not helpful in distinguishing liver from muscle injury. Other associated muscle enzymes can be useful in making that distinction. To prevent aminotransferase elevations, subjects not accustomed to moderate-high intensity workouts, are recommended to undertake gradual increase in intensity. When causes of liver injury have been ruled out, investigation into bodybuilding, extreme exercise, and supplement use is warranted.

Exertional rhabdomyolysis in a 21-year-old healthy man resulting from lower extremity training: A case report

RATIONALE

The incidence exercise-induced rhabdomyolysis is increasing in the healthy general population. Rhabdomyolysis can lead to the life-threatening systemic complications of acute kidney injury (AKI), compartment syndrome, and disseminated intravascular coagulopathy.

PATIENT CONCERNS

A 21-year-old man had bilateral lower limb pain and soreness, dark brown urine after lower exremity training. Laboratory results showed that creatinine kinase (CK) and myoglobin (Mb) increased to 140,500 IU/L and 8632 μg/L respectively, with elevated liver enzymes, Scr, and proteinuria.

DIAGNOSES

Exercise-induced rhabdomyolysis with AKI.

INTERVENTIONS

The patient was hospitalized and treated with vigorous hydration and sodium bicarbonate for 6 days.

OUTCOMES

After 6 days of treatment, the patient had a significant decrease in the CK and Mb levels. His renal function returned to normal. His laboratory tests had completely normalized during 2-week follow-up.

LESSONS

Exercise-induced rhabdomyolysis can cause serious complications such as AKI. Delayed diagnosis can be critical, so timely manner should be taken to achieve a favorable prognosis.

The Genetic Challenges and Opportunities in Advanced Heart Failure

The causes of heart failure are diverse. Inherited causes represent an important clinical entity and can be divided into 2 major categories: familial and metabolic cardiomyopathies. The distinct features that might be present in early disease states can become broadly overlapping with other diseases, such as in the case of inherited cardiomyopathies (ie, familial hypertrophic cardiomyopathy or mitochondrial diseases). In this review article, we focus on genetic issues related to advanced heart failure. Because of the emerging importance of this topic and its breadth, we sought to focus our discussion on the known genetic forms of heart failure syndromes, genetic testing, and newer data on pharmacogenetics and therapeutics in the treatment of heart failure, to primarily encourage clinicians to place a priority on the diagnosis and treatment of these potentially treatable conditions.

[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.

Spinning-induced rhabdomyolysis: A case report and review of literature

Rhabdomyolysis is a condition of skeletal muscle breakdown in which muscle injury causes a release of myoglobin and the muscle enzymes creatine phosphokinase (CPK), lactate dehydrogenase (LDH), and transaminases. Exertional rhabdomyolysis, which is precipitated by exercise or exertion, ranges from mild muscle injury with negligible symptoms or systemic effects to fulminant cases. Herein, we report a 26-year-old female patient who was admitted to our Physical Medicine and Rehabilitation outpatient clinics with severe bilateral thigh pain persisting for 5 days after participating in a spinning class and diagnosed with exertional rhabdomyolysis. Timely diagnosis and treatment prevented the potentially life-threatening consequences. We assume that it is essential to raise the awareness of this phenomenon not only by physicians but also by the community, since regular exercise and being physically active are increasingly encouraged in modern life.

Rhabdomyolysis. The role of diagnostic and prognostic factors

Rhabdomyolysis, literally meaning the breakdown of muscle tissue, is a common syndrome with many causes, acquired ones such as exertion, trauma, infections, temperature extremes, drugs, toxins, electrolyte and endocrine abnormalities, and congenital ones such as myopathies and connective tissue disorders. All results in a common pathophysiologic pathway which ends with the dispersing of muscle tissue content into the circulation. Rhabdomyolysis has characteristic clinical, laboratory and radiologic features, but does require a high index of suspicion so that the diagnosis would not be missed. The sensitivity and specificity of the various characteristics, as well as clinical guidelines, are discussed in this paper. The syndrome may present with several complications, e.g. arrhythmias, electrolyte abnormalities, acute renal injury, acidosis, volume depletion, compartment syndrome and disseminated intravascular coagulation. The prognosis is highly variable and depends on the underlying etiologies and complications, but is in general considered as good. The milestone of treatment is vigorous fluid resuscitation. Treatment options, in practice and in research, are discussed in the following pages.