Serum procalcitonin levels are associated with rhabdomyolysis following exertional heatstroke: an over 10-year intensive care survey

BACKGROUND:Heatstroke has become a common emergency event in hospitals.Procalcitonin(PCT)is used as a biomarker of infection in the emergency department(ED),but its role in rhabdomyolysis(RM)following exertional heatstroke(EHS)remains unclear.METHODS:A retrospective cohort study enrolled patients with EHS from the intensive care unit(ICU).We collected RM biomarkers,inflammation markers,critical disease scores at admission,24 h,48 h,and discharge,and 90-day mortality.Correlation analysis,linear regression and curve fi tting were used to identify the relationship between PCT and RM.RESULTS:A total of 162 patients were recruited and divided into RM(n=56)and non-RM(n=106)groups.PCT was positively correlated with myoglobin(Mb),acute hepatic injury,disseminated intravascular coagulation(DIC),Sequential Organ Failure Assessment(SOFA)score,and Acute Physiology and Chronic Health Evaluation II(APACHE II)score,with correlation coefficients of 0.214,0.237,0.285,0.454,and 0.368,respectively(all P<0.05).Interestingly,the results of curve fi tting revealed a nonlinear relationship between PCT and RM,and a two-piecewise linear regression model showed that PCT was related to RM with an odds ratio of 1.3 and a cut-off of<4.6 ng/mL.Survival analysis revealed that RM was associated with higher mortality compared to non-RM cases(P=0.0093).CONCLUSION:High serum PCT concentrations are associated with RM after EHS in critically ill patients.Elevated PCT concentrations should be interpreted cautiously in patients with EHS in the ED.

Understanding rhabdomyolysis induced acute kidney injury in patients with COVID-19

This work comments on an article published in the recent issue of the World Journal of Virology.Rhabdomyolysis is a complex condition with symptoms such as myalgia,changes to urination,and weakness.With the potential for substantial kidney impairment,it has also been shown to be a severe complication of coronavirus disease 2019(COVID-19).To date,various theoretical explanations exist for the development of rhabdomyolysis induced acute kidney injury(RIAKI)in COVID-19 infection,including the accumulation of released striated muscle myoglobin in the urine(myoglobinuria).In their article,they(2024)demonstrate in a retrospective study that RIAKI in COVID-19 patients tended to have elevated levels of C-reactive protein,ferritin,and procalcitonin.These patients also had poorer overall prognoses when compared to COVID-19 patients who have acute kidney injury(AKI)due to other causes.It is clear from these findings that clinicians must closely monitor and assess for the presence of rhabdomyolysis in COVID-19 patients who have developed AKIs.Moreover,additional research is required to further understand the mechanisms behind the development of RIAKI in COVID-19 patients in order to better inform treatment guidelines and protocols.

Rhabdomyolysis-related acute kidney injury in patients with COVID- 19

BACKGROUND Viral and bacterial infections may be complicated by rhabdomyolysis,which has a spectrum of clinical presentations ranging from asymptomatic laboratory abnor-malities to life-threatening conditions such as renal failure.Direct viral injury as well as inflammatory responses may cause rhabdomyolysis in the course of coronavirus disease 2019(COVID-19).When presented with acute kidney injury(AKI),rhabdomyolysis may be related to higher morbidity and mortality.AIM To compare rhabdomyolysis-related AKI with other AKIs during COVID-19.METHODS A total of 115 patients with COVID-19 who had AKI were evaluated retrospec-tively.Fifteen patients had a definite diagnosis of rhabdomyolysis(i.e.,creatine kinase levels increased to>5 times the upper normal range with a concomitant increase in transaminases and lactate dehydrogenase).These patients were aged 61.0±19.1 years and their baseline creatinine levels were 0.87±0.13 mg/dL.Patients were treated according to national COVID-19 treatment guidelines.They were compared with patients with COVID-19 who had AKI due to other reasons.RESULTS For patients with rhabdomyolysis,creatinine reached 2.47±1.17 mg/dL during follow-up in hospital.Of these patients,13.3%had AKI upon hospital admission,and 86.4%developed AKI during hospital follow-up.Their peak C-reactive protein reached as high as 253.2±80.6 mg/L and was higher than in patients with AKI due to other reasons(P<0.01).Peak ferritin and procalcitonin levels were also higher for patients with rhabdomyolysis(P=0.02 and P=0.002,respective-ly).The mortality of patients with rhabdomyolysis was calculated as 73.3%,which was higher than in other patients with AKI(18.1%)(P=0.001).CONCLUSION Rhabdomyolysis was present in 13.0%of the patients who had AKI during COVID-19 infection.Rhabdomyolysis-related AKI is more proinflammatory and has a more mortal clinical course.

Exertional Rhabdomyolysis Induced Acute Kidney Injury: A Case Report and Literature Review

Background: The exRML (exertional rhabdomyolysis) is a pathophysiologic condition of skeletal muscle cell damage and breakdown associated with high intensity or prolonged exercise, normal exercise under extreme circumstances, or sudden and excessive skeletal muscle contraction. It may manifest from the increase in CK (creatine kinase) or MYO (myoglobin), a protein that can cause life-threatening injury to the kidney (AKI, acute kidney injury), and may or may not be associated with myoglobinuria. Here, we presented a case of exRML with AKI, and then reviewed the related reports. Vigorous hydration, sodium bicarbonate and furosemide are key treatments. Aim: To examine an elderly patient with exRML induced AKI and the key treatment process. Case summary: A 61-year-old man left our hospital without permission after his admission and has been walking for almost 30 kms with no water and food intake, then was diagnosed exRML and exRML induced AKI with an obvious elevation of CK, MYO and decrease of eGFR (estimated glomerular filtration rate) after coming back, and was treated with vigorous hydration, loop diuresis, sodium bicarbonate, prostaglandin and Shenkang injection. After vigorous resuscitation, the patient’s renal function, CK and MYO returned normal. Conclusions: The exRML can cause serious complications such as AKI and death. Delayed diagnosis can be critical;therefore, manner of time should be taken to achieve a favorable prognosis.

Clinical Case Report of Acute Heart Injury and Acute Rhabdomyolysis Due to Cyanide Poisoning

Cyanide poisoning is one of the most dangerous poisonings, and it can be absorbed into the body through the mouth, inhalation and through the skin. A 32-year-old female patient was admitted to our poison control center because of high fever, severe vomiting, and seizures. Physical examination found that the patient was drowsy, had a high fever of 40 degrees Celsius, pulse of 140 beats/minute, and increased tendon and bone reflexes. Exploiting the patient’s information, it was discovered that the patient bought Cyanide to drink with the intention of committing suicide. The patient was quickly treated with gastric lavage and activated charcoal. Echocardiography recorded EF: 35%, reduced movement of the entire myocardium. CK blood test: 4562 U/L. The patient’s condition rapidly deteriorated and the patient was made ECMO, IHD and CVVHDF. After 3 days of treatment, the patient’s condition did not improve, so the family asked for the patient to go home. This article aims to describe the rapidly progressing and severe damage to the heart and muscles of patients with cyanide poisoning.

Paraneoplastic myopathy-related rhabdomyolysis and pancreatic cancer:A case report and review of the literature

BACKGROUND Rhabdomyolysis is a life-threatening condition,often leading to progressive renal failure and death.It is caused by destruction of skeletal muscle and the release of myoglobin and other intracellular contents into the circulation.The most frequent cause of this condition is“crush syndrome”,although several others have been described and paraneoplastic inflammatory myopathies associated with various types of cancer are repeatedly reported.CASE SUMMARY We describe a rare case of a patient with pancreatic cancer who developed rhabdomyolysis early on,possibly due to paraneoplastic myositis leading to acute renal failure and eventually to rapid death.A 78-year-old Caucasian woman was referred to our hospital for obstructive jaundice and weight loss due to a lesion in the pancreatic head.She presented increasingly severe renal insufficiency with anuria,a dramatic increase in creatine phosphokinase(36000 U/L,n.v.20-180 U/L)and myoglobin(>120000μg/L,n.v.12-70μg/L).On clinical examination,the patient showed increasing pain in the lower limbs associated with muscle weakness which was severe enough to immobilize her.Paraneoplastic myopathy linked to the malignant lesion of the pancreatic head was suspected.The patient was treated with hemodialysis and intravenous methylprednisolone.Despite all the efforts to prepare the patient for surgery,her general condition rapidly deteriorated and she eventually died 30 d after hospital admission.CONCLUSION The possible causes of rhabdomyolysis in this patient with pancreatic cancer are discussed,the development of paraneoplastic myopathy being the most likely.Clinicians should bear in mind that these syndromes may become clinically manifest at any stage of the cancer course and their early diagnosis and treatment could improve the patient’s prognosis.

Myositis and rhabdomyolysis in scrub typhus infection: A case report

Rationale:Fever with myositis and rhabdomyolysis is a medical emergency requiring prompt diagnosis and management.Scrub typhus associated myositis with rhabdomyolysis is rare.Patient concerns:A 36-year-old female presented with intermittent fever up to 38.6℃,jaundice and progressive weakness of all four limbs.Diagnosis:Scrub typhus associated myositis and rhabdomyolysis.Intervention:Doxycycline 100 mg twice daily and injection of ceftriaxone 1 gm twice daily along with continuous intravenous fluids.Outcome:Fever resolved with normalization of liver function and recovery of muscle power.Lessons:Presence of myositis and rhabdomyolysis is uncommon in scrub typhus;high clinical suspicion should be kept in patients with atypical manifestations of scrub typhus.

Rhabdomyolysis-induced acute kidney injury after administration of a red yeast rice supplement:A case report

BACKGROUND A few reports have revealed induction of rhabdomyolysis by a red yeast rice(RYR)supplement or by RYR in combination with abiraterone(an androgen biosynthesis inhibitor).CASE SUMMARY A 76-year-old man presented with progressive limb weakness,muscle soreness,and acute kidney injury(AKI).He had been taking the anti-prostate cancer drug abiraterone for 14 mo and had added a RYR supplement 3 mo before symptom onset.After being diagnosed with rhabdomyolysis-induced AKI,the patient discontinued these drugs and responded well to hemodialysis and hemoperfusion.After 23 d of treatment,creatine kinase levels returned to normal and serum creatinine levels decreased.CONCLUSION We speculate that statins,the main lipid-lowering component of RYR,or a combination of statins and abiraterone,will increase the risk of rhabdomyolysis.

Adult Patient with Diabetic Ketoacidosis and Rhabdomyolysis

Rhabdomyolysis, acute kidney injury and diabetic ketoacidosis all are life-threatening conditions. Coincidence of them can be missed because the patient is usually asymptomatic or has mild symptoms related to rhabdomyolysis. The development of rhabdomyolysis as a complication of diabetic ketoacidosis is not well understood and only a few clinical studies address the phenomenon. We are reporting, along with a literature review, a 39-year-old male, who presented with diabetic ketoacidosis complicated with rhabdomyolysis and acute kidney injury. To the best of our knowledge, this is the first case reported in the United Arab Emirates. We highlight the syndrome because it is curable with early detection and proper treatment.

Management of Rhabdomyolysis and Acute Renal Failure Following Strenuous Exercise in Young Adult: A Case Report

Introduction: Rhabdomyolysis is severe and life threating condition in which skeletal muscles are damaged by dissolution of striped muscles. Acute kidney injury (AKI) has been widely reported (13% - 50%) as a complication of Rhabdomyolysis in which the main pathophysiological mechanisms are intra-renal vasoconstriction, intraluminal cast formation (Tamm-Horsefall) and direct myoglobin toxicity. In this report we are going to describe the management of Acute Kidney Injury due to Rhabdomyolysis that is not responding to vigorous rehydration. Objective: Reporting about acute renal failure induced by Rhabdomyolysis due to Excessive Exercise and dehydration in young patient. Case Report: A 20 years male came to the outpatient clinic complaining of sever lower limb pain, back pain and vomiting. He was anuric and hypertensive (BP = 150/90 mmHg) with serum creatinine and urea levels of 15.72 mg/dl and 235 mg/dl, respectively. The diagnosis was based on the laboratory finding of creatine kinase = 3127 IU/l. The patient, then, has been referred to the emergency department. The Management plan was based on two arms: Emergency Management with Urgent Hemodialysis for AKI and high fluid replacement therapy. Patient started to recover after three hemodialysis sessions but the peak of recovery was noted after starting manual fluid replacement therapy with a target urine output of greater than 2 ml/kg, a urine pH of greater than 6. Manual fluid replacement therapy consisted of loop diuretics, intravenous fluids and intravenous sodium bicarbonate 1.26%. Full recovery was noted after one month of hospital admission with inpatient care and regular follow-up. A follow-up after one month has been set to assess the patient progression and monitor his kidney functions. Relevance and Impact: Home messages and lessons are;Firstly, young adults are vulnerable to Rhabdomyolysis, second, the diagnosis of Rhabdomyolysis can be made on the clinical bases but a confirmatory laboratory test of Creatine Kinase is mandatory, and lastly’ acute kidney injury needs to be treated urgently. Also, reducing the risk of infection is one of the management objectives to achieve recovery.

Exercise-induced rhabdomyolysis mechanisms and prevention:A literature review

Exercise-induced rhabdomyolysis(exRML), a pathophysiological condition of skeletal muscle cell damage that may cause acute renal failure and in some cases death. Increased Ca^(2+) level in cells along with functional degradation of cell signaling system and cell matrix have been suggested as the major pathological mechanisms associated with exRML. The onset of exRML may be exhibited in athletes as well as in general population. Previous studies have reported that possible causes of exRML were associated with excessive eccentric contractions in high temperature, abnormal electrolytes balance, and nutritional deficiencies possible genetic defects. However, the underlying mechanisms of exRML have not been clearly established among health professionals or sports medicine personnel. Therefore, we reviewed the possible mechanisms and correlated prevention of exRML, while providing useful and practical information for the athlete and general exercising population.

Abnormal liver function tests associated with severe rhabdomyolysis

Rhabdomyolysis is a syndrome of skeletal muscle injury with release of cellular constituents such as potassium,phosphate,urate and intracellular proteins such as myoglobin into the circulation,which may cause complications including acute kidney injury,electrolyte disturbance and cardiac instability.Abnormal liver function tests are frequently observed in cases of severe rhabdomyolysis.Typically,there is an increase in serum aminotransferases,namely aspartate aminotransferase and alanine aminotransferase.This raises the question of liver injury and often triggers a pathway of investigation which may lead to a liver biopsy.However,muscle can also be a source of the increased aminotransferase activity.This review discusses the dilemma of finding abnormal liver function tests in the setting of muscle injury and the potential implications of such an association.It delves into some of the clinical and experimental evidence for correlating muscle injury to raised aminotransferases,and discusses pathophysiological mechanisms such as oxidative stress which may cause actual liver injury.Serum aminotransferases lack tissue specificity to allow clinicians to distinguish primary liver injury from muscle injury.This review also explores potential approaches to improve the accuracy of our diagnostic tools,so that excessive or unnecessary liver investigations can be avoided.

Liquorice-induced severe hypokalemic rhabdomyolysis with Gitelman syndrome and diabetes: A case report

BACKGROUND Licorice-induced severe hypokalemic rhabdomyolysis is clinically rare. Gitelman syndrome(GS) is the most common inherited renal tubular disease, while diabetes is one of the most prevalent diseases in the world. Recently, some studies have found that GS patients had higher diabetic morbidity. However, the coexistence of these three diseases has yet to be reported.CASE SUMMARY We report the case of a 62-year-old Chinese man who was admitted with weakness in the extremities, muscle pain, and dark-colored urine. He had consumed liquorice water daily for seven days prior to admission. The laboratory tests revealed a serum potassium level of 1.84 mmol/L, magnesium 0.68 mmol/L, creatinine phosphokinase(CK) 10117 IU/L, and marked hemoglobinuria. Fractional chloride excretion and fractional magnesium excretion were increased. Plasma renin activity and aldosterone concentration were within the normal ranges. Sequence analysis of the SLC12 A3 gene revealed that he had compound heterozygous mutations. The diagnosis of liquoriceinduced severe hypokalemic rhabdomyolysis with GS and diabetes was thus genetically confirmed. Serum potassium and CK quickly improved with potassium replacement therapy, hydration, and discontinuation of liquorice ingestion. Upon follow-up at 3 mo, the levels of CK, myoglobin, and potassium remained normal, and magnesium was above 0.6 mmol/L.CONCLUSION This case emphasizes that liquorice consumption and GS should be considered causes of hypokalemia and that the diabetic status of GS patients should be noted in the clinic.

A rare case of hypokalemia-induced rhabdomyolysis

A 68-year-old male was complained of chest pain for two years and fatigue for one week. He was admitted to other hospitals two years ago because of severe chest pain. A diagnosis of acute non-ST segment elevation myocardial infarction （NSTEMI） was made. But the coronary angiography was refused by himself. After effective conservative treatment, he got better and discharged. A regular administration of aspirin, metoprolol and simvastatin was taken. No recurrent sympotoms occurred. However, he felt fatigue and palpitation after 30-m walking one week ago without predisposing factors.

Rhabdomyolysis following severe hypokalemia caused by familial hypokalemic periodic paralysis

Rhabdomyolysis continues to appear with increasing frequency and represents a medical emergency requiring rapid appropriate treatment. One of the unusual causes of nontraumatic rhabdomyolysis is hypokalemic periodic paralysis without secondary causes. Primary hypokalemic periodic paralysis is a rare genetic disease characterized by episodic attacks of muscle weakness due to decreases in serum potassium. A 30-year-old woman who had 3 episodic attacks of hypokalemic periodic paralysis was admitted in emergency room with sudden onset symmetrical muscle weakness. After several hours, she started to complain myalgia and severe ache in both calves without any changes. Laboratory test showed markedly elevated creatine phosphokinase, lactic dehydrogenase levels with hypokalemia, rhabdomyolysis resulting from hypokalemia was diagnosed. Here, we report an unusual case of rhabdomyolysis caused by severe hypokalemia, which was suggested a result of familial hypokalemic periodic paralysis.

Rhabdomyolysis after midazolam administration in a cirrhotic patient treated with atorvastatin

The administration of statins in patients with liver disease is not an absolute contraindication. Hepatotoxicity is a rare and often dose-related event and in the literature there are only a few described cases of fatal rhab-domyolysis in patients with chronic liver disease after statin administration. During treatment with 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors,the factors responsible for myopathy may either be related to the patient,or due to interactions with other medications that are metabolic substrates of the same isozymes and therefore able to increase blood statin concentration. The most important side effects consist of increased transaminase levels,abdominal pain or muscle weakness,increased serum levels of creatine kinase and rhabdomyolysis. In this article we report a case of fatal rhabdomyolysis with acute renal failure after gastric endoscopy,where midazolam was used as a sedation agent in a patient with chronic liver disease treated with a high dose of atorvastatin. Therefore,we suggest paying particular attention to the potential risks of associating atorvastatin and midazolam in patients with chronic liver disease who need to undergo gastric endoscopy.

Rhabdomyolysis induced by simvastatin-diltiazem interaction in unrecognized hypothyriodism

Simvastatin,a 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor,is widely prescribed to patients with hypercholesteremia and its muscular toxicity has been widely reported.The metabolism of simvastatin depends on the enzymic activity of cytochrome P450 3A4 （CYP3A4） and inhibitors of CYP3A4 can result in clinical events by interacting with simvastatin.Diltiazem is a moderate inhibitor of CYP3A4,which is known to increase the serum concentration of simvastatin.Here we report a patient with unrecognized hypothyroidism who had been stable for more than one year on low-dose simvastatin therapy of hypercholesteremia and rhabdomyolysis occurred with the addition of diltiazem.This is one of scanty reports of rhabdomyolysis induced by simvastatindiltiazem drug interaction,especially in hypothyroid patient.This case reminds the clinicians that although diltiazem as a moderate CYP3A4 inhibitor can be used cautiously with small doses of CYP3A4-dependent statius （eg,simvastatin）,these two commonly used drugs should be avoided in hypothyroid patient.

Three Cases of Rhabdomyolysis Induced by Viral Infections in Children and Literature Review

The clinical data of 3 patients with rhabdomyolysis(RM)caused by different viral infections were retrospectively reviewed.The diagnoses were established according to the clinical symptoms,physical signs,myocardial enzymes,and muscle biopsy.Case 1 was a 11-year-old boy with influenza A virus infection,whose major symptoms were fever,cough and myalgia.After the treatment of active anti-virus,hydration,and alkalinization,the patient completely recovered.Case 2 was a 10-year-old girl with Epstein-Barr(EB)virus infection who had significant musculoskeletal pain and muscle weakness symptoms with significantly elevated serum creatine kinase.After active hydration and anti-infective treatment,the patient s condition returned to normal.Case 3 was a 15-year・old boy with human cytomegalovirus infection,whose symptoms were mainly repeated fever,accompanied by myalgia and facial edema.Antibacterial therapy was ineffective,and the disease progressed with respiratory muscle weakness and multiple organ injuries.After antiviral treatment,respiratory support and hemofiltration,the symptoms relieved and patient recovered without sequela.With literature review,we believe that although influenza virus,Epstein-Barr virus and cytomegalovirus rarely cause RM in children,it should be attached attention to.With early diagnosis and treatment,the prognosis is favorable.

Rhabdomyolysis with different etiologies in childhood

AIM To investigate different etiologies and management of the rhabdomyolysis in children.METHODS Eight pediatric rhabdomyolysis cases who applied to the Dokuz Eylul University Faculty of Medicine Department of Pediatric Nephrology with different etiologies between January 2004 and January 2012 were evaluated in terms of age, gender, admission symptoms, physical examination findings, factors provoking rhabdomyolysis, number of rhabdomyolysis attacks, laboratory results, family history and the final diagnosis received after the treatment. RESULTS Average diagnosis ages of eight cases were 129(24-192) ± 75.5 mo and five of them were girls. All of them had applied with the complaint of muscle pain, calf pain, and dark color urination. Infection(pneumonia) and excessive physical activity were the most important provocative factors and excessive licorice consumption was observed in one case. In 5 cases, acute kidney injury was determined and two cases needed hemodialysis. As a result of the further examinations; the cases had received diagnoses of rhabdomyolysis associated with mycoplasma pneumoniae, sepsis associated rhabdomyolysis, licorice-induced hypokalemic rhabdomyolysis, carnitine palmitoyltransferase Ⅱ deficiency, very long-chain acyl-CoA dehydrogenase deficiency, congenital muscular dystrophy and idiopathic paroxysmal rhabdomyolysis(Meyer-Betz syndrome).CONCLUSION It is important to distinguish the sporadic and recurrent rhabdomyolysis cases from each other. Recurrent rhabdomyolysis cases should follow up more regardful and attentive.

Exertional rhabdomyolysis and heat stroke: Beware of volatile anesthetic sedation

In view of the enormous popularity of mass sporting events such as half-marathons, the number of patients with exertional rhabdomyolysis or exercise-induced heat stroke admitted to intensive care units(ICUs) has increased over the last decade. Because these patients have been reported to be at risk for malignant hyperthermia during general anesthesia, the intensive care community should bear in mind that the same risk of life-threatening rhabdomyolysis is present when these patients are admitted to an ICU, and volatile anesthetic sedation is chosen as the sedative technique. As illustrated by the three case studies we elaborate upon, a thorough diagnostic work-up is needed to clarify the subsequent risk of strenuous exercise, and the anesthetic exposure to volatile agents in these patients and their families. Other contraindications for the use of volatile intensive care sedation consist of known malignant hyperthermia susceptibility, congenital myopathies, Duchenne muscular dystrophy, and intracranial hypertension.