Rhabdomyolysis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ayesha Javid, MBBS[2]
Synonyms and keywords: Familial paroxysmal rhabdomyolysis
Overview
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ayesha Javid, MBBS[2]
Overview
Rhabdomyolysis is a syndrome characterized by skeletal muscle necrosis and the release of intracellular muscle contents, such as myoglobin and electrolytes, into the blood circulation.[1]
Causes
The causes can be divided into 3 categories:[2][3][4]
- Traumatic or muscle compression.
- Nontraumatic exertional.
- Nontraumatic non-exertional.
| Causes of Rhabdomyolysis | |||||||||||||||||||||||||||||||||||||||
| Traumatic | Atraumatic | ||||||||||||||||||||||||||||||||||||||
| C01 | C02 | C03 | |||||||||||||||||||||||||||||||||||||
Diagnosis
Physical Examination
A physical usually reveals no abnormalities, but there may be tenderness, weakness, or atrophy.
Electrocardiogram
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).
References
- ↑ Bagley WH, Yang H, Shah KH (2007). “Rhabdomyolysis”. Intern Emerg Med. 2 (3): 210–8. doi:10.1007/s11739-007-0060-8. PMID 17909702 PMID: 17909702 Check
|pmid=value (help). - ↑ Gabow PA, Kaehny WD, Kelleher SP (1982). “The spectrum of rhabdomyolysis”. Medicine (Baltimore). 61 (3): 141–52. doi:10.1097/00005792-198205000-00002. PMID 7078398 PMID: 7078398 Check
|pmid=value (help). - ↑ Melli G, Chaudhry V, Cornblath DR (2005). “Rhabdomyolysis: an evaluation of 475 hospitalized patients”. Medicine (Baltimore). 84 (6): 377–85. doi:10.1097/01.md.0000188565.48918.41. PMID 16267412 PMID: 16267412 Check
|pmid=value (help). - ↑ Torres PA, Helmstetter JA, Kaye AM, Kaye AD (2015). “Rhabdomyolysis: pathogenesis, diagnosis, and treatment”. Ochsner J. 15 (1): 58–69. PMC 4365849. PMID 25829882 PMID: 25829882 Check
|pmid=value (help).
Historical Perspective
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
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Overview
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. [1] [2]
References
- ↑ Huerta-Alardín AL, Varon J, Marik PE (2005). “Bench-to-bedside review: Rhabdomyolysis — an overview for clinicians”. Crit Care. 9 (2): 158–69. doi:10.1186/cc2978. PMC 1175909. PMID 15774072 PMID: 15774072 Check
|pmid=value (help). - ↑ Rizzi D, Basile C, Di Maggio A, Sebastio A, Introna F, Rizzi R; et al. (1991). “Clinical spectrum of accidental hemlock poisoning: neurotoxic manifestations, rhabdomyolysis and acute tubular necrosis”. Nephrol Dial Transplant. 6 (12): 939–43. doi:10.1093/ndt/6.12.939. PMID 1798593 PMID: 1798593 Check
|pmid=value (help).
Classification
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References
Pathophysiology
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Pathophysiology
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 kidney damage in severe cases. The injured muscle also leaks potassium, leading to hyperkalemia, which may cause fatal 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 plasma volumes and leading to shock and reduced bloodflow to the kidneys.
References
Causes
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Venkata Sivakrishna Kumar Pulivarthi M.B.B.S [2]
Overview
The aetiological spectrum of rhabdomyolysis is extensive in many cases, multiple muscle insults are usually needed to produce rhabdomyolysis unless an underlying myopathy is present. The most common causes of rhabdomyolysis in adults are illicit drugs, alcohol abuse, medication, muscle diseases, trauma, neuroleptic malignant syndrome (NMS), seizures and immobility, Whereas in paediatric patients, the most common causes are viral myositis, trauma, connective tissue disorders, exercise, and drug overdose.[1]
Causes
Life-Threatening Causes
- Burns
- Crush injury
- Electrical injury
- Exertional Heat stroke
- Compartmental syndrome
- Malignant hyperthermia
- Neuroleptic malignant syndrome
- Electrolyte abnormalities such as Hypokalemia
Common Causes
- Burns
- crush injury
- Long-lasting muscle compression in Coma patients, under the influence of alcohol, medication or illicit drugs
- Electrical injury
- Snake venom
- Heat stroke
- Seizures
Causes by Pathophysiology
| Rhadomyolysis | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Traumatic or Muscle Compression | Non – Traumatic | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Non-Traumatic Exertional | Non-Traumatic Non-Exertional | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Non – Traumatic Exertional Rhadomyolysis in a Normal Muscle | Non – Traumatic Exertional Rhadomyolysis in an Abnormal Muscle | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| ❑ Crush injury ❑ Coma ❑ Post ictal state ❑ Post – Operative Surgical trauma ❑ Electrical Injury ❑ Compartment Syndrome ❑ Immobilizaion | ❑ Exertional Heat Stroke ❑ Sickle cell trait ❑ Hyperkinetic States Such as * Grand mal Seizures * Delirium tremens * Psychotic agitation * Amphetamine Overdose | ❑ Metabolic myopathies ❑ Mitochondrial myopathies ❑ Malignant hyperthermia ❑ Neuroleptic malignant syndrome | ❑ Drugs and toxins ❑ Infections ❑ Electrolyte abnormalities ❑ Endocrinopathies ❑ Inflammatory myopathies ❑ Miscellaneous | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Non-Traumatic Non-Exertional Causes | |
|---|---|
Infections
|
Viral infections : Adenovirus, Coxsackievirus, Cytomegalovirus, Echovirus , Epstein-Barr , Herpes simplex, Human immunodeficiency virus, Influenza A and B, Parainfluenza Bacterial infections : Bacterial pyomyositis, Coxiella burnetii(Q fever), E. coli, Ehrlichiosis,Falciparum malaria, Legionella, Leptospirosis, Mycoplasma pneumoniae, Salmonella, Staphylococcal infection, Streptococcus, Tularemia |
Electrolyte abnormalities
|
Hypokalemia, Hypophosphatemia |
Endocrinopathies
|
Hypothyroidism, Diabetic ketoacidosis , Non-ketotic hyperglycemia |
Inflammatory myopathies
|
Dermatomyositis, Polymyositis |
Miscellaneous
|
Alcoholism, Baclofen withdrawl, Capillary leak syndrome, Status asthmaticus |
Causes by Alphabetical Order
- Adenovirus
- Alcoholism
- Alpha-methylacyl-coa racemase (amacr) deficiency
- Anti parkison drug withdrawl
- Antiemetic agents
- Aripiprazole
- Asenapine maleate
- Baclofen withdrawl
- Bacterial pyomyositis
- Barth syndrome
- Brody myopathy (calcium adenosine triphosphatase deficiency)
- Bromocriptine
- Burns
- Cabergoline
- Capillary leak syndrome
- Carnitine deficiency
- Carnitine palmitoyltransferase deficiency
- Chlorpromazine
- Chronic Progressive External Ophthalmoplegia
- Clozapine
- Coma
- Compartment syndrome
- Coxiella burnetii (Q fever)
- Coxsackievirus
- Crush injury
- Cytomegalovirus
- Depolarising neuro-muscular blocker
- Dermatomyositis
- Desflurane
- Diabetic ketoacidosis
- Domperidone
- Droperidol
- E. coli
- Echovirus
- Ehrlichiosis
- Electrical injury
- Electrolyte abnormalities
- Endocrinopathies
- Epstein-barr
- Falciparum malaria
- Fluphenazine
- GRACILE syndrome
- Haloperidol
- Halothane
- Herpes simplex
- Human immunodeficiency virus
- Hypokalemia
- Hypophosphatemia
- Hypothyroidism
- Iloperidone
- Immobilizaion
- Inflammatory myopathies
- Influenza A and B
- Isoflurane
- Isolated myopathy
- Kearns-Sayre syndrome
- Lactate dehydrogenase deficiency
- L-dopa
- Legionella
- Leigh’s disease
- Leptospirosis
- Lipin-1 deficiency
- Long-chain acyl-CoA dehydrogenase deficiency
- Loxapine
- Malignant hyperthermia
- Malignant hyperthermia susceptibility caused by ryr1 gene mutations
- Metabolic myopathies
- Metoclopramide
- Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS)
- Mitochondrial myopathies
- Mycoplasma pneumoniae
- Myoadenylate deaminase deficiency
- Myoclonic epilepsy with ragged red fibers (MERRF)
- Myophosphorylase deficiency
- Neuroleptic malignant syndrome
- Neuroleptics
- Non-ketotic hyperglycemia
- Olanzapine
- Paliperidone
- Parainfluenza
- Perphenazine
- Phosphofructokinase deficiency
- Phosphoglycerate kinase deficiency
- Phosphoglycerate mutase deficiency
- Phosphorylase kinase deficiency
- Polymyositis
- Post – operative surgical trauma
- Post ictal state
- Prochlorperazine
- Promethazine
- Quetiapine
- Risperidone
- Salmonella
- Severe encephalomyopathy of infancy or childhood
- Sevoflurane
- Short-chain acyl-coenzyme A dehydrogenase deficiency
- Staphylococcal infection
- Status asthmaticus
- Streptococcus
- Succinylcholine
- Thioridazine
- Thiothixene
- Trifluoperazine
- Tularemia
- Volatile anesthetic agent
- Ziprasidone
References
- ↑ Khan FY (2009) Rhabdomyolysis: a review of the literature. Neth J Med 67 (9):272-83. PMID: 19841484
Symptoms
Differentiating Rhabdomyolysis from other Diseases
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References
Epidemiology and Demographics
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References
Risk Factors
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References
Natural History, Complications and Prognosis
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Natural History, Complications and Prognosis
- Acute renal failure/Uremia: Estimated (1/3). Etiology multifactorial. Not only from pigmenturia. Has been seen with CKs as low as <20,000.
- Metabolic:
- Hyperphosphatemia
- Hyperkalemia: Can be to life threatening levels
- Hypocalcemia: Thought to be caused by chelation of calcium phosphate into muscle. Eventually resolves and may overshoot.
- Hyperuricemia
- Compartment syndromes: Compressive ischemia from swelling
References
Diagnosis
Diagnosis
History and Symptoms | Physical Examination | Laboratory Findings | Electrocardiogram | X Ray | CT | MRI | Echocardiography or Ultrasound | Other Imaging Findings | Other Diagnostic Studies
Treatment
Treatment
Medical Therapy | Surgery | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies
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