An increase in the number of admitted patients with exercise-induced rhabdomyolysis

Exertional Rhabdomyolysis in Athletes: Systematic Review and Current Perspectives

OBJECTIVE

Exertional rhabdomyolysis results from a breakdown of skeletal muscle cells after intense exercise in otherwise healthy patients, causing increased levels of creatine kinase (CK) or myoglobin, as well as urine dipstick positive for blood, and may result in kidney insufficiency. The aim of this study was to outline the current perspectives of exertional rhabdomyolysis in athletes and subsequent treatment based on the current literature.

DATA SOURCES

We searched the MEDLINE/PubMed and Google databases for ([exercise] OR [exertional]) AND rhabdomyolysis following the PRISMA guidelines. All abstracts were reviewed by 2 independent examiners. Inclusion criteria consisted of original articles presenting studies on exertional rhabdomyolysis or exercise-induced rhabdomyolysis with 7 or more cases. All case reports, case series, or editorials were excluded.

MAIN RESULTS

A total of 1541-abstracts were screened, leaving 25 studies for final inclusion and analysing 772patients. Especially, young male patients were affected at a mean age of 28.7 years (range 15.8-46.6 years). Most of the athletes performed running, including marathons in 54.3% of cases (n = 419/772), followed by weightlifting in 14.8% (n = 114/772). At the time of presentation, the mean creatine kinase was 31 481 IU/L (range 164-106,488 IU/L). Seventeen studies reported the highest level of CK, which was 38 552 IU/L (range 450-88,496 IU/L). For treatment, hydration was the most common method of choice reported by 8 studies.

CONCLUSIONS

Exertional rhabdomyolysis seems to be underestimated, and it is essential to screen patients who present with muscle soreness/cramps and/or dark urine after heavy endurance events to avoid any further complications.

LEVEL OF EVIDENCE

II; systematic review.

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.

Application of Ultrasonography in the Diagnosis of Rhabdomyolysis

Early diagnosis and treatment of rhabdomyolysis are very important, but difficult to achieve for some atypical cases. Our study was aimed at determining the diagnostic value of ultrasonography in rhabdomyolysis caused by different factors. The study enrolled 50 patients with rhabdomyolysis diagnosed in our hospital. Among the 50 cases (mean age = 38.4 y, 22 women) of rhabdomyolysis, 26 cases (mean age = 35.5 y, 8 women) were induced by exercise. During the patients' first visit, 5 cases (mean age = 30.6 y, 1 woman) were suspected of having rhabdomyolysis and were diagnosed by clinicians; 12 cases (mean age = 34.8 y, 5 women) were correctly diagnosed under ultrasound; and 9 cases (mean age = 39.2 y, 2 women) were misdiagnosed. Ultrasound did not play a critical role in 24 patients (mean age = 41.5 y, 14 women) with rhabdomyolysis caused by trauma, infection, crayfish consumption, drugs, alcohol and heat stroke. We then concluded that exercise-induced rhabdomyolysis is a common type of rhabdomyolysis. Ultrasonography plays an important role in the early diagnosis of exercise-induced rhabdomyolysis but has limited value in the diagnosis of rhabdomyolysis caused by other etiologies.

Case Report: Exertional rhabdomyolysis in a spin class participant with sickle cell trait

Exertional rhabdomyolysis is more common in sickle trait due to a predisposition to dehydration and inability to concentrate the urine. Spinning, an indoor cycling workout, has been associated with exertional rhabdomyolysis in recent reports. A consequence of rhabdomyolysis is acute kidney injury, which may be expected to be more common in patients with sickle trait. We report a case of spinning induced rhabdomyolysis in a woman with sickle trait that did not result in renal injury. "Spin rhabdo" is thought to be more severe than other causes of exertional rhabdomyolysis and is associated with higher creatine kinase levels than other causes of exertional rhabdomyolysis. Therefore, individuals with known sickle trait should consider visiting their physician prior to participation in spin classes for the first time. We might also consider voluntary screening for sickle trait in at risk populations prior to enrolling in spin classes given that many patients are unaware of their sickle trait status.

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.

High intensity resistance training causes muscle damage and increases biomarkers of acute kidney injury in healthy individuals

PURPOSE

High-intensity interval resistance training (HIIRT) is an increasingly popular exercise program that provides positive results with short sessions. This study aimed to evaluate whether an HIIRT session causes muscle and kidney damage.

METHODS

Fifty-eight healthy volunteers (median age 24 years, 50% women) participated in this study and performed a HIIRT session. The Borg CR10 scale for pain (CR10P) and blood and urine samples were collected before (baseline) and 2 and 24 hours after the HIIRT session. Blood samples were analyzed for serum creatinine (SCr), creatine kinase (CK) and myoglobin. Urine samples were assessed for creatinine, neutrophil gelatinase-associated lipocalin, interleukin 18, calbindin, microalbuminuria, trefoil factor-3 and β-2 microglobulin.

RESULTS

CR10P had a significant increase at 2 and 24 hours post-workout, and CK increased significantly at 2 hours and increased further at 24 hours. Myoglobin increased significantly at 2 hours and remained elevated at 24 hours. SCr increased modestly but significantly at 24 hours only in men. Three men met the KDIGO diagnostic criteria for acute kidney injury. The urinary kidney injury biomarkers increased significantly at 2 hours and returned to the baseline values 24 hours after HIIRT.

CONCLUSIONS

A single HIIRT session caused early and significant elevations in CK, myoglobin, SCr, microalbuminuria and urinary biomarkers indicative of kidney tubular injury, suggesting the occurrence of muscle and kidney damage.

How to do it: investigate exertional rhabdomyolysis (or not)

Rhabdomyolysis is the combination of symptoms (myalgia, weakness and muscle swelling) and a substantial rise in serum creatine kinase (CK) >50 000 IU/L; there are many causes, but here we specifically address exertional rhabdomyolysis. The consequences of this condition can be severe, including acute kidney injury and requirement for higher level care with organ support. Most patients have ‘physiological’ exertional rhabdomyolysis with no underlying disease; they do not need investigation and should be advised to return to normal activities in a graded fashion. Rarely, exertional rhabdomyolysis may be the initial presentation of underlying muscle disease, and we review how to identify this much smaller group of patients, who do require investigation.

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.

Cluster of exertional rhabdomyolysis in three young women

Three young women, aged 18-24 years, presented to general practice with signs and symptoms of exertional rhabdomyolysis in 2016. All attended the same gym and had undertaken an intensive physical workout. Presenting symptoms were severe muscle pain and swelling, significantly reduced range of motion in affected muscles and, in two cases, dark-coloured urine. One case had presented to the out-of-hours service 4 months previously with similar symptoms but rhabdomyolysis was not considered, although retrospective history taking suggests that was the likely diagnosis. All three women were admitted to hospital, treated with intravenous fluids and discharged between 1 and 6 days later. All made a full recovery with no renal sequelae. The cases were questioned about potential risk factors, and the only commonality was unaccustomed strenuous exercise.