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| '''For patient information click [[{{PAGENAME}} (patient information)|here]]
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| __NOTOC__ | | __NOTOC__ |
| {{Infobox_Disease |
| | '''For patient information click [[{{PAGENAME}} (patient information)|here]].''' |
| Name = {{PAGENAME}} |
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| Image = |
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| Caption = |
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| DiseasesDB = 11472 |
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| ICD10 = {{ICD10|M|62|8|m|60}}, {{ICD10|T|79|6|t|79}} |
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| ICD9 = {{ICD9|728.88}} |
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| ICDO = |
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| OMIM = |
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| MedlinePlus = 000473 |
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| MeshID = D012206 |
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| }}
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| {{Rhabdomyolysis}} | | {{Rhabdomyolysis}} |
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| {{CMG}} | | {{CMG}}; {{AE}} {{AyeshaFJ}} |
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| {{SK}}: Familial paroxysmal rhabdomyolysis; rhabdomyolysis | | {{SK}} Familial paroxysmal rhabdomyolysis |
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| ==[[Rhabdomyolysis overview|Overview]]== | | ==[[Rhabdomyolysis overview|Overview]]== |
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| ==[[Rhabdomyolysis causes|Causes]]== | | ==[[Rhabdomyolysis causes|Causes]]== |
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| | ==[[Rhabdomyolysis symptoms|Symptoms]]== |
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| ==[[Rhabdomyolysis differential diagnosis|Differentiating Rhabdomyolysis from other Diseases]]== | | ==[[Rhabdomyolysis differential diagnosis|Differentiating Rhabdomyolysis from other Diseases]]== |
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| ==Diagnosis== | | ==Diagnosis== |
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| [[Rhabdomyolysis diagnostic criteria|Diagnostic Criteria]] | [[Rhabdomyolysis history and symptoms|History and Symptoms]] | [[Rhabdomyolysis physical examination|Physical Examination]] | [[Rhabdomyolysis elecrocardiogram|Electrocardiogram]] | [[Rhabdomyolysis x ray|X ray]] | [[Rhabdomyolysis CT|CT]] | [[Rhabdomyolysis MRI|MRI]] | [[Rhabdomyolysis echocardiography or ultrasound|Echocardiography or Ultrasound]] | [[Rhabdomyolysis other imaging findings|Other Imaging Findings]] | [[Rhabdomyolysis other diagnostic studies|Other Diagnostic Studies]]
| | [[Rhabdomyolysis history and symptoms|History and Symptoms]] | [[Rhabdomyolysis physical examination|Physical Examination]] | [[Rhabdomyolysis laboratory findings|Laboratory Findings]] | [[Rhabdomyolysis electrocardiogram|Electrocardiogram]] | [[Rhabdomyolysis x ray|X Ray]] | [[Rhabdomyolysis CT|CT]] | [[Rhabdomyolysis MRI|MRI]] | [[Rhabdomyolysis echocardiography or ultrasound|Echocardiography or Ultrasound]] | [[Rhabdomyolysis other imaging findings|Other Imaging Findings]] | [[Rhabdomyolysis other diagnostic studies|Other Diagnostic Studies]] |
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| ==Treatment== | | ==Treatment== |
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| ==Case Studies== | | ==Case Studies== |
| [[Rhabdomyolysis case study one|Case #1]] | | [[Rhabdomyolysis case study one|Case #1]] |
| ==Overview==
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| '''Rhabdomyolysis''' is the rapid breakdown of [[skeletal muscle]] tissue due to traumatic injury, either mechanical, physical, or chemical. The principal result is a large release of the [[creatine kinase]] (CK) enzymes and other cell byproducts into the blood system and [[acute renal failure]] due to accumulation of muscle breakdown products, several of which are injurious to the [[kidney]]. Treatment is with intravenous fluids, and [[dialysis]] if necessary.
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| ==History==
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| First reports of rhabdomyolysis are thought to be from the Bible. The Book of Numbers reports many Israelites dying with “stained urine” during the exodus from Egypt. Historical reports indicate that consumption of quail that had eaten hemlock seeds on the island of Lesbos caused rhabdomyolysis. Quail related rhabdomyolysis still occurs in Greece and Algiers.
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| ==Causes==
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| Injury leading to rhabdomyolysis can be due to mechanical, physical, and chemical causes:
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| * mechanical: crush trauma, burns, excessive exertion, [[seizure|intractable convulsions]], [[choreoathetosis]], [[surgery]], compression by a [[tourniquet]] left for too long, local muscle compression due to [[coma]]tose states, [[compartment syndrome]], rigidity due to [[neuroleptic malignant syndrome]]
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| * physical: high [[fever]] or [[hyperthermia]], electric current, extreme physical exertion (although most heavy exercise does not cause kidney damage)<ref>{{cite journal |author=Clarkson P, Kearns A, Rouzier P, Rubin R, Thompson P |title=Serum creatine kinase levels and renal function measures in exertional muscle damage |journal=Med Sci Sports Exerc |volume=38 |issue=4 |pages=623-7 |year=2006 |pmid=16679975}}</ref>
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| * chemical: [[metabolic disorder]]s, [[anoxia]] of the muscle (e.g., [[Bywaters' syndrome]], toxin- and drug-related); various animal toxins, certain mushrooms like ''[[Tricholoma equestre]]'', some [[antibiotics]], [[statin]]s, first-generation H1-receptor antagonists (e.g., [[diphenhydramine]]), [[alcoholic beverage|alcohol]], heritable muscle enzyme deficiencies, electrolyte abnormalities, infections, or endocrinopathies. Skeletal muscle relaxants that are consumed in overdose are rarely associated with this condition.<ref name="pmid16846511">{{cite journal |author=Chabria SB |title=Rhabdomyolysis: a manifestation of cyclobenzaprine toxicity |journal=Journal of occupational medicine and toxicology (London, England) |volume=1 |issue= |pages=16 |year=2006 |pmid=16846511 |doi=10.1186/1745-6673-1-16 |url=http://www.occup-med.com/content/1/1/16}}</ref>
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| Any drug that directly or indirectly impairs the production or use of [[adenosine triphosphate]] (ATP) by skeletal muscle, or increases energy requirements so as to exceed ATP production, can cause rhabdomyolysis.<ref name="pmid17344731">{{cite journal |author=Larbi EB |title=Drug-induced rhabdomyolysis |journal=Annals of Saudi medicine |volume=18 |issue=6 |pages=525–30 |year=1998 |pmid=17344731 |doi= |url=http://www.kfshrc.edu.sa/annals/186/98-069.html}}</ref>
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| ==Complete Differential Diagnosis of Rhabdomyolysis==
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| * Drugs
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| *:* Alcohol
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| *:*Amlodipine
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| *:* Amphetamine
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| *:* Cocaine
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| *:* Heroin
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| *:* Lipid Lowering Agents (gemfibrozil and statins)
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| *:* PCP (phencyclidine)
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| * Exertion
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| *:* Status Epilepticus/Asthmaticus
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| *:* “Weekend Warrior”
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| *:* Psychotic, Heat Stroke
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| * Metabolic
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| *:* [[Hypokalemia]]
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| *:* [[Hypophosphatemia]]
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| *:* Hyperosmolar
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| *:* [[Hyponatremia]]
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| *:* [[Hypothyroid]]
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| * Direct Injury
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| *:* Crush
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| *:*:* Prolonged Immobilization
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| *:*:* Burns
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| *:*:* Frostbite
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| *:*:* Electric Shock
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| * Infections(5% overall)
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| *:* Viral
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| *:*:* Various
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| *:*:* 50% Influenza A.(higher risk of renal failure).
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| *:* Bacterial
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| *:*:* Legionella
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| *:*:* Tularemia
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| *:*:* Streptococcus
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| *:*:* Clostridia
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| * Hereditary Defects
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| *:* Enzyme
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| *:*:* Classical is Mcardle’s Disease (myophosphorylase deficiency), many others.
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| *:* Sickle Cell Trait
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| *:*:* Presumable through muscle ischemia
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| ==Pathophysiology==
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| Severe cases of rhabdomyolysis often result in [[myoglobinuria]], a condition wherein the [[myoglobin]] from muscle breakdown spills into the [[urine]], making it dark, or "tea colored" (myoglobin contains [[heme]], like [[hemoglobin]], giving muscle tissue its characteristic red color). This condition can cause serious [[acute renal failure|kidney damage]] in severe cases. The injured muscle also leaks [[potassium]], leading to [[hyperkalemia]], which may cause fatal [[cardiac arrhythmia|disruptions in heart rhythm]]. In addition, myoglobin is metabolically degraded into potentially-[[toxic]] substances for the kidneys. Massive skeletal muscle [[necrosis]] may further aggravate the situation, by reducing [[Blood plasma|plasma]] volumes and leading to [[Shock (medical)|shock]] and reduced bloodflow to the kidneys.
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| ==Diagnosis==
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| In general, the diagnosis is made when an abnormal [[renal function]] and elevated [[creatine kinase|CPK]] are observed in a patient. To distinguish the causes, a careful medication history is considered useful. Testing for [[myoglobin]] levels in blood and urine is rarely performed due to its cost, but may be useful.
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| Often the diagnosis is suspected when a urine dipstick test is positive for blood, but no cells are seen on microscopic analysis. This suggests myoglobinuria, and usually prompts a measurement of the serum CPK, which confirms the diagnosis.
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| === Approach to the Evaluation of Rhabdomyolysis===
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| * Minimum Evaluation
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| *:* Etiology certain:
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| *:*:* CBC (complete blood count)
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| *:*:* [[CK]]
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| *:*:* Chemistries
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| *:*:* Liver function tests
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| *:*:* Urine pH
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| *:* Consider looking for [[hypothyroidism]] and sickle cell trait.
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| * Extensive Evaluation:
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| *:* If etiology is uncertain, can check:
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| *:*:* [[Thyroid stimulating hormone]]
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| *:*:* Erythrocyte glycolytic enzymes
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| *:*:* CPT I/II in leukocytes
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| *:*:* Serum [[carnitine]]
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| *:*:* Organic acids in urine.
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| ===Symptoms===
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| * Constitutional symptoms
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| * Muscle swelling stiffness, weakness of especially postural muscles (Only 50% will have primary muscular complaints)
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| * Decreased urine output and red urine
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| * Familial cases tend to be recurrent and can be precipitated by multiple factors (see below). Ask if symptoms are related to fasting or exercise. Symptoms can be prominent during first 10 minutes of exercise then get better with rest. (Second wind phenomenon).
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| * Anesthesia induced muscle problems: (myopathy, tetany)
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| ===Physical Examination===
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| * Physical usually reveals no abnormalities: May see tenderness, weakness or atrophy
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| ===Laboratory Studies===
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| * '''Urinalysis'''
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| *:* Blood (+)
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| *:* No red blood cells on microscopy. This situation is either hemoglobin in the urine or myoglobin. The serum will be pink with hemoglobinuria.
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| * '''Serum Markers'''
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| *:* Elevated serum creatinine kinase
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| *:*:* CK elevation: Generally accepted >5 times normal. Corresponds to about 200g of muscle.
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| *:*:* Begins to rise 2-12 hrs after onset. Peaks 1-3 days in. Declines 3-5 days after the process stops.
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| *:* Myoglobin
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| *:*:* Myoglobin: Starts earlier than CK but clears faster, so serum and urine myoglobin useful early in course of the disease. Myoglobin is eventually urinated and/or converted to bilirubin.
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| *:*:* All myoglobinuria is caused by rhabdomyolysis, but not all rhabdomyolysis causes myoglobinuria. Urine changes color when >1mg/ml.
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| *:* LDH (lactic dehydrogenase)
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| *:* Aldolase, AST (aspartate aminotransferase), ALT (alanine aminotransferase), carbonic anhydrase III (most specific)
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| === Electrocardiogram ===
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| The EKG can show non specific ST T wave changes and [[T wave]] inversions. Despite the very high level of CK, the criteria for [[MI]] requires a 5% MB index (may vary by assay and gender).
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| === Other Diagnostic Studies ===
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| * Muscle biopsy
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| *:* Look for viral inclusions and examine histochemically for metabolic/biochemical deficiency.
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| ==Therapy==
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| The main therapeutic measure is hyperhydration (by administering intravenous fluids), and, if necessary, the use of osmotic [[diuretic]]s (to prevent fluid overload). Alkalinisation of the urine with [[bicarbonate]] reduces the amount of myoglobin accumulating in the [[kidney]].
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| Hydration should be aggressive and patients may require as much as 10 liters of fluid. The fluid may be third spaced into muscle. Once the patient has been hyperhydrated, then forced diuresis is utilized. The urine can be alkalinized with D5W + 2/3 amp Bicarbonate. However, be aware that thisi may worsen hypocalcemia. Avoid replacement of calcium since it will chelate with phosphate. When rhabdomyolysis resolves, patients will often become [[hypercalcemic]]. Patients may require dialysis for [[hyperkalemia]], [[uremia]] or volume overload.
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| As the electrolytes are frequently deranged, these may require correction, especially [[hyperkalemia]] (elevated potassium levels in the blood). [[Calcium in biology|Calcium]] levels are initially low ([[hypocalcemia]]), as circulating calcium precipitates in the damaged muscle tissue, presumably with [[phosphate]] released from intracellular stores. When the acute renal failure resolves, [[vitamin D]] levels rise rapidly, causing [[hypercalcemia]] (elevated calcium). Although this resolves eventually, high calcium levels may require treatment with [[bisphosphonate]]s (e.g., [[pamidronate]]).
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| If the exacerbating cause includes overdose of skeletal muscle relaxants and/or [[tricyclic antidepressant]]s, the treatment protocols include [[gastric]] decontamination. This procedure is fairly effective because the anticholinergic effects of tricyclics and cyclobenzaprine delay gastric emptying; and, therefore, it becomes possible to obtain tablet residues even after significant time elapse. [[Ventricular]] arrhythmias, QRS widening, or intraventricular conduction abnormalities should be treated with [[sodium bicarbonate]] 1 meq/kg IV bolus and repeated if arrhythmias persist. This should be followed by IV infusion of sodium bicarbonate to produce an arterial pH of 7.5; the mechanism of sodium bicarbonate's action in this role is unknown.<ref name="pmid16846511">{{cite journal |author=Chabria SB |title=Rhabdomyolysis: a manifestation of cyclobenzaprine toxicity |journal=Journal of occupational medicine and toxicology (London, England) |volume=1 |issue= |pages=16 |year=2006 |pmid=16846511 |doi=10.1186/1745-6673-1-16 |url=http://www.occup-med.com/content/1/1/16}}</ref> However, sodium bicarbonate's beneficial effect on kidney function is known to be via the effects of alkalinisation both increasing the urinary solubility of myoglobin leading to its increased excretion<ref name="pmid2716281">{{cite journal |author=Zager RA |title=Studies of mechanisms and protective maneuvers in myoglobinuric acute renal injury |journal=Lab. Invest. |volume=60 |issue=5 |pages=619–29 |year=1989 |pmid=2716281 |doi=}}</ref> and stabilizing ferryl myoglobin complex so preventing myoglobin-induced lipid peroxidation.<ref name="pmid9822635">{{cite journal |author=Moore KP, Holt SG, Patel RP, ''et al'' |title=A causative role for redox cycling of myoglobin and its inhibition by alkalinization in the pathogenesis and treatment of rhabdomyolysis-induced renal failure |journal=J. Biol. Chem. |volume=273 |issue=48 |pages=31731–7 |year=1998 |pmid=9822635 |doi= |url=http://www.jbc.org/cgi/content/full/273/48/31731}}</ref><ref name="pmid10729745">{{cite journal |author=Holt S, Moore K |title=Pathogenesis of renal failure in rhabdomyolysis: the role of myoglobin |journal=Exp. Nephrol. |volume=8 |issue=2 |pages=72–6 |year=2000 |pmid=10729745 |doi=}}</ref>
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| ==Complications==
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| * Acute renal failure/Uremia: Estimated (1/3). Etiology multifactorial. Not only from pigmenturia. Has been seen with CKs as low as <20,000.
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| * Metabolic:
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| *:* [[Hyperphosphatemia]]
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| *:* [[Hyperkalemia]]: Can be to life threatening levels
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| *:* [[Hypocalcemia]]: Thought to be caused by chelation of calcium phosphate into muscle. Eventually resolves and may overshoot.
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| *:* [[Hyperuricemia]]
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| * [[Compartment syndrome]]s: Compressive [[ischemia]] from swelling
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| == Acknowledgements ==
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| The content on this page was first contributed by: Resident Report by Duane Pinto and {{CMG}}.
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| ==References==
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| {{refbegin}}
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| * {{cite book |author=Dennis Ausiello; Goldman, Lee |title=Cecil Textbook of Medicine Single Volume e-dition -- Text with Continually Updated Online Reference |publisher=W.B. Saunders Company |location=Philadelphia, PA |year= |pages= |isbn=0721639011 |oclc= |doi= |url=http://www.cecilmedicine.com/buy.cfm?book=goldman}}
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| * {{cite book |author=Edward Benz; David Weatherall; David Warrell; Cox, Timothy J.; Firth, John B. |title=Oxford Textbook of Medicine |publisher=Oxford University Press |location=Oxford [Oxfordshire] |year= |pages= |isbn=0198569785 |oclc= |doi= |url=http://www.oup.com/uk/catalogue/?ci=9780198569787}}
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| * {{cite journal |author=Holt SG, Moore KP |title=Pathogenesis and treatment of renal dysfunction in rhabdomyolysis |journal=Intensive care medicine |volume=27 |issue=5 |pages=803–11 |year=2001 |pmid=11430535 |doi=}}<br/>'''Subsequent reply''':<br/>* {{cite journal |author=Korantzopoulos P, Galaris D, Papaioannides D |title=Pathogenesis and treatment of renal dysfunction in rhabdomyolysis |journal=Intensive care medicine |volume=28 |issue=8 |pages=1185; author reply 1186 |year=2002 |pmid=12400515 |doi=}}* {{cite journal |author=Llach F, Felsenfeld AJ, Haussler MR |title=The pathophysiology of altered calcium metabolism in rhabdomyolysis-induced acute renal failure. Interactions of parathyroid hormone, 25-hydroxycholecalciferol, and 1,25-dihydroxycholecalciferol |journal=N. Engl. J. Med. |volume=305 |issue=3 |pages=117–23 |year=1981 |pmid=6894630 |doi=}}
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| * {{cite journal |author=de Meijer AR, Fikkers BG, de Keijzer MH, van Engelen BG, Drenth JP |title=Serum creatine kinase as predictor of clinical course in rhabdomyolysis: a 5-year intensive care survey |journal=Intensive care medicine |volume=29 |issue=7 |pages=1121–5 |year=2003 |pmid=12768237 |doi=10.1007/s00134-003-1800-5}}
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| * Subramaniam PN Garcia CA Hill MK. ECG abnormalities in myoglobinuria: review of the literature. Am J Med Sci (1987 Jan) 293(1):45-9.
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| * Curry SC Chang D Connor D. Drug- and toxin-induced rhabdomyolysis. Ann Emerg Med (1989 Oct) 18(10):1068-84.
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| * Singh U Scheld WM. Infectious etiologies of rhabdomyolysis: three case reports and review. Clin Infect Dis (1996 Apr) 22(4):642-9.
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| * Poels PJ Gabreels FJ. Rhabdomyolysis: a review of the literature. Clin Neurol Neurosurg (1993 Sep) 95(3):175-92.
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| * Bessa O Jr. Alcoholic rhabdomyolysis: a review. Conn Med (1995 Sep) 59(9):519-21.
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| {{refend}}
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| ==Footnotes==
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| {{reflist|2}}
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| ==External links==
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| * {{cite web |author=Baggaley, P. |title=Rhabdomyolysis |url=http://members.tripod.com/~baggas/rhabdo.html |date=1997 |accessdate=2007-10-14}}
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| {{Consequences of external causes}} | | {{Consequences of external causes}} |
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| [[Category:Nephrology]] | | [[Category:Nephrology]] |
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| [[Category:Surgery]] | | [[Category:Surgery]] |
| [[Category:Emergency medicine]] | | [[Category:Emergency medicine]] |
| | [[Category:Disease]] |
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| [[da:Rhabdomyolyse]]
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| [[de:Rhabdomyolyse]]
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| [[fr:Rhabdomyolyse]]
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| [[it:Rabdomiolisi]]
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| [[he:תמס שריר]]
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| [[nl:Rhabdomyolyse]]
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| [[zh:横纹肌溶解症]]
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