Incidence, etiology, and outcomes of rhabdomyolysis in a single tertiary referral center

Acute diquat poisoning causes rhabdomyolysis

We studied the case of a 36-year-old female patient who self-administered about 30 ml of diquat solution (200 g/L) during a suicide attempt. She developed nausea, vomiting, dizziness, and weakness in her limbs and was admitted to the emergency department of our hospital 4 h later. The patient developed progressive swelling and pain in both calves 12 h after admission. Based on symptoms, lower limb color Doppler ultrasound, and elevated levels of myoglobin and creatine kinase, the patient was diagnosed with rhabdomyolysis caused by diquat poisoning. The patient recovered and was discharged after treatment with hemoperfusion, continuous venovenous hemodialysis, acid suppression, liver protection, low-dose glucocorticoids, etc. Rhabdomyolysis caused by diquat poisoning has not been previously reported. We attempted to analyze the mechanism of this symptom through a literature review. We recommend the routine monitoring of creatine phosphokinase (CK) and myoglobin (MYO) in patients with diquat poisoning to avoid missed diagnosis. Further, the mechanism of this poisoning symptom was discussed through the literature review.

Acute fungicide self-poisoning - a prospective case series

BACKGROUND

Pesticide self-poisoning is a global clinical and public health problem. While self-poisoning with insecticides and herbicides has been extensively studied, there is minimal literature on acute fungicide self-poisoning. We aimed to study the clinical course and outcome of fungicide self-poisoned patients recruited to a prospective cohort in Sri Lanka.

METHODS

We conducted a prospective study of patients presenting with fungicide self-poisoning to nine hospitals in Sri Lanka between 2002 and 2020. Patients were enrolled by clinical research assistants, with clinical outcomes being recorded at regular review for each patient.

RESULTS

We identified 337 cases of self-poisoning with fungicides (alcohol as only co-ingestant), including 28 different fungicides across 5 different fungicide classes. Median time from ingestion to examination was 3.1 (1.8-5.7) h. Nearly all presented to hospital fully conscious (GCS 15, 15-15)- only 27 patients (8.0%) presented with reduced GCS (<15) and only 2 (0.6%) had GCS 3/15. Most patients (333/337, 98.8%) made a full recovery, of whom only eight (2.37%) required intubation and ventilation. Four patients died (case fatality rate: 1.2%; 95% CI 0.0-23.4) after ingestion of edifenphos (n = 2), propamocarb and pyraclostrobin.

CONCLUSION

Fungicide self-poisoning appears to be less hazardous than insecticide or herbicide self-poisoning, with a substantially lower case fatality in the same cohort. Edifenphos is an exception to this 'less toxic' rule; as a WHO Class Ib highly hazardous pesticide, we recommend its withdrawal from, and replacement in, global agricultural practice. Propamocarb should be listed in the WHO hazard classification as propamocarb hydrochloride to reflect the higher toxicity of the common agricultural formulation. Pyraclostrobin currently has no WHO classification; one is urgently required now that its ingestion has now been linked the death of a patient. Additional prospective clinical data on fungicide self-poisoning is required to expand knowledge on the effects of these diverse compounds.

Causes and outcome of rhabdomyolysis in patients admitted to medical wards in the Prince of Wales Hospital

Background

Rhabdomyolysis with a marked elevation of serum creatine kinase (CK) can be caused by various conditions. Acute kidney injury (AKI) is a potential complication of severe rhabdomyolysis and leads to a rapid increase in serum creatinine.

Methods

This study was performed to identify medical cases diagnosed with rhabdomyolysis and to examine the likely causes. Patients diagnosed with rhabdomyolysis during admission to the medical wards of Prince of Wales Hospital (PWH) in Hong Kong from January 1, 2004 to May 31, 2012 were identified by searching computer records. Details of hospital admissions were retrieved, and the underlying causes of the rhabdomyolysis and clinical outcomes were analyzed.

Results

There were 95 Chinese patients with a median age of 72 years (range, 22–92 years) assigned a diagnosis of rhabdomyolysis. A mild degree of AKI was defined as an increase of serum creatinine more than 20% above the baseline value before onset of acute illness and with the highest creatinine greater than 120 µmol/L. Mild AKI was identified in 63 patients. Rhabdomyolysis appeared to contribute to a fatal outcome in eight patients who had multiple preexisting morbidities. The maximum CK had a median value of 9,829 U/L (range, 472–258,100 U/L). Twelve patients with peak CK levels <10× the upper limit of normal (ULN) may not have had rhabdomyolysis by this standard definition. Of the remaining 83 patients with maximum CK values >10× the ULN, the most common contributing factors were trauma (n=19) and infection (n=17). Other common underlying causes included drug abuse (heroin and alcohol) and ischemia/immobility.

Conclusions

Most patients recovered with appropriate medical interventions and had a median hospital stay of 13 days. One patient was thought to have drug-related rhabdomyolysis due to taking bezafibrate during an episode of renal impairment.

Catalase activity as signal of antioxydant system affection under influence of limb ischemia-reperfusion

The use of hemostatic tourniquet is a proved means of primary care. However, systemic disorders, as well as ultrastructural, in the area of compression can significantly worsen the condition of the injured organism. The aim. Estimation of catalase level in rats’ liver on the background of modifications of ischemic-reperfusion syndrome to know the severest pathogenic combination for organism. Materials and methods. 260 white adult male rats were divided into 5 groups: control (KG), EG1 – simulation of isolated ischemia-reperfusion syndrome (IRS) of the limb, EG2 – simulation of isolated volumetric blood loss, EG3 – combination of IRS of the limb with blood loss, EG4 – simulation of isolated mechanical injury of the thigh, EG5 – combination of IRS of the limb and mechanical injury. The variability of catalase level in liver was analyzed. Results. It was found that each of the experimental interventions has led to changes of catalase activity in the liver. The most expressed pathological expressions were observed on the 3rd after interventions, when the studied index in EG3 was lower than in EG1 and EG2 in 6,2 times and by 33,1 %. On the 7th day catalase activity in EG3 was in 9,4 times and by 44,5 % times lower than in EG1 and in EG2 data concordantly. The combination of limb ischemia-reperfusion with blood loss in EG3 led to exhausting of liver antioxydant enzyme catalase in the most critical posttraumatic period (day 3). The same, but less significant effect was registered in the group of combination of mechanical trauma with ischemia-reperfusion in EG5. This proved the role of the tourniquet as a factor that complicated the course of traumatic disease due to ischemic reperfusion. Conclusions. In this experiment, founded risk factors of combination of ischemia-reperfusion with heavy blood loss emphasized the importance and particular attention on such widespread method of bleeding tratment, as the imposition of a tourniquet, as in our experiment it triggered risk factors of ischemia-reperfusion. It was shown katalase activity depression respectively to the periods of increasing of lipid peroxydation. There was peculiarity, that on the base of isolated IRS catalase activity was increased in 2,5 times comparely to control group, whereas the hardest depression of it was found on the background of IRS, combined with blood loss – catalase activity was lower, comparely to KG – in 2,5 times. The importance of understanding the suppression of hepatocytes’ antyoxydants is great, as it might help in prevention the development of liver failure or hepatorenal syndrome on the background of limb ischemia-reperfusion.

Rhabdomyolysis After the Use of Percussion Massage Gun: A Case Report

OBJECTIVE

Percussion massage guns are commonly used by professional athletes and nonathletes worldwide for warm-up and physical recovery; however, there are no published clinical or evidence-based reports on percussion guns regarding their benefits, indications, contraindications, and even side effects. The purpose of this case report is to describe the first case of rhabdomyolysis as a severe and potentially life-threatening illness following use of a percussion gun.

METHODS

A young Chinese woman with untreated iron deficiency anemia presented with fatigue and pain in her thigh muscles for 3 days and tea-colored urine for 1 day, after cycling and subsequently receiving percussion gun treatment by her coach for the purpose of massage and relaxing tired muscles. Muscle tenderness and multiple hematomas were found on her thighs, and her urinalysis indicated hemoglobinuria. Her serum creatine kinase was reported as "undetectably high," a hallmark of serious muscle damage leading to a diagnosis of severe rhabdomyolysis. Aggressive intravenous fluid resuscitation, urine alkalinization via intravenous alkaline solution, assessment of urine output, and maintenance of electrolyte balance were administered during hospitalization.

RESULTS

The patient's clinical presentation gradually improved with the decline of creatine kinase, and she recovered well during follow-up.

CONCLUSION

A case of severe rhabdomyolysis after percussion massage should alert caregivers, sports professionals, and the public to suspect and recognize the potentially serious adverse effects of percussion guns and to ensure that percussion massage guns be used appropriately and safely in rehabilitation therapy, especially in individuals with an underlying disease or condition. Research is needed to examine the benefits, indications, contraindications, and adverse reactions of percussion guns.

Does melamine exposure during infancy cause rhabdomyolysis?

We investigated the possible toxic effects of melamine on muscle tissue in rats using biochemical, hematological and histopathological methods. We used three groups of female albino Wistar rats. The first group was given 0.1 ml saline. The second and third groups were given 50 and 75 mg/kg melamine dissolved in 0.1 ml saline, respectively, daily for 21 days. On day 45, all rats were sacrificed, and whole blood and plasma were analyzed for hematologic and biochemical characteristics. Muscle samples were stained with hematoxylin and eosin for histopathological investigation. Other sections were immunostained for matrix metalloproteinase-9 (MMP-9) and type IV collagen. We found a significant increase in the lymphocytosis-compliant leukocyte number in the 75 mg/kg melamine group compared to the other groups. We also found significant decreases in the hemoglobin levels and hematocrit values in the 75 mg/kg compared to the other groups. We found that the 75 mg/kg melamine group exhibited a significant increase in plasma aspartate aminotransferase (AST) activity compared to the other groups. Changes in plasma creatine kinase and lactate dehydrogenase activity were not statistically significant. Plasma AST activity and mean corpuscular hemoglobin levels were correlated with the lymphocyte:neutrophil ratio. We found mononuclear cell infiltration at the periphery of muscle bundles and in the connective tissue bundles in the melamine treated group. We found MMP-9 expression in muscle cell membranes and type IV collagen expression in degenerative connective tissue fibers. Whole blood, plasma and muscle tissue analysis indicated that the 75 mg/kg melamine group exhibited rhabdomyolysis that was associated with lymphocytosis and anemia. The underlying mechanisms by which melamine causes rhabdomyolytic effects remain unclear.

The Anion Gap is a Predictive Clinical Marker for Death in Patients with Acute Pesticide Intoxication

Pesticide formulation includes solvents (methanol and xylene) and antifreeze (ethylene glycol) whose metabolites are anions such as formic acid, hippuric acid, and oxalate. However, the effect of the anion gap on clinical outcome in acute pesticide intoxication requires clarification. In this prospective study, we compared the anion gap and other parameters between surviving versus deceased patients with acute pesticide intoxication. The following parameters were assessed in 1,058 patients with acute pesticide intoxication: blood chemistry (blood urea nitrogen, creatinine, glucose, lactic acid, liver enzymes, albumin, globulin, and urate), urinalysis (ketone bodies), arterial blood gas analysis, electrolytes (Na(+), K(+), Cl(-) HCO3 (-), Ca(++)), pesticide field of use, class, and ingestion amount, clinical outcome (death rate, length of hospital stay, length of intensive care unit stay, and seriousness of toxic symptoms), and the calculated anion gap. Among the 481 patients with a high anion gap, 52.2% had a blood pH in the physiologic range, 35.8% had metabolic acidosis, and 12.1% had acidemia. Age, anion gap, pesticide field of use, pesticide class, seriousness of symptoms (all P < 0.001), and time lag after ingestion (P = 0.048) were significant risk factors for death in univariate analyses. Among these, age, anion gap, and pesticide class were significant risk factors for death in a multiple logistic regression analysis (P < 0.001). In conclusions, high anion gap is a significant risk factor for death, regardless of the accompanying acid-base balance status in patients with acute pesticide intoxication.

Acute Kidney Injury Facilitates Hypocalcemia by Exacerbating the Hyperphosphatemic Effect of Muscle Damage in Rhabdomyolysis

BACKGROUND/AIMS

Hypocalcemia is an important complication of rhabdomyolysis for which several pathogenic factors, including acute kidney injury (AKI), have been proposed. To gain insight regarding the hypocalcemic roles of AKI in rhabdomyolysis, we retrospectively examined patients with rhabdomyolysis.

METHODS

Of 28,387 patients admitted to the Department of Internal Medicine, 51 patients met the inclusion criteria for the study. Serum calcium was analyzed based on laboratory data including indicators of AKI, serum creatine kinase (CK) and serum inorganic phosphate (iP).

RESULTS

Twenty-two patients (43%) had hypocalcemia. Compared with patients without hypocalcemia, they had a higher prevalence of AKI (82 vs. 55%; p = 0.046), higher levels of peak CK (39,100 ± 50,600 vs. 9,800 ± 11,900 IU/l; p = 0.003) and higher levels of peak iP (1.77 ± 1.10 vs. 1.10 ± 0.35 mmol/l; p = 0.007). Indicators of AKI were correlated with peak CK and peak iP and were not significant variables in the regression analysis for hypocalcemia. Peak CK and peak iP were not correlated with each other. Impaired phosphate use by muscle contributed to the increased iP.

CONCLUSION

These findings indicate that muscle damage is the primary hypocalcemic factor in rhabdomyolysis. AKI facilitated hypocalcemia by exacerbating the hyperphosphatemic effects of muscle damage. Aggressive hydration, which could increase oxygen supply and subsequently repair phosphate use in muscle, might reduce the incidence of hypocalcemia in rhabdomyolysis.

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.