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Microsoft Academic Search

Rhabdomyolysis is a syndrome involving the breakdown of skeletal muscle causing myoglobin and other intracellular proteins\\u000a and electrolytes to leak into the circulation. The development of rhabdomyolysis is associated with a wide variety of diseases,\\u000a injuries, medications and toxins. While the exact mechanisms responsible for all the causes are not fully understood, it is\\u000a clear that muscle damage can occur

W. H. Bagley; H. Yang; K. H. Shah





Rhabdomyolysis is a well-known clinical syndrome of muscle injury associated with myoglobinuria, electrolyte abnormalities, and often acute kidney injury (AKI). The pathophysiology involves injury to the myocyte membrane and/or altered energy production that results in increased intracellular calcium concentrations and initiation of destructive processes. Myoglobin has been identified as the primary muscle constituent contributing to renal damage in rhabdomyolysis. Although rhabdomyolysis was first described with crush injuries and trauma, more common causes in hospitalized patients at present include prescription and over-the-counter medications, alcohol, and illicit drugs. The diagnosis is confirmed by elevated creatine kinase levels, but additional testing is needed to evaluate for potential causes, electrolyte abnormalities, and AKI. Treatment is aimed at discontinuation of further skeletal muscle damage, prevention of acute renal failure, and rapid identification of potentially life-threatening complications. Review of existing published data reveals a lack of high-quality evidence to support many interventions that are often recommended for treating rhabdomyolysis. Early and aggressive fluid resuscitation to restore renal perfusion and increase urine flow is agreed on as the main intervention for preventing and treating AKI. There is little evidence other than from animal studies, retrospective observational studies, and case series to support the routine use of bicarbonate-containing fluids, mannitol, and loop diuretics. Hyperkalemia and compartment syndrome are additional complications of rhabdomyolysis that must be treated effectively. A definite need exists for well-designed prospective studies to determine the optimal management of rhabdomyolysis. PMID:24008958

Zimmerman, Janice L; Shen, Michael C





Rhabdomyolysis is the destruction of a significant amount of striated muscle, leading to disruptions in fluid balance, electrolytes and renal function. It may have either traumatic (such as crush injury) or non-traumatic causes. Diagnosis is typically made through the timely determination of the serum creatine kinase activity in a patient with a suggestive history or clinical features. Treatment is supportive, with generous intravenous hydration and correction of electrolyte abnormalities. Sometimes haemofiltration or dialysis is required, but the renal prognosis is generally good. PMID:22504713

de Wolff, Jacob F



Rhabdomyolysis and listeria monocytogenes.  


Non-traumatic rhabdomyolysis occurs as a complication of a wide variety of infections and is often discovered as a result of the associated renal failure. We report a case of meningitis due to Listeria monocytogenes, an uncommon cause of infection in adults which was associated with rhabdomyolysis. This confirms a recent first case report of this association. PMID:2799374

Clark, P; Lough, M; Whiting, B



Acute pediatric rhabdomyolysis.  


Rhabdomyolysis is a relatively common condition that may occur intermittently in chronic and inflammatory myopathy, muscular dystrophy, and metabolic myopathy. Rhabdomyolysis can also present acutely in otherwise healthy individuals. The list of etiologies for acute muscle cell lysis is enormous, with new causes described yearly. Series on acute pediatric rhabdomyolysis have not yet been published. This article describes a retrospective review of children admitted to the authors' institution during an 8-year period in whom rhabdomyolysis was recognized as a complication during their hospital stay. Patients with intermittent or relapsing rhabdomyolysis were excluded. Nineteen children were identified. Trauma (five cases), nonketotic hyperosmolar coma (two cases), viral myositis (two cases), dystonia (two cases), and malignant hyperthermia-related conditions (two cases) were the most common causes of rhabdomyolysis. Acute renal failure was the most frequent complication, occurring in 42% of cases. The mean age of renal failure patients was 13.9 years, compared to 8 years for non-renal failure children. Careful assessment of the initial urinalysis would have suggested a diagnosis of rhabdomyolysis in 9 of 16 patients tested. PMID:10805187

Watemberg, N; Leshner, R L; Armstrong, B A; Lerman-Sagie, T



Acute Exertional Rhabdomyolysis.  

National Technical Information Service (NTIS)

Forty Marine Corps recruits were hospitalized at the Naval Hospital, Beaufort, S. C., with acute exertional rhabdomyolysis following several days of excessive upper body calisthenics. After an uncomplicated hospital course, they returned to the regular tr...

M. A. Demos E. L. Gitin



Rhabdomyolysis detected by bone imaging  

SciTech Connect

Rhabdomyolysis involves necrosis of skeletal muscle and may arise from multiple conditions both traumatic and nontraumatic. Bone imaging with Technetium-99m phosphates is a very sensitive indicator of acute muscle damage and may be used to visualize the extent of rhabdomyolysis and its resolution. A case of alcohol-induced rhabdomyolysis is presented.

Sanders, J.A.



Rhabdomyolysis Secondary to Bee Sting  

PubMed Central

Insect stings belonging to Hymenoptera defined as wasps, yellow jackets, bees, or hornets by human usually result in unserious clinical pictures that go with pain. Rhabdomyolysis following a bee sting is a rare condition. This paper emphasizes “rhabdomyolysis” as a rare complication of this frequently observed envenomation. Rare but severe clinical results may occur due to multiple bee stings, such as intravascular hemolysis, rhabdomyolysis, acute renal insufficiency, and hepatic dysfunction. In bee stings as in our case, clinicians should be alert for rhabdomyolysis in cases with generalized body and muscle pain. Early onset alkaline diuresis and management in patients with rhabdomyolysis are vital in protecting the renal functions and preventing morbidity and mortality.

Akdur, Okhan; Can, Serdar; Afacan, Goksu



MR imaging of rhabdomyolysis  

SciTech Connect

The use of magnetic resonance (MR) imaging in two cases of rhabdomyolysis, one resulting from prolonged muscle compression and one from electrical burns, is described. The involved muscles were clearly demonstrated with MR. Recognition and assessment of the extent of rhabdomyolysis are important since life-threatening sequelae including severe metabolic disorders are possible. In one case, spin-echo and inversion-recovery MR imaging provided greater detail of muscle abnormalities than did 99mTc-pyrophosphate radionuclide scanning. Both cases illustrate the usefulness of MR in evaluation of skeletal muscle disorders.

Zagoria, R.J.; Karstaedt, N.; Koubek, T.D.



Exercise-induced rhabdomyolysis.  


Rhabdomyolysis is a debilitating condition that promotes muscle breakdown and eventually leads to renal dysfunction if not properly managed. The initial presentation may involve lower-extremity muscles, making the foot and ankle specialist one of the first specialists to recognize and diagnose this condition. Proper management of renal function is the primary concern; however, the underlying muscle breakdown needs to be addressed and the condition managed to prevent future problems. In this article we discuss treatment of a patient with exercise-induced rhabdomyolysis; a rehabilitation regimen is presented whose purpose is to condition muscles in order to prevent recurrence of exercise-induced muscle destruction after an acute event. PMID:17507535

Caban, Gregorio; Marin, Luis; Scavone, Frederick


Rhabdomyolysis after Laparoscopic Bariatric Surgery  

Microsoft Academic Search

Background: Postoperative rhabdomyolysis is an uncommon event. The aim of this study was to determine the incidence of rhabdomyolysis\\u000a following laparoscopic obesity surgery. Methods: Rhabdomyolysis was studied prospectively. Over a 6-month period, 66 consecutive\\u000a patients underwent bariatric surgery (gastric banding (n=50) and gastric bypass (n=16)). All patients underwent laparoscopic\\u000a procedures. A range of blood tests, including serum creatine phosphokinase (CPK)

Philippe Mognol; Stéphane Vignes; Denis Chosidow; Jean-Pierre Marmuse



Rhabdomyolysis and drugs of abuse  

Microsoft Academic Search

Rhabdomyolysis is a disorder in which injury to muscle results in leakage of myocyte intracellular contents into the plasma. It has been associated with a tremendous number and diversity of clinical conditions and substances. Several physiological and biochemical mechanisms for this syndrome have been described. The most likely etiology of rhabdomyolysis in patients presenting to the emergency department is ingestion

John R Richards



Rhabdomyolysis secondary to bee sting.  


Insect stings belonging to Hymenoptera defined as wasps, yellow jackets, bees, or hornets by human usually result in unserious clinical pictures that go with pain. Rhabdomyolysis following a bee sting is a rare condition. This paper emphasizes "rhabdomyolysis" as a rare complication of this frequently observed envenomation. Rare but severe clinical results may occur due to multiple bee stings, such as intravascular hemolysis, rhabdomyolysis, acute renal insufficiency, and hepatic dysfunction. In bee stings as in our case, clinicians should be alert for rhabdomyolysis in cases with generalized body and muscle pain. Early onset alkaline diuresis and management in patients with rhabdomyolysis are vital in protecting the renal functions and preventing morbidity and mortality. PMID:23606996

Akdur, Okhan; Can, Serdar; Afacan, Göksu



Rhabdomyolysis: report of eleven cases.  

PubMed Central

This article reports the results of a retrospective study of 11 patients with rhabdomyolysis-induced acute renal failure. All patients had multiple risk factors for rhabdomyolysis, the most common of which were alcoholism, illicit drug abuse, compression, and trauma. Patients with combined alcohol/illicit drug abuse had more severe electrolyte imbalances than patients without alcohol/illicit drug abuse. Myoglobinuria was detected in only half the patients despite rhabdomyolysis and urine "hematest" positivity. The serum creatine phosphokinase level was elevated in all of the patients, which is a good marker for rhabdomyolysis. Rhabdomyolysis is a relatively common disorder in municipal hospitals. Routine serum creatine phosphokinase levels should be checked on patients at risk, especially alcoholics, illicit drug abusers, and older patients.

Ellinas, P. A.; Rosner, F.



Acute Rhabdomyolysis from Eating Quail.  

National Technical Information Service (NTIS)

Acute rhabdomyolysis results from susceptible persons eating quail during the migrating season. The etiology is unknown. Muscular exercise is an important precipitating factor. In this paper the literature on this and related rhabdomyolytic and hemolytic ...

J. B. Bateman



Rhabdomyolysis associated with kava ingestion.  


We report a case of rhabdomyolysis temporally related to the ingestion of a large amount of kava. Kava is a naturally occurring plant used in the United States and elsewhere in the world for its sedative properties. A previous case report also related rhabdomyolysis to the ingestion of kava. It is not clear whether this is an action of the kava itself, perhaps, due to its action on voltage ion channels or, perhaps, due to an adulterant in the product. Our patient developed peak creatine phosphokinase levels in excess of 30 000 U/L but had no significant renal damage. PMID:21458945

Bodkin, Ryan; Schneider, Sandra; Rekkerth, Donna; Spillane, Linda; Kamali, Michael



Nuclear medicine imaging in rhabdomyolysis  

Microsoft Academic Search

A case of severe rhabdomyolysis is reported in which, some seven and one-half weeks after its occurrence, a gallium scan was strongly positive, due to abscess formation in the damaged muscle. A bone scan was weakly positive in the same area, due to gallium photons. A review of the the reported cases reveals that bone scans are a very sensitive




Rhabdomyolysis due to Multiple Wasp Stings  

PubMed Central

Wasp sting is a relatively common arthropod assault, but is sometimes fatal because of anaphylaxis. Rhabdomyolysis is a serious condition, with destruction of striated muscles, and can be induced by various causes such as drugs, heart attacks, CRASH syndrome, and viper bites. Mass envenomation by multiple wasp stings can also cause rhabdomyolysis followed by acute renal failure, although it is extremely rare. We herein report a case who had an anaphylaxis-like reaction and rhabdomyolysis due to multiple wasp stings.

Ito, K.; Imafuku, S.; Nakayama, J.



Hypothyroidism-induced rhabdomyolysis and renal failure.  


Renal failure, due to rhabdomyolysis, is a rare complication of hypothyroidism. We report an elderly patient with primary hypothyroidism symptoms initially presented with inability to walk, leading to renal failure. Laboratory examinations disclosed rhabdomyolysis and primary hypothyroidism. Creatinine phosphokinase, lactate dehydrogenase, and renal function test decreased to normal values shortly after thyroid hormone replacement. This report highlights that hypothyroidism should be considered in patients presenting with renal impairment associated with rhabdomyolysis. PMID:21500981

Ardalan, Mohammad Reza; Ghabili, Kamyar; Mirnour, Reshad; Shoja, Mohammadali M



Rhabdomyolysis and acute renal failure in children  

Microsoft Academic Search

.   Acute renal failure (ARF) is an important complication of rhabdomyolysis. However, the contributing factors to the development\\u000a of ARF in children with rhabdomyolysis remain obscure. The aim of this study was to clarify the factors contributing to the\\u000a development of ARF in children with rhabdomyolysis. This is a retrospective review of the clinical characteristics, laboratory\\u000a data, pediatric risk of

Toru Watanabe



Cough mixture abuse and rhabdomyolysis.  


Cough mixture abuse is an emerging problem among young men in Oriental countries. Its metabolic consequences have been recognised only recently. Such abusers can develop severe folate deficiency, which may be related to peripheral and central nervous system defects. We report three cough mixture abusers with rhabdomyolysis. All suffered from folate deficiencies and also had a history of anti-psychotic drug use. This represents one more life-threatening side-effect from cough mixture abuse. PMID:22302917

Tsang, Jenny S K; Au, W Y



Nuclear medicine imaging in rhabdomyolysis  

SciTech Connect

A case of severe rhabdomyolysis is reported in which, some seven and one-half weeks after its occurrence, a gallium scan was strongly positive, due to abscess formation in the damaged muscle. A bone scan was weakly positive in the same area, due to gallium photons. A review of the the reported cases reveals that bone scans are a very sensitive indicator of acute muscle damage and are useful to monitor its repair.

Cornelius, E.A.



Rhabdomyolysis among acute human poisoning cases  

Microsoft Academic Search

Rhabdomyolysis is a clinical and biochemical syndrome occurring when skeletal muscle cells erupt and result in release of creatine phosphokinase (CPK), lactate dehydrogenase (LDH) and myoglobin into the interstitial space and plasma. Mechanical trauma, compression, excessive muscle activity and ischemia are frequent causes, but non-traumatic rhabdomyolysis is usually caused by a toxic reaction to drugs.In this study, 181 patients suspected

H. Talaie; A. Pajouhmand; M. Abdollahi; R. Panahandeh; H. Emami; S. Hajinasrolah; M. Tghaddosinezhad



Determinants of Rhabdomyolysis in the Diabetic State  

Microsoft Academic Search

To evaluate the determinants of rhabdomyolysis in the diabetic state, we compared biochemical and clinical features of diabetic patients with (group 1, 41 patients) and without (group 2, 36 patients) rhabdomyolysis. There was no difference in values for serum potassium, bicarbonate, phosphate and calcium between the two groups. Nineteen patients in group 2 and 21 patients in group 1 were

Pravin C. Singhal; Mirel Abramovici; Shashidharan Ayer; Lionel Desroches



[Acute rhabdomyolysis during pneumococcal pneumonia: two cases].  


Acute rhabdomyolysis is a clinical and biological syndrome generally with a toxic or traumatic cause. Only 5% of cases are infectious, and rarely in relation to a pneumococcal infection. We report two cases of acute rhabdomyolysis which developed in patients with severe Streptococcus pneumoniae pneumonia. No other cause could be identified in these two patients aged 32 and 37 years. Rhabdomyolysis was discovered in the first patient because of acute kidney failure and elevated serum transaminase levels. The second patient presented an inflammatory edema affecting the soft tissues. Blood cultures isolated a pneumococcus in both patients. The rhabdomyolysis regressed favorably in both patients despite the transient renal failure in the first patient. Prognosis is generally poor for rhabdomyolysis during the course of pneumococcal pneumonia, with increased morbidity and mortality for these infections. Early detection of bacteriemia enables rapid and adequate treatment and prevention of renal failure. PMID:17607215

Aouina, H; Aïssa, I; Baccar, M A; Gharbi, L; Azzabi, S; Bouacha, H



Exercise Myoglobinemia and Acute Exertional Rhabdomyolysis.  

National Technical Information Service (NTIS)

Twenty-one Marine recruits in three training programs at the Marine Corps Recruit Depot, Parris Island, SC, were prospectively studied for one week for the presence of myoglobinemia and development of clinical rhabdomyolysis. Myoglobinemia was found in tw...

M. A. Demos E. L. Gitin L. J. Kagen



Early fluid resuscitation in patients with rhabdomyolysis.  


Extensive rhabdomyolysis is often lethal unless treated immediately. Early mortality arises from hypovolemic shock, hyperkalemia, acidosis and myoglobinuric acute kidney injury (AKI). Many individuals with rhabdomyolysis could be saved, and myoglobinuric AKI prevented, by early vigorous fluid resuscitation with ?12 l daily intravenous infusion of alkaline solution started at the scene of injury. This regimen stabilizes the circulation and mobilizes edema fluids sequestered in the injured muscles into the circulation, corrects hyperkalemia and acidosis, and protects against the nephrotoxic effects of myoglobinemia and hyperuricosuria. This regime results in a large positive fluid balance, which is well tolerated in young, carefully monitored individuals. In patients with rhabdomyolysis caused by muscle crush syndrome, mortality has been reduced from nearly 100% to <20% over the past 70 years through utilization of this intervention. This Perspectives discusses the lifesaving and limb-saving potential of early vigorous fluid resuscitation in patients with extensive traumatic and nontraumatic rhabdomyolysis. PMID:21587227

Better, Ori S; Abassi, Zaid A



[Recurrent rhabdomyolysis: screening for underlying disease].  


Rhabdomyolysis is a rare potentially dangerous syndrome resulting from the dissolution of skeletal muscle fibres. An isolated attack of rhabdomyolysis can have various causes, such as trauma, hyperpyrexia, infections, electrolyte imbalances, seizures, severe exertion, and drugs or substance abuse or a combination of these. Recurrent episodes and/or a family history of rhabdomyolysis is more likely caused by an underlying genetic defect. Three patients with rhabdomyolysis are described. One patient had an isolated episode due to excessive exercise. The other patients had a medical history or accompanying symptoms that suggested an underlying genetic metabolic myopathy confirmed in both by DNA analysis. An algorithm on when and how to screen for underlying genetic diseases is presented. Diagnosis of these genetic diseases is important for adequate counselling and dietary measures to prevent future episodes. PMID:21083951

Zutt, Rodi; van der Kooi, Anneke J; Linthorst, Gabor E; Wanders, Ronald J A; Verschuuren, Jan J G M; de Visser, Marianne



Pressure-induced Rhabdomyolysis after Bariatric Surgery  

Microsoft Academic Search

Rhabdomyolisis most commonly occurs after muscle injury, alcohol ingestion, drug intake and exhaustive exercise. Prolonged\\u000a muscle compression at the time of surgery may produce this complication. Obesity has been reported as a risk factor for pressure-induced\\u000a rhabdomyolysis, but no reports associated with bariatric surgery could be found in the literature. We report 3 superobese\\u000a patients who developed rhabdomyolysis after bariatric

Gonzalo Torres-Villalobos; Eric Kimura; Juan Luis Mosqueda; Eduardo García-García; Miguel F. Herrera





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PubMed Central

Statins have come to the forefront of treatments for hyperlipidemias, coronary artery diseases and strokes. They have been shown to cause myotoxicity and rhabdomyolysis. In most cases, rhabdomyolysis is self-limiting and needs supportive therapy. Two cases of statin-induced rhabdomyolysis are reported emphasizing the definition, risk factors, clinical features and the self-limiting nature of the disorder.

Al-Sulaiman, Abdulsalam A.; Al-Muslim, Nora I.; Al-Quorain, Abdulaziz A.; Al-Sulaiman, Raed M.



Adolescent with Rhabdomyolysis due to Undiagnosed Hypothyroidism  

PubMed Central

Exercise-induced rhabdomyolysis has been described in military recruits, trained athletes and daily runners. Statin use, quail ingestion, infection by Epstein-Barr virus (EBV), and hypothyroidism, though rare, are risk factors for the development of rhabdomyolysis. We describe the case of a 15-year-old female who presented with myalgias, weakness, and pigmenturia following marching band practice. Laboratory tests confirmed an elevated creatine kinase (CK) level as well as a profound hypothyroid state. Muscle biopsy revealed severe muscle necrosis and myositis. Treatment with levothyroxine resulted in obtaining an euthyroid state and regain of muscle strength as well as decrease in CK levels. Although rare, hypothyroidism should be considered as a potential cause of rhabdomyolysis in pediatric patients undergoing a myopathy workup.

Farias Moeller, Raquel; Zecavati, Nassim; Sherafat-Kazemzadeh, Rosa; Aleinikoff, Shoshana; Rennert, Wolfgang



Natural history of exertional rhabdomyolysis: a population-based analysis.  


Exertional rhabdomyolysis is a potentially catastrophic syndrome with an incidence and rate of recurrence that are unknown. In this study patients with rhabdomyolysis were identified retrospectively from the Wilford Hall Medical Center records. A population-based analysis was performed on exertional rhabdomyolysis patients enrolled in basic military training. A retrospective cohort was analyzed for rate and risks of recurrence. Of 177 rhabdomyolysis patients, 63 were exertional in mechanism. The rate of renal failure was lower in exertional rhabdomyolysis patients (odds ratio 0.45, 95% confidence interval 0.22-0.95, P = 0.04). There were 44 cases of exertional rhabdomyolysis from a population of 198,399 total military trainees over the study period, or 22.2 cases per 100,000 per year. A cohort of 22 exertional rhabdomyolysis patients was followed for a mean of 31.2 months, with only 1 recurrence (recurrence risk of 0.08% per person per year). Exertional rhabdomyolysis is associated with lower rates of complications than other causes of rhabdomyolysis. Among young, physically active patients, the incidence of exertional rhabdomyolysis is low, as is the risk of recurrence. PMID:20730874

Alpers, Joshua P; Jones, Lyell K



Rhabdomyolysis and Acute Renal Failure Induced by Paraphenylenediamine  

Microsoft Academic Search

1 We present a 40-year-old healthy man who developed a typical clinical picture of rhabdomyolysis following the administration of paraphenylenediamine by a witchdoctor as a pain killer.2 Two groups of 15 mice were given paraphenylenediamine 70 mg\\/kg and 35 mg\\/kg respectively. Biochemical and histological findings of rhabdomyolysis developed in both groups, without kidney damage.3 Paraphenylenediamine may cause rhabdomyolysis resulting in

Z. Averbukh; D. Modai; Y. Leonov; J. Weissgarten; G. Lewinsohn; L. Fucs; A. Golik; E. Rosenmann



Anaesthesia induced rhabdomyolysis a case report  

Microsoft Academic Search

Anaesthesia-induced rhabdomyolysis (AIR) is a rare but serious complication of general anaesthesia. We report the occurrence\\u000a of this event in a previously healthy three-year-old male, with a strongly positive family history ofDuchenne muscular dystrophy.\\u000a Following an uneventful anaesthetic, which included succinylcholine, myoglobinuria developed and led to renal failure which\\u000a fortunately reversed with conservative treatment. Based on review of reports of

J. D. McKishnie; D. P. Girvan



Risk factors for rhabdomyolysis following doxylamine overdose  

Microsoft Academic Search

The objective of this prospective study was to identify risk factors for developing rhabdomyolysis in patients with doxylamine overdose. Patients who were admitted to a university teaching hospital between July 2000 and September 2005 due to doxylamine overdose were recruited. Demographic information, clinical variables, and laboratory data were investigated. Twenty-seven (M\\/F 12\\/15, age 33.2 ±13.1 years) patients were enrolled. Sixteen

Young-Il Jo; Jong-Oh Song; Jung-Hwan Park; Soon-Young Koh; Seung-Min Lee; Tae-Ho Seo; Jong-Ho Lee



Rhabdomyolysis and concomitant neurological lesions after intravenous heroin abuse  

Microsoft Academic Search

Seven cases of rhabdomyolysis in heroin addicts are presented. All patients showed concomitant neurological symptoms suggesting mononeuropathy, incomplete plexus lesions or myelopathy. In most cases rhabdomyolysis occurred without preceding trauma to the muscles (for example tissue compression or coma). Five patients had a history of recently resumed heroin abuse after prolonged abstinence. An allergic or toxic reaction to heroin or

J de Gans; J Stam; G K van Wijngaarden




Microsoft Academic Search

SUMMARY A 30-year woman developed rhabdomyolysis and acute renal failure. She had history of amenor- rhea after her last delivery. On admission, she was pale, afebrile and ill, had slight tenderness of the muscles. Her muscle enzyme was high and her renal function decreased rapidly, suggesting rhabdomyolysis. Her laboratory investigation was compatible with panhypopituitarism. Treat- ment was started with levothyroxine

Mohammad Reza Rezvanfar; Parvin Soltani; Mona Hagaga Bozorgi


Acute Pediatric Rhabdomyolysis: Causes and Rates of Renal Failure  

Microsoft Academic Search

OBJECTIVES.The goals were to (1) compare the causes, clinical presentation, and prevalence of acute renal failure in pediatric rhabdomyolysis with the published data for adults; (2) determine predictors of acute renal failure in pediatric patients with rhabdomyolysis; and (3) explore the relationship of acute renal failure with treatment modalities such as fluid and bicarbonate administration. METHODS.We performed a retrospective chart

Rebekah Mannix; Mei Lin Tanb; Robert Wright; Marc Baskin



Rhabdomyolysis in Community Acquired Bacterial Sepsis - A Retrospective Cohort Study  

PubMed Central

Background and Objectives Rhabdomyolysis is often associated with sepsis and gram positive bacterial pathogens are reported to be the most frequent cause of sepsis induced rhabdomyolysis. We report the pattern of infecting bacterial pathogens and associated causal factors in a South-Indian cohort. Design, Setting, Participants & Measurements Retrospective cohort study of adult patients with community acquired bacterial sepsis complicated by rhabdomyolysis from March 2003 - August 2008. Rhabdomyolysis was defined as serum creatine kinase >2000 IU/L. The study population was divided into group-I (sepsis with gram positive pathogens), group–II (sepsis with gram negative pathogens) and group-III (culture negative sepsis). Results 103 patients (group I -15, group II- 34 and group III- 54) formed the study cohort. Mean age was 55 years and two-third had diabetes. Mean creatine kinase was 7114 IU/L and mean serum creatinine on admission was 2.4 mg/dl. Causative pathogen of sepsis was identified in 47.5%. Gram negative pathogens were more frequently (33%) associated with rhabdomyolysis than gram positive pathogens (14.5%). Lung was the commonest foci of sepsis (38.8%). 78.6% of the study population had one or more additional causal factor for rhabdomyolysis like statin intake, chronic alcoholism, hypokalemia, hypernatremia and hypophosphatemia. Mortality was 59%. Conclusions Gram negative bacterial pathogens were more frequently associated with rhabdomyolysis than gram positive pathogens. Rhabdomyolysis in patients with sepsis is multifactorial and is associated with high mortality.

Kumar, Anita A.; Bhaskar, Emmanuel; Palamaner Subash Shantha, Ghanshyam; Swaminathan, Porchelvan; Abraham, Georgi



Bench-to-bedside review: Rhabdomyolysis – an overview for clinicians  

Microsoft Academic Search

Rhabdomyolysis ranges from an asymptomatic illness with elevation in the creatine kinase level to a life-threatening condition associated with extreme elevations in creatine kinase, electrolyte imbalances, acute renal failure and disseminated intravascular coagulation. Muscular trauma is the most common cause of rhabdomyolysis. Less common causes include muscle enzyme deficiencies, electrolyte abnormalities, infectious causes, drugs, toxins and endocrinopathies. Weakness, myalgia and

Ana L Huerta-Alardín; Joseph Varon; Paul E Marik



Exertional heat stroke, rhabdomyolysis and susceptibility to malignant hyperthermia.  


Unexpectedly severe exertional heat stroke and rhabdomyolysis should prompt a clinician to look for susceptibility to malignant hyperthermia. We report a case of exertional heat stroke and rhabdomyolysis in a man later determined to have the malignant hyperthermia phenotype. We review the existing literature regarding this association and suggest future research that could address areas of remaining clinical uncertainty. PMID:24004393

Thomas, J; Crowhurst, T



Rhabdomyolysis and acute renal failure following radical perineal prostatectomy  

Microsoft Academic Search

Rhabdomyolysis and acute renal failure can be a rare but serious complication resulting from compromising operative positions following some urologic and gynecologic procedures. We report a lethal case of rhabdomyolysis following radical perineal prostatectomy. The possibility of this complication must be considered prior to performing any operation in the exaggerated lithotomy position. Prevention, early diagnosis, and aggressive treatment are the

R. Grady Bruce; Frank H. Kim; J. William McRoberts



Exertional Rhabdomyolysis: What Is It and Why Should We Care?  

ERIC Educational Resources Information Center

|Exertional rhabdomyolysis gained increased attention recently when 13 football players from the University of Iowa developed this condition after an especially demanding practice session and were hospitalized. Exertional rhabdomyolysis may lead to severe kidney stress, kidney failure, and even sudden death. Anyone who does physical exercise at a…

Thomas, David Q.; Carlson, Kelli A.; Marzano, Amy; Garrahy, Deborah



Exertional rhabdomyolysis in a patient with calcium adenosine triphosphatase deficiency  

Microsoft Academic Search

A patient with exertional rhabdomyolysis and continuously elevated serum creatine kinase (CK) was investigated. The known causes of recurrent attacks of rhabdomyolysis were ruled out by appropriate histochemical and biochemical investigations. During ischaemic exercise tests an abnormal K(+)-efflux from exercising muscles was observed. The patient was found to have a deficiency of muscular Ca(2+)-ATPase. Dantrolene sodium therapy gave relief of

P J Poels; R A Wevers; J P Braakhekke; A A Benders; J H Veerkamp; E M Joosten



Fatal rhabdomyolysis in systemic lupus erythematosus  

Microsoft Academic Search

The authors describe herein the sixth lupus case that evolved with rhabdomyolysis. A 36-year-old woman with systemic lupus\\u000a erythematosus was admitted to our hospital with malaise, myalgia, dysphagia, fever, preserved muscle strength, leukocytosis\\u000a (15,600 cells), and increased creatine kinase of 1,358 IU\\/L that reached 75,000 IU\\/L in few days. She denied the use of myotoxic\\u000a drugs and alcohol. Urine 1 showed false

Jozélio Freire de Carvalho; Licia Maria Henrique da Mota; Eloisa Bonfa


Gluteal compartment syndrome with severe rhabdomyolysis.  


Gluteal compartment syndrome is a rare entity but a recognised complication of prolonged immobilisation. It can present as renal failure as a result of severe rhabdomyolysis and can lead to sepsis and death. We report a case of gluteal compartment syndrome in a 25-year-old man who was found unconscious following intoxication with alcohol and cocaine of an unknown duration. He presented with tense tight left buttock swelling, right thigh swelling, cold immobile extremeties and acute renal failure. Immediate left gluteal, thigh and calf fasciotomy resulting in an improvement of lower limb and renal function. PMID:23933861

Narayan, Nitisha; Griffiths, Martin; Patel, Hasu D L



The "bat sign" of pectoral rhabdomyolysis.  


A 22-year-old man with foot pain was referred for evaluation of sesamoiditis. A Tc-99m methylene-diphosphonate bone scan was performed which revealed increased radiopharmaceutical uptake in the big toes, but also showed curious abnormal thoracic activity. Normal activity at sternoclavicular joints and sternum mimics ears, head and body of a bat, and the pectorals mimic the wings. The patient mentioned that he had started lifting weights a few days earlier. Clinical and echographic evaluations were diagnostic of pectoral inflammation suggesting rhabdomyolysis. PMID:19692835

Armijo, Soledad; Peña, Mónica; Bustos, Felipe; Morales, Bárbara



[Severe rhabdomyolysis revealing a myopathy linked to autoimmune hypothyroidism].  


While muscular manifestations are common of hypothyroidism, hypothyroid myopathy is most often limited to myalgia, muscular stiffness and cramps with, in some patients, elevated levels of muscle enzymes. We report two cases of rhabdomyolysis related to hypothyroid myopathy. One of the patients developed acute renal failure. Thyroid hormone replacement therapy improved thyroid and renal function with involution of rhabdomyolysis. Hypothyroidism appears to be an authentic cause of rhabdomyolysis and should be carefully ruled out in all patients with elevated serum levels of muscle enzymes. PMID:18603225

Mouzouri, H; El Omri, N; Sekkach, Y; Frikh, R; Nzambe, C; Qacif, H; Baizri, H; Makouar, F; Qatni, M El; Belmejdoub, G; Rkiouak, F; Ghafir, D; Ohayon, V; Archane, M I



Acute renal failure secondary to fenofibrate monotherapy-induced rhabdomyolysis.  


Fenofibrate, a fibric acid derivative, is used to treat diabetic dyslipidemia, hypertriglyceridemia, and combined hyperlipidemia alone or in combination with statins. Rhabdomyolysis is defined as a pathological condition of skeletal muscle cell damage leading to the release of toxic intracellular material into the circulation. Its major causes include trauma, ischemia, toxins, metabolic disorders, infections, and drugs. Rhabdomyolysis associated with fenofibrate is extremely rare. In nearly all of the presented cases, there was a predisposing factor for rhabdomyolysis such as diabetes, older age, renal insufficiency, and hypothyroidism. Here, we report a nondiabetic, nonhypothyroidic young female patient without any known prior renal disease presenting with acute renal failure developing after fenofibrate treatment. PMID:17994463

Tahmaz, M; Kumbasar, B; Ergen, K; Ure, U; Karatemiz, G; Kazancioglu, R



Fatal Rhabdomyolysis in a Patient with Head Injury  

PubMed Central

Rhabdomyolysis is a rare but potentially life-threatening disorder caused by the release of injured skeletal muscle components into the circulation. The authors report a case of severe head injury, in which a hyperosmolar state and continuous seizure complicated by severe rhabdomyolysis and acute renal failure evolved during the course of treatment resulted in a fatal outcome despite intensive supportive treatment. Our bitter experience suggests that rhabdomyolysis should be born in mind in patients with severe head injury who may develop hyperosmolar state and continuous seizure.

Park, Yong Jin



Acute rhabdomyolysis caused by combination therapy with atorvastatin and warfarin.  


Atorvastatin and warfarin are commonly prescribed in combination. Acute rhabdomyolysis is a rare but recognized side effect of atorvastatin occurring within a few weeks of initiation. This article presents a case of a 69-year-old man, on stable atorvastatin therapy, who developed acute rhabdomyolysis following initiation of warfarin. Rising international normalized ratio is a well-recognized feature of interaction between warfarin and various statins (fluvastatin, lovastatin and simva-statin). There has only been one previous similar case of acute rhabdomyolysis following the commencement of warfarin, reported in a patient on stable simvastatin therapy. To the authors' knowledge, no similar case has been reported with atorvastatin. PMID:22504754

Mackay, J W; Fenech, M E; Myint, K S



Myopathic causes of exercise intolerance with rhabdomyolysis.  


We review the muscular dystrophies and metabolic myopathies associated with myalgia and rhabdomyolysis together with some less well-recognized associations based upon the personal practice of the authors. A careful history and clinical examination will direct investigation towards an accurate molecular diagnosis. Non-specific exercise-induced myalgia in the presence of muscle hypertrophy and a high creatine kinase will point towards a muscular dystrophy. Symptoms occurring within minutes of exercise and with isometric contraction, especially with a history of a 'second wind' phenomenon, suggest a disorder of glycogen metabolism. In those patients in whom symptoms occur after prolonged exercise, infections, fasting, stress, and cold, a disorder of fatty acid oxidation should be considered. Heat-induced rhabdomyolysis caused by exercising in hot and humid climates should lead the clinician to suspect a mutation in RYR1. Serum creatine kinase level should be a checked in all children presenting with leg pains. A careful history and examination and laboratory confirmation of myoglobinuria will target investigations leading to a correct molecular diagnosis. PMID:22616958

Quinlivan, Ros; Jungbluth, Heinz



Rhabdomyolysis in a young vegetarian athlete.  


Rhabdomyolysis is a rare but potentially life-threatening disorder. The long list of known risk factors includes trauma, drug intoxication, alcoholism, hyperpyrexia, vascular occlusion, infections, electrolyte imbalances, heat intolerance, seizures, severe exertion, and substance abuse. Exercise-induced muscle damage is commonly experienced after physical activity, and different studies showed that the amount of protein consumed seems to affect its magnitude. In this regard, some concern has been raised about vegetarian athletes. We present a case of rhabdomyolysis that occurred in a young athlete following a poorly planned vegetarian diet. The athlete experienced progressive weakness and intermittent muscle aches particularly in the legs, malaise, episodic tachycardia, and nausea. Serum creatine kinase was markedly elevated (9952 units/liter), and a mild alteration of transaminase values was observed. The patient was hydrated intravenously and recovered fully within 5 days. The controlled introduction of a planned amount of protein in the diet allowed the athlete to carry on with his sporting activity fully without any further muscle problems. Physical exercise mainly engages the muscular system, and a balanced diet is essential to ensure the energy demands and the anabolic response. A vegetarian diet per se is not associated with detrimental effects in athletes, but an optimal protein intake should be achieved through careful planning with an emphasis on protein-rich plant foods. PMID:19661778

Borrione, Paolo; Spaccamiglio, Angela; Salvo, Raffaella Antonella; Mastrone, Antonietta; Fagnani, Federica; Pigozzi, Fabio



Rhabdomyolysis caused by co-medication with simvastatin and clarithromycin  

Microsoft Academic Search

Springer-Verlag 2009 Sirs, Rhabdomyolysis is a rare side-effect of 3-hydroxy-3methylglutaryl coenzyme A (HMG-CoA) reductase-inhibitors. Co-medication with inhibitors of the cytochrome P450 3A4 (CYP34A) pathway may increase this risk. We describe the case of a female patient who developed severe rhabdomyolysis due to concomitant use of simvastatin (20 mg) and clarithromycin. Previous reports on this interaction involved patients on high doses

Judith Wagner; Christine Suessmair; Hans-Walter Pfister



Rhabdomyolysis: A rare adverse effect of diphenhydramine overdose  

Microsoft Academic Search

Drug- and toxin-induced rhabdomyolysis is a nonspecific clinical syndrome resulting from the release of skeletal muscle cell contents into the plasma and urine. Antihistamine drugs are the active ingredients in a number of over-the-counter preparations and are frequently ingested in suicide attempts. We report rhabdomyolysis as a rare adverse effect of diphenhydramine toxicity in a 29-year-old man who ingested an

Seyed M Emadian; E. Martin Caravati; Robert D Herr



Ischemic neuropathy and rhabdomyolysis as presenting symptoms of postpartum cardiomyopathy  

Microsoft Academic Search

Rhabdomyolysis and peripheral neuropathy are two distinct disease entities which are rarely encountered in combination. We\\u000a present a woman with rhabdomyolysis and peripheral neuropathy 3 weeks postpartum. Her symptoms were caused by bilateral femoral\\u000a artery thrombosis due to postpartum cardiomyopathy (PPCM). This demonstrates that PPCM may present with predominantly non-cardial\\u000a symptoms and underscores the importance of rapidly recognizing this disorder.

Rick C. G. Helmich; Hanneke W. M. van Laarhoven; Hennie C. Schoonderwaldt; Mirian C. H. Janssen



Rhabdomyolysis in children: a 3-year retrospective study.  


The case reports of 4 pediatric patients illustrate the complex clinical scenarios in which childhood rhabdomyolysis/myoglobinuria occurs. Children ranged in age from 8-18 years. Presumed etiologies of rhabdomyolysis/myoglobinuria included Neisseria sepsis, exertion-related episodes, dialysis disequilibrium, and diabetic ketoacidosis. No child developed respiratory or renal failure. all children were discharged with normal muscle power, indicating the benign nature of this disease and the importance of aggressive management. PMID:1908680

Chamberlain, M C


Rhabdomyolysis associated with polydipsia induced hyponatraemia.  


A 41-year-old white male with a history of alcoholism and depression was brought from prison into the emergency department (ED) after having had a witnessed tonic-clonic seizure lasting approximately 5 min. During the 24 h prior to admission, the patient's cell mate reported that he was restless and had consumed 11 litres of water. The patient had also been taking regular escitalopram for his depression. On arrival to the ED, the patient was found to have a sodium level of 112 mmol/l. After correction of his hyponatraemia the patient developed rhabdomyolisis with a creatine kinase level of 65 064 IU/l. To prevent an acute kidney injury a high volume alkaline diuresis protocol was started. Once corrected, his sodium level remained normal and he was discharged home after making a full neurological recovery. Rhabdomyolysis has rarely been associated with the correction of hyponatraemia. PMID:22679167

Bennett, Michael; Fitzpatrick, Gerry; Donnelly, Maria



[Acute rhabdomyolysis. A study of 44 cases].  


Fourty four patients suffering non traumatic rhabdomyolysis (RM) are studied. The most frequently encountered etiologies were neurologic abnormalities in 26 patients, followed by infections in 7 patients and metabolic abnormalities in four cases. Eleven patients (25%) presented several associated factors. The clinical manifestations of RM were not very significant, with only 18% of patients presenting muscle pain, 38.6% proteinuria and 36.4% hematuria. A significant increase in K, CPK, LDH, and ASAT values was observed after the RM episode (p less than 0.05). Those patients with an infectious RM were older (p less than 0.05) and presented higher urea (p less than 0.01) and creatinine (p less than 0.05) values. Only two patients presented renal failure. One patient with septic shock died. RM is a relatively common condition, often secondary to multiple systemic processes, which can go unnoticed due to the underlying disease. PMID:2270337

Pascual, J M; Górriz, J L; Prosper, M; Collado, A; Belda, A; Michavila, J; Redón, J



Bortezomib-induced rhabdomyolysis in multiple myeloma.  


Although multiple myeloma (MM) remains an incurable disease, its treatment has improved over the past decade. This improvement has been at least in part due to the introduction of novel antimyeloma agents with new mechanisms of action, including those that target both myeloma cells and the tumor microenvironment, with antiangiogenic and immunomodulatory properties. Among these drugs, bortezomib (Velcade), a selective proteasome inhibitor, has been approved for the treatment of relapsed and refractory MM patients after one line of therapy. The toxicity profile of bortezomib includes gastrointestinal symptoms, fatigue, thrombocytopenia, peripheral neuropathy, postural hypotension, as well as some uncommon events. A patient with relapsed MM who developed recurrent bortezomib-induced rhabdomyolysis is reported. To our knowledge, this adverse event has not been previously described is this context. PMID:17016040

Cibeira, M Teresa; Mercadal, Santiago; Arenillas, Leonor; Muntañola, Anna; Salamero, Olga; Bladé, Joan



Investigations Regarding the Etiology of Acute Exertional Rhabdomyolysis Using an Animal Model.  

National Technical Information Service (NTIS)

The purpose of these studies was to establish whether acute exertional rhabdomyolysis could be produced in potassium- or magnesium-deficient dogs. In addition, attempts were made to induce exertional rhabdomyolysis in control dogs by repetitive exhaustive...

J. E. Olerud W. H. Pryor R. L. Eason H. W. Carroll



Psychosis and Severe Rhabdomyolysis Associated with Synthetic Cannabinoid Use.  


Background: Synthetic cannabinoid (SC) or "spice" refers to a variety of herbal/chemical mixtures, which mimic the effects of marijuana. They are generally marked as "herbal incense" and best known by the brand names of "K2", "spice", "aroma", "Mr. nice guy" and "dream". Little data is available on the psychopathological and physical effects of SC.Case description: We reported on a 23-year-old man without prior psychiatric history, who developed acute psychosis and severe rhabdomyolysis (CPK: 44,300 UI/L) associated with "Mr. nice guy" consumption. To our knowledge, this is the first case report of severe rhabdomyolysis associated with SC use in the U.S.Conclusion: Physicians should be aware to the possibility of new-onset psychotic symptoms and rhabdomyolysis in patients that use SC. PMID:23518784

Durand, Dante; Delgado, Leticia L; de la Parra-Pellot, Dhizarah Matus; Nichols-Vinueza, Diana



Exertional rhabdomyolysis and acute kidney injury.  


Skeletal muscle breakdown occurs normally with exercise, followed by muscle repair and physiologic adaptation. Strenuous, unaccustomed, prolonged, and repetitive exercise, particularly when associated with other risk factors such as hot and humid climate or sickle cell trait can cause clinically significant exertional rhabdomyolysis (ER). Although most cases are asymptomatic and resolve without sequelae, ER is the most common cause of exercise-related myoglobinuric acute renal injury and acute renal failure in athletes. Exercise-related muscle pain, elevated serum creatine kinase (CK), and "cola-colored" urine have been described as a classic presentation of ER. The exact mechanism of ER has not been clearly elucidated. Most studies suggest a cascade of events that include depletion of adenosine triphosphate (ATP), impaired function of the Na+- K+ ATPase system, intracellular excess calcium accumulation, sarcolemma damage, and release of intracellular proteins and other substances into blood. Excess myoglobin that is filtered at the glomerulus can lead to myoglobinuric acute renal injury. Cessation of physical activity, relative rest during clinical recovery, and early aggressive fluid replacement are mainstays of treatment. Return to play after recovery from ER is influenced by associated risk factors that may predispose the athlete to recurrence and is guided by signs, symptoms, and CK levels. This article reviews the definitions, pathophysiology, diagnosis, and management of ER with specific relevance to acute kidney injury. PMID:20048490

Patel, Dilip R; Gyamfi, Richmond; Torres, Alfonso



Paraphenylene Diamine Hair Dye Poisoning: An Uncommon Cause of Rhabdomyolysis.  


Paraphenylene daimine (PPD) is a kind of aromatic amine that is widely used in several industrial products. Women also use PPD added to henna (Lawasonia alba) as a hair dye. Though rare in Western countries, PPD poisoning is quite common in East Africa, India and Middle Eastern countries because it is a traditional product at these countries. Different pathologies were described as caused by PPD ingestion including angioedema of head and neck, rhabdomyolysis, and acute renal failure. The authors report a case of systemic poisoning with PPD that lead to angioedema resulting in tracheostomy and rhabdomyolysis. PMID:23723080

Elevli, Murat; Civilibal, Mahmut; Ersoy, Ozlem; Demirkol, Demet; Gedik, Ahmet Hakan



Rhabdomyolysis and acute renal failure in unsuspected malignant hyperpyrexia.  


Malignant hyperpyrexia is an inherited disorder of skeletal muscle characterized by intermittent hypermetabolic crises, usually triggered by anaesthetic agents. We present the case of a 19-year-old man who developed acute renal failure following an apparently uneventful general anaesthetic for appendicectomy. His renal failure was found to be secondary to rhabdomyolysis, and he made a full recovery after requiring haemodialysis for 14 days. Both the patient and his father were later discovered to have an underlying metabolic susceptibility to malignant hyperpyrexia. We propose that an undetected hypermetabolic crisis precipitated rhabdomyolysis and subsequent acute renal failure in this patient. PMID:8210298

Burns, A P; Hopkins, P M; Hall, G; Pusey, C D



Genetic polymorphisms associated with exertional rhabdomyolysis.  


Exertional rhabdomyolysis (ER) occurs in young, otherwise healthy, individuals principally during strenuous exercise, athletic, and military training. Although many risk factors have been offered, it is unclear why some individuals develop ER when participating in comparable levels of physical exertion under identical environmental conditions and others do not. This study investigated possible genetic polymorphisms that might help explain ER. DNA samples derived from a laboratory-based study of persons who had never experienced an episode of ER (controls) and clinical ER cases referred for testing over the past several years were analyzed for single nucleotide polymorphisms (SNPs) in candidate genes. These included angiotensin I converting enzyme (ACE), ?-actinin-3 (ACTN3), creatine kinase muscle isoform (CKMM), heat shock protein A1B (HSPA1B), interleukin 6 (IL6), myosin light chain kinase (MYLK), adenosine monophosphate deaminase 1 (AMPD1), and sickle cell trait (HbS). Population included 134 controls and 47 ER cases. The majority of ER cases were men (n = 42/47, 89.4 %); the five women with ER were Caucasian. Eighteen African Americans (56.3 %) were ER cases. Three SNPs were associated with ER: CKMM Ncol, ACTN3 R577X, and MYLK C37885A. ER cases were 3.1 times more likely to have the GG genotype of CKMM (odds ratio/OR = 3.1, confidence interval/CI 1.33-7.10), 3.0 times for the XX genotype of ACTN3 SNP (OR = 2.97, CI 1.30-3.37), and 5.7 times for an A allele of MYLK (OR = 21.35, CI 2.60-12.30). All persons with HbS were also ER cases. Three distinct polymorphisms were associated with ER. Further work will be required to replicate these findings and determine the mechanism(s) whereby these variants might confer susceptibility. PMID:23543093

Deuster, Patricia A; Contreras-Sesvold, Carmen L; O'Connor, Francis G; Campbell, William W; Kenney, Kimbra; Capacchione, John F; Landau, Mark E; Muldoon, Sheila M; Rushing, Elisabeth J; Heled, Yuval



Dysferlinopathy presenting as rhabdomyolysis and acute renal failure.  


Dysferlinopathies are a heterogeneous group of autosomal recessive muscle disorders resulting from defects or deficiencies in dysferlin. Reported phenotypes range from isolated hyperCKemia to muscular dystrophy. We present a 15-year-old male adolescent who was diagnosed with a dysferlinopathy after presenting with acute renal failure secondary to rhabdomyolysis. PMID:22550092

Moody, Shadé; Mancias, Pedro



Postoperative rhabdomyolysis in patients with end-stage renal failure  

Microsoft Academic Search

Four patients with end-stage renal failure on intermittent hemodialysis in whom rhabdomyolysis developed after major surgery are described. This possibly underdiagnosed complication was manifested by extreme hyperphosphatemia, hypocalcemia, and elevated creatine phosphokinase levels. Serum myoglobin levels further supported the diagnosis. The metabolic abnormalities reached a peak on the fourth postoperative day. The possible precipitating factors included opiates used for anesthesia

Y Ori; A Korzets; C Gruzman; A Chagnac; D Zevin; T Weinstein; M Herman; U Gafter



Vitamin E and exertional rhabdomyolysis during endurance sled dog racing  

Microsoft Academic Search

Exertional rhabdomyolysis (ER) is common in sled dogs, animals with high energy expenditures that consume high fat (60% of ingested calories) diets. Associations between pre-race plasma [vitamin E] and total antioxidant status (TAS) and risk of developing ER were examined in dogs competing in the 1998 Iditarod race. Pre-race blood samples were collected from 750 dogs and a second sample

Richard J Piercy; Kenneth W Hinchcliff; Paul S Morley; Robert A DiSilvestro; Gregory A Reinhart; Stuart L Nelson; Karin E Schmidt; A. Morrie Craig



Pathogenesis and treatment of renal dysfunction in rhabdomyolysis  

Microsoft Academic Search

Rhabdomyolysis is a major cause of acute renal failure, and recent experimental data have provided a better understanding of the pathophysiology of the renal dysfunction. Renal failure is due to renal vasoconstriction, tubular damage caused by oxidant injury, and possibly tubular obstruction. Recent studies have provided greater insight into the rationale behind current therapy and potential treatment strategies. This review

S. Holt; K. Moore



Pathogenesis of Renal Failure in Rhabdomyolysis: The Role of Myoglobin  

Microsoft Academic Search

Rhabdomyolysis causes renal dysfunction associated with renal vasoconstriction, tubular toxicity and luminal obstruction. There is now accumulating evidence that renal injury, caused by lipid peroxidation, is important in the pathogenesis of renal failure. The proposed central role of free iron in this process is examined. Current data have shown that the heme center of myoglobin can initiate lipid peroxidation and

Steve Holt; Kevin Moore



Liver Aminotransferases Are Elevated with Rhabdomyolysis in the Absence of Significant Liver Injury  

Microsoft Academic Search

Rhabdomyolysis is an uncommon finding in the emergency department. However, the clinical implications of rhabdomyolysis are\\u000a important, with a significant minority of patients developing acute renal failure and multiorgan failure. When present, the\\u000a cause of elevated aminotransferases in the setting of rhabdomyolysis is often unclear. We sought to determine the incidence\\u000a of abnormal aminotransferases (defined as aspartate aminotransferase (AST) or

Kathryn Weibrecht; Matthew Dayno; Chad Darling; Steven B. Bird



Incidence of Hospitalized Rhabdomyolysis in Patients Treated With Lipid-Lowering Drugs  

Microsoft Academic Search

Main Outcome Measure Incidence rates of rhabdomyolysis per 10000 person- years of treatment, number needed to treat, and relative risk of rhabdomyolysis. Results In 252460 patients treated with lipid-lowering agents, 24 cases of hospi- talized rhabdomyolysis occurred during treatment. Average incidence per 10000 person- years for monotherapy with atorvastatin, pravastatin, or simvastatin was 0.44 (95% confidence interval (CI), 0.20-0.84); for

David J. Graham; Judy A. Staffa; Deborah Shatin; Susan E. Andrade; Jerry H. Gurwitz; K. Arnold Chan; Michael J. Goodman; Richard Platt


Fatal rhabdomyolysis as a complication of ET-743 (Yondelis) chemotherapy for sarcoma.  


Rhabdomyolysis is a clinical syndrome in which skeletal muscle damage and necrosis leads to the release of intracellular muscle contents, which can ultimately lead to electrolyte disturbances, renal failure and even death. Chemotherapy is an extremely rare cause of rhabdomyolysis. Herein, we describe a fatal case of rhabdomyolysis in a patient with metastatic sarcoma after receiving the chemotherapeutic agent Ecteinascidin-743 (ET-743, trabectedin) as palliative chemotherapy treatment. PMID:17611408

Skorupa, Amy; Beldner, Matthew; Kraft, Andrew; Montero, Alberto J



Hypokalemic rhabdomyolysis due to watery diarrhea, hypokalemia, achlorhydria (WDHA) syndrome caused by vipoma.  


Mild hypokalemia is common and encountered in a multitude of diseases, but severe hypokalemia leading to rhabdomyolysis is relatively rare. The watery diarrhea, hypokalemia, achlorhydria (WDHA) syndrome caused by vasoactive intestinal polypeptide (VIP)-producing tumors, is an extremely rare cause of hypokalemic rhabdomyolysis and the literature is limited to one case report. We report a second case of an adult who presented with rhabdomyolysis due to severe hypokalemia. Further evaluation revealed that he had a VIP-producing pancreatic neuroendocrine tumor (NET), which was the cause of his hypokalemic rhabdomyolysis. Although rare in occurrence, a high index of suspicion is of paramount importance for establishing the correct diagnosis and treatment. PMID:19488018

Kibria, Rizwan; Ahmed, Sameer; Ali, Syed A; Barde, Christopher J



Rhabdomyolysis caused by tocolytic therapy with ritodrine hydrochloride.  


We report a case of rhabdomyolysis with severe generalized weakness and muscle pain after administration of ritodrine hydrochloride, in a pregnant patient without history of neuromuscular disease. Laboratory tests showed an increase of blood CK value and myoglobinuria. An electromyography was performed, revealing a typical myogenic pattern and diffuse denervation activity. Muscular biopsy allowed to rule out inflammatory and metabolic myopathy. After delivery, the patient underwent intensive rehabilitation with progressive improvement of her clinical situation, until complete recovery. Three months later, both neurological assessment and CK levels were normal. This case highlights that rhabdomyolysis has to be considered even in patient treated with ritodrine alone and without history of neuromuscular disease. Therefore, muscular symptoms and CK levels should be monitored in women treated with ritodrine for premature labour. PMID:19556131

Verriello, L; D'Amico, D; Pauletto, G; Gigli, G L; Bergonzi, P



Rhabdomyolysis in an adolescent with nonpurging bulimia nervosa.  


A 14-year-old girl with a history of nonpurging bulimia nervosa (BN) was presented with muscular pain and weakness after several days of fasting and vigorous exercise. On hospital admission, the serum creatine kinase was 3,277 U/L and serum potassium was 2.5 mmol/L. The creatine kinase level reached a peak of 4,588 U/L before declining after intravenous hydration and correction of electrolytes. Renal function remained normal throughout hospitalization. Rhabdomyolysis has not been previously reported as a complication of BN in an adolescent or in nonpurging BN. Practitioners who treat patients with eating disorders, including BN, should be aware of rhabdomyolysis as a potential complication, because delay in treatment can lead to acute renal failure. PMID:21402275

Sondike, Stephen B



Factors associated with acute renal failure in children with rhabdomyolysis  

Microsoft Academic Search

Pigment nephropathy accounts for approximately 3% of all cases of acute renal failure (ARF) in children. Studies of risk factors\\u000a associated with ARF and the need for renal replacement therapy (RRT) in children with rhabdomyolysis-associated pigment nephropathy\\u000a consist of retrospective case series with variable inclusion criteria. Our objective was to evaluate clinical and laboratory\\u000a characteristics, etiology, initial fluid therapy, prevalence

Diana Zepeda-Orozco; Bettina H. Ault; Deborah P. Jones



Hypokalemic rhabdomyolysis in a child due to amphotericin B therapy  

Microsoft Academic Search

Hypokalemia can result in life-threatening complications if not treated appropriately. Although hypokalemia is a frequent\\u000a adverse effect of amphotericin B therapy, there are no reports in the pediatric literature on hypokalemia-associated rhabdomyolysis\\u000a induced by this drug. A ten-year-old boy with a history of one week amphotericin B treatment was admitted with weakness of\\u000a the lower extremities, inability to walk and

Paulo Sérgio Lucas da Silva; Simone Brasil de Oliveira Iglesias; Jaques Waisberg



Marked Hypokalemic Rhabdomyolysis with Myoglobinuria due to Diuretic Treatment  

Microsoft Academic Search

A 74-year-old male was admitted to hospital with acute rhabdomyolysis and myoglobinuria due to hypokalemia. The hypokalemia resulted from diuretic treatment. He had no family history of myopathy, and no diarrhea and vomiting. The neurological examination revealed painful quadriplegia. The blood pressure was 160\\/74 mm Hg. Laboratory examination showed hypokalemic and hypochloremic metabolic alkalosis (serum K 1.5 mEq\\/1, serum CI

Shuzo Shintani; Tatsuo Shiigai; Hiroshi Tsukagoshi



Cardiac arrhythmias and rhabdomyolysis in Bartter–Gitelman patients  

Microsoft Academic Search

Recent data demonstrate that patients affected with hypokalemic salt-losing tubulopathies are prone to acute cardiac arrhythmias\\u000a and rhabdomyolysis. The tendency to these potentially fatal complications is especially high if chronic hypokalemia is severe,\\u000a in patients with diarrhea, vomiting or a prolonged QT interval on standard electrocardiography, in patients on drug management\\u000a with compounds prolonging the electrocardiographic QT interval (including antiarrhythmic

Cinzia Cortesi; Sebastiano A. G. Lava; Alberto Bettinelli; Fabiana Tammaro; Olivier Giannini; Maria Caiata-Zufferey; Mario G. Bianchetti



Rhabdomyolysis caused by tocolytic therapy with ritodrine hydrochloride  

Microsoft Academic Search

We report a case of rhabdomyolysis with severe generalized weakness and muscle pain after administration of ritodrine hydrochloride, in a pregnant patient without history of neuromuscular disease.Laboratory tests showed an increase of blood CK value and myoglobinuria. An electromyography was performed, revealing a typical myogenic pattern and diffuse denervation activity.Muscular biopsy allowed to rule out inflammatory and metabolic myopathy.After delivery,

L. Verriello; D. D’Amico; G. Pauletto; G. L. Gigli; P. Bergonzi



Myopathy and rhabdomyolysis with lipid-lowering drugs  

Microsoft Academic Search

Drug-induced myopathy and rhabdomyolysis are rare adverse drug reactions (ADR). They have been seen after the introduction of modern lipid-lowering drugs more regularly. The first description after medication with clofibrate dates back to 1968. Apparently, all fibrates can induce myopathy. It usually starts after a few days of medication, or after prolonged use, showing muscle weakness and\\/or pain. Concomitantly, the

Christian Hodel



Serotonin syndrome and rhabdomyolysis in venlafaxine poisoning: a case report.  


Newer, more selective, antidepressant agents are increasingly being used as first-line treatment. However, clinical experience in patients after a deliberate overdose is limited. We present a case of venlafaxine intoxication complicated by a late rise in creatine kinase, seizures and serotonin syndrome. Rhabdomyolysis prolonged the hospital stay in our patient but had no other serious consequences. Physicians should be aware of this late phenomenon in patients with venlafaxine poisoning. PMID:16186642

Hanekamp, B B; Zijlstra, J G; Tulleken, J E; Ligtenberg, J J M; van der Werf, T S; Hofstra, L S



Acute renal failure due to non-traumatic rhabdomyolysis  

Microsoft Academic Search

Seventeen patients with acute renal failure of diverse aetiology showed myoglobinuria and elevated levels of serum creatine phosphokinase (mean 119·2 Sigma u.\\/ml) and adolase (mean 88·5 Sibley-Lehninger (SL)u.\\/ml), indicating the presence of diffuse muscle cell injury. The primary conditions which led to rhabdomyolysis and acute renal failure were burns, eclampsia, prolonged labour, crush injury, epileptiform convulsions, status asthmaticus, viral myositis

K. S. Chugh; I. V. S. Nath; H. S. Ubroi; P. C. Singhal; S. K. Pareek; A. K. Sarkar



Rhabdomyolysis and Dengue Fever: A Case Report and Literature Review  

PubMed Central

The medical literature contains only a few reports of rhabdomyolysis occurring in patients with dengue fever. We report the case of a 25-year-old Jamaican man who was admitted to a private hospital four days after the onset of an acute febrile illness with fever, myalgia, and generalized weakness. Dengue fever was confirmed with a positive test for the dengue antigen, nonstructural protein 1. He remained well and was discharged on day 6 of his illness. On day 8, he started to pass red urine and was subsequently admitted to the University Hospital of the West Indies. On admission he was found to have myoglobinuria and an elevated creatine phosphokinase (CPK) of 325,600?U/L, leading to a diagnosis of rhabdomyolysis. Dengue IgM was positive. He was treated with aggressive hydration and had close monitoring of his urine output, creatinine, and CPK levels. His hospital course was uneventful without the development of acute renal failure and he was discharged after 14 days in hospital, with a CPK level of 2463?U/L. This case highlights that severe rhabdomyolysis may occur in patients with dengue fever and that early and aggressive treatment may prevent severe complications such as acute renal failure and death.

Sargeant, Tanya; Harris, Tricia; Wilks, Rohan; Barned, Sydney; Galloway-Blake, Karen; Ferguson, Trevor



Preventing Renal Failure in Patients with Rhabdomyolysis: Do Bicarbonate and Mannitol Make a Difference?  

Microsoft Academic Search

Background: The combination of bi- carbonate and mannitol (BIC\\/MAN) is commonly used to prevent renal failure (RF) in patients with rhabdomyolysis de- spite the absence of sufficient evidence validating its use. The purpose of this study was to determine whether BIC\\/ MAN is effective in preventing RF in patients with rhabdomyolysis caused by trauma. Methods: This study was a review

Carlos V. R. Brown; Peter Rhee; Linda Chan; Kelly Evans; Demetrios Demetriades; George C. Velmahos



Rhabdomyolysis Associated with Fenofibrate Monotherapy in a Patient with Chronic Myelogenous Leukemia  

Microsoft Academic Search

Rhabdomyolysis associated with fenofibrate monotherapy is extremely rare. Here, we report a rare case of rhabdomyolysis of the psoas muscle in an 82-year-old man with chronic myelogenous leukemia (CML). He was prescribed fenofibrate because of a hypertriglyceridemia. The patient reported generalized muscle pain and right abdominal pain while receiving fenofibrate monotherapy. An abdominal computed tomography scan and an abdominal ultrasound

Kazuya Kato; Astushi Nagase; Minoru Matsuda; Yurina Kato; Kazuhiko Onodera; Takako Kawakami; Mineko Higuchi; Yoshiaki Iwasaki; Masahiko Taniguchi; Hiroyuki Furukawa



Biochemical and Ultrastructural Lung Damage Induced by Rhabdomyolysis in the Rat  

Microsoft Academic Search

Rhabdomyolysis-induced oxidative stress is associated with morphological and functional damage to the kidney and other organs, but applications of this model in the lung are still lacking. The aim of the present study was to determine the relationship between oxidative stress and the morphological changes occurring in the lungs of rats subjected to rhabdo- myolysis. Rhabdomyolysis was induced by intramuscular



Methamphetamine abuse and rhabdomyolysis in the ED: A 5-year study  

Microsoft Academic Search

Patients with methamphetamine toxicity are presenting in greater numbers each year to emergency departments (ED) in the US. These patients are frequently agitated, violent, and often require physical and chemical restraint. The incidence and risk of rhabdomyolysis in this subpopulation is unknown. We conducted a 5-year retrospective review of all ED patients who received the final diagnosis of rhabdomyolysis. Patients

John R Richards; Emily B Johnson; Randy W Stark; Robert W Derlet



Propofol-associated Rhabdomyolysis with Cardiac Involvement in Adults: Chemical and Anatomic Findings  

Microsoft Academic Search

Propofol, a central-acting sedative agent, has been im- plicated in the development of rhabdomyolysis in chil- dren. We describe two adults who developed rhabdo- myolysis after receiving high rates of propofol infusion. Rhabdomyolysis of both skeletal and cardiac muscle was suggested in both patients by marked increases of creatine kinase (>170 000 U\\/L) and cardiac troponin I (11 and 46

Edward B. Stelow; Vandita P. Johari; Stephen A. Smith; John T. Crosson; Fred S. Apple


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


We have encountered numerous cases of rhabdomyolysis associated with acute pesticide intoxication; however, the cause, incidence, and treatment outcomes of rhabdomyolysis have not been studied. The current study involved 2,125 patients hospitalized with acute chemical poisoning. Based on clinical and laboratory parameters and treatment outcomes, we found that overall incidence of rhabdomyolysis in our hospital was 0.06% (93 of 143,830 patients admitted), but the incidence associated with acute pesticide intoxication was 1.8% (33 of 1,793 cases). The incidence of rhabdomyolysis after pesticide intoxication was significantly higher in men than in women (P = 0.010). The amount of pesticide ingested was significantly higher in rhabdomyolysis patients than that in those who did not develop rhabdomyolysis (mean ± SD, 114.1 ± 79.5 mL vs 74.1 ± 94.2 mL, P = 0.010). Our results show that pesticide intoxication is a frequent cause of rhabdomyolysis and is more common among men than women. The volume of pesticide ingested, and not the degree of human toxicity, is the main factor influencing the incidence of rhabdomyolysis. PMID:23960447

Park, Jae-Seok; Seo, Min-Sook; Gil, Hyo-Wook; Yang, Jong-Oh; Lee, Eun-Young; Hong, Sae-Yong



Frostbite with rhabdomyolysis and renal failure: radionuclide study. [/sup 99m/Tc  

SciTech Connect

There is a growing list of muscle lesions exhibiting concentration of bone-seeking /sup 99m/Tc-labeled phosphate complexes; however, rhabdomyolysis due to cold injury has not been included. We performed a multiradiopharmaceutical study that yielded interesting results on a patient who sustained frostbite injury of the legs that led to rhabdomyolysis and acute renal failure.

Rosenthall, L.; Kloiber, R.; Gagnon, R.; Damtew, B.; Lough, J.



Rhabdomyolysis in association with Duchenne’s muscular dystrophy  

Microsoft Academic Search

Purpose  To present a case of rhabdomyolysis which developed in a child with a known history of Duchenne’s muscular dystrophy, following\\u000a an anesthetic which included sevoflurane.\\u000a \\u000a \\u000a \\u000a Clinical features  An 11 yr old boy with a known history of Duchenne’s muscular dystrophy underwent anesthesia for strabismus repair. The anesthetic\\u000a consisted of sevoflurane and nitrous oxide without the use of a muscle relaxant. His

Ryoji Obata; Yasuhiro Yasumi; Akira Suzuki; Yoshiki Nakajima; Shigehito Sato



Rhabdomyolysis in response to weight-loss herbal medicine.  


The authors report rhabdomyolysis following the ingestion of weight-loss herbal medicine in an otherwise healthy 54-year-old woman. Three hours after ingestion of the herbal medicine, the patient suffered chest pain that continued for 2 hours and resolved gradually. Laboratory investigation showed the presence of rhabdomyolysis with peak serum creatine kinase (CK) of 1028 IU/L, which gradually decreased and normalized after the herbal medicine was discontinued. The pharmacological effects of the active ingredients of the herbal medicine, ma huang (ephedrine), guarana (active alkaloid caffeine), chitosan, Gymnena sylvestre, Garcinia cambogia (50% hydroxycitric acid), and chromium, are discussed, and similar case reports are reviewed. The elevation of CK in this case is of concern, as it may denote that muscle breakdown may be one of the mechanisms of weight loss in these herbal remedies. Further studies are needed to investigate their effects on muscle bulk or CK. Physicians should be aware of the potential side effects of many herbal medicines. It may be advisable to measure serum CK enzyme for patients who admit using weight-loss herbs. PMID:15201651

Mansi, Ishak A; Huang, Jian



Severe Rhabdomyolysis Associated with the Cerivastatin-Gemfibrozil Combination Therapy  

PubMed Central

Cerivastatin is the new 3rd-generation of the synthetic 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors, the 1st drugs of choice for treating hypercholesterolemia. A potent inhibitor of HMG-CoA reductase, it possesses a high affinity for liver tissue and decreases plasma low-density lipoprotein cholesterol at microgram doses. Cerivastatin produces reductions in low-density lipoprotein cholesterol of 31.3% and 36.1% at doses of 0.3 and 0.4 mg/day, respectively. It is an uncomplicated agent with regard to its pharmacokinetic profile, low potential for interaction with other drugs, and suitability for use in those with impaired renal function. Most other statins have been implicated in causing rhabdomyolysis, either as mono-therapy or in combination with other agents. We report what to our knowledge is the most profound case yet in the literature of rhabdomyolysis in association with ceriva-statin-gemfibrozil combination therapy, in regard both to the extreme elevation in serum creatinine kinase and to the patient's near-paralytic weakness.

Lau, Theodore K.; Leachman, D. Richard; Lufschanowski, Roberto



Rapid onset of rhabdomyolysis after switching to a raltegravir-based antiretroviral regimen.  


Raltegravir is the first integrase inhibitor antiretroviral agent that has been demonstrated to have antiviral efficacy and safety. However, the US Food and Drug Administration has recommended use with caution in patients with risk factors for rhabdomyolysis, based on four case reports of rhabdomyolysis in patients with identifiable risk factors. We present a 32-year-old Asian man with human immunodeficiency virus (HIV), but without other underlying diseases, who developed rapid-onset, raltegravir-associated rhabdomyolysis and hyperlactatemia. Our patient lacked predisposing factors for rhabdomyolysis, and the rapid onset time of 4 days was the shortest reported. Therefore, clinicians should exercise caution when using raltegravir and closely monitor all patients for the symptoms of muscle pain and weakness. This case has been reported to the National Adverse Drug Reactions Reporting System of the Department of Health in Taiwan. PMID:23612027

Tsai, Wan-Jung; Lee, Susan Shin-Jung; Tsai, Hung-Chin; Sy, Cheng-Len; Chen, Jui-Kuang; Wu, Kuang-Sheng; Wang, Yung-Hsin; Chen, Yao-Shen



Incidence of Acute Exertional Rhabdomyolysis. Serum Myoglobin and Enzyme Levels as Indicators of Muscle Injury.  

National Technical Information Service (NTIS)

This study was conducted to determine, on a prospective basis, the incidence of acute exertional rhabdomyolysis (AER) among recruits at the Marine Corps Recruit Depot, San Diego, California. Blood samples were taken from each of 337 voluteer recruits on e...

J. E. Olerud L. D. Homer H. W. Carroll



Acute Exertional Rhabdomyolysis: A Syndrome of Increasing Importance to the Military Physician.  

National Technical Information Service (NTIS)

Acute exertional rhabdomyolysis is a syndrome that is being diagnosed with greater frequency by the military physician. It is characterized by muscle pain, weakness, soreness, induration, and myoglobinuria. This occurs after an episode of very vigorous ph...

E. L. Gitin M. A. Demos



Rhabdomyolysis presenting with severe hypokalemia in hypertensive patients: a case series  

PubMed Central

Background Rhabdomyolysis presenting with severe hypokalemia as the first manifestation of primary hyperaldosteronism is extremely rare. Case presentation Two middle-aged Chinese females were admitted to our emergency department for muscular weakness and limb pain, and both have the history of early onset hypertension. Laboratory test showed elevated creatinine phosphokinase (4, 907 and 8, 531 IU/L) and extremely low serum potassium (1.38 mmol/L and 1.98 mmol/L). Rhabdomyolysis and severe hypokalemia were established as first diagnosis. Hypokalemic rhabdomyolysis was confirmed after nervous system disorders, autoimmune diseases and trauma were excluded. Adrenal computerized tomography scan and postural stimulation test revealed aldosterone-producing adenomas. They both received laparoscopic adrenalectomy and were stable at the 2-year follow-up visit. Conclusion The two cases remind physicians to bear in mind the risk of hypokalemia-induced rhabdomyolysis among patients with primary hyperaldosteronism.



A case of rhabdomyolysis in the presence of multiple risk factors and dextroamphetamine use.  


A 44-year-old Caucasian woman presented to the emergency room with worsening low back pain and loss of cutaneous sensation over the paraspinal muscles from T10 to S1. The patient had ingested the attention-deficit disorder medication dextroamphetamine before engaging in intense physical exercise with subsequent consumption of 3 alcoholic beverages before developing symptoms. The patient's creatine kinase levels remained elevated for 8 days with constant severe pain under standard treatment for rhabdomyolysis. Despite stabilization of pain and laboratory values at discharge, the patient continues to experience low paraspinal back pain. In patients with risk factors for rhabdomyolysis, the use of dextroamphetamine should be monitored closely. Outside our findings, there is no literature linking dextroamphetamine with rhabdomyolysis at nontoxic concentrations or with use of the supplement caffeine containing weight loss supplement, Hydroxycut. The authors believe that further research into the potential role of dextroamphetamine use in the setting of other risk factors for rhabdomyolysis is warranted. PMID:23276898

Santoro, Jonathan D; Black, Jeanette M; Hamm, L Lee



A case of rhabdomyolysis with fatal outcome after a treatment with levofloxacin  

Microsoft Academic Search

Fluoroquinolones are known to cause rhabdomyolysis. Levofloxacin is a recent fluoroquinolone and its muscular toxicity is not well documented. We describe the case of a 77-year-old female patient, who presented with an acute rhabdomyolysis after treatment with levofloxacin. She had a background of serious cardio-pulmonary disease. She received an oral ambulatory treatment with levofloxacin for pulmonary infection. After 6 days, she

Fabrice Petitjeans; Julien Nadaud; Jean Paul Perez; Bruno Debien; Frederic Olive; Thierry Villevieille; Bruno Pats



Epidemiological Analysis of Factors Influencing an Episode of Exertional Rhabdomyolysis in High School Students  

Microsoft Academic Search

Background:An episode of rhabdomyolysis occurred after an endurance test in high school students in Taipei County in November 2003.Purpose:To determine the incidence, outcome, and risk factors in an episode of exertional rhabdomyolysis in high school students.Study Design:Descriptive epidemiology study.Methods:We enrolled all 225 high school students who had performed an endurance test. Using data from retrospective questionnaires, we estimated the incidence

Hsingwen Lin; Weichu Chie; Huangchun Lien



Incidence of hospitalized rhabdomyolysis in patients treated with lipid-lowering drugs  

Microsoft Academic Search

CONTEXT: Lipid-lowering agents are widely prescribed in the United States. Reliable estimates of rhabdomyolysis risk with various lipid-lowering agents are not available.\\u000aOBJECTIVE: To estimate the incidence of rhabdomyolysis in patients treated with different statins and fibrates, alone and in combination, in the ambulatory setting.\\u000aDESIGN, SETTING, AND PATIENTS: Drug-specific inception cohorts of statin and fibrate users were established using

David J. Graham; Judy A. Staffa; Deborah Shatin; Susan E. Andrade; Stephanie D. Schech; Jerry H. Gurwitz; K. Arnold Chan; Michael J. Goodman; Richard Platt



Serum creatine kinase as predictor of clinical course in rhabdomyolysis: a 5-year intensive care survey  

Microsoft Academic Search

ObjectiveTo evaluate the risk factors for the development of acute renal failure (ARF) in severe rhabdomyolysis.DesignObservational historical cohort study.SettingGeneral intensive care unit of a university hospital.PatientsTwenty-six patients with severe rhabdomyolysis, who were admitted between July 1996 and July 2001.Measurements and resultsClinical and laboratory data were reviewed and groups were stratified according to presence or absence of acute renal failure. The

Arthur R. de Meijer; Bernard G. Fikkers; Marinus H. de Keijzer; Baziel G. M. van Engelen; Joost P. H. Drenth



Exertional rhabdomyolysis following excessive exercise of university freshman cheer-training.  


Exertional rhabdomyolysis is a life threatening condition resulting from lysis of muscle cells after vigorous exercise. It can cause many complications such as renal failure. It occurs most commonly in military personnel but also in civilians who have excessive excercise after work. Two cases of freshmen who had exertional rhabdomyolysis were reported to illustrate the potential risk of cheer-training. Appropriate measures should be arranged to prevent this condition. Diagnosis and treatment should be given promptly to prevent serious complications. PMID:12948279

Mahakkanukrauh, Ajanee; Sangchan, Apichat; Mootsikapun, Piroon



Severe rhabdomyolysis following massive ingestion of oolong tea: caffeine intoxication with coexisting hyponatremia.  


A 36-y-o patient with schizophrenia, who had consumed gradually increasing quantities of oolong tea that eventually reached 15 L each day, became delirious and was admitted to a psychiatric hospital. After abstinence from oolong tea his delirium resolved. He was transferred to our hospital when he was discovered to have acute renal failure with hyponatremia (118 mEq/L) and severe rhabdomyolysis (creatine phosphokinase, 227,200 IU/L). On admission rhabdomyolysis had begun to improve despite a worsening of the hyponatremia (113 mEq/L). With aggressive supportive therapy, including hypertonic saline administration and hemodialysis, the patient fully recovered without detectable sequelae. The clinical course suggests that caffeine, which is present in oolong tea, was mainly responsible for the rhabdomyolysis as well as the delirium, although severe hyponatremia has been reported to cause rhabdomyolysis on rare occasions. We hypothesize that caffeine toxicity injured the muscle cells, which were fragile due to the potassium depletion induced by the coexisting hyponatremia, to result in unusually severe rhabdomyolysis. The possibility of severe rhabdomyolysis should be considered in a patient with water intoxication due to massive ingestion of caffeine-containing beverages. PMID:10592946

Kamijo, Y; Soma, K; Asari, Y; Ohwada, T



Fatal rhabdomyolysis after acute sodium monensin (Rumensin) toxicity: case report.  


Myoglobinuria or rhabdomyolysis occurs when myoglobin escapes into the blood and then into the urine after acute muscle necrosis. It can be a serious medical condition leading to renal failure and death. There are many causes including exertion, crush syndromes, ischaemia, metabolic disorders, exogenous toxins and drugs, heat stroke and hereditary disorders such as malignant hyperthermia. We report the case of a 17 year-old boy who developed myoglobinuria, renal failure and death 11 days after ingesting sodium monensin, possibly with the intention of developing muscles. Sodium monensin, the active principle of Rumensin(R), is a dietary additive used as a growth promoter for confined cattle. There are no previous reports of human intoxication. Accidental or experimental sodium monensin intoxication in animals produces similar findings to those seen in this case. PMID:11588643

Kouyoumdjian, J A; Morita, M P; Sato, A K; Pissolatti, A F



Vitamin E and exertional rhabdomyolysis during endurance sled dog racing.  


Exertional rhabdomyolysis (ER) is common in sled dogs, animals with high energy expenditures that consume high fat (60% of ingested calories) diets. Associations between pre-race plasma [vitamin E] and total antioxidant status (TAS) and risk of developing ER were examined in dogs competing in the 1998 Iditarod race. Pre-race blood samples were collected from 750 dogs and a second sample was collected from 158 dogs withdrawn from the race at various times. Plasma creatine kinase activity was used to identify withdrawn dogs with ER. There was no association between pre-race plasma [vitamin E] and risk of development of ER. Dogs that developed ER started the race with higher TAS, but when withdrawn, had lower TAS than unaffected dogs and had similar pre-race [vitamin E] but higher [vitamin E] at time of withdrawal. Hence, the risk of ER in sled dogs is not affected by plasma [vitamin E] before the race. PMID:11297943

Piercy, R J; Hinchcliff, K W; Morley, P S; DiSilvestro, R A; Reinhart, G A; Nelson, S L; Schmidt, K E; Craig, A M



Acute Exertional Rhabdomyolysis and Triceps Compartment Syndrome During a High School Football Camp  

PubMed Central

Background: Acute exertional rhabdomyolysis has been infrequently reported among adolescents. In August 2010, several high school football players from one team developed rhabdomyolysis and triceps compartment syndrome following an upper arm exercise held in a non-air-conditioned wrestling room. Purpose: To confirm the diagnoses, characterize the spectrum of illnesses, and determine the factors contributing to rhabdomyolysis and triceps compartment syndromes. Study Design: Descriptive epidemiology study. Methods: The authors reviewed hospital medical records and interviewed players, coaches, school administrators, and hospital staff, using a standardized questionnaire that assessed symptoms, exposures, and activities. Results: Among 43 players, 22 (51%) experienced rhabdomyolysis (peak creatine kinase range, 2434-42 000 U/L): 22 patients had upper arm myalgia; 12 were hospitalized; 3 experienced triceps compartment syndrome; none experienced renal failure. Illnesses started 1 to 3 days after the triceps exercise. Forty players (93%) completed questionnaires. Among 19 players receiving at least 1 vote from a teammate as 1 of the 3 hardest working players, 13 (68%) experienced rhabdomyolysis versus 7 (33%) of 21 not considered hardest working (relative risk, 2.1; 95% confidence interval, 1.04-4.0). Of 40 players, 10 (25%) reported creatine supplement use, which was not associated with rhabdomyolysis. No player acknowledged use of alcohol, illicit drugs, or performance-enhancing drugs; results of performance-enhancing drug tests on the 4 players tested were negative. Environmental investigation did not identify additional factors contributing to illness. Conclusions: The upper arm exercise, possibly exacerbated by heat, led to rhabdomyolysis and compartment syndrome. Greater awareness of specific exercise hazards and prevention strategies can minimize risk for clinically significant muscle injury.

Oh, John Y.; Laidler, Matthew; Fiala, Steven C.; Hedberg, Katrina



Histopathological findings in horses with and without clinical signs of rhabdomyolysis with special reference to polysaccharide storage myopathy  

Microsoft Academic Search

Objective of the study was to assess histopathological changes in horses with a clinical history of exertional rhabdomyolysis (ER) with special reference to polysaccharide storage myopathy and to compare histopathological findings in horses with and without a clinical history of ER. In total 39 muscle samples were collected, from horses with a history of repeated episodes of exertional rhabdomyolysis (test

E. Ludvikova; I. D. Wijnberg; P. Fictum; Z. Lukas; J. H. van der Kolk; J. Hanak; P. Jahn


Rhabdomyolysis associated with fenofibrate monotherapy in a patient with chronic myelogenous leukemia.  


Rhabdomyolysis associated with fenofibrate monotherapy is extremely rare. Here, we report a rare case of rhabdomyolysis of the psoas muscle in an 82-year-old man with chronic myelogenous leukemia (CML). He was prescribed fenofibrate because of a hypertriglyceridemia. The patient reported generalized muscle pain and right abdominal pain while receiving fenofibrate monotherapy. An abdominal computed tomography scan and an abdominal ultrasound showed a large and low attenuation and high echogenicity, respectively, in the right middle abdominal area. Laboratory values included a serum creatine concentration of 4.1 mg/dl and a creatinine phosphokinase concentration of 5,882 IU/l. During laparotomy, a large hematoma and necrotic mass was identified in the right psoas muscle. Histological examination revealed that the resected specimens were of the psoas muscle with irregular fiber sizes, degenerating fibers surrounding the inflammatory reaction, and fiber necrosis that is typical for polymyositis. Based on these findings and the clinical history, a diagnosis of fenofibrate-induced rhabdomyolysis was made. To the best of our knowledge, no patient has ever been diagnosed with fulminant psoas rhabdomyolysis due to a fenofibrate monotherapy. This report details the rare case of rhabdomyolysis in a patient with CML associated with fenofibrate monotherapy and offers a review of the literature. PMID:21960954

Kato, Kazuya; Nagase, Astushi; Matsuda, Minoru; Kato, Yurina; Onodera, Kazuhiko; Kawakami, Takako; Higuchi, Mineko; Iwasaki, Yoshiaki; Taniguchi, Masahiko; Furukawa, Hiroyuki



Five factors contributing to severe rhabdomyolysis in a 21 yr old IV drug abuser: a case report.  


Rhabdomyolysis is a potentially life-threatening condition resulting from the release of large quantities of myocyte breakdown products into the circulation, following injury to striated muscles. There are several causes of rhabdomyolysis - traumatic and non-traumatic. We present a 21-year-old male intravenous drug abuser, who was referred to us with fever, altered sensorium and seizures. He developed severe rhabdomyolysis following a mixed meningeal infection by Streptococcus pneumoniae and Mycobacterium tuberculosis. This patient's examination and investigation suggested a combination of factors leading to the severe rhabdomyolysis which proved fatal. The patient's creatine phosphokinase was elevated to 167,000 U/L, following hyperpyrexia, seizures, meningitis (pneumococcal and tuberculous), pentazocine and alcohol abuse. The increase in mortality rate with the onset of rhabdomyolysis warrants immediate cessation of the insult and aggressive management. PMID:19829812

Ganeshram, Prasanthi; Goundan, Poorani Nallam; Jeyachandran, Vijay; Arthur, Preetham



Crayfish-related Haff disease rhabdomyolysis; diagnosis supported by bone scintigraphy.  


A number of people suffered rhabdomyolysis caused by eating crayfish in China and the final diagnosis was a rare disease called Haff disease. In this study, we present a 26 years old man with a history of severe muscular soreness for whole body after eating crayfish and this status lasted for about 3 months. Blood analysis showed significant increase in serum creatine kinase and lactate dehydrogenase. The pathology of left biceps brachii muscle revealed rhabdomyolysis. Technetium-99m-methylene diphosphonate ((99m)Tc-MDP) whole body bone scintigraphy showed increased uptake of nearly all muscles, especially those of proximal extremities. The diagnosis was Haff disease supported by histology and clinical characteristics. In conclusion, this case report shows that using bone imaging supports the diagnosis of Haff disease and locates the sites of rhabdomyolysis. PMID:23570026

Xie, Peng; Hu, Jing; Huang, Jian-Min; Liu, Xiao-Mei


[A case of rhabdomyolysis caused by saw palmetto of healthy foods].  


An 82-year-old man visited our hospital when he developed a fever of over 38 degrees C after having consumed 5 types of health foods. He had previously been treated for chronic obstructive pulmonary disease, hypertension and hyperuricemia. Blood examination on admission revealed renal dysfunction, marked elevation of C-reactive protein, and an elevated level of serum creatine kinase. According to the laboratory data and his clinical history, rhabdomyolysis complicated by acute renal failure was suspected, but his condition improved and his fever was reduced with fluid infusion. As a drug lymphocyte stimulation test was positive for only saw palmetto in the 5 health foods, we diagnosed the case as rhabdomyolysis induced by saw palmetto. We believe that this is the first case of a health food being the cause of rhabdomyolysis. PMID:22768426

Hanaka, Minako; Yoshii, Chiharu; Yatera, Kazuhiro; Ito, Chiyo; Chojin, Yasuo; Nagata, Shuya; Yamasaki, Kei; Nishida, Chinatsu; Kawanami, Toshinori; Kawanami, Yukiko; Ishimoto, Hiroshi; Mukae, Hiroshi



Rhabdomyolysis following Acute Extended-Release Quetiapine Poisoning: A Case Report  

PubMed Central

Background. During the past few years, there have been a number of case reports concerning rhabdomyolysis following quetiapine poisoning; however, there has been none concerning the medication in its extended-release form. Methods. We present the case report of a 48-year-old man presenting a major depressive disorder and borderline personality disorder, who after voluntary intoxication with 12000?mg of quetiapine extended-release developed signs of acute rhabdomyolysis. Results. The rhabdomyolysis was confirmed by the laboratory and the clinical findings, with elevated levels of creatinine, creatine phosphokinase, and CRP. Discussion. We would like to pinpoint the importance of this complication and our concern of prescribing it for psychiatric patients with chronic somatic comorbidities.

Liolios, Antonios; Sentissi, Othman



Rhabdomyolysis and acute renal failure following prolonged surgery in the lithotomy position.  


Operative positions commonly used in urogenital surgeries when perineal exposure is required include the lithotomy and the exaggerated lithotomy positions (LPs), which expose patients to the risk of rhabdomyolysis. We report a patient with bladder outflow obstruction, benign prostatic hypertrophy and a very large bladder stone, which was removed with cystoscopy and cystolitholapaxy in the LP. The procedure was complicated by posterior bladder perforation and abdominal distention leading to prolonged surgery duration (5.5 h). The patient developed rhabdomyolysis and acute renal failure (ARF) without compartmental syndrome. On the other hand, there was a potential role of glycine solution, used for bladder irrigation, in the appearance of ARF. Overall, our case shows that rhabdomyolysis and ARF can develop in operative positions, and duration of surgery is the most important risk factor for such complications. PMID:23538360

Guella, Adnane; Al Oraifi, Ibrahim



Rhabdomyolysis after neurosurgery: a review and a framework for prevention.  


Rhabdomyolysis (RM) is a potentially fatal or disabling clinical syndrome resulting in muscle necrosis and leakage of muscle constituents into the blood. Lactic acidosis and more serious complications such as acute renal failure may occur in up to half of recognized cases, so accurate diagnosis is required. We present three cases in which RM occurred in patients undergoing neurosurgical procedures performed in the lateral position. A review of the literature is provided together with a framework for the prevention of this surgical complication. Three patients underwent neurosurgical procedures in the lateral position for left facial/glossopharyngeal neuralgia, for jugular foramen tumor, and for a petroclival meningioma, respectively. All patients were obese and all three showed massive postoperative elevation in creatine kinase (CK) levels characteristic of RM. Myoglobinuria was identified in two patients and all three showed hyperintensity of the hip gird muscles in the short tau inversion recovery sequence magnetic resonance imaging. All recovered spontaneously and none went on to develop renal failure. A literature review showed that RM has been rarely reported after neurosurgery. However, the duration of procedures of the cases of reported RM indicates that the prevalence of the condition is likely highly under-recognized in neurosurgery. This is particularly important given the rising obesity rates seen in many countries. Obese patients undergoing long neurosurgical procedures, particularly in the lateral position, should be suspected of RM and should be closely monitored for CK levels, myoglobinuria, and acidosis. We outline a framework of strategies for the prevention of the condition. PMID:22940824

De Tommasi, Claudio; Cusimano, Michael D



Technetium-99m pyrophosphate imaging in acute renal failure associated with nontraumatic rhabdomyolysis  

SciTech Connect

Technetium-99m pyrophosphate (Tc-PYP) imaging was performed in five patients with acute renal failure associated with nontraumatic rhabdomyolysis. Four patients had phencyclidine intoxication and one had viral pneumonia. During the acute phase, marked uptake of pyrophosphate was seen in all patients in several muscle groups, but always in the thigh adductors. The results show that phencyclidine intoxication can result in diffuse muscle uptake of Tc-PYP without overt evidence of muscle injury. Tc-PYP imaging may provide a clue to the cause of acute renal failure in patients with suspected rhabdomyolysis in whom elevations of serum creatine phosphokinase concentrations are equivocal.

Patel, R.; Mishkin, F.S.



Rhabdomyolysis with acute renal failure triggered by the seasonal flu vaccination in a patient taking simvastatin.  


A man in his 70s presented with bilateral, painful legs and feeling generally unwell following the seasonal flu vaccination. The patient had a background of B cell lymphoma in partial remission. His current medications included simvastatin. Initial investigations revealed rhabdomyolysis and acute renal failure. He was admitted to critical care for renal replacement treatment. Other causes of rhabdomyolysis were excluded and expert opinion agreed that the most likely cause was the influenza vaccination with the concurrent use of simvastatin. The patient's renal function gradually normalised and after several months the patient has regained full power in his legs. PMID:22778082

Shah, S V; Reddy, K



Rhabdomyolysis with acute renal failure triggered by the seasonal flu vaccination in a patient taking simvastatin  

PubMed Central

A man in his 70s presented with bilateral, painful legs and feeling generally unwell following the seasonal flu vaccination. The patient had a background of B cell lymphoma in partial remission. His current medications included simvastatin. Initial investigations revealed rhabdomyolysis and acute renal failure. He was admitted to critical care for renal replacement treatment. Other causes of rhabdomyolysis were excluded and expert opinion agreed that the most likely cause was the influenza vaccination with the concurrent use of simvastatin. The patient's renal function gradually normalised and after several months the patient has regained full power in his legs.

Shah, S V; Reddy, K



Severe rhabdomyolysis and acute renal failure in an adolescent with hypothyroidism.  


Hypothyroidism has been reported rarely as the cause of rhabdomyolysis in adults and children. We present here a non-compliant adolescent with a diagnosis of hypothyroidism who developed rhabdomyolysis and acute renal failure with no additional predisposing factor. A 13-year-old girl with a previous history of hypothyroidism due to thyroid hypoplasia presented with generalized myalgia, malaise, vomiting, and oliguria lasting for three days. Neurological examination revealed bilateral marked weakness and tenderness of muscles of both lower and upper extremities. Urine had bloody appearance and urine analysis showed blood reaction with dipstick test, but there were no erythrocytes on microscopic examination. Serum creatine phosphokinase and myoglobin levels were elevated. Thyroid stimulating hormone (TSH) levels were high, and free thyroxine (T4) and triiodothyronine (T3) levels were low, compatible with uncontrolled hypothyroidism. Renal function tests showed acute renal failure. Other causes of rhabdomyolysis such as muscular trauma, drugs, toxins, infections, vigorous exercise, and electrolyte abnormalities were excluded. Hemodialysis was administered for 24 sessions. After L-thyroxine therapy, thyroid function tests normalized, muscle strength improved, serum muscle enzyme levels returned to normal levels, and renal function tests recovered. One must be aware that rhabdomyolysis may develop in a non-compliant patient with hypothyroidism. PMID:22272466

Comak, Elif; Koyun, Mustafa; Kiliçarslan-Akkaya, Bahar; Bircan, Iffet; Akman, Sema


A rare case of brucine poisoning complicated by rhabdomyolysis and acute renal failure.  


Brucine is the predominant alkaloid present in the bark of the tree Strychnos nux vomica and is a weaker alkaloid when compared to strychnine. However, its toxicological property is akin to strychnine. We report a rare case of brucine poisoning complicated by acute renal failure and rhabdomyolysis. A 24-year-old male presented with a history of consumption of a decoction made from the bark of the Strychnos nux vomica tree. Soon after, he developed widespread muscle spasms and convulsions, which were promptly treated. On the fifth day of admission, he developed features of rhabdomyolysis and acute renal failure. Investigations revealed elevated creatine phosphokinase levels and elevated blood urea and serum creatinine. The patient was managed with hemodialysis and recovered gradually. There are many reports of strychnine poisoning producing rhabdomyolysis and renal failure. In this case report, attention is drawn to the fact that brucine, although a weaker alkaloid, can also produce life threatening complications like rhabdomyolysis and acute renal failure. PMID:19694317

Naik, B Sadananda; Chakrapani, M



Rhabdomyolysis after the Administration of Itraconazole to an Asthmatic Patient with Bronchopulmonary Aspergillosis  

Microsoft Academic Search

It is known that the coadministration of itraconazole with cholesterol-lowering statins may induce muscle damage. We describe the case of a patient with steroid-dependent asthma, steroid-induced severe myopathy and allergic bronchopulmonary aspergillosis who developed rhabdomyolysis and acute renal failure following a ?6-week treatment with itraconazole, even without the concomitant use of HMG-CoA reductase inhibitors.

Marcello Ferrari; Ilaria Bodini; Vincenzo Lo Cascio



Exertional rhabdomyolysis: attrition through exercise, a case series and review of the literature.  


Rhabdomyolysis is a common syndrome that can range from asymptomatic to a severe life-threatening condition. It is the result of acute muscle fiber necrosis leading to cell lysis and subsequent transfer of those byproducts into the circulatory system.1-3 The most significant constituent of these byproducts is myoglobin, which has been known to cause renal failure in 10?50% of patients that develop rhabdomyolysis.4,5 In addition, the electrolytes contained within these cells are leached into the blood stream, which can lead to significant electrolyte abnormalities. The etiology of rhabdomyolysis is broad and includes inherited diseases, drugs, toxins, muscle compression or overexertion, infections, and more. This syndrome may carry a mortality rate ranging from 7?80%.3,6 We describe five patients assigned to various companies within 160th Special Operations Aviation Regiment (Airborne) that developed exertional rhabdomyolysis of the bilateral upper extremities between June 2011 and January 2012. In this case series we will describe the events leading up to the diagnosis, lack of risk factors or family history, diagnostic criteria, treatment, and future concerns related to the condition. PMID:23032321

Reese, Jason M; Fisher, Scott D; Robbins, David P



Exertional rhabdomyolysis: a clinical review with a focus on genetic influences.  


In this review, the clinical and laboratory features of exertional rhabdomyolysis (ER) are discussed in detail, emphasizing the full clinical spectrum from physiological elevations of serum creatine kinase after exertion to life-threatening rhabdomyolysis with acute kidney injury and associated systemic complications. Laboratory markers used to diagnose both ER and rhabdomyolysis are very sensitive, but not very specific, and imperfectly distinguish "subclinical" or asymptomatic from severe, life-threatening illness. However, genetic factors, both recognized and yet to be discovered, likely influence this diverse clinical spectrum of disease and response to exercise. Genetic mutations causative for McArdle disease, carnitine palmitoyl transferase deficiency 2, myoadenylate deaminase deficiency, and malignant hyperthermia have all been associated with ER. Polymorphic variations in the myosin light chain kinase, ?-actin 3, creatine kinase-muscle isoform, angiotensin I-converting enzyme, heat shock protein, and interleukin-6 genes have also been associated with either ER or exercise-induced serum creatine kinase elevations typical of ER. The prognosis for ER is significantly better than that for other etiologies of rhabdomyolysis, but the risk of recurrence after an initial episode is unknown. Guidelines for management are provided. PMID:22538307

Landau, Mark E; Kenney, Kimbra; Deuster, Patricia; Campbell, William



Rhabdomyolysis and acute encephalopathy in late onset medium chain acyl-CoA dehydrogenase deficiency  

Microsoft Academic Search

A previously asymptomatic 30 year old man presented with rhabdomyolysis, muscle weakness, and acute encephalopathy after strenuous exertion in the cold without adequate food intake. Serum and muscle carnitine concentrations were decreased. Urinary excretion of carnitine and glycine esters and biochemical examination of skeletal muscle and fibroblasts led to the diagnosis of medium chain acyl-CoA dehydrogenase (MCAD) deficiency. A point

W. Ruitenbeek; P. J. E. Poels; D. M. Turnbull; B. Garavaglia; R. A. Chalmers; R W Taylor; F. J. M. Gabreëls



Mutations in RYR1 are a common cause of exertional myalgia and rhabdomyolysis.  


Mutations in the skeletal muscle ryanodine receptor (RYR1) gene are a common cause of neuromuscular disease, ranging from various congenital myopathies to the malignant hyperthermia (MH) susceptibility trait without associated weakness. We sequenced RYR1 in 39 unrelated families with rhabdomyolysis and/or exertional myalgia, frequent presentations in the neuromuscular clinic that often remain unexplained despite extensive investigations. We identified 9 heterozygous RYR1 mutations/variants in 14 families, 5 of them (p.Lys1393Arg; p.Gly2434Arg; p.Thr4288_Ala4290dup; p.Ala4295Val; and p.Arg4737Gln) previously associated with MH. Index cases presented from 3 to 45 years with rhabdomyolysis, with or without exertional myalgia (n=12), or isolated exertional myalgia (n=2). Rhabdomyolysis was commonly triggered by exercise and heat and, less frequently, viral infections, alcohol and drugs. Most cases were normally strong and had no personal MH history. Inconsistent additional features included heat intolerance, and cold-induced muscle stiffness. Muscle biopsies showed mainly subtle changes. Familial RYR1 mutations were confirmed in relatives with similar or no symptoms. These findings suggest that RYR1 mutations may account for a substantial proportion of patients presenting with unexplained rhabdomyolysis and/or exertional myalgia. Associated clinico-pathological features may be subtle and require a high degree of suspicion. Additional family studies are paramount in order to identify potentially MH susceptible relatives. PMID:23628358

Dlamini, N; Voermans, N C; Lillis, S; Stewart, K; Kamsteeg, E-J; Drost, G; Quinlivan, R; Snoeck, M; Norwood, F; Radunovic, A; Straub, V; Roberts, M; Vrancken, A F J E; van der Pol, W L; de Coo, R I F M; Manzur, A Y; Yau, S; Abbs, S; King, A; Lammens, M; Hopkins, P M; Mohammed, S; Treves, S; Muntoni, F; Wraige, E; Davis, M R; van Engelen, B; Jungbluth, H



Biochemical and ultrastructural lung damage induced by rhabdomyolysis in the rat.  


Rhabdomyolysis-induced oxidative stress is associated with morphological and functional damage to the kidney and other organs, but applications of this model in the lung are still lacking. The aim of the present study was to determine the relationship between oxidative stress and the morphological changes occurring in the lungs of rats subjected to rhabdomyolysis. Rhabdomyolysis was induced by intramuscular glycerol injection (50% v/v, 10 ml/kg), and the control group was injected with saline vehicle. Arterial blood samples were drawn at 0, 2, 4, and 6 hrs for measurement of arterial gases, creatine kinase activity, and plasma free F2-isoprostane levels. Six hours later, the lungs were removed to determine the wet-to-dry weight ratio, reduced glutathione (GSH) and GSH disulfide (GSSG) levels, and activity of antioxidant enzymes (catalase [CAT], superoxide dismutase [SOD], and GSH peroxidase [GSH-Px]). Protein carbonylation and lipid peroxidation were assessed in the lungs by measurement of carbonyl and malondialdehyde (MDA) production, respectively. Bronchoalveolar lavage, cell counts, and lung ultrastructural studies were also performed. Six hours after glycerol injection, arterial PO2 and PCO2 were 23% and 38% lower, respectively, and plasma free F2-isoprostane levels were 72% higher, compared with control values. In lungs, protein carbonyl and MDA production were 58% and 12% higher, respectively; the GSH:GSSG ratio and GSH-Px activity were 43% and 60% lower, respectively; and activities of CAT and SOD showed no significant differences compared with controls. Rhabdomyolysis-induced ultrastructural impairment of the lung showed Type II cell damage, extracytoplasmic lamellar bodies and lack of tubular myelin reorganization, endothelial cellular edema, and no disruption of the alveolar-capillary barrier. These results provide evidence that rhabdomyolysis could induce tissue injury associated with increased oxidative stress, suggesting the contribution of oxidative stress to the pathogenic mechanism of acute lung injury. PMID:16946412

Rodrigo, Ramón; Trujillo, Sergio; Bosco, Cleofina



Exertional rhabdomyolysis in an adolescent athlete during preseason conditioning: a perfect storm.  


Cleary, MA, Sadowski, KA, Lee, SY-C, Miller, GL, and Nichols, AW. Exertional rhabdomyolysis in an adolescent athlete during preseason conditioning: a perfect storm. J Strength Cond Res 25(12): 3506-3513, 2011-The purpose of this brief review is to present a case of a healthy, male adolescent athlete (age = 16 years, body mass = 67.9 kg, height = 165.5 cm) who participated in a 3-day preseason wrestling camp which resulted in hospitalization for exertional rhabdomyolysis. As part of the preseason conditioning program directed by the coaches, the athlete completed 60 minutes of short, intense intervals of wall-sits, squats, sit-ups, push-ups, lunges, and plyometric jumps. The following day, the athlete continued his vigorous training consisting of running drills. That night he noticed voiding dark brown urine the color of cola. The day after the camp ended, the athlete reported to his Athletic Trainers with the chief complaint of severe bilateral leg pain in his quadriceps. Two days after the initial assessment, he was admitted to the hospital where he was diagnosed with exertional rhabdomyolysis based on creatine kinase (CK) levels that peaked at 146,000 IU·L, elevated far beyond normal (normal range = 58-280 IU·L). The athlete was hospitalized for 6 days where he received intravenous normal saline for rehydration, and his CK levels were assessed daily. Athletic Trainers, personal trainers, physical education teachers, and coaches should be aware that exertional rhabdomyolysis is the most common form of rhabdomyolysis and affects individuals who participate in novel and intense exercise to which they are unaccustomed. Stressful ambient conditions may lead to dehydration and exacerbation of the condition, particularly when the individual is not accustomed to the exercise intensity. PMID:22080315

Cleary, Michelle A; Sadowski, Kelsey A; Lee, Samuel Y-C; Miller, Gretchen L; Nichols, Andrew W



Rhabdomyolysis in a Healthy Peripheral Blood Stem Cell Donor following Mobilization with Filgrastim  

PubMed Central

Summary Background Although granulocyte colony stimulating factor (G-CSF) mobilization is generally well tolerated by healthy donors, there is also a wide spectrum of adverse events associated with it. Among these events, rhabdomyolysis in peripheral blood stem cell (PBSC) donors is very rare. In this paper, we present a first case of rhabdomyolysis after administration of filgrastim for PBSC mobilization. Case Report A 6-year-old donor received 10 ?g/kg/day filgrastim subcutaneously for 5 days. On the 3rd day of filgrastim, the donor complained of bone pain; a single dose of paracetamol (250 mg) was given to relieve pain. On the 4th day, she complained of bone pain, myalgia, and vomiting. On laboratory analysis, serum creatine phosphokinase was 1,095 U/l (40–226 U/l), LDH 312 U/l (100–190 U/l), aspartate aminotransferase 85 U/l (0–40 U/l), potassium 3.3 mmol/l (3.6–5.1 mmol/l). Urine myoglobin was 110 ng/ml (<5 ng/ml). Rhabdomyolysis was suspected on clinical and laboratory findings. Clinical manifestations regressed and the laboratory results returned to normal within three days after intravenously forced diuresis and potassium replacement. Stem cells were successfully harvested from peripheral blood on the 5th day of G-CSF therapy. Conclusion Rhabdomyolysis is a rare but important adverse effect of G-CSF. Allogeneic PBSC donors should be closely monitored with regard to rhabdomyolysis after G-CSF administration in the mobilization setting.

Hacioglu, Sibel; Altuntas, Fevzi; Kaynar, Leylagul; Sari, Ismail; Patiroglu, Turkan; Cetin, Mustafa



Diagnostic efficiency of selected biochemical variables to predict the clinical outcome of exertional rhabdomyolysis in Egyptian draft horses  

Microsoft Academic Search

As little is known about redox status in horses with rhabdomyolysis, the present study was carried out to evaluate the diagnostic\\u000a efficiency of oxidative stress markers as well as selected biochemical variables to predict the clinical outcome of exertional\\u000a rhabdomyolysis (ER) in Egyptian draft horses. ER was tentatively diagnosed based on the competent case history and physical\\u000a examination findings and

Maged R. El-Ashker


Renal tubular acidosis, hypokalemic paralysis, rhabdomyolysis, and acute renal failure--a rare presentation of Chinese herbal nephropathy.  


We encountered a 66-year-old Chinese man presented with hypokalemic paralysis, rhabdomyolysis and acute renal failure after administration of mixed Chinese herbs. Proximal renal tubular acidosis and selective glucosuria were the main tubular dysfunctions. The renal failure recovered smoothly and rapidly after resuscitation and the tubular function abnormalities regained spontaneously after medicine withdrawal. It should be recognized that renal tubular acidosis with hypokalemic paralysis, rhabdomyolysis and subsequent acute renal failure may develop after taking Chinese mixed herbal medicine. PMID:10088184

Lee, C T; Wu, M S; Lu, K; Hsu, K T



Single-dose-dexketoprofen-induced acute kidney injury due to massive rhabdomyolysis.  


A 70-year-old male patient was admitted complaining of weakness and pain in his arms and lower limbs. His serum creatine kinase and serum creatinine were markedly elevated (36,248 IU/L and 2.8 mg/dL, respectively). He had taken dexketoprofen trometamol because of a common cold, which had developed the previous night. Acute kidney injury caused by dexketoprofen-induced rhabdomyolysis was diagnosed by ruling out other possible causes, such as dermato/polymyositis, myxedema, brucellosis, and hepatitis. Dexketoprofen administration was stopped. As diuresis did not restore spontaneously, the patient was treated with I.V. alkaline solutions and mannitol. Hemodialysis was performed because of anuria and severe metabolic acidosis. The patient's renal function later recovered. In conclusion, dexketoprofen may be a potential risk factor for acute kidney injury and rhabdomyolysis. PMID:21553112

Sav, Tansu; Unal, Aydin; Erden, Abdulsamet; Gunal, Ali Ihsan



[Anesthetic management of a patient with carnitine palmitoyltransferase deficiency with a history of rhabdomyolysis].  


Carnitine palmitoyltransferase (CPT) makes the fatty acids available through beta-oxidation. Deficiency of CPT causes difficulties of muscle cells to metabolize fatty acid. In affected patients, exercise, fast for a prolonged period, and stress, lead to exhaustion of the store of glucose in the body, and rhabdomyolysis may occur, since muscle can not utilize fatty acid as an alternative energy source. Therefore, anesthetic management of CPT deficiency needs infusion of glucose continuously, avoiding the use of the drugs that cause rhabdomyolysis and suppressing the surgical stress. A 67-year-old man, who had previous history of rhabdmyolysis during the postoperative period, and diagnosed CPT deficiency was scheduled for total gastrectomy. General anesthesia was induced with remifentanil, thiamylal and rocuronium after epidural catheter insertion. During surgery, general anesthesia was maintained with remifentanil, sevoflurane, and blood glucose was monitored frequently, with continuous glucose infusion. No complications occurred during anesthesia and perioperative course was uneventful. PMID:23544345

Nakamura, Sayaka; Sugita, Michiko; Nakahara, Eriko; Yamamoto, Tatsuo



Rhabdomyolysis and acute renal failure in chronic alcoholics with myopathy, unrelated to acute alcohol ingestion.  


Rhabdomyolysis leading to acute renal failure necessitating hemodialysis is described in three chronic alcoholics. In each case an acute medical or surgical event, but not alcoholic intoxication, was implicated. Renal biopsies demonstrated acute tubular necrosis with intraluminal deposits consisting of Tamm-Horsfall protein and myoglobin. After recovery all three patients were demonstrated to have proximal muscle weakness with similar electromyographic abnormalities but nerve-conduction was impaired in only two. Muscle biopsies showed mixed, but predominantly type II fiber atrophy and reduced muscle phosphorylase levels. In the one patient tested the lactate response to forearm muscle ischemia was abnormal. It is postulated that chronic alcoholics may be predisposed to rhabdomyolysis and acute renal failure following acute medical and surgical stress as well as acute alcohol abuse. The muscle damage in these patients may be due to impaired intra cellular glycogen metabolism. PMID:6733997

Saltissi, D; Parfrey, P S; Curtis, J R; Gower, P E; Phillips, M E; Woodrow, D F; Valkova, B; Perkin, G D; Sethi, K D



Rhabdomyolysis, acute renal failure, and multiple focal neuropathies after drinking alcohol soaked with centipede.  


Many Chinese like to drink alcohol soaked with creatures for promoting health. This study reports a 49-year-old male who presented with multiple focal neuropathies of the upper limbs, coagulopathy, erythematous swelling of the bilateral upper extremities and trunk with bullous skin lesions, and rhabdomyolysis associated with acute renal failure after drinking alcohol soaked with centipede. Soaking a centipede, Scolopendra subspinipes mutilans, in 53% alcohol, produced the wine. Supportive treatment was administered, and the skin lesions and renal failure improved with subsequent neurologic deficit during the week following initial presentation. Alcohol binge or immobilization was the likely cause of neuropathy, bullous skin lesions and rhabdomyolysis in the patient. However, there is a possibility that centipede venom also contributed to the illness in this patient. PMID:15083930

Wang, I-Kuan; Hsu, Shih-Pin; Chi, Ching-Chi; Lee, Kam-Fai; Lin, Paul Yann; Chang, Hsueh-Wen; Chuang, Feng-Rong



Simvastatin-Induced Rhabdomyolysis in a Patient with Chronic Renal Failure  

Microsoft Academic Search

Simvastatin belongs to a class of lipid-lowering drugs which completely inhibit 3-hydroxy-3-methylglutaryl co-enzyme A (HMG CoA) reductase. The commonest adverse effects of therapy with simvastatin HMG CoA reductase inhibitors are gastro-intestinal disturbance, myositis and myopathy. Rhabdomyolysis leading to renal failure has been reported, but it appears to be very rare, except in patients also receiving cyclosporin, nicotinic acid or gemfibrozil.

Saad Al Shohaib



New onset diabetes complicated by haemolysis and rhabdomyolysis: a case report and review of the literature  

Microsoft Academic Search

INTRODUCTION: Previously undiagnosed glucose-6-phosphate dehydrogenase (G6PD) deficiency can be unmasked by a diabetic crisis and both can be associated with rhabdomyolysis. The relationship between diabetes and G6PD deficiency is discussed and the possible triggers for haemolysis as outlined in this case report. The incidence of G6PD deficiency is 10% in African-American males and up to 35% in parts of Africa

Clare M Galtrey; Rohan Pathansali



Short term treatment with clarithromycin resulting in colchicine-induced rhabdomyolysis.  


A case of colchicine-induced rhabdomyolysis is reported. A 48 year old African-American male with history of hypertension and chronic gout on colchicine 0.6 mg daily presented with symptoms of a community acquired pneumonia. The patient was started on 500 mg of clarithromycin orally twice daily and represented to the emergency room after 3 days complaining of severe muscle pain. His liver panel showed elevations in the serum aminotransferases; AST 513 mU/ml (nl 15-41) and ALT 182 mU/ml (nl 17-63). His complete blood count showed an elevated white blood cell count of 18,800/ml (nl 4,000-10,000/ml). Urine analysis was positive for myoglobin with no red cells present. Serum creatine kinase (CK) was 22,996 mU/ml (nl 31-221) with a normal troponin I 0.18 (nl <0.4).Investigations confirmed the presence of rhabdomyolysis and discontinuation of colchicine and clarithromycin resulted in resolution of clinical and biochemical features of rhabdomyolysis. By hospital day four, his muscle soreness had improved markedly. His serum CK improved to 3,389 mU/ml (nl 31-221 mU/ml) and serum creatinine improved to 1.5 mg/dl (nl 0.8-1.2). On hospital day five, the patient was discharged on oral anti-hypertensive medication and a ten-day course of doxycycline. Metabolism of colchicine by the cytochrome P450 3A4 system has been previously described, but this is the first published report of colchicine associated rhabdomyolysis secondary to drug metabolism interactions with an antibiotic. A review of medications that are metabolized via the cytochrome 3A4 and A-SLAVED-LIVER (Amiodarone, Simvastatin, Lovastatin, Atorvastatin, Verapamil, Erythromycin, Diltiazem, cLarithromycin, Itraconazole, Voriconazole, colchicinE, Ritonavir) pneumonic was established. PMID:19734738

McKinnell, James; Tayek, John A



Malignant lymphoma in skeletal muscle with rhabdomyolysis: a report of two cases  

Microsoft Academic Search

.  ?Malignant lymphoma is rarely found in skeletal muscle. In this article, we present two cases of malignant lymphomas that\\u000a were located in skeletal muscle and caused rhabdomyolysis. One case was a primary skeletal muscle lymphoma (which is quite\\u000a rare), and the other was a skeletal muscle metastasis of lymphoma. The patient with primary skeletal muscle lymphoma was diagnosed\\u000a with a

Satoru Masaoka; Tatsuo Fu



Novel single base pair COX III subunit deletion of mitochondrial DNA associated with rhabdomyolysis  

Microsoft Academic Search

A high number of cytochrome c oxidase (COX)-negative muscle fibres (approximately 45%) without ragged red fibres was found in a 27-year-old male patient with a single unprovoked episode of severe rhabdomyolysis. There was no family history of neuromuscular disorder and sequencing revealed a novel COX III single base pair deletion (MT-CO3{NC_012920.1}:m.[9559delC]).The deletion creates a frame shift and downstream termination codon

Rosetta Marotta; Judy Chin; Denise M. Kirby; Maria Chiotis; Mark Cook; Steven J. Collins



Acute kidney injury following hypokalemic rhabdomyolysis: complication of chronic heavy cola consumption in an adolescent boy  

Microsoft Academic Search

A 16-year-old boy presented with acute kidney injury (AKI) which was attributed to chronic heavy cola consumption. Habitual\\u000a heavy cola ingestion might lead to hypokalemic rhabdomyolysis by its glycyrrhizin content. AKI has been described rarely in\\u000a association with this clinical picture. It is important for physicians to keep heavy cola and other soft drink consumption\\u000a in mind as a cause

Belde Kasap; Alper Soylu; Benhur ?irvan Çetin; Seçil A. Çamlar; Mehmet A. Türkmen; Salih Kavukçu



Pasteurella multocida infective endocarditis in an immunocompetent patient complicated by rhabdomyolysis and permanent hearing loss  

PubMed Central

Pasteurella multocida is an inhabitant of the oral cavity of a variety of livestock and domestic pet species, especially cats and dogs. The case reported illustrates a 60-year-old, immunocompetent female patient who presented with P. multocida sepsis and aortic valve endocarditis. This required surgical bioprosthetic aortic valve replacement. Investigation also found infection-induced rhabdomyolysis and permanent hearing loss, both previously unassociated with P. multocida infection.

Mikaberidz, Nino; Li, Eric Y.; Taub, Cynthia C.



Acute kidney injury mediated by oxidative stress in Egyptian horses with exertional rhabdomyolysis  

Microsoft Academic Search

The present study was carried out to evaluate the role of oxidative stress in the pathophysiologic process of acute renal\\u000a failure associated with exertional rhabdomyolysis (ER) in Egyptian horses. ER was tentatively diagnosed in 31 Baladi horses\\u000a based on case history, physical examination findings and confirmed by elevation of plasma creatine kinase (CK) and urine myoglobin\\u000a concentrations. According to severity

Maged R. El-Ashker



Rhabdomyolysis and acute renal failure in a child with influenza A infection  

Microsoft Academic Search

.   A 13-year-old previously healthy girl developed rhabdomyolysis and acute renal failure during influenza A infection. The\\u000a patient recovered renal function completely with supportive therapy. This complication has been described in adult patients,\\u000a but progression to acute renal failure in this context has not been reported previously in children. This diagnosis should\\u000a be considered in the differential diagnosis of a

Katherine MacRae Dell; Seth L. Schulman



Therapeutic plasmapheresis and red blood cell exchange in a sickle cell trait patient with rhabdomyolysis.  


We report a case of a 16-year-old African-American male with sickle cell trait and a past medical history significant for asthma that was transferred to our hospital for management of respiratory failure. On the fourth day of hospitalization, the patient was found to have increased creatine kinase (CK) levels and urine myoglobin levels consistent with rhabdomyolysis. No clear etiology was identified. Aggressive standard hydration and urine alkalization were applied without response. On the sixth day of hospitalization, the patient underwent a 1-1.5 plasma volume therapeutic plasma exchange (TPE) resulting in a transient reduction of serum CK and myoglobin by 50%, which became elevated once again within 4 h. Since his clinical presentation resembles exertional rhabdomyolysis documented in patients with sickle cell trait, RBC exchange was performed. The patient tolerated the procedure without complications. In addition to his improved overall condition, the patient's post-exchange CK and serum myoglobin levels dropped dramatically without rebound. To our knowledge, this case represents the first reported case of TPE followed by RBC exchange in a SCT patient with rhabdomyolysis. PMID:22887576

Huang, Richard S P; Tholpady, Ashok; Wahed, Amer; Chang, Brian; Bai, Yu



Tubular von Hippel-Lindau Knockout Protects against Rhabdomyolysis-Induced AKI.  


Renal hypoxia occurs in AKI of various etiologies, but adaptation to hypoxia, mediated by hypoxia-inducible factor (HIF), is incomplete in these conditions. Preconditional HIF activation protects against renal ischemia-reperfusion injury, yet the mechanisms involved are largely unknown, and HIF-mediated renoprotection has not been examined in other causes of AKI. Here, we show that selective activation of HIF in renal tubules, through Pax8-rtTA-based inducible knockout of von Hippel-Lindau protein (VHL-KO), protects from rhabdomyolysis-induced AKI. In this model, HIF activation correlated inversely with tubular injury. Specifically, VHL deletion attenuated the increased levels of serum creatinine/urea, caspase-3 protein, and tubular necrosis induced by rhabdomyolysis in wild-type mice. Moreover, HIF activation in nephron segments at risk for injury occurred only in VHL-KO animals. At day 1 after rhabdomyolysis, when tubular injury may be reversible, the HIF-mediated renoprotection in VHL-KO mice was associated with activated glycolysis, cellular glucose uptake and utilization, autophagy, vasodilation, and proton removal, as demonstrated by quantitative PCR, pathway enrichment analysis, and immunohistochemistry. In conclusion, a HIF-mediated shift toward improved energy supply may protect against acute tubular injury in various forms of AKI. PMID:23970125

Fähling, Michael; Mathia, Susanne; Paliege, Alexander; Koesters, Robert; Mrowka, Ralf; Peters, Harm; Persson, Pontus Börje; Neumayer, Hans-Hellmut; Bachmann, Sebastian; Rosenberger, Christian



A 45-year-old female with hypokalemic rhabdomyolysis due to VIP-producing composite pheochromocytoma.  


The watery diarrhea, hypokalemia and achlorhydria (WHDA) syndrome due to vasoactive intestinal polypeptide (VIP)-producing extra-pancreatic tumors is rare. We report on a 45-year-old woman who suffered from persistent secretory diarrhea for six years and who was admitted to hospital with complaints of muscular weakness and myalgia. Biochemical testing revealed pronounced rhabdomyolysis due to severe hypokalemia. Gastrointestinal evaluation of long-standing diarrhea including endoscopy of the upper and lower gastrointestinal tract and the small intestine did not show any pathologies. An abdominal computed tomography scan revealed a mass of 4 × 5 cm in the left adrenal gland demonstrating a strong uptake in the 123I-labelled metaiodobenzylguanidine scintigraphy. Plasma levels of chromogranin A, calcitonin, parathormone, basal renin and most prominently VIP were increased in line with a increased 24 hour urinary secretion of noradrenaline, dopamine, normetanephrine and vanillymandelic acid. A WDHA (watery diarrhea, hypokalaemia, achlorhydria) syndrome with hypokalemic rhabdomyolysis due to a VIP-producing adrenal tumor was diagnosed that was removed surgically. The histological evaluation demonstrated a composite pheochromocytoma. Diarrhea stopped immediately after surgery together with a normalization of laboratory parameters. In conclusion, this case report focuses on the rare clinical presentation of secretory diarrhea and electrolyte disturbances in combination with hypokalemic rhabdomyolysis which was caused by a VIP-producing composite pheochromocytoma. PMID:22660994

Ende, K; Henkel, B; Brodhun, M; Salomon, C; Lauten, P; Conrad, E; Seifert, M; Stier, A; Scharf, J-G



A risk prediction score for kidney failure or mortality in rhabdomyolysis.  


IMPORTANCE Rhabdomyolysis ranges in severity from asymptomatic elevations in creatine phosphokinase levels to a life-threatening disorder characterized by severe acute kidney injury requiring hemodialysis or continuous renal replacement therapy (RRT). OBJECTIVE To develop a risk prediction tool to identify patients at greatest risk of RRT or in-hospital mortality. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of 2371 patients admitted between January 1, 2000, and March 31, 2011, to 2 large teaching hospitals in Boston, Massachusetts, with creatine phosphokinase levels in excess of 5000 U/L within 3 days of admission. The derivation cohort consisted of 1397 patients from Massachusetts General Hospital, and the validation cohort comprised 974 patients from Brigham and Women's Hospital. MAIN OUTCOMES AND MEASURES The composite of RRT or in-hospital mortality. RESULTS The causes and outcomes of rhabdomyolysis were similar between the derivation and validation cohorts. In total, the composite outcome occurred in 19.0% of patients (8.0% required RRT and 14.1% died during hospitalization). The highest rates of the composite outcome were from compartment syndrome (41.2%), sepsis (39.3%), and following cardiac arrest (58.5%). The lowest rates were from myositis (1.7%), exercise (3.2%), and seizures (6.0%). The independent predictors of the composite outcome were age, female sex, cause of rhabdomyolysis, and values of initial creatinine, creatine phosphokinase, phosphate, calcium, and bicarbonate. We developed a risk-prediction score from these variables in the derivation cohort and subsequently applied it in the validation cohort. The C statistic for the prediction model was 0.82 (95% CI, 0.80-0.85) in the derivation cohort and 0.83 (0.80-0.86) in the validation cohort. The Hosmer-Lemeshow P values were .14 and .28, respectively. In the validation cohort, among the patients with the lowest risk score (<5), 2.3% died or needed RRT. Among the patients with the highest risk score (>10), 61.2% died or needed RRT. CONCLUSIONS AND RELEVANCE Outcomes from rhabdomyolysis vary widely depending on the clinical context. The risk of RRT or in-hospital mortality in patients with rhabdomyolysis can be estimated using commonly available demographic, clinical, and laboratory variables on admission. PMID:24000014

McMahon, Gearoid M; Zeng, Xiaoxi; Waikar, Sushrut S



Dopamine-deficiency-enhanced hyperthermia and rhabdomyolysis during a heat wave in a metachromatic leucodystrophy heterozygote with metabolic myopathy.  


Whether a dopamine-deficiency syndrome in a Parkinson-syndrome (PS) may occur more easily during a heat wave than during more temperate climate conditions is unknown. We report a case that may suggest this. A 56 yo male with heterozygosity for metachromatic leucodystrophy and a history of metabolic myopathy, PS and diabetes experienced worsening of the PS during a heat wave. His condition further deteriorated upon reduction of ropinirol, resulting in hyperthermia, respiratory insufficiency, rhabdomyolysis, and severe thrombocytopenia. One month later he was alert but tetraplegic and required ventilatory support. Hyper-CK-emia returned to similar levels as before rhabdomyolysis. Reduction of dopamine agonists during a heat wave may induce a dopamine deficiency syndrome with hyperthermia, rhabdomyolysis and thrombocytopenia. PMID:22368973

Finsterer, Josef; Reining-Festa, Alice; Stollbergr, Claudia; Voigtlander, Till



Acute kidney injury mediated by oxidative stress in Egyptian horses with exertional rhabdomyolysis.  


The present study was carried out to evaluate the role of oxidative stress in the pathophysiologic process of acute renal failure associated with exertional rhabdomyolysis (ER) in Egyptian horses. ER was tentatively diagnosed in 31 Baladi horses based on case history, physical examination findings and confirmed by elevation of plasma creatine kinase (CK) and urine myoglobin concentrations. According to severity of the condition, the diseased horses were categorized into two main groups; the first group included 18 horses with minimal clinical signs and plasma CK <60 000 IU/L; whereas, the second group included 13 horses with overt clinical signs and plasma CK >100 000 IU/L). It was found that plasma creatol (CTL) was positively correlated (p?rhabdomyolysis in horses. It is suggested that exaggeration of oxidative stress associated with increased muscle membrane leakage plays a key role in acute kidney injury in Baladi horses with severe rhabdomyolysis. PMID:21461642

el-Ashker, Maged R



A fatal case of cutaneous adverse drug-induced toxic epidermal necrolysis associated with severe rhabdomyolysis.  


Toxic epidermal necrolysis represents an immunologic reaction to a foreign antigen and is most often caused by drugs. Atorvastatin, a blood cholesterol-lowering agent, is a recognized cause of rhabdomyolysis; while naproxen, a widely used nonsteroidal anti-inflammatory drug, is a known cause of photo-induced skin lesions. We report the first fatal case of drug-induced toxic epidermal necrolysis associated with severe muscle necrosis due to the use of a nonsteroidal anti-inflammatory drug and a statin with very high levels of creatine phosphokinase leading to acute kidney injury, disseminated intravascular coagulation, and complete skin necrosis leading to death. PMID:22588445

Noordally, Sheik Oaleed; Sohawon, Schoeb; Vanderhulst, Julien; Duttmann, Ruth; Corazza, Francis; Devriendt, Jacques


Severe acute rhabdomyolysis induced by multi-agent chemotherapy for alveolar rhabdomyosarcoma in a 15-year-old female: a case report.  


This is the first paper to report the association of cancer chemotherapy with rhabdomyolysis in children. A previously healthy, 15-year-old Japanese female was diagnosed as having alveolar rhabdomyosarcoma. She received the first cycle of multi-agent chemotherapy without any adverse effects. However, she developed severe acute rhabdomyolysis shortly after the second cycle of multi-agent chemotherapy, which consisted of etoposide, ifosfamide, actinomycin-D and vincristine. Her condition deteriorated rapidly and she was treated with mechanical ventilation and fluid replacement. After further evaluation, anticancer drugs were thought to be responsible for the rhabdomyolysis. PMID:24019778

Matsuzaki, Hiroshi; Koga, Yuhki; Suminoe, Aiko; Oba, Utako; Takimoto, Tomohito; Hara, Toshiro



Dengue Viral Myositis Complicated with Rhabdomyolysis and Superinfection of Methicillin-Resistant Staphylococcus aureus  

PubMed Central

Dengue is endemic in Sri Lanka and the physician should be aware of different and unusual presentation of the illness. Rhabdomyolysis is a well-known complication following many viral and bacterial infections; however, only a few cases have been reported with dengue viral infections. Further occurrence of coinfection by dengue and bacteria such as methicillin-resistant Staphylococcus aureus (MRSA) has been underestimated, and few reports have been published so far. This case describes a 17-year-old boy who presented with prolonged severe myalgia, dark red urine, and a febrile illness that was diagnosed as having dengue viral myositis, dark red urine, and a febrile illness that was diagnosed as having dengue viral myositis complicated with rhabdomyolysis and superinfection of MRSA. Despite intensive care management, he died due to multiorgan failure. Autopsy and serological studies confirmed the diagnosis. This case stresses that red-coloured urine in dengue patients is not always due to haematuria, and if a patient's vital signs do not respond to appropriate fluid management in DHF, sepsis from a secondary pathogen including MRSA should be suspected.

Kanapathipillai, Thirumavalavan; Edirisinghe, P. A. S.; Dassanayake, K. M. M. P.; Premawansa, I. H. G. S.



Improving effect of ethyl eicosapentanoate on statin-induced rhabdomyolysis in Eisai hyperbilirubinemic rats.  


The effect of ethyl eicosapentanoate (EPA-E) on statin-induced rhabdomyolysis was investigated by co-administration of EPA-E and pravastatin (PV), as a typical statin, to Eisai hyperbilirubinemic rats (EHBR). It was confirmed that the plasma PV concentration was not affected by simultaneous administration of EPA-E, and there was no cumulative increase of PV during prolonged co-administration of EPA-E and PV. Muscular degeneration was prominent (incidence 5/5; average grade 3.5 (range 2-4)) in EHBR treated with PV alone at 200 mg/kg/day for 14 days, but co-administration of EPA-E at doses of 100, 300, and 1000 mg/kg/day decreased the average grades to 1.4 (range 0.3-3.0), 0.5 (0.2-1.0), and 0.6 (0.0-1.7), respectively. Creatine phosphokinase (CPK) and myoglobin levels in plasma were well correlated with the grade of skeletal muscle degeneration. Thus, EPA-E appears to reduce the severity of statin-induced rhabdomyolysis. PMID:16364247

Naba, Hiroyasu; Kakinuma, Chihaya; Ohnishi, Shuhei; Ogihara, Takuo



[McArdle disease revealed by exercise intolerance associated with severe rhabdomyolysis].  


McArdle's disease (MAD) is a rare hereditary myopathy secondary to a deficit in myophosphorylase, an essential enzyme for the use of muscular glycogen reserves. Exercise intolerance to a variable degree is the fundamental manifestation. Muscular enzymes are usually normal or slightly elevated, except during episodes of rhabdomyolysis. Generally, the electromyogram has poor sensitivity for the diagnosis of exercise myopathies. The muscular biopsy can be misleadingly normal. The role of MRI in the diagnosis of MAD is not well clarified in the literature. We report the case of a 16-year-old patient, hospitalized in July 2008 for exercise intolerance. On admission, he was asymptomatic and the physical examination was non contributive. Serum creatine kinase levels and renal function measures were normal. Cycloergometer exercise testing unmasked the disease. EMG and muscular biopsies were normal. During the second hospitalization, this time for rhabdomyolysis, T2 weighted MRI of the thighs showed high intensity signals from the gracilis muscles. The control MRI, made after 2 weeks of rest, was normal. Right gracilis muscle biopsy demonstrated excess glycogen with myophosphorylase deficiency, establishing the diagnosis of MAD. MAD is a rare metabolic myopathy to consider in patients with a history of exercise intolerance. The muscle biopsy can be misleadingly normal and should be, to our opinion, be guided by MRI findings. PMID:19878922

Amezyane, T; El Kharras, A; Abouzahir, A; Fatihi, J; Bassou, D; Mahassin, F; Ghafir, D; Ohayon, V



Severe acute rhabdomyolysis associated with Streptococcus equi infection in four horses.  


Four Quarter Horses (9 months to 7 years of age) with submandibular lymphadenopathy and firm muscles (palpation of which elicited signs of pain) were evaluated; in general, the horses had a stiff gait, and 3 horses became recumbent. Streptococcus equi was cultured from aspirates of lymph nodes or samples of purulent material collected from the auditory tube diverticula. Once the horses were recumbent, their condition deteriorated rapidly despite aggressive antimicrobial and antiinflammatory treatment, necessitating euthanasia within 24 to 48 hours. One horse did not become recumbent and recovered completely. Among the 4 horses, common clinicopathologic findings included neutrophilia, hyperfibrinogenemia, and high serum activities of creatine kinase and aspartate aminotransferase. Necropsies of the 3 euthanatized horses revealed large, pale areas most prominent in the semimembranosus, semitendinosus, sublumbar, and gluteal muscles that were characterized histologically by severe acute myonecrosis and macrophage infiltration of necrotic myofibers. Streptococcus equi was identified in sections of affected muscle by use of immunofluorescent stains for Lancefield group C carbohydrate and S. equi M protein. In the 4 horses of this report, acute severe rhabdomyolysis without clinical evidence of muscle atrophy or infarction was associated with S. equi infection; rhabdomyolysis was attributed to either an inflammatory cascade resembling streptococcal toxic shock or potentially direct toxic effects of S. equi within muscle tissue. PMID:16342530

Sponseller, Beatrice T; Valberg, Stephanie J; Tennent-Brown, Brett S; Foreman, Jonathan H; Kumar, Pawan; Timoney, John F



Rhabdomyolysis after Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: A Case Report  

PubMed Central

Gastric cancer with peritoneal carcinomatosis is a disease with a poor prognosis. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal perioperative chemotherapy (HIPEC) can improve prognosis, although in most cases this should still be considered as a palliative treatment. Therefore, morbidity has to be avoided at all cost as quality of life is of utmost importance. We describe the case of a 64-year-old female with an adenocarcinoma of the stomach that was initially treated with a Billroth II gastrectomy, adjuvant chemotherapy and radiotherapy. During follow-up, the diagnosis of peritoneal carcinomatosis was made, and the patient was referred for CRS and HIPEC. Postoperatively, she developed rhabdomyolysis in both gastrocnemius muscles. Renal function remained within normal limits, but ultrasonography of the lower legs suggested the presence of bilateral abscesses. Drainage with pigtail catheters was necessary for more than 1 month, significantly impairing quality of life. The objective of this case report is to heighten awareness for this complication. Rhabdomyolysis is a rare complication of CRS and HIPEC, with a significant impact on quality of life. Prevention is necessary and can be achieved by adequate surgical positioning, using the altered lithotomy position, sufficient padding and by preventing hypovolemia.

Bielen, Rob; Verswijvel, Geert; Van der Speeten, Kurt



Severe rhabdomyolysis and acute renal failure secondary to use of simvastatin in undiagnosed hypothyroidism.  


A 52-year-old Indian woman with underlying diabetes mellitus and hyperlipidemia, presented with generalized musculoskeletal pain and oliguria for three days. The patient was taking 80 mg of simvastatin initiated 20 days earlier after cardiac catheterization for an inferior myocardial infarction. Laboratory investigations revealed the following serum levels: creatine kinase 81,620 U/L, aspartate aminotransferase 2497 U/L, alanine aminotransferase 1304 U/L, blood urea nitrogen 21.7 mmol/L, creatinine 447 micromol/L, Free T4 12.6 pmol/L, and thyroid stimulating hormone (TSH) 22.7 microIU/L. Simvastatin was discontinued and the patient received forced alkaline diuresis. Her hypothyroidism was treated with thyroxin, which was continued upon discharge, and her renal function recovered within two months. This case report discusses the incidence of rhabdomyolysis in a patient with primary hypothyroidism receiving large doses of simvastatin. PMID:19112232

Qari, Faiza A



Novel single base pair COX III subunit deletion of mitochondrial DNA associated with rhabdomyolysis.  


A high number of cytochrome c oxidase (COX)-negative muscle fibres (approximately 45%) without ragged red fibres was found in a 27-year-old male patient with a single unprovoked episode of severe rhabdomyolysis. There was no family history of neuromuscular disorder and sequencing revealed a novel COX III single base pair deletion (MT-CO3{NC_012920.1}:m.[9559delC]). The deletion creates a frame shift and downstream termination codon affecting the last 136 amino acids (MT-CO3{YP_003024032.1}:p.[Pro118GlnfsX124]). The heteroplasmic mutation load in muscle was approximately 58% and single COX-negative fibres harboured significantly greater levels of mutant mitochondrial DNA than COX-positive fibres. PMID:21163656

Marotta, Rosetta; Chin, Judy; Kirby, Denise M; Chiotis, Maria; Cook, Mark; Collins, Steven J



Equine biochemical multiple acyl-CoA dehydrogenase deficiency (MADD) as a cause of rhabdomyolysis.  


Two horses (a 7-year-old Groninger warmblood gelding and a six-month-old Trakehner mare) with pathologically confirmed rhabdomyolysis were diagnosed as suffering from multiple acyl-CoA dehydrogenase deficiency (MADD). This disorder has not been recognised in animals before. Clinical signs of both horses were a stiff, insecure gait, myoglobinuria, and finally recumbency. Urine, plasma, and muscle tissues were investigated. Analysis of plasma showed hyperglycemia, lactic acidemia, increased activity of muscle enzymes (ASAT, LDH, CK), and impaired kidney function (increased urea and creatinine). The most remarkable findings of organic acids in urine of both horses were increased lactic acid, ethylmalonic acid (EMA), 2-methylsuccinic acid, butyrylglycine (iso)valerylglycine, and hexanoylglycine. EMA was also increased in plasma of both animals. Furthermore, the profile of acylcarnitines in plasma from both animals showed a substantial elevation of C4-, C5-, C6-, C8-, and C5-DC-carnitine. Concentrations of acylcarnitines in urine of both animals revealed increased excretions of C2-, C3-, C4-, C5-, C6-, C5-OH-, C8-, C10:1-, C10-, and C5-DC-carnitine. In addition, concentrations of free carnitine were also increased. Quantitative biochemical measurement of enzyme activities in muscle tissue showed deficiencies of short-chain acyl-CoA dehydrogenase (SCAD), medium-chain acyl-CoA dehydrogenase (MCAD), and isovaleryl-CoA dehydrogenase (IVD) also indicating MADD. Histology revealed extensive rhabdomyolysis with microvesicular lipidosis predominantly in type 1 muscle fibers and mitochondrial damage. However, the ETF and ETF-QO activities were within normal limits indicating the metabolic disorder to be acquired rather than inherited. To our knowledge, these are the first cases of biochemical MADD reported in equine medicine. PMID:17540595

Westermann, C M; de Sain-van der Velden, M G M; van der Kolk, J H; Berger, R; Wijnberg, I D; Koeman, J P; Wanders, R J A; Lenstra, J A; Testerink, N; Vaandrager, A B; Vianey-Saban, C; Acquaviva-Bourdain, C; Dorland, L



Severe Rhabdomyolysis Associated With Concurrent Use of Simvastatin and Sirolimus After Cisplatin-Based Chemotherapy in a Kidney Transplant Recipient.  


Objectives: Cardiovascular disease is the most common cause of sickness and death for long-term kidney transplant recipients, and dyslipidemia is an important risk factor for developing cardiovascular disease. Lipid-lowering strategies, with the use of statins, have been shown to reduce the cardiovascular risks related to dyslipidemia, but concomitant use of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors and immunosuppressive agents may increase the risk of rhabdomyolysis owing to a drug-drug interaction. We report a case of simvastatin-induced rhabdomyolysis and acute kidney injury triggered by addition of sirolimus and cisplatin-based chemotherapy to a kidney transplant recipient who had previously tolerated chronic statin therapy. PMID:23734754

Hong, Yu Ah; Kim, Hyung Duk; Jo, Kwanhoon; Park, Yun Kyung; Lee, Jonghoon; Sun, In O; Chung, Byung Ha; Park, Cheol Whee; Yang, Chul Woo; Choi, Bum Soon



Massive Postoperative Rhabdomyolysis Following Combined CABG\\/Abdominal Aortic Replacement: A Possible Association With HMG-CoA Reductase Inhibitors  

Microsoft Academic Search

Objective. The beneficial effects of the treatment of hyperlipidemia in the secondary prevention of ischemic heart disease are well established. Pravastatin is a 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductase inhibitor often prescribed for the treatment of hypercholesterolemia. Occasional side effects include increased creatine kinase levels and myalgias worsened by exertion, rarely presenting with severe myopathy and rhabdomyolysis resulting in myoglobinuria

Mathias Wilhelmi; Michael Winterhalter; Stefan Fischer; Thorsten Walles; Janusz Zuk; Martin Strüber; Axel Haverich



Rhabdomyolysis of Gluteal Muscles Leading to Renal Failure: A Potentially Fatal Complication of Surgery in the Morbidly Obese  

Microsoft Academic Search

Background: Rhabdomyolysis is a well-known cause of renal failure and is most commonly caused by ischemia\\/reperfusion or crush\\u000a injury. We describe a new cause of this syndrome in a series of 6 patients who underwent necrosis of the gluteal muscles after\\u000a bariatric surgery, 3 of whom eventually died of renal failure. Methods: Potential etiologic factors were studied by comparing\\u000a these

David Bostanjian; Gary J. Anthone; Nahid Hamoui; Peter F. Crookes



Molsidomine, a nitric oxide donor and l-arginine protects against rhabdomyolysis-induced myoglobinuric acute renal failure  

Microsoft Academic Search

Rhabdomyolysis-induced myoglobinuric acute renal failure accounts for about 10–40% of all cases of acute renal failure (ARF). Nitric oxide and reactive oxygen intermediates play a crucial role in the pathogenesis of myoglobinuric acute renal failure (ARF). This study was designed to investigate the effect of molsidomine and l-arginine in glycerol induced ARF in rats. Six groups of rats were employed

Vikas Chander; Kanwaljit Chopra



Performance of serum and dried blood spot acylcarnitine profiles for detection of fatty acid ?-oxidation disorders in adult patients with rhabdomyolysis.  


BACKGROUND: Plasma/serum and dried blood spot (DBS) acylcarnitine profiles (ACPs) are key to the diagnosis of mitochondrial fatty acid ?-oxidation disorders (FAODs). Despite their significant clinical applications, limited published data exists to compare their sensitivities and specificities. We retrospectively evaluated these two methods in adult patients with a history of rhabdomyolysis; investigated for an underlying FAOD. METHODS: A retrospective study was completed for adult patients (investigated between 2003 and 2011) meeting the inclusion criteria of a history of recurrent rhabdomyolysis or one episode of rhabdomyolysis with a history of exercise intolerance. All subjects underwent investigations for an underlying FAOD including DBS and serum ACP analysis concurrently collected during a symptom-free period, and skin biopsy for cultured fibroblast fatty acid oxidation studies or enzyme activity measurement, as indicated, with or without molecular confirmation. Their medical records were reviewed, and the performance of the two methods were compared. RESULTS: Seven out of 31 subjects (22.6 %) were diagnosed with an underlying FAOD. Long chain acylcarnitines were more markedly elevated in serum samples from confirmed CPTII cases (n?=?4) as compared to matched DBS profiles. The sensitivity and specificity of DBS ACP was 71.4 % (95 % CI, 0.30-0.95) and 100 % (95 % CI, 0.79-1.00), respectively, compared to a sensitivity of 100 % (95 % CI, 0.56-1.00) and a specificity of 94.7 % (95 % CI, 0.72-1.00) for serum ACP. CONCLUSION: FAODs appear to be a common cause of recurrent rhabdomyolysis or rhabdomyolysis with a history of exercise induced myalgia. At least historically, FAODs maybe underdiagnosed in adults with rhabdomyolysis. This study suggests that serum ACP might be more sensitive than DBS ACP for detection of an underlying FAOD in adults with rhabdomyolysis while asymptomatic. PMID:23296367

Al-Thihli, Khalid; Sinclair, Graham; Sirrs, Sandra; Mezei, Michelle; Nelson, Judie; Vallance, Hilary



Exertional Rhabdomyolysis in a Collegiate American Football Player After Preventive Cold-Water Immersion: A Case Report  

PubMed Central

Objective: To describe a case of exertional rhabdomyolysis in a collegiate American football player after preventive cold-water immersion. Background: A healthy man (19 years old) participated in full-contact football practice followed by conditioning (2.5 hours). After practice, he entered a coach-mandated post-practice cold-water immersion and had no signs of heat illness before developing leg cramps, for which he presented to the athletic training staff. After 10 minutes of repeated stretching, massage, and replacement of electrolyte-filled fluids, he was transported to the emergency room. Laboratory tests indicated a creatine kinase (CK) level of 2545 IU/L (normal range, 45–260 IU/L), CK-myoglobin fraction of 8.5 ng/mL (normal < 6.7 ng/mL), and CK-myoglobin relative index of 30% (normal range, 25%– 30%). Myoglobin was measured at 499 ng/mL (normal = 80 ng/mL). The attending physician treated the athlete with intravenous fluids. Differential Diagnosis: Exercise-associated muscle cramps, dehydration, exertional rhabdomyolysis. Treatment: The patient was treated with rest and rehydration. One week after the incident, he began biking and swimming. Eighteen days later, the patient continued to demonstrate elevated CK levels (527 IU/L) but described no other symptoms and was allowed to return to football practice as tolerated. Two months after the incident, his CK level remained high (1900 IU/L). Uniqueness: The athlete demonstrated no signs of heat illness upon entering the cold-water immersion but experienced severe leg cramping after immersion, resulting in a diagnosis of exertional rhabdomyolysis. Previously described cases have not linked cold-water immersion with the pathogenesis of rhabdomyolysis. Conclusions: In this football player, CK levels appeared to be a poor indicator of rhabdomyolysis. Our patient demonstrated no other signs of the illness weeks after the incident, yet his elevated CK levels persisted. Cold-water immersion immediately after exercise should be monitored by the athletic training staff and may not be appropriate to prevent muscle damage, given the lack of supporting evidence.

Kahanov, Leamor; Eberman, Lindsey E.; Wasik, Mitchell; Alvey, Thurman



Facilitating adverse drug event detection in pharmacovigilance databases using molecular structure similarity: application to rhabdomyolysis  

PubMed Central

Background Adverse drug events (ADE) cause considerable harm to patients, and consequently their detection is critical for patient safety. The US Food and Drug Administration maintains an adverse event reporting system (AERS) to facilitate the detection of ADE in drugs. Various data mining approaches have been developed that use AERS to detect signals identifying associations between drugs and ADE. The signals must then be monitored further by domain experts, which is a time-consuming task. Objective To develop a new methodology that combines existing data mining algorithms with chemical information by analysis of molecular fingerprints to enhance initial ADE signals generated from AERS, and to provide a decision support mechanism to facilitate the identification of novel adverse events. Results The method achieved a significant improvement in precision in identifying known ADE, and a more than twofold signal enhancement when applied to the ADE rhabdomyolysis. The simplicity of the method assists in highlighting the etiology of the ADE by identifying structurally similar drugs. A set of drugs with strong evidence from both AERS and molecular fingerprint-based modeling is constructed for further analysis. Conclusion The results demonstrate that the proposed methodology could be used as a pharmacovigilance decision support tool to facilitate ADE detection.

Vilar, Santiago; Harpaz, Rave; Chase, Herbert S; Costanzi, Stefano; Rabadan, Raul



Acute Liver Impairment in a Young, Healthy Athlete: Hypoxic Hepatitis and Rhabdomyolysis following Heat Stroke  

PubMed Central

Any process that substantially diminishes arterial blood flow or arterial oxygen content to the liver can result in hypoxic (ischaemic) hepatitis. 90% of hypoxic hepatitis occurs in unstable patients in intensive care units with haemodynamic failure secondary to heart failure, respiratory failure and toxic shock. The rate of in-hospital mortality in hypoxic hepatitis is very high with studies recording mortalities of 61.5%. It tends to be very uncommon in healthy, young patients with no underlying medical problems. We report here the case of a young healthy athlete who developed heat stroke associated with rhabdomyolysis and hypoxic hepatitis while he was running the final stages of a marathon. The patient required intensive care admission and inotropic support for a few hours after he was admitted with heat stroke. He underwent a rapid recovery after he was resuscitated with fluids. N-acetyl cysteine was also given during the acute stage of the hepatitis. This case highlights an uncommon case of hypoxic hepatitis in a young, healthy patient secondary to hypotension and heat stroke. Inotropic support might have precipitated the hypoxic hepatitis in this young patient.

Azzopardi, Neville; Chetcuti, Stephania; Sant, Jessica; Pocock, James



Genetic mapping of recurrent exertional rhabdomyolysis in a population of North American Thoroughbreds.  


Recurrent exertional rhabdomyolysis is a heritable disorder that results in painful skeletal muscle cramping with exercise in up to 10% of all Thoroughbred racehorses. Here, we report a genome-wide association study with 48 282 SNPs analyzed among 48 case and 37 control Thoroughbreds. The most significant SNPs spanned approximately 13 Mb on ECA16, and the P-value of the most significant SNP after correcting for population structure was 8.0 × 10(-6) . This region on ECA16 was further evaluated by genotyping 247 SNPs in both the initial population and a second population of 34 case and 98 control Thoroughbreds. Several SNPs across the 13-Mb region on ECA16 showed significance when each population was analyzed separately; however, the exact positions of the most significant SNPs within this region on ECA16 varied between populations. This variability in location may be attributed to lack of power owing to insufficient sample sizes within each population individually, or to the relative distribution of long, conserved haplotypes, characteristic of the Thoroughbred breed. Future genome-wide association studies with additional horses would likely improve the power to resolve casual loci located on ECA16 and increase the likelihood of detecting any additional loci on other chromosomes contributing to disease susceptibility. PMID:22497487

Fritz, K L; McCue, M E; Valberg, S J; Rendahl, A K; Mickelson, J R



A patient who experienced thyroid storm complicated by rhabdomyolysis, deep vein thrombosis, and a silent pulmonary embolism: a case report.  


BACKGROUND: Thyroid storm is a serious condition of thyrotoxicosis. Hyperthyroidism often presents with thrombotic events, especially at cerebral sites; however, the possible association between a lower extremity deep vein thrombosis (LEDVT) and thyroid storm has not been previously reported. We encountered a patient who developed thyroid storm, associated with rhabdomyolysis, followed by LEDVT and a small silent pulmonary embolism (PE). The case is discussed with references to the pertinent literature. CASE PRESENTATION: A 50-year-old woman with no past medical history was referred to our hospital because of severe diarrhea, muscle weakness in her lower limbs (manual muscle testing: MMT 3), and disturbances of consciousness. She was diagnosed as having Graves' disease based on the presence of struma, exophthalmos, and hyperthyroidism with TSH receptor antibody positivity; we further determined that the patient was experiencing thyroid storm based on the results of the Burch-Wartofsky scoring system and a Japanese diagnostic criteria. Treatment with steroids, iodine potassium, methimazole, and propranolol was initiated. Severe watery diarrhea continued, and the laboratory data revealed hypokalemia (2.0 meq/L). On day 14, a blood analysis showed a sudden elevation in her creatinine kinase (CK) level, leading to a diagnosis of rhabdomyolysis. Thereafter, the muscle weakness in her lower limbs advanced to a degree of MMT 1. Seven days after the diagnosis of rhabdomyolysis, pitting edema began to appear in bilateral lower extremities. Contrast-enhanced CT scans revealed a LEDVT involving the left common iliac vein, bilateral femoral veins, and left popliteal vein. Furthermore, a small PE was identified. Hyperthyroidism often presents with thrombotic events, especially at cerebral sites, but few reports of PE or LEDVT have been made. CONCLUSION: This case suggests that the occurrence of thyroid storm may be associated with a risk of LEDVT and/or PE. We suggest that DVT preventive measures are undertaken, and that a lower limb venous echo or contrast-enhanced CT examination would be considered if LEDVT is suspected. PMID:23687997

Umezu, Taro; Ashitani, Keigo; Toda, Takahiro; Yanagawa, Tatsuo



A patient who experienced thyroid storm complicated by rhabdomyolysis, deep vein thrombosis, and a silent pulmonary embolism: a case report  

PubMed Central

Background Thyroid storm is a serious condition of thyrotoxicosis. Hyperthyroidism often presents with thrombotic events, especially at cerebral sites; however, the possible association between a lower extremity deep vein thrombosis (LEDVT) and thyroid storm has not been previously reported. We encountered a patient who developed thyroid storm, associated with rhabdomyolysis, followed by LEDVT and a small silent pulmonary embolism (PE). The case is discussed with references to the pertinent literature. Case presentation A 50-year-old woman with no past medical history was referred to our hospital because of severe diarrhea, muscle weakness in her lower limbs (manual muscle testing: MMT 3), and disturbances of consciousness. She was diagnosed as having Graves’ disease based on the presence of struma, exophthalmos, and hyperthyroidism with TSH receptor antibody positivity; we further determined that the patient was experiencing thyroid storm based on the results of the Burch-Wartofsky scoring system and a Japanese diagnostic criteria. Treatment with steroids, iodine potassium, methimazole, and propranolol was initiated. Severe watery diarrhea continued, and the laboratory data revealed hypokalemia (2.0 meq/L). On day 14, a blood analysis showed a sudden elevation in her creatinine kinase (CK) level, leading to a diagnosis of rhabdomyolysis. Thereafter, the muscle weakness in her lower limbs advanced to a degree of MMT 1. Seven days after the diagnosis of rhabdomyolysis, pitting edema began to appear in bilateral lower extremities. Contrast-enhanced CT scans revealed a LEDVT involving the left common iliac vein, bilateral femoral veins, and left popliteal vein. Furthermore, a small PE was identified. Hyperthyroidism often presents with thrombotic events, especially at cerebral sites, but few reports of PE or LEDVT have been made. Conclusion This case suggests that the occurrence of thyroid storm may be associated with a risk of LEDVT and/or PE. We suggest that DVT preventive measures are undertaken, and that a lower limb venous echo or contrast-enhanced CT examination would be considered if LEDVT is suspected.



Rhabdomyolysis in a Prostate Cancer Patient Taking Ketoconazole and Simvastatin: Case Report and Review of the Literature (February).  


OBJECTIVE: To report a case of severe rhabdomyolysis resulting in acute renal failure caused by an interaction between ketoconazole and simvastatin in a patient with prostate cancer. CASE SUMMARY: A 64-year-old man who received ketoconazole for prostate cancer, along with simvastatin and fenofibrate for dyslipidemia, presented to our ambulatory clinic with complaints of blood in his urine and weakness following an increase in his ketoconazole dose. Two days after presentation, the patient was admitted with rhabdomyolysis and acute renal failure, as evidenced by elevatedvserum creatine kinase (>32,000 IU/L), serum myoglobin (20.6 ng/mL), and serum creatinine (4.2 mg/dL) as well as abnormal bone scintigraphy findings. Ketoconazole, fenofibrate, and simvastatin were discontinued. Renal function did not normalize with hydration, and intermittent hemodialysis was initiated; 10 days of hemodialysis resulted in normalization of electrolytes and creatine kinase. Symptom improvement and normalization of laboratory parameters were observed after prolonged hospitalization (24 days). DISCUSSION: Prostate cancer is the most common malignancy among men in the US. Androgen deprivation therapy is the standard initial treatment for biochemical recurrence or metastatic disease. Most patients experience progression to a castrate-resistant disease state, requiring the use of additional therapies. Ketoconazole is considered a secondary hormonal treatment option. We describe an interaction in a patient with prostate cancer between a 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor and ketoconazole resulting in rhabdomyolysis, requiring hemodialysis. An objective causality assessment using the Horn Drug Interaction Probability Scale revealed that the adverse drug reaction was a possible result of the interaction. CONCLUSIONS: The temporal fashion in which the episode occurred suggests that a possible simvastatin-ketoconazole interaction precipitated rhabdomyolysis in this patient. The use of ketoconazole for castrate-resistant prostate cancer can lead to drug-drug interactions in patients taking simvastatin or other HMG-CoA reductase inhibitors. Clinicians should be aware of this severe adverse event and take steps to minimize its occurrence. PMID:21304039

Watkins, Jack L; Atkinson, Bradley J; Pagliaro, Lance C



Acute heroin intoxication with complications of acute pulmonary edema, acute renal failure, rhabdomyolysis and lumbosacral plexitis: a case report.  


After intravenous injection of heroin, a 27-year-old male with altered mental status and hypotension was seen at the Emergency Service where acute pulmonary edema was noted. The problem was resolved three days later after oxygen therapy had been administered by face mask. Acute renal failure, rhabdomyolysis and monoplegia of the patient's left leg were exhibited during his stay at the Intensive Care Unit. Neurological examination and electro-diagnostic studies (electromyography and nerve conduction velocity) showed left lumbosacral plexitis. Hemodialysis was given. Though the patient's hospital course was uneventful, satisfactory recovery from his left leg weakness, which persisted for one year after hospital discharge, was finally achieved. PMID:7641126

Chan, P; Lin, T H; Luo, J P; Deng, J F



Severe falciparum malaria with dengue coinfection complicated by rhabdomyolysis and acute kidney injury: an unusual case with myoglobinemia, myoglobinuria but normal serum creatine kinase  

PubMed Central

Background Acute kidney injury (AKI) is a complication of severe malaria, and rhabdomyolysis with myoglobinuria is an uncommon cause. We report an unusual case of severe falciparum malaria with dengue coinfection complicated by AKI due to myoglobinemia and myoglobinuria while maintaining a normal creatine kinase (CK). Case presentation A 49-year old Indonesian man presented with fever, chills, and rigors with generalized myalgia and was diagnosed with falciparum malaria based on a positive blood smear. This was complicated by rhabdomyolysis with raised serum and urine myoglobin but normal CK. Despite rapid clearance of the parasitemia with intravenous artesunate and aggressive hydration maintaining good urine output, his myoglobinuria and acidosis worsened, progressing to uremia requiring renal replacement therapy. High-flux hemodiafiltration effectively cleared his serum and urine myoglobin with recovery of renal function. Further evaluation revealed evidence of dengue coinfection and past infection with murine typhus. Conclusion In patients with severe falciparum malaria, the absence of raised CK alone does not exclude a diagnosis of rhabdomyolysis. Raised serum and urine myoglobin levels could lead to AKI and should be monitored. In the event of myoglobin-induced AKI requiring dialysis, clinicians may consider using high-flux hemodiafiltration instead of conventional hemodialysis for more effective myoglobin removal. In Southeast Asia, potential endemic coinfections that can also cause or worsen rhabdomyolysis, such as dengue, rickettsiosis and leptospirosis, should be considered.



Typhoid rhabdomyolysis with acute renal failure and acute pancreatitis: a case report and review of the literature.  


We report a case of typhoid rhabdomyolysis with acute renal failure and acute pancreatitis in a 23-year-old Vietnamese male who was admitted to the intensive care unit with a 15-day history of fever followed by severe abdominal pain. On examination, the patient was febrile and his abdomen was diffusely tender. Serum creatinine was 533 micromol/L, pancreatic amylase 1800 U/L and lipase 900 U/L; the myoglobin blood level was high, which is associated with significant myoglobinuria. Blood, urine and stool culture yielded Salmonella enterica serovar typhi, which was sensitive to ceftriaxon, ampicillin and ciprofloxacin. Ceftriaxon was initiated for a total of 14 days. Subsequently, the patient maintained a good urine output with improved renal parameters and accordingly was discharged. In this report, we review the literature and discuss the pathogenesis of the disease thoroughly. PMID:19147385

Khan, Fahmi Yousef; Al-Ani, Ahmed; Ali, Hamda Abdulla



Salmonella myocarditis in a young adult patient presenting with acute pulmonary edema, rhabdomyolysis, and multi-organ failure.  


The mortality and morbidity of salmonella infections is seriously underestimated. Salmonella myocarditis is an unusual complication of salmonella sepsis in adults. Cases that do occur may be associated with high morbidity and mortality. We present a rare case of salmonella myocarditis with multi-organ failure in a previously healthy young adult man who was brought to the emergency room with fever, diarrhea, shortness of breath, and altered sensorium, discovered to have acute pulmonary edema and respiratory compromise for which he was assisted with mechanical ventilation for 8 days. Blood culture grew Salmonella typhi. Biochemically he exhibited myocardial, hepatic, and muscular enzymatic surge with renal failure, features of rhabdomyolysis, and disseminated intravascular coagulation. The patient showed a progressive improvement on treatment with ceftriaxone for 2 weeks in addition to decongestive therapy. He was discharged in good condition afterward. PMID:19944325

Al-aqeedi, Rafid Fayadh; Kamha, Ahmed; Al-aani, Fuad K; Al-ani, Ahmed A



Statin-induced myotoxicity: pharmacokinetic differences among statins and the risk of rhabdomyolysis, with particular reference to pitavastatin.  


3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) are the most widely prescribed therapeutic class of drugs worldwide, with established clinical benefits both in terms of improving serum lipid profiles and reducing cardiovascular events and mortality. Although statins have a favorable risk-to-benefit ratio, they have the potential to cause adverse events which can result in muscular inflammation (myositis), muscle breakdown (rhabdomyolysis) and, ultimately, kidney failure. While the incidence of rhabdomyolysis is approximately 3.4 cases per 100,000 person-years with standard-dose statin therapy, the risk of developing the condition increases substantially at higher therapeutic doses. This effect may be exacerbated by prescribing statins in combination with certain other medications because drug ? drug interactions increase statin exposure by interacting with enzymes that would normally be involved in their metabolism and clearance. Co-administration of drugs that inhibit the cytochrome P450 (CYP) enzymes responsible for metabolizing statins, or that interact with the organic anion-transporting polypeptides (OATPs) responsible for statin uptake into hepatocytes, substantially increases the risk of developing myotoxicity. Such effects vary among statins according to their metabolic profile. For example, pitavastatin, a novel statin approved for the treatment of hypercholesterolemia and combined (mixed) dyslipidemia, is not catabolized by CYP3A4, unlike other lipophilic statins, and may be less dependent on the OATP1B1 transporter for its uptake into hepatocytes before clearance. Such differences in drug ? drug interaction profiles among available statins offer the possibility of reducing the risk of myotoxicity among high-risk patients. PMID:22022768

Catapano, Alberico L



Rhabdomyolysis: a case study exploring the possible side effect of lipid lowering medication by a HIV positive patient taking a protease inhibitor  

PubMed Central

This case study explores the incidence of rhabdomyolysis in a HIV positive patient that was taking a lipid lowering drug and a protease inhibitor concurrently while under chiropractic treatment for generalized muscular soreness. Dyslipidemia is a very common problem both in the general and HIV population, with many patients being prescribed lipid lowering drugs. While extremely rare, adverse effects of lipid lowering drugs have been documented to include myopathy such as rhabdomyolysis. It is imperative that chiropractors are aware of the possible adverse side effect of lipid lowering drug therapy in their patients complaining of musculoskeletal pain. It is even more important that chiropractors treating the HIV population are aware of the potential interactions between these medications and protease inhibitors to cause myopathy.

De Carvalho, Diana; Citro, Mark; Tibbles, Anthony



A frameshift variant of CYP2C8 was identified in a patient who suffered from rhabdomyolysis after administration of cerivastatin  

Microsoft Academic Search

A hypercholesterolemic patient medicated with cerivastatin for 22 days resulted in acute rhabdomyolysis. CYP2C8 and CYP3A4 are the major enzymes responsible for the metabolism of cerivastatin, and a transporter, OATP2, contributes to uptake of cerivastatin to the liver. In this study, the patient’s DNA was sequenced in order to identify a variant that would lead to the adverse effect of

Chikako Ishikawa; Hiroshi Ozaki; Toshiaki Nakajima; Toshihiro Ishii; Saburo Kanai; Saeko Anjo; Kohji Shirai; Ituro Inoue



Ubiquinol rescues simvastatin-suppression of mitochondrial content, function and metabolism: implications for statin-induced rhabdomyolysis.  


Statin medications diminish cholesterol biosynthesis and are commonly prescribed to reduce cardiovascular disease. Statins also reduce production of ubiquinol, a vital component of mitochondrial energy production; ubiquinol reduction may contribute to rhabdomyolysis. Human rhabdomyosarcoma cells were treated with either ethanol and dimethyl sulfoxide (DMSO) control, or simvastatin at 5 µM or 10 µM, or simvastatin at 5 µM with ubiquinol at 0.5 µM or 1.0 µM for 24 h or 48 h. PGC-1? RNA levels were determined using quantitative reverse transcriptase polymerase chain reaction (qRT-PCR). Mitochondrial content was determined using flow cytometry and immunocytochemistry. Metabolism was determined by quantification of extracellular acidification rate and oxygen consumption rate. Treatment of human rhabdomyosarcoma cells with simvastatin significantly reduced oxidative, total metabolism, and cellular ATP content in a time- and dose-dependent manner which was rescued by concurrent treatment with ubiquinol. Treatment with simvastatin significantly reduced mitochondrial content as well as cell viability which were both rescued by simultaneous treatment with ubiquinol. This work demonstrates that the addition of ubiquinol to current statin treatment regimens may protect muscle cells from myopathies. PMID:23624330

Vaughan, Roger A; Garcia-Smith, Randi; Bisoffi, Marco; Conn, Carole A; Trujillo, Kristina A



Exercise-Induced Rhabdomyolysis and Stress-Induced Malignant Hyperthermia Events, Association with Malignant Hyperthermia Susceptibility, and RYR1 Gene Sequence Variations  

PubMed Central

Exertional rhabdomyolysis (ER) and stress-induced malignant hyperthermia (MH) events are syndromes that primarily afflict military recruits in basic training and athletes. Events similar to those occurring in ER and in stress-induced MH events are triggered after exposure to anesthetic agents in MH-susceptible (MHS) patients. MH is an autosomal dominant hypermetabolic condition that occurs in genetically predisposed subjects during general anesthesia, induced by commonly used volatile anesthetics and/or the neuromuscular blocking agent succinylcholine. Triggering agents cause an altered intracellular calcium regulation. Mutations in RYR1 gene have been found in about 70% of MH families. The RYR1 gene encodes the skeletal muscle calcium release channel of the sarcoplasmic reticulum, commonly known as ryanodine receptor type 1 (RYR1). The present work reviews the documented cases of ER or of stress-induced MH events in which RYR1 sequence variations, associated or possibly associated to MHS status, have been identified.



Exercise-induced rhabdomyolysis and stress-induced malignant hyperthermia events, association with malignant hyperthermia susceptibility, and RYR1 gene sequence variations.  


Exertional rhabdomyolysis (ER) and stress-induced malignant hyperthermia (MH) events are syndromes that primarily afflict military recruits in basic training and athletes. Events similar to those occurring in ER and in stress-induced MH events are triggered after exposure to anesthetic agents in MH-susceptible (MHS) patients. MH is an autosomal dominant hypermetabolic condition that occurs in genetically predisposed subjects during general anesthesia, induced by commonly used volatile anesthetics and/or the neuromuscular blocking agent succinylcholine. Triggering agents cause an altered intracellular calcium regulation. Mutations in RYR1 gene have been found in about 70% of MH families. The RYR1 gene encodes the skeletal muscle calcium release channel of the sarcoplasmic reticulum, commonly known as ryanodine receptor type 1 (RYR1). The present work reviews the documented cases of ER or of stress-induced MH events in which RYR1 sequence variations, associated or possibly associated to MHS status, have been identified. PMID:23476141

Carsana, Antonella



Rhabdomyolysis Complicating Doxylamine Overdose  

Microsoft Academic Search

A 16-year-old male presenting with anticholinergic symptoms was found to have hematuria and oliguria. Evaluation of the patient revealed a serum creatinine of 2.2 mg\\/d1, myoglobinuria, and a creatine phosphokinase (CPK) level of 78, 750 IU\\/1 with 99 percent fraction 3 isoenzyme. A toxic screen showed the presence of doxylamine, an antihistamine of the ethanolamine class, at a level of

Fernando S. Mendoza; Joshua O. Atiba; Alan M. Krensky; Lynne M. Scannell



Extensive extraosseous localization of bone imaging agent in a patient with renal failure and rhabdomyolysis accompanied by combined hypercalcemia and hyperphosphatemia  

SciTech Connect

Four sequential Tc-99m pyrophosphate (PYP) imaging studies were performed in a 28-year-old man with high fever and exudate pharyngitis associated with renal failure. Radiotracer localization in the left ventricle (LV), lungs, kidneys, and skeletal muscles were seen in two, initial imaging studies. In the second and third imaging studies, area of increase in activity was seen in the left-sided bowel. In studies done two months later (in the third study), the radioactivity in the skeletal muscles was no longer seen. Studies obtained nine months (in the fourth study) after the first imaging showed less radiotracer localization in the LV, lungs, and kidneys as compared to that seen in the initial study. Myocardial necrosis and microcalcification were proved by LV biopsy. The exact mechanism of extraosseous bone-imaging agent localization is unknown. However, this phenomenon may be related to renal failure, rhabdomyolysis, hypercalcemia, hyperphosphatemia, or elevated parathyroid hormone. The Tc-99m PYP imaging study is useful and sensitive in the detection of extraosseous tissue calcification and monitoring of the disease process.

Shih, W.J.; Flueck, J.; O'Connor, W.; Domstad, P.A.



Rhabdomyolysis and Salmonella enteritidis Infection  

Microsoft Academic Search

failure and death. Our patient had several underlying conditions, namely, a history of diabetes, vasculopathy, broad-spectrum antimicrobial therapy, abdominal surgery, and pacemaker implantation, that could have predisposed him to invasive infection with a typically saprophytic fungus; perhaps most importantly, he had endocarditis that did not respond well to antimicrobial therapy. In addition, during the current hospitalization, he had numerous vascular

D. Neau; Y. Delmas; P. Merville; H. Dutronc; M. El Kadiri; L. Potaux; J. M. Ragnaud



Phenolic antioxidants tert-butyl-bisphenol and vitamin E decrease oxidative stress and enhance vascular function in an animal model of rhabdomyolysis yet do not improve acute renal dysfunction.  


Rhabdomyolysis (RM) caused by severe burn releases extracellular myoglobin (Mb) that accumulates in the kidney. Extracellular Mb is a pro-oxidant. This study tested whether supplementation with tert-butyl-bisphenol (BP) or vitamin E (Vit E, as ?-tocopherol) at 0.12% w/w in the diet inhibits acute renal failure (ARF) in an animal model of RM. After RM-induction in rats, creatinine clearance decreased (p < 0.01), proteinuria increased (p < 0.001) and renal-tubule damage was detected. Accompanying ARF, biomarkers of oxidative stress (lipid oxidation and hemeoxygenase-1 (HO-1) gene and protein activity) increased in the kidney (p < 0.05). Supplemented BP or Vit E decreased lipid oxidation (p < 0.05) and HO-1 gene/activity and restored aortic cyclic guanylyl monophosphate in control animals (p < 0.001), yet ARF was unaffected. Antioxidant supplementation inhibited oxidative stress, yet was unable to ameliorate ARF in this animal model indicating that oxidative stress in kidney and vascular cells may not be causally related to renal dysfunction elicited by RM. PMID:21726176

Kim, Hyun Bo; Shanu, Anu; Wood, Sarah; Parry, Sarah N; Collet, Michael; McMahon, Aisling; Witting, Paul K



Rhabdomyolysis And Hepatitis Associated With Pravastatin Therapy  

Microsoft Academic Search

A 65-year-old woman with diabetes mellitus type II, hypercholesterolemia and depressive disorder, admitted to the hospital with one-week history of generalized weakness and fatigability. Her medications included gliclazide, pravastatin, fluoxetine hydrochloride (Prozac), Hydroxyzine hydrochloride and Lorazepam. Clinical examination was unremarkable. Both myoglobin and creatine kinase (CK) level were elevated as well as liver enzymes. The urine myoglobin test result was



Rhabdomyolysis from Statins: What's the Risk?  


... cardiologist, specializing in cardiovascular (CV) imaging modalities (echocardiography, nuclear cardiology and CT), coronary artery disease and prevention of coronary artery disease. His research interests are the application of imaging technology to ...


Exertional Rhabdomyolysis in Naval Aviation Officer Candidates.  

National Technical Information Service (NTIS)

In eight young men undergoing heavy repetitive exertion a syndrome of severe myalgia, myoglobinuria, elevated muscle-cell enzymes, and impaired muscle function persisting for weeks or months has been observed. Transient azotemia was present in six of the ...

R. F. Smith



Bortezomib-Induced Rhabdomyolysis in Multiple Myeloma  

Microsoft Academic Search

Although multiple myeloma (MM) remains an incurable disease, its treatment has improved over the past decade. This improvement has been at least in part due to the introduction of novel antimyeloma agents with new mechanisms of action, including those that target both myeloma cells and the tumor microenvironment, with antiangiogenic and immunomodulatory properties. Among these drugs, bortezomib (Velcade®), a selective

M. Teresa Cibeira; Santiago Mercadal; Leonor Arenillas; Anna Muntañola; Olga Salamero; Joan Bladé



Rhabdomyolysis: a lesson on the perils of exercising and drinking  

Microsoft Academic Search

Acute abdomen is a common presentation to the emergency department (ED), accounting for 5% to 10% of ED visits.Of these, 10% require surgery, and 25% go undiagnosed.Usually, most of the cases of undiagnosed abdominal pain are in young women with pelvic etiologies, although occasionally, unusual causes of abdominal pain lead to diagnostic dilemmas and can have adverse clinical outcomes.We present

Saurabh Chawla; Abdo Asmar; Christopher A. Smith



Rhabdomyolysis in an Adolescent With Nonpurging Bulimia Nervosa  

Microsoft Academic Search

A 14-year-old girl with a history of nonpurging bulimia nervosa (BN) was presented with muscular pain and weakness after several days of fasting and vigorous exercise. On hospital admission, the serum creatine kinase was 3,277 U\\/L and serum potassium was 2.5 mmol\\/L. The creatine kinase level reached a peak of 4,588 U\\/L before declining after intravenous hydration and correction of

Stephen B. Sondike



Rhabdomyolysis and Unilateral Renal Infarction After a Motor Vehicle Crash  

Microsoft Academic Search

A 46-year-old man with no previous history of abnormal urinalysis findings or renal dysfunction was admitted to a local hospital because of a motor vehicle crash. An open laparotomy was performed to treat a perforation of the small intestine. After operation, oliguria and renal dysfunction developed, and he was admitted to our hospital because of acute renal failure after trauma.

Toru Sanai; Masaaki Yokoyama; Akinari Murata; Kei Ukon; Kazumi Fuchigami



Severe, self-limiting lactic acidosis and rhabdomyolysis accompanying convulsions  

Microsoft Academic Search

A 26 year old man with no previous history of convulsions presented in status epilepticus and severe lactic acidosis. He regained consciousness and the acidosis resolved after several hours of conservative management without intravenous bicarbonate, but he developed severe myalgia associated with marked elevation of creatine kinase and moderate raised plasma creatinine levels which resolved spontaneously after 3 days. Severe

P. H. Winocour; A. Waise; G. Young; K. J. Moriarty



Catastrophic medical events with exhaustive exercise: “White collar rhabdomyolysis  

Microsoft Academic Search

Each year, especially in the United States, young and middle aged men die from a variety of causes during or following intense physical exertion. For unknown reasons, death and disability as a consequence of physical effort are virtually unknown in women, despite the fact that they participate heavily in competitive sports.The most important complications of exhaustive exercise are shown in

James P Knochel



Clinical Reasoning: Rhabdomyolysis after combined treatment with simvastatin and fluconazole  

Microsoft Academic Search

SECTION 1 A 65-year-old woman with obesity, hypertension, coronary artery disease, ventricular tachycardia, and hypercholesterolemia presented with 2 weeks of pro- gressive, proximal muscle tenderness and weakness. She was unable to walk. Neurologic examination re- vealed a severe proximal tetraparesis predominantly of the legs. Sensation was normal. The patellar reflex was slightly reduced on the right side. The remainder of

O. Findling; N. Meier; J. Sellner; K. Nedeltchev; M. Arnold



The Incidence of Myoglobinemia and Exertional Rhabdomyolysis in Marine Recruits.  

National Technical Information Service (NTIS)

Specimens of blood from 330 Marine recruits at the Marine Corps Recruit Depot, Parris Island, South Carolina, were obtained daily during the first week of their recruit training. Each sample was analyzed for serum myoglobin, CPK, GOT and LDH. It was found...

M. A. Demos E. L. Gitin



Concomitant administration of simvastatin and danazol associated with fatal rhabdomyolysis  

Microsoft Academic Search

Background: Simvastatin, a 3-hydroxy-3-methylglutarylcoenzyme A reductase inhibitor, is indicated for the treatment of hypercholesterolemia and plays an important role in both the primary and secondary prevention of cardiovascular disease. Danazol is a steroid analogue approved for the treatment of endometriosis, fibrocystic breast disease, and hereditary angioedema. Despite not being licensed, danazol has been used for other off-label indications, such as

Ivan Stankovic; Alja Vlahovic-Stipac; Biljana Putnikovic; Zorica Cvetkovic; Aleksandar N. Neskovic



A novel sporadic mutation in cytochrome c oxidase subunit II as a cause of rhabdomyolysis.  


Disorders of the mitochondrial genome are an important cause of neurological disease, with patients presenting a variety of different phenotypes. Exercise induced muscle pain and myoglobinuria have been described with a number of metabolic defects, but because of the enormous variability of the mitochondrial genome identifying causative mitochondrial DNA mutations can be extremely difficult. Since mitochondrial tRNA genes were considered to be hot spots for mutation, sequencing was initially often confined to these genes. In a patient with symptoms and signs of exercise intolerance and myoglobinuria we originally ascribed pathogenicity to a mitochondrial-tRNA(Phe) mutation but here we show that the true pathogenic mutation was a novel mutation in the gene encoding subunit II of cytochrome c oxidase. We believe that this study demonstrates the importance of whole mitochondrial genome sequencing and of access to large sequence databases. PMID:14733964

McFarland, Robert; Taylor, Robert W; Chinnery, Patrick F; Howell, Neil; Turnbull, Douglass M



Hypokalemic paralysis with rhabdomyolysis and arterial hypertension caused by liquorice ingestion  

Microsoft Academic Search

Sirs: We report about a 47-year-old male who acutely developed muscle weakness of the lower extremities accompanied by a tingling paraesthesia. By the next day the weakness had progressed and involved the thoracolumbar spine, the posterior neck, left shoulder and the finger flexors of the left hand. The patient had been feeling well until 5 days prior to admission, when

Christian Templin; Mechthild Westhoff-Bleck; Jelena-Rima Ghadri



Cylindrical spirals of myofilamentous origin associated with exertional cramps and rhabdomyolysis  

Microsoft Academic Search

We describe the presence of cylindrical spirals on muscle biopsy from a 31-year-old man who developed rhabodomyolysis following a long run. He had a prior history of exertional cramps and myoglobinuria. His maternal grandfather had similar symptoms. Transmission electron micrographs demonstrated continuity between the lamellae of the cylindrical spirals and native myofilaments. Whether these unusual structures confer a derangement in

Gil I Wolfe; Dennis K Burns; Daniel Krampitz; Richard J Barohn



A New Case of Phosphoglycerate Kinase Deficiency: PGK Creteil Associated With Rhabdomyolysis and Lacking Hemolytic Anemia  

Microsoft Academic Search

A new case of phosphoglycerate kinase (PGK) deficiency is described. The propositus displayed episodes of rhabdo- myolysis crises and acute renal failure but did not exhibit any sign of hemolysis. A severe deficiency in phospho- glycerate kinase was revealed in muscle and was also found in erythrocytes, white cells and platelets. A partial defect in the same enzyme was present

Raymonde Rosa; Claude George; Michel Fardeau; Marie-Claude Calvin; Maurice Rapin; Jean Rosa



A novel sporadic mutation in cytochrome c oxidase subunit II as a cause of rhabdomyolysis  

Microsoft Academic Search

Disorders of the mitochondrial genome are an important cause of neurological disease, with patients presenting a variety of different phenotypes. Exercise induced muscle pain and myoglobinuria have been described with a number of metabolic defects, but because of the enormous variability of the mitochondrial genome identifying causative mitochondrial DNA mutations can be extremely difficult. Since mitochondrial tRNA genes were considered

Robert McFarland; Robert W. Taylor; Patrick F. Chinnery; Neil Howell; Douglass M. Turnbull



Salt Loading as a Possible Factor in the Production of Potassium Depletion, Rhabdomyolysis, and Heat Injury.  

National Technical Information Service (NTIS)

The benefits of supplementary salt in unacclimatised people performing physical labour in humid heat are well known: without suitable quantities of salt and water there is a risk of hypertonic dehydration and cardiovascular collapse. Features of potassium...

J. P. Knochel R. M. Vertel



Simvastatin-loaded ?-TCP drug delivery system induces bone formation and prevents rhabdomyolysis in OVX mice.  


Bone formation and regeneration is a prolonged process that requires a slow drug release system to assist in the long-term recovery. A drug-delivery system is developed that allows for the controlled release of simvastin, without exhibiting the side effects associated with high concentrations of simvastatin, and is still capable of inducing constant bone formation. PMID:23184712

Chou, Joshua; Ito, Tomoko; Otsuka, Makoto; Ben-Nissan, Besim; Milthorpe, Bruce



Research Paper Rhabdomyolysis in Patients with West Nile Encephalitis and Meningitis  

Microsoft Academic Search

Since 1999, more than 6,500 cases of West Nile virus neuroinvasive disease (WNND) have been reported in the United States. Patients with WNND can present with muscle weakness that is often assumed to be of neurologi- cal origin. During 2002, nearly 3,000 persons with WNV meningitis or encephalitis (or both) were reported in the United States; in suburban Cook County,



Rhabdomyolysis and pancreatitis associated with coadministration of danazol 600 mg\\/d and lovastatin 40 mg\\/d  

Microsoft Academic Search

Background: Danazol is a steroid analogue with anabolic and androgenic effects and is indicated for the treatment of endometriosis, fibrocystic diseases of the breast, and hereditary angioedema. Lovastatin has been prescribed to lower total cholesterol and low-density lipoprotein cholesterol, reducing cardiovascular-related morbidity and mortality in patients with hypercholesterolemia. As monotherapies, both danazol and lovastatin have been reported to induce myopathy

Cheng-Yang Hsieh; Chih-Hung Chen



Biphasic hypercalcemia in severe rhabdomyolysis: serial analysis of PTH and vitamin D metabolites. A case report and literature review  

Microsoft Academic Search

Calcemic fluxes with hypocalcemia leading to hypercalcemia in acute rhabdomyolisis are poorly understood. Analyses in the literature of the factors modulating the blood calcium level include 2, possibly 3 systems. Conflicting results implicate the parathyroid hormone and vitamin D metabolites, but additional contribution from skeletal and muscle calcium ion deposition and dissolution have been cited in some cases, potentially even

Sarju M. Shrestha; Jacqueline L. Berry; Michael Davies; Francis W. Ballardie



Rhabdomyolyse métabolique au cours d’un traitement par statine  

Microsoft Academic Search

The occurrence of rhabdomyolysis during statin treatment for dyslipidemia is a well-known side effect. However, the differential diagnosis of rhabdomyolysis is large. We report on a patient treated with statin who presented a rhabdomyolysis. The persistence of laboratory abnormalities allowed to discover a metabolic rhabdomyolysis, namely a carnitine palmitoyltransférase II deficiency. The diagnosis of the genetic abnormality allows to modify

N. Vergely; V. Leca; J.-C. Antoine; N. Germain; Y. Khalfallah; B. Estour



Quail Consumption can be Harmful  

Microsoft Academic Search

Background: Intoxication due to quail consumption is rarely seen. Such a toxicological syndrome (also called coturnism) occurs during the migration of quails from north to south, when they consume hemlock seeds. The clinical symptoms and laboratory results are indicative of acute rhabdomyolysis. Objectives: Acute rhabdomyolysis has a wide range of etiologies. Coturnism is a rare cause of acute rhabdomyolysis that

?lhan Korkmaz; Fatma Mutlu Kukul Güven; ?evki Hakan Eren; Zeki Dogan



Rabdomiólise devido ao uso de estatina em altas doses: relato de caso  

Microsoft Academic Search

High Doses Statins Administration Causing Rhabdomyolysis: Case Report. Rhabdomyolysis has been the theme in medical literature for the last fifty years. In these last decades, with statins being used in primary and sec- ondary cardiovascular prevention events, this theme returns and statins are now pointed as the trigger to this almost always fatal complication. Rhabdomyolysis due to statins administration occurs

Mirnaluci P. Ribeiro Gama; Silviane Pellegrinello; Sheyla Santos Quelle Alonso; Juliana Filus Coelho; Caroline F. Luz Martins; Gleyne Lopes Kujew Biagini



Fenofibrate Therapy in Carnitine Palmitoyl Transferase Type 2 Deficiency  

PubMed Central

Bezafibrate therapy has been shown to improve beta-oxidation of fatty acids and to reduce episodes of rhabdomyolysis in patients with carnitine palmitoyltransferase type-2 (CPT2) deficiency. We report the efficacy of fenofibrate in a patient with CPT2 deficiency, in whom beta-oxidation was improved but an episode of rhabdomyolysis nevertheless occurred. This suggests additional methods to avoid rhabdomyolysis in patients with CPT2 deficiency should accompany fibrate therapy, including avoidance of muscular overexertion, dehydration, and heat exposure.

Hamilton-Craig, I.; Yudi, M.; Johnson, L.; Jayasinghe, R.



Malignant hyperthermia  


Amputation Breakdown of muscle tissue ( rhabdomyolysis ) Compartment syndrome (swelling of the hands and feet and problems with blood flow and nerve function) Death Disseminating intravascular coagulation (abnormal ...


Myoglobinuria with acute renal failure and hot kidneys seen on bone imaging  

SciTech Connect

We report a case of myoglobinuria secondary to prolonged seizures. The child showed ''hot kidneys'' with bone scintigraphy. The disease entity and etiologies of nontraumatic rhabdomyolysis are discussed.

Sheth, K.J.; Sty, J.R.; Johnson, F.; Tisdale, P.



~) " f  

Center for Drug Evaluation (CDER)

Text Version... Additional signs may include elevated creatine phosphokinase, myoglobinuria (rhabdomyolysis), and acute renal failure. ... More results from


Amelioration of myoglobinuric renal damage in rats by chronic exposure to flavonol-rich red wine  

Microsoft Academic Search

Background. Myoglobinuric acute renal failure causes increased oxidative stress. Since ethanol upregulates renal antioxidant enzymes and wine polyphenols behave as antioxidants, we tested the hypothesis that red wine components would ameliorate the renal damage caused by rhabdomyolysis. Methods. Adult rats received water (control), alcohol- free red wine, ethanol 12.5% (v\\/v) or red wine for 10 weeks. Rhabdomyolysis was induced by

Ramon Rodrigo; Cleofina Bosco; Patricia Herrera; Gonzalo Rivera



Spinal myoclonus following intrathecal administration of diatrizoate meglumine.  


Life-threatening myoclonus developed in a patient following inadvertent intrathecal usage of 60% diatrizoate meglumine. Rhabdomyolysis and myoglobinuria occurred. The patient was successfully treated with midazolam and vecuronium and complete recovery occurred. PMID:8903083

Sam, M C; Gutmann, L



Department of Health and Human Services Public Health ...  

Center for Biologics Evaluation and Research (CBER)

Text Version... Rhabdomyolysis is labeled in the warning section of the ... The patient had no history of hepatitis and no ... of the cases and medical histories did not ... More results from


Trilipix (ACCORD) Advisory Committee Meeting  

Center for Biologics Evaluation and Research (CBER)

Text Version... (no cerivastatin) Rhabdomyolysis events HMO (1998 - 2008) HMO (2004 - 2007) Source population i3/Abbott Study 2 i3/Abbott Study 1 7066.01 ... More results from


Genetics Home Reference: Brody myopathy  


... Brody myopathy? autosomal ; autosomal recessive ; calcium ; cell ; contraction ; enzyme ; gene ; ions ; mutation ; myoglobin ; myoglobinuria ; prevalence ; protein ; recessive ; rhabdomyolysis ; sarcoplasmic reticulum ; skeletal muscle ; tissue You may find definitions for these and many other terms in the ...


The Role of Potassium Ion in Muscle Glycogenolysis and Glycolysis.  

National Technical Information Service (NTIS)

Ineffective energy metabolism has been documented as an etiologic factor in exertional rhabdomyolysis. The importance of potassium ion as a cofactor in enzymatic reactions necessary for normal energy metabolism has been well established. Since rhabdomyoly...

J. E. Olerud W. H. Pryor R. L. Eason H. W. Carroll



Information for Healthcare Professionals: Reports of Altered ...  

Center for Drug Evaluation (CDER)

... risk factor for altered kidney function, such as cardiac insufficiency, hypertension, pancreatitis, rhabdomyolysis, and urinary tract infection, as well as ... More results from


Genetics Home Reference: Malignant hyperthermia  


... malignant hyperthermia may experience muscle rigidity, breakdown of muscle fibers (rhabdomyolysis), a high fever, increased acid levels in ... in calcium ion concentration inside muscle cells stimulates muscle fibers to contract. Mutations in the RYR1 or CACNA1S ...


Genetics Home Reference: Multiminicore disease  


... the sensation of pain, and with a particular type of muscle relaxant. If given these drugs, people at risk for malignant hyperthermia may experience muscle rigidity, breakdown of muscle fibers (rhabdomyolysis), a high fever, increased acid levels in ...


Genetics Home Reference: Central core disease  


... the sensation of pain, and with a particular type of muscle relaxant. If given these drugs, people at risk for malignant hyperthermia may experience muscle rigidity, breakdown of muscle fibers (rhabdomyolysis), a high fever, increased acid levels in ...


Pneumonie à Légionelle compliquée d'une insuffisance rénale aiguë par rhabdomyolyse : à propos d'un cas  

Microsoft Academic Search

The infectious origin of non-traumatic rhabdomyolysis is rare (5% of cases). An elevated muscle enzyme level is often reported in the legionnaire's disease. We report the case of a 39-year-old male, with no previous medical history, admitted for renal failure (creatininemia=977 ?mol\\/l) secondary to rhabdomyolysis and a twelve-day history of infectious syndrome with pneumonia in the left base. Legionella pneumophila was considered

J. Labidi; W. Fdhila; R. Battikh; S. Ellouze; N. Ben Abdelhafidh; B. Louzir; F. M'sadek; S. Othmani



Withdrawal of cerivastatin from the world market  

Microsoft Academic Search

Cerivastatin was recently withdrawn from the market because of 52 deaths attributed to drug-related rhabdomyolysis that lead to kidney failure. The risk was found to be higher among patients who received the full dose (0.8 mg\\/day) and those who received gemfibrozil concomitantly. Rhabdomyolysis was 10 times more common with cerivastatin than the other five approved statins. We address three important

Curt D Furberg; Bertram Pitt



Perioperative cardiac arrest in a patient with previously undiagnosed Becker's muscular dystrophy after isoflurane anaesthesia for elective surgery.  


A previously fit 12-yr-old boy, who had no previous history of anaesthesia, underwent general anaesthesia using isoflurane for an elective circumcision. After uneventful surgery and anaesthesia, he suffered a cardiorespiratory arrest in the recovery room. Prompt oxygenation and cardiopulmonary resuscitation (CPR) were instituted. The initial serum potassium was >13 mmol litre(-1) and prolonged CPR was required while potassium levels were reduced. Further investigation demonstrated a creatine kinase (CK) >70 000 U litre(-1) which was consistent with a diagnosis of rhabdomyolysis. Despite requiring CPR for 1 h 45 min and a prolonged intensive care admission for multi-organ failure, the child has made an excellent recovery, including normal cognitive function. Subsequent genetic analysis has shown that the boy has previously undiagnosed Becker's muscular dystrophy. We believe that the patient had acute rhabdomyolysis as a result of a volatile anaesthetic agent in association with an undiagnosed muscular dystrophy. In recent years, largely based on case report literature, there has been a shift in opinion as to the cause of such adverse perioperative events. What was previously thought to be malignant hyperpyrexia (MH) is now considered to be anaesthesia-induced rhabdomyolysis, an alternative and distinct reaction. The distinguishing feature of anaesthesia-induced rhabdomyolysis from MH is an acute rhabdomyolysis, without preceding hypermetabolism. PMID:20190256

Poole, T C; Lim, T Y J; Buck, J; Kong, A S



Super vasomol hair dye poisoning  

PubMed Central

Hair dye poisoning is not rare but is an emerging poisoning in India. The main component of hair dye causing toxicity is paraphenylenediamine (PPD). Acute poisoning by PPD causes characteristic severe angioedema of the upper airway accompanied by a swollen, dry, hard, and protruding tongue. Systemic intoxication results in multisystem involvement and can cause rhabdomyolysis, acute renal failure (ARF). PPD consumption is an uncommon cause of ARF. There is no specific antidote for PPD and treatment is mainly supportive. We report a case of suicidal ingestion of hair dye that presented with cervicofascial edema and later developed rhabdomyolysis and ARF. Our patient improved with dialysis and symptomatic management.

Kumar, Praveen A. S.; Talari, Keerthi; Dutta, T. K.



Partial muscle carnitine palmitoyltransferase-A deficiency  

SciTech Connect

After initiation of ibuprofen therapy, a 45-year-old woman developed muscle weakness and tenderness with rhabdomyolysis, culminating in respiratory failure. A muscle biopsy specimen showed a vacuolar myopathy, and markedly decreased muscle carnitine content and carnitine palmitoyltransferase activity. Following recovery, muscle carnitine content was normal but carnitine palmitoyltransferase activity was still abnormally low. The ratio of palmitoyl-coenzyme A plus carnitine to palmitoylcarnitine oxidation by muscle mitochondria isolated from the patient was markedly decreased. The authors conclude that transiently decreased muscle carnitine content interacted with partial deficiency of carnitine palmitoyltransferase-A to produce rhabdomyolysis and respiratory failure and that ibuprofen may have precipitated the clinical event.

Ross, N.S.; Hoppel, C.L.



Recurrent acute kidney failure due to McArdle disease.  


We present an adolescent with McArdle disease and recurrent acute kidney failure due to rhabdomyolysis. The patient was admitted with acute kidney failure for 3 times and due to a history of proximal weakness, fatigue, and muscular cramps after physical activities a glycogen-storage disease was suspected. Serum creatine phosphokinase and urine myoglobin were found to be elevated. McArdle disease was diagnosed based on pathologic examination of muscle tissue specimen. Patients presenting with rhabdomyolysis following strenuous exercise should be evaluated for McArdle disease. PMID:19377243

Noshad, Hamid; Sadreddini, Shahram; Ghaffari, Ali Reza



Statin myopathy.  


Many different classes of medications can cause toxic myopathy. One of the most frequently implicated classes is the statins. Statin myotoxicity ranges from asymptomatic creatine kinase elevations or myalgias to muscle necrosis and fatal rhabdomyolysis. Statins may also cause an autoimmune myopathy requiring immunosuppressive treatment. The mechanisms of statin myotoxicity are unclear. If unrecognized in its early manifestations, complications from continued statin therapy may lead to rhabdomyolysis and death. Risk factors for myotoxicity include concomitant medication use and medical conditions, and the patient's underlying genetic constitution. We review these considerations along with the recommended evaluation and treatment for patients presenting with statin myotoxicity. PMID:18367041

Radcliffe, Kristofer A; Campbell, William W



Hypothyroidism Complicating Nephropathy in a Diabetes Patient  

PubMed Central

We describe a patient with type 2 diabetes mellitus and autoimmune hypothyroidism who presented with elevated serum creatinine possibly due to subclinical rhabdomyolysis induced by hypolipidemic drug therapy in the background of diabetic nephropathy. Both hypothyroidism and rhabdomyolysis were asymptomatic in this case as evidenced by lack of classical clinical features of hypothyroidism despite elevated serum TSH and absent pigment cast in renal biopsy. The combination of diabetes mellitus and hypothyroidism is common in the general population and should not be forgotten in patients with diabetes and kidney disease.

Veerappan, Ilangovan; Abraham, Anila; Hariharan, Somasundaram



Hypothyroidism complicating nephropathy in a diabetes patient.  


We describe a patient with type 2 diabetes mellitus and autoimmune hypothyroidism who presented with elevated serum creatinine possibly due to subclinical rhabdomyolysis induced by hypolipidemic drug therapy in the background of diabetic nephropathy. Both hypothyroidism and rhabdomyolysis were asymptomatic in this case as evidenced by lack of classical clinical features of hypothyroidism despite elevated serum TSH and absent pigment cast in renal biopsy. The combination of diabetes mellitus and hypothyroidism is common in the general population and should not be forgotten in patients with diabetes and kidney disease. PMID:23304572

Sahoo, Jayaprakash; Veerappan, Ilangovan; Abraham, Anila; Hariharan, Somasundaram



A clinical approach to common electrolyte problems: 3. Hypophosphatemia.  

PubMed Central

Hypophosphatemia is a common disorder caused by decreased intake, increased loss or transcellular shift of phosphorus. Symptoms of severe hypophosphatemia include reversible depression of myocardial function, acute respiratory failure, coma, rhabdomyolysis, osteomalacia, renal tubular acidosis and hemolysis. This paper discusses common clinical disorders associated with hypophosphatemia and presents an approach to diagnosis and treatment. Images p17-a

Berkelhammer, C.; Bear, R. A.



Acute renal failure in association with cosmetic suction lipectomy.  

PubMed Central

A case of severe non-oliguric acute renal failure following cosmetic suction lipectomy in a 33 year old woman is described. The renal failure, although requiring emergency treatment, resolved spontaneously with only negligible residual impairment of renal function. An aetiology involving rhabdomyolysis and myoglobinuria is proposed and other mechanisms are discussed. Images Figure 1

Rose, G. E.



Gender and Cocaine Use Influence the Expression of Urinary Markers of Inflammation and Oxidative Stress  

Microsoft Academic Search

The purpose of this study was to investigate whether or not gender differences may be present in the expression of a number of urinary proteins which may serve as markers of inflammation and oxidative stress. Males and females have different patterns of illness and different life spans, suggesting basic biological traits exert significant control on the incidence of rhabdomyolysis, renal

Marie Meagher Bourgeois



Injuries in the event horse: Training versus competition  

Microsoft Academic Search

Two related studies on injuries sustained by event horses during competition and during training are reported. During the cross-country phase of competition, the most common injuries were lacerations and abrasions to the carpus and stifle. Superficial digital flexor tendonitis and exertional rhabdomyolysis were significantly more common during Cours Complete Internationale (CCI) competitions compared to one-day event (ODE) competitions. The difference

Ellen R. Singer; Jane Barnes; Fiona Saxby; Jane K. Murray



A Fatal Hyperthermic Syndrome in a Patient with Myokymia  

Microsoft Academic Search

A fatal hyperthermic syndrome occurred in a patient with myokymia. The patient suffered acute circulatory collapse and severe rhabdomyolysis associated with hyperthermia. Although these symptoms, were similar to neuroleptic malignant syndrome or malignant hyperthermia, he did not have a history of antipsychotic medication or anesthesia. Continuous muscular contraction due to myokymia likely led to the development of hyperthermic syndrome.

Hiromi Ashida; Nobuaki Shime; Noriko Hiramatsu; Kyoko Kageyama; Satoru Hashimoto



Gluteal compartment syndrome: a case report  

Microsoft Academic Search

INTRODUCTION: Gluteal compartment syndrome is a rare, often unrecognized syndrome that may manifest as renal failure, sepsis, and death. Delay in diagnosis can result in significant morbidity and possible mortality. We report a case of occult gluteal compartment syndrome causing unresolving rhabdomyolysis. CASE PRESENTATION: A 50-year-old Caucasian American man with history of chronic obstructive pulmonary disease was admitted status post

Nadia M Mustafa; Aerin Hyun; James S Kumar; Lalitha Yekkirala



Révélation d’une maladie de Mc Ardle par une intolérance musculaire à l’effort associée à une rhabdomyolyse sévère  

Microsoft Academic Search

McArdle's disease (MAD) is a rare hereditary myopathy secondary to a deficit in myophosphorylase, an essential enzyme for the use of muscular glycogen reserves. Exercise intolerance to a variable degree is the fundamental manifestation. Muscular enzymes are usually normal or slightly elevated, except during episodes of rhabdomyolysis. Generally, the electromyogram has poor sensitivity for the diagnosis of exercise myopathies. The

T. Amezyane; A. El Kharras; A. Abouzahir; J. Fatihi; D. Bassou; F. Mahassin; D. Ghafir; V. Ohayon



Generalized Muscle Rigidity and Hypercarbia with Halothane and Isoflurane  

Microsoft Academic Search

he combination of halothane and succinylcholine is linked to masseter muscle spasm, generalized muscle rigidity, rhabdomyolysis with myoglo- binuria, and malignant hyperthermia. However, re- ports of these symptoms are rare when succinylcho- line is not used (l-4). We present a case of generalized muscle rigidity in which succinylcholine was not used. Case Report A 2-yr-old girl with a history of

Karla A. Medina; James F. Mayhew



An uncommon adverse effect of levodopa withdrawal in a patient taking antipsychotic medication: neuroleptic malignant-like syndrome.  


A patient with symptoms suggestive of neuroleptic malignant syndrome after levodopa withdrawal is described. The patient presented with persistent high fever, stupor, autonomic dysfunction, rigidity, and rhabdomyolysis. He was successfully treated with intravenous dantrolene, resumption of levodopa, and forced alkaline diuresis. Doctors should be aware of the risk of abrupt cessation of dopamine agonists. PMID:21282831

Man, S P



Treatment of hyperlipidemia with combined niacin–statin regimens  

Microsoft Academic Search

Combined use of niacin with a statin is an attractive option, since these types of medication have the best records in clinical trials for reduction in cardiovascular events and improvement in progression\\/regression of coronary lesions. In early use, the niacin–statin combination generated a few case reports documenting severe myopathy and rhabdomyolysis. Subsequent prospective trials in >400 patients, however, have not

John R Guyton; David M Capuzzi



Peripheral Zonal Hepatic Necrosis Caused by Accidental Ingestion of Methyl Ethyl Ketone Peroxide  

Microsoft Academic Search

Fatal massive peripheral zonal hepatic necrosis developed in a 47-year-old man who accidentally ingested a solution of methyl ethyl ketone peroxide (MEKP) in dimethyl phtalate. Such solutions contain about 10% active oxygen. The clinical course was characterized by temporary cardiac arrest, abdominal burns, severe metabolic acidosis, rapid hepatic failure, rhabdomyolysis and respiratory insufficiency. A fatal outcome resulted 4 d afterwards

P. J. Karhunen; I. Ojanperä; K. Lalu; E. Vuori



Myo and hepatotoxic effects of cultivated mushrooms in mice  

Microsoft Academic Search

Mushrooms are currently examined for their potential as functional foods. At the same time, novel types of mushroom intoxications, such as rhabdomyolysis after prolonged consumption, have been described in edible species. The aim of the present study was to perform an acute toxicity test to establish if the most commonly cultivated species would have myo- or hepatotoxic effects. Mice (n=6\\/group)

Petteri Nieminen; Vesa Kärjä; Anne-Mari Mustonen



Managing the underestimated risk of statin-associated myopathy  

Microsoft Academic Search

In clinical practice 5–10% of patients receiving statins develop myopathy, a side effect that had been systematically underestimated in the randomized controlled trials with statins. The most common manifestation of myopathy is muscle pain (usually symmetrical, involving proximal muscles) without creatinine kinase (CK) elevation or less frequently with mild CK elevation. Clinically significant rhabdomyolysis (muscle symptoms with CK elevation >10

Loukianos S. Rallidis; Katerina Fountoulaki; Maria Anastasiou-Nana


Drugs of abuse (Amfetamines, BZP, cannabis, cocaine, GHB)  

Microsoft Academic Search

The features of amfetamine poisoning are related predominantly to stimulation of central and peripheral adrenergic receptors, and in severe cases, excitability, agitation, paranoid delusions, hallucinations with violent behaviour, hypertonia and hyperreflexia develop. Convulsions, rhabdomyolysis, hyperthermia, intracerebral haemorrhage and cardiac arrhythmias are less common. In addition, hyperthermia and hyponatraemia are features of severe MDMA toxicity.Benzylpiperazine (BZP) has stimulant and amfetamine-like properties.

Allister Vale


HMG CoA Reductase Inhibitor-Induced Myotoxicity: Pravastatin and Lovastatin Inhibit the Geranylgeranylation of Low-Molecular-Weight Proteins in Neonatal Rat Muscle Cell Culture  

Microsoft Academic Search

In previous studies, inhibition of cholesterol synthesis by HMG CoA reductase inhibitors (HMGRI) was associated with myotoxicity in cultures of neonatal rat skeletal myotubes, and rhabdomyolysis in rats, rabbits, and humansin vivo. In vitromyotoxicity was directly related to HMGRI-induced depletion of mevalonate, farnesol, and geranylgeraniol, since supplementation with these intermediate metabolites abrogated the toxicity. Both farnesol and geranylgeraniol are required

Oliver P. Flint; Barbara A. Masters; Richard E. Gregg; Stephen K. Durham



Accident vasculaire cérébral ischémique à la suite d’une envenimation vipérine grave au Maroc, traitée par un antivenin inadapté  

Microsoft Academic Search

An ischemic stroke is a rare complication of viper envenomation that is due to multifactorial pathophysiological mechanisms. The authors describe the case of a 55-year-old patient bitten by the viper Cerastes cerastes. The patient was admitted to the intensive care unit with multiple organ failure, disseminated intravascular coagulopathy, rhabdomyolysis, anuria and elevated troponin level. The persistent disturbance of consciousness has

M. Chani; A. Abouzahir; C. Haimeur; N. Drissi Kamili; G. Mion


Hair Dye Poisoning in a Paediatric Patient  

PubMed Central

Hair dye ingestion with suicidal intention has increased among rural Indian population and is associated with significant mortality. We report a teenager who presented with cervicofacial edema, respiratory distress, rhabdomyolysis, and myocarditis after ingesting the hair dye Super Vasmol 33. Early and supportive treatment can prevent morbidity and mortality.

Chandran, Jolly; Manners, Rimi; Agarwal, Indira; Ebenezer, Kala



Hair dye poisoning in a paediatric patient.  


Hair dye ingestion with suicidal intention has increased among rural Indian population and is associated with significant mortality. We report a teenager who presented with cervicofacial edema, respiratory distress, rhabdomyolysis, and myocarditis after ingesting the hair dye Super Vasmol 33. Early and supportive treatment can prevent morbidity and mortality. PMID:22953145

Chandran, Jolly; Manners, Rimi; Agarwal, Indira; Ebenezer, Kala



Acute Renal Failure with Severe Loin Pain and Patchy Renal Ischemia after Anaerobic Exercise in Patients with or without Renal Hypouricemia  

Microsoft Academic Search

Acute renal failure induced by rhabdomyolysis after strenuous exercise is well known. We describe here a new type of acute renal failure with severe loin pain which develops after anaerobic exercise (ALPE), for example, 200-meter track racing. The patients complained of severe loin pain several hours after exercise and presented at the emergency room. Since our first description 118 cases

Isao Ishikawa



Genetics Home Reference: Freeman-Sheldon syndrome  


... to block the sensation of pain. A particular type of muscle relaxant may also trigger the reaction. If given these drugs, people at risk for malignant hyperthermia may experience muscle rigidity, breakdown of muscle fibers (rhabdomyolysis), a high fever, increased acid levels in ...


Clinical Manifestation and a New "ISCU" Mutation in Iron-Sulphur Cluster Deficiency Myopathy  

ERIC Educational Resources Information Center

|Myopathy with deficiency of succinate dehydrogenase and aconitase is a recessively inherited disorder characterized by childhood-onset early fatigue, dyspnoea and palpitations on trivial exercise. The disease is non-progressive, but life-threatening episodes of widespread weakness, severe metabolic acidosis and rhabdomyolysis may occur. The…

Kollberg, Gittan; Tulinius, Mar; Melberg, Atle; Darin, Niklas; Andersen, Oluf; Holmgren, Daniel; Oldfors, Anders; Holme, Elisabeth



Acidosis, lactate, electrolytes, muscle enzymes, and other factors in the blood of Sus scrofa following repeated TASER ® exposures  

Microsoft Academic Search

Repeated exposure to electro-muscular incapacitating devices could result in repetitive, sustained muscle contraction, with little or no muscle recovery period. Therefore, rhabdomyolysis and other physiological responses, including acidosis, hyperkalaemia, and altered levels of muscle enzymes in the blood, would be likely to occur. Experiments were performed to investigate effects of repeated exposures of TASER® International's Advanced TASER® X26 on muscle

James R. Jauchem; Clifford J. Sherry; David A. Fines; Michael C. Cook



Statins and myotoxicity  

Microsoft Academic Search

The withdrawal of cerivastatin from the world market because of deaths from rhabdomyolysis (a disorder that results from skeletal muscle injury with release of muscle cell contents into the plasma) focused attention on the risk of adverse events and, in particular, myotoxicity that are associated with statins. The World Health Organization (WHO) Collaborating Center for International Drug Monitoring carried out

Lin Yan; Fen Lan; Zhen-Gang Wang; You-Ping Li



Use of myoglobin as a marker and predictor in myoglobinuric acute kidney injury.  


Serum creatine kinase (CK) is routinely used as a marker in the assessment of rhabdomyolysis and acute myoglobinuric kidney injury (Mb-AKI), while the use of myoglobin is much less explored in this respect. We retrospectively analyzed the incidence of Mb-AKI (creatinine [Cr]?>?200??mol/L) and the need for hemodialysis (HD) in 484 patients (70.5% males) with suspected rhabdomyolysis, grouped according to peak serum myoglobin (A: 1-5?mg/L, B: 5-15?mg/L, C: >15?mg/L). The median peak myoglobin was 7163??g/L. Both peak Cr and peak CK were significantly higher in group C. The incidence of Mb-AKI was 24.6% in group A, 38.6% in group B (P?20?mg/L. Creatine kinase correlated with the severity of rhabdomyolysis, but less so with Mb-AKI. The peak Cr levels were not significantly different between patients divided by CK 60??kat/L, or grouped into CK tertiles or quartiles. A significant proportion of patients with rhabdomyolysis experienced Mb-AKI, whose frequency increased in parallel with myoglobin levels. Myoglobin levels above 15?mg/L were most significantly related to the development of AKI and the need for HD. Blood myoglobin could serve as a valuable early predictor and marker of rhabdomyolysis and Mb-AKI. PMID:23931877

Premru, Vladimir; Kova?, Janko; Ponikvar, Rafael



Acidosis, lactate, electrolytes, muscle enzymes, and other factors in the blood of Sus scrofa following repeated TASER1 exposures  

Microsoft Academic Search

Repeated exposure to electro-muscular incapacitating devices could result in repetitive, sustained muscle contraction, with little or no muscle recovery period. Therefore, rhabdomyolysis and other physiological responses, including acidosis, hyperkalaemia, and altered levels of muscle enzymes in the blood, would be likely to occur. Experiments were performed to investigate effects of repeated exposures of TASER1 International's Advanced TASER1 X26 on muscle

James R. Jauchem; Clifford J. Sherry; David A. Fines; Michael C. Cook



Perioperative thrombotic occlusion of left external iliac artery during anterior lumbar interbody fusion  

Microsoft Academic Search

We report a case of thrombotic occlusion of left external iliac artery during the procedure of anterior lumbar interbody fusion.\\u000a The diagnosis was confirmed by computed tomography angiography. The patient also developed severe rhabdomyolysis postoperatively.\\u000a In spite of receiving emergent thromboendarterectomy, the patient expired on postoperative day 3. This report attempts to\\u000a remind spinal surgeons and anesthesiologists of this rare but

Jen-Hsuan Huang; Cheng-Hung Lee; Tzung-chieh Tsai; Shih-Yen Peng



A Variable Myopathy Associated with Heterozygosity for the R503C Mutation in the Carnitine Palmitoyltransferase II Gene  

Microsoft Academic Search

Adult-onset carnitine palmitoyltransferase II (CPT II) deficiency is an autosomal recessive disease characterized by muscle pain and stiffness with rhabdomyolysis and myoglobinuria in severe cases. Exercise, fasting, viral infection, anesthesia, or extremes in temperature may trigger symptoms. A 54-year-old woman exhibited a 35-year history of progressive weakness and myopathic symptoms. CPT II activity in the patient's lymphoblasts, cultured skin fibroblasts,

Georgirene D. Vladutiu; Michael J. Bennett; David Smail; Lee-Jun Wong; R. Thomas Taggart; Herbert B. Lindsley



Exacerbation of acetazolamide-responsive sodium channel myotonia by uterotonic agents  

Microsoft Academic Search

The symptoms of myotonia can worsen during pregnancy and tocolysis with ritodrine has been associated with rhabdomyolysis. We describe a patient with myotonia who developed hypertonus immediately following the administration of uterotonic agents. A 24-year-old, G2P1 at 31 weeks of gestation with a history of acetazolamide-responsive myotonia presented with premature rupture of membranes. During cesarean delivery she experienced significant hypertonus

K. Fujii; H. Iranami; Y. Hatano



Rhabdomyolyse localisée après un choc anaphylactique au suxaméthonium  

Microsoft Academic Search

A young woman without remarkable medical history, experienced a life threatening anaphylactoid reaction after induction of general anaesthesia for an emergency curettage. Hypersensitivity reaction involving IgE antibodies against suxamethonium was proven by positive skin test and detection of specific IgE by radio-immuno assay. After intensive therapy for 2 to 3 hours, the patient exhibited rhabdomyolysis localized on both calves. This

D Perret; P Mahul; Y Rochette; C Auboyer



Severe hyperthermia during tetrabenazine therapy for tardive dyskinesia  

Microsoft Academic Search

We recently observed a 45-year-old patient with a history of psychiatric illness who presented with severe hyperthermia (rectal\\u000a temperature above 41 °C) with intense rhabdomyolysis and liver cytolysis during tetrabenazine therapy for neuroleptic tardive\\u000a dyskinesia. In addition to tetrabenazine, this patient took lorazepam and two antidepressant drugs: clomipramine, a potent\\u000a serotonin-reuptake inhibitor, and mianserin. Hyperthermia responded to parenteral sodium dantrolene

E. Stevens; A. Roman; M. Houa; D. Razavi; N. Jaspar



Renal Failure Associated with Laxative Abuse  

Microsoft Academic Search

Eating disorder patients often abuse laxatives in an attempt to purge excess food. Laxative abuse can cause hypokalemia and volume depletion. Hypokalemia, in turn, can lead to rhabdomyolysis. Laxative-induced hypokalemia and volume depletion have been previously reported to cause renal insufficiency, but not severe enough to require hemodialysis. A 27-year-old woman with a long history of laxative abuse presented with

Paul M. Copeland



An unusual presentation of baclofen overdose  

Microsoft Academic Search

Baclofen has become increasingly popular in the treatment of spasticity disorders. Its availability for misuse has also increased. We report a case of baclofen overdose in a 20-year-old man, who manifested atypical symptoms of baclofen overdose—that is, delirium and rhabdomyolysis. He was treated successfully with full supportive management, and was discharged from the hospital on the 12th day following admission.

C-F Chong; T-L Wang



Duchenne muscular dystrophy and idiopathic hyperCKemia segregating in a family  

Microsoft Academic Search

A 7-month-old boy with gross motor delay and failure to thrive presented with rhabdomyolysis following an acute asthmatic episode. During hospitalization an electrocardiographic conversion to a Wolff-Parkinson-White type 1 (WPW) pattern took place. Duchenne muscular dystrophy (DMD) was suspected based on elevated creatine kinase (CK) serum levels, muscle biopsy, and family history. The diagnosis was confirmed by molecular analysis, which

Moshe Frydman; Rachel Straussberg; Ruth Shomrat; C. Legum; Yossi Shiloh



Acute basagranTM poisoning mimicking neuroleptic malignant syndrome  

Microsoft Academic Search

A 27-year-old robust man, without any medical and surgical history, attempted to commit suicide by consumption of 300 cc (44.1%, 132.3 g) basagranTM, a readily available herbicide. This poisoning resulted in vomiting, fever, sweating, pipe-like muscle rigidity, sinus tachycardia, drowsiness, leukocytosis, rhabdomyolysis and hepatorenal damage.Emperical treatment with bromocriptine was temporally associated with resolution of above signs and symptoms. His clinical

T. J. Lin; D. Z. Hung; W. H. Hu; D. Y. Yang; T. C. Wu



Pharmacokinetics of the combination of fluvastatin and gemfibrozil  

Microsoft Academic Search

High-risk patients with dyslipidemias resistant todiet and single-agent pharmacotherapy may require combination therapy to achieve target levels of low density lipoprotein, triglycerides, and high density lipoprotein. Combinations of fibrates and 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors are effective, but because of safety concerns related to myopathy and rhabdomyolysis, it is important to consider the possibility of pharmacokinetic interactions when such combinations are

J. David Spence; Claudio E. Munoz; Lisa Hendricks; Lilian Latchinian; Henry E. Khouri



Hazards of ultra-marathon running in the Scottish highlands: exercise-associated hyponatraemia  

Microsoft Academic Search

The case histories are presented of four athletes taking part in a 95-mile ultra-endurance foot race in Scotland who were hospitalised after developing exercise-associated hyponatraemia and rhabdomyolysis. Exercise-associated hyponatraemia is relatively uncommon in temperate climates. Risk factors disposing to this disorder are discussed. Exercise-associated hyponatraemia is thought to be due to overconsumption of hypotonic fluid with other associated pathophysiology including

J A Cuthill; C Ellis; A Inglis



Acute Renal Failure in McArdle’s Disease  

Microsoft Academic Search

This is a report of a case of acute renal failure associated with McArdle’s disease. A 45-year-old man had acute renal failure that required dialysis. His case was subsequently diagnosed as rhabdomyolysis secondary to McArdle’s disease, a primary myopathy due to myophosphorylase deficiency. History-taking revealed nothing suspected to be responsible for precipitating the renal failure.Copyright © 1986 S. Karger AG,

Tsutomu Tabata; Kiichiro Kikunami; Yoshiki Matsushita; Takayuki Inoue; Takashi Inoue; Teruo Okamoto; Norio Kono; Mitsuo Takahashi; Seiichiro Tarui; Hirotoshi Morii



Exertional Compartment Syndrome of the Thigh: A Rare Diagnosis and Literature Review  

Microsoft Academic Search

Exercise-induced acute compartment syndrome of the thigh is an uncommon entity. We present a rare case of bilateral exercise-induced three-compartment syndrome of the thighs that required fasciotomies. The objective of this study was to understand the history, physical examination, signs, symptoms, pathophysiology, diagnosis, and treatment of compartment syndrome and rhabdomyolysis. A 42-year-old man presented to the Emergency Department (ED) complaining

Timothy W. King; Oren Z. Lerman; Joseph J. Carter; Stephen M. Warren



Atorvastatin Decreases the Coenzyme Q10 Level in the Blood of Patients at Risk for Cardiovascular Disease and Stroke  

Microsoft Academic Search

Background: Statins (3-hydroxy-3-methylglutaryl co- enzyme A reductase inhibitors) are widely used for the treatment of hypercholesterolemia and coronary heart dis- ease and for the prevention of stroke. There have been various adverse effects, most commonly affecting muscle and ranging from myalgia to rhabdomyolysis. These ad- verse effects may be due to a coenzyme Q10 (CoQ10) de- ficiency because inhibition of

Tatjana Rundek; Ali Naini; Ralph Sacco; Kristen Coates; Salvatore DiMauro



Renal complications of seasonal and pandemic influenza A virus infections.  


Renal complications of influenza A virus infections are uncommon but can contribute to a deterioration in the patient's condition, which include acute kidney injury (AKI) in critically ill patients, rhabdomyolysis, hemolytic uremic syndrome (HUS), acute glomerulonephritis (AGN), disseminated intravascular coagulation (DIC), Goodpasture's syndrome, and acute tubulointerstitial nephritis (TIN). The clinical characteristics of AKI in critically ill patients with pandemic influenza A(H1N1) 2009 virus (A(H1N1)pdm09) infection are similar to uninfected patients. Underlying conditions associated with AKI include older age, diabetes mellitus, obesity, pregnancy, history of asthma, and chronic kidney disease. Histologic examination of the kidneys from patients with A(H1N1)pdm09 infection who died include acute tubular necrosis (ATN), myoglobin pigment, and DIC. A(H1N1)pdm09 is present in the kidneys of some patients. The clinical characteristics of patients with rhabdomyolysis associated with influenza A include younger age and the frequent occurrence of muscle symptoms. AKI occurs in approximately one third of patients with rhabdomyolysis due to influenza A. HUS is associated with A(H1N1)pdm09 as follows: Streptococcus pneumoniae-associated HUS following A(H1N1)pdm09 infection, HUS triggered by A(H1N1)pdm09 in patients with genetic complement dysregulation, and HUS associated with A(H1N1)pdm09 without known underlying disorder. AGN, Goodpasture's syndrome, and acute TIN are extremely rare complications of influenza A virus infection. Although the pathogenesis underlying renal injuries due to influenza A virus has not been delineated, some hypotheses have been advanced, including ATN due to renal hypoperfusion or rhabdomyolysis, glomerular microthrombosis due to DIC, direct viral injury to the kidney, and an altered immune system with systemic mononuclear cell activation following influenza A virus infections. PMID:23064728

Watanabe, Toru



Multiple hymenoptera stings in children: clinical and laboratory manifestations  

Microsoft Academic Search

Multiple hymenoptera stings are a cause of rhabdomyolysis, elevated liver enzymes, clotting abnormalities, kidney injury,\\u000a and even death. However, the progression of the clinical and laboratory findings has been described mainly in sporadic case\\u000a reports. We report the clinical and laboratory manifestations of multiple hymenoptera stings in six children who were hospitalized\\u000a and referred for a nephrology evaluation and follow-up

Arnon Broides; Michal S. Maimon; Daniel Landau; Matitiahu Lifshitz




Microsoft Academic Search

\\u000a Summary   In rhabdomyolysis, muscle cell damage causes leakage of myocyte content into the circulation which elevates plasma creatinine\\u000a kinase and leads to myoglobinuria. The good long-term prognosis of the primary muscular syndrome manifesting with muscle swelling\\u000a and painful weakness contrasts with the serious systemic complications of the disease. These consist of metabolic coma, renal\\u000a failure, cardiac arrhythmias together with severe

Hans-Christian Hansen



Elevated Serum Cardiac Markers in Asymptomatic Marathon Runners after Competition: Is the Myocardium Stunned?  

Microsoft Academic Search

Prolonged strenuous exercise may trigger acute myocardial infarction (AMI), as exemplified by the occurrence of sudden cardiac death during marathon running. Serum creatine kinase MB (CK-MB) may be elevated in asymptomatic marathon runners after competition from exertional rhabdomyolysis of skeletal muscle altered by training, limiting its utility for evaluating acute cardiac injury in such athletes. Myoglobin and CK-MB2 isoform levels

Arthur J Siegel; Michelle Sholar; Jane Yang; Ela Dhanak; Kent B Lewandrowski



Pharmacokinetic and pharmacodynamic alterations of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors: Drug–drug interactions and interindividual differences in transporter and metabolic enzyme functions  

Microsoft Academic Search

3-Hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) are widely used for the treatment of hypercholesterolemia. Their efficacy in preventing cardiovascular events has been shown by a large number of clinical trials. However, myotoxic side effects, sometimes severe, including myopathy or rhabdomyolysis, are associated with the use of statins. In some cases, such toxicity is associated with pharmacokinetic alterations. In this

Yoshihisa Shitara; Yuichi Sugiyama



Delayed onset malignant hyperthermia after sevoflurane.  


Malignant hyperthermia is a hypermetabolic response to inhalation agents (such as halothane, sevoflurane, and desflurane), succinylcholine, vigorous exercise, and heat. Reactions develop more frequently in males than females (2?:?1). The classical signs of malignant hyperthermia are hyperthermia, tachycardia, tachypnea, increased carbon dioxide production, increased oxygen consumption, acidosis, muscle rigidity and rhabdomyolysis. In this case report, we present a case of delayed onset malignant hyperthermia-like reaction after the second exposure to sevoflurane. PMID:23819066

Turhan, K Sanem Cakar; Bayta?, Volkan; Batislam, Ye?im; Ozatamer, Oya



Ameliorative Effect of Hepatocyte Growth Factor on Glycerol-Induced Acute Renal Failure with Acute Tubular Necrosis  

Microsoft Academic Search

Background\\/Aims: Hepatocyte growth factor (HGF), a multi-potent growth factor, is known to promote regeneration of damaged renal epithelial cells. Glycerol injection into rats induces severe acute renal failure (ARF) with ischemia and tubular necrosis, a model which shares many features with human ARF or rhabdomyolysis. We investigated the efficacy of HGF in this glycerol-induced ARF rat model. Methods: ARF was

Tomokazu Nagano; Ikue Mori-Kudo; Atsushi Tsuchida; Takao Kawamura; Mutsuo Taiji; Hiroshi Noguchi



Aseptic gingivitis related to quetiapine hemifumarate.  


Quetiapine hemifumarate (QF) is widely used in psychiatry and is associated with regularly occurring side effects such as dizziness and metabolic problems. Apart from these typical adverse events the agent has attracted attention for several rare phenomena (priapism, cholestasis, rhabdomyolysis) that indeed feature anecdotal character, but are nevertheless indispensable for a comprehensive understanding of the factual risk profile of quetiapine. We present the first report of aseptic gingivitis associated with QF in a patient with mental retardation. PMID:22915485

Gahr, M; Kölle, M A; Freudenmann, R W; Schönfeldt-Lecuona, C



Influence of lipid lowering fibrates on P-glycoprotein activity in vitro  

Microsoft Academic Search

Statin\\/fibrate combinations are frequently used to treat mixed dyslipidemia. However, these combinations may cause life-threatening drug interactions (e.g. rhabdomyolysis) possibly induced by modifications of cytochrome P450 isozyme activities. Some statins are also transported by P-glycoprotein (Pgp) and may act as inhibitors of this drug efflux pump. So far, nothing is known about possible Pgp modulating effects of fibrates. We tested

Manuela Ehrhardt; Heike Lindenmaier; Juergen Burhenne; Walter Emil Haefeli; Johanna Weiss



Exposure of atorvastatin is unchanged but lactone and acid metabolites are increased several-fold in patients with atorvastatin-induced myopathy  

Microsoft Academic Search

Background: The most serious side effect from statin treatment is myopathy, which may proceed to rhabdomyolysis. This is the first study to investigate whether the pharmacokinetics of either atorvastatin or its metabolites, or both, is altered in patients with atorvastatin-related myopathy compared with healthy controls.Methods: A 24-hour pharmacokinetic investigation was performed in 14 patients with atorvastatin-related myopathy. Relevant polymorphisms in

Monica Hermann; Martin P. Bogsrud; Espen Molden; Anders Åsberg; Beata U. Mohebi; Leiv Ose; Kjetil Retterstøl



The syndrome of irreversible acidosis after prolonged propofol infusion  

Microsoft Academic Search

Introduction: Propofol infusion syndrome is described in the pediatric literature as metabolic acidosis, rhabdomyolysis, and bradycardia\\u000a that results in death. The pathogenesis of this syndrome is thought to be activation of the systemic inflammatory response,\\u000a which culminates in acidosis and muscle necrosis.\\u000a \\u000a \\u000a Materials and Methods: Retrospective chart review of three patients in the Neurological Critical Care Units at Hahnemann and

Monisha A. Kumar; Victor C. Urrutia; Carole E. Thomas; Karine J. Abou-Khaled; Robert J. Schwartzman



Plasma Concentration Profiles of Simvastatin 3Hydroxy3-Methylglutaryl-Coenzyme A Reductase Inhibitory Activity in Kidney Transplant Recipients with and without Ciclosporin  

Microsoft Academic Search

A few cases of severe rhabdomyolysis have been reported in heart transplant recipients treated simultaneously with ciclosporin (CS) and the 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitor lovastatin. When measured, plasma lovastatin HMG-CoA reductase inhibitor concentrations in these patients were higher than expected. This prompted us to study the plasma concentration profiles of simvastatin HMG-CoA reductase inhibitory activity after a single dose

Margret Arnadottir; Lars-Olof Eriksson; Hans Thysell; John D. Karkas



Renal cortical necrosis, peripheral gangrene, perinephric and retroperitoneal haematoma in a patient with a viper bite.  


Snakebites are estimated to affect more than 2.5 million people annually, of whom more than 100,000 die. Viper bites cause various systemic symptoms such as: coagulopathy; haemolysis; acute renal failure; a generalized increase in capillary permeability; rhabdomyolysis; and neurotoxicity. Wide spectrums of vascular complications are seen. We report the case of a patient developing gangrenous changes in a lower limb along with the development of perinepheric and retroperitoneal haematoma with acute cortical necrosis of the kidneys. PMID:22316624

Kumar, Susheel; Sharma, Aman; Sodhi, Kushaljit S; Wanchu, Ajay; Khandelwal, Niranjan; Singh, Surjit



Effects of ezetimibe add-on therapy for high-risk patients with dyslipidemia  

Microsoft Academic Search

BACKGROUND: Ezetimibe (Zetia®) is a potent inhibitor of cholesterol absorption that has been approved for the treatment of hypercholesterolemia. Statin, an inhibitor of cholesterol synthesis, is the first-choice drug to reduce low-density lipoprotein-cholesterol (LDL-C) for patients with hypercholesterolemia, due to its strong effect to lower the circulating LDL-C levels. Because a high dose of statins cause concern about rhabdomyolysis, it

Minako Yamaoka-Tojo; Taiki Tojo; Rie Kosugi; Yuko Hatakeyama; Yuki Yoshida; Yoji Machida; Naoyoshi Aoyama; Takashi Masuda; Tohru Izumi



Membranous Glomerulonephritis May Be Associated With Heavy Marijuana Abuse  

Microsoft Academic Search

It is well documented that drug abuse can cause renal diseases. Nephropathy and proteinuria among heroin addicts has been recognized since the early 1970s. The predominant lesions in heroin-associated nephropathy are segmental glomerulosclerosis in African-Americans and membranous glomerulonephritis (MGN) in the Caucasian population. Cocaine may induce kidney damage, predominantly acute renal failure in the course of rhabdomyolysis. However, there are

M. Bohatyrewicz; E. Urasinska; J. Rozanski; K. Ciechanowski



Exertional compartment syndrome of the thigh: a rare diagnosis and literature review.  


Exercise-induced acute compartment syndrome of the thigh is an uncommon entity. We present a rare case of bilateral exercise-induced three-compartment syndrome of the thighs that required fasciotomies. The objective of this study was to understand the history, physical examination, signs, symptoms, pathophysiology, diagnosis, and treatment of compartment syndrome and rhabdomyolysis. A 42-year-old man presented to the Emergency Department (ED) complaining of worsening pain and swelling in both thighs 45 h after performing a lower extremity exercise regimen. The patient's thighs were tender and swollen, but there was no ecchymosis or evidence of trauma. Admitting serum creatinine kinase (CK) was 106,289 U/L. Treatment for rhabdomyolysis was initiated. The next day, he complained of escalating bilateral thigh pain. Repeat serum CK was 346,580 U/L. The patient was diagnosed with bilateral thigh compartment syndrome and immediately taken to the operating room for fasciotomies. Postoperatively, the patient's symptoms improved rapidly and his serum CK quickly returned to normal. His incisions were closed and he returned to normal activities of daily living. Because exercise-induced compartment syndrome is an extremely rare diagnosis with a high risk of poor outcome, this article serves to emphasize the importance of considering this diagnosis during the work-up of patients presenting to the ED with rhabdomyolysis. PMID:18597970

King, Timothy W; Lerman, Oren Z; Carter, Joseph J; Warren, Stephen M



Safety of statins  

PubMed Central

Statins are an established class of drugs with proven efficacy in cardiovascular risk reduction. The concern over statin safety was first raised with the revelation of myopathy and rhabdomyolysis with the use of now withdrawn cerivastatin. Enhanced understanding of the mechanisms behind adverse effects of statins including an insight into the pharmacokinetic properties have minimised fear of statin use among clinicians. Studies reveal that occurrence of myopathy and rhabdomyolysis are rare 1/100000 patient-years. The risk of myopathy/rhabdomyolysis varies between statins due to varying pharmacokinetic profiles. This explains the differing abilities of statins to adverse effects and drug interaction potentials that precipitate adverse effects. Higher dose of rosuvastatin (80 mg/day) was associated with proteinuria and hematuria while lower doses were devoid of such effects. Awareness of drugs interacting with statins and knowledge of certain combinations such as statin and fibrates together with monitoring of altered creatine kinase activity may greatly minimise associated adverse effects. Statins also asymptomatically raise levels of hepatic transaminases but are not correlated with hepatotoxicity. Statins are safe and well tolerated including more recent potent statins such as, rosuvastatin. The benefits of intensive statin use in cardiovascular risk reduction greatly outweigh risks. The present review discusses underlying causes of statin-associated adverse effects including management in high risk groups.

Maji, Debasish; Shaikh, Shehla; Solanki, Dharmesh; Gaurav, Kumar



Two patients subdued with a TASER® device: cases and review of complications.  


In the United States, an increasing number of law enforcement agencies have employed the use of TASER® (TASER International Inc., Scottsdale, AZ) devices to temporarily immobilize violent subjects. There are reports in the lay press of adverse outcomes occurring in patients on whom TASER® devices have been deployed. Rhabdomyolysis has been associated with patients sustaining a TASER® shock, with a 1% incidence rate in subjects subdued with earlier versions of the device and then brought to the Emergency Department (ED). We present the cases of 2 patients who were seen in our ED after exhibiting violent behavior and receiving TASER® shocks. Both were hospitalized and received treatment for mild rhabdomyolysis. Both patients had multiple other characteristics that have been found to have an association with the development of rhabdomyolysis, in addition to the shocks they received. A review and discussion of the available medical literature on the subject follows, describing several complications that have been documented in patients after receiving TASER® shocks. Although a direct link between the TASER® and the reported adverse effects has not been established, patients who undergo restraint via this device frequently have pre-existing conditions or have exhibited behavior that places them at risk for the development of those effects. Such awareness of these possible complications is vital because the evaluation and management of patients developing adverse effects after these events will commonly occur in the ED. PMID:18439781

Sanford, Janyce M; Jacobs, Gregory J; Roe, Edward J; Terndrup, Thomas E



Acute kidney injury with pigment nephropathy following spider bite: a rarely reported entity in India.  


Acute kidney injury (AKI) can be seen in tropical regions following bites of various venomous animals and insects. Renal failure is seen most commonly following the bite of spiders of the Loxosceles spp. Dermonecrosis, systemic inflammatory response, hemolysis, rhabdomyolysis, and direct venom-related effects are postulated as causes of AKI. We report a documented case of AKI with pigment nephropathy following the bite of a brown spider from a tropical region which is known to have many venomous animals but has no previous reports of AKI following spider bite. Whether this is due to absence of toxic spider species or underreporting needs to be determined. PMID:23438217

Golay, Vishal; Desai, Atul; Hossain, Aref; Roychowdhary, Arpita; Pandey, Rajendra



Deep brain stimulation for medically refractory life-threatening status dystonicus in children  

PubMed Central

Generalized dystonic syndromes may escalate into persistent episodes of generalized dystonia known as status dystonicus that can be life-threatening due to dystonia-induced rhabdomyolysis and/or respiratory compromise. Treatment of these conditions usually entails parenteral infusion of antispasmodic agents and sedatives and occasionally necessitates a medically induced coma for symptom control. The authors report a series of 3 children who presented with medically intractable, life-threatening status dystonicus and were successfully treated with bilateral pallidal deep brain stimulation. Bilateral globus pallidus internus stimulation appears to be effective in the urgent treatment of medically refractory and life-threatening movement disorders.

Walcott, Brian P.; Nahed, Brian V.; Kahle, Kristopher T.; Duhaime, Ann-Christine; Sharma, Nutan; Eskandar, Emad N.



[Survival following lightning strike and treatment of sequelae].  


Lightning strike is an unpredictable weather phenomenon which can cause a variety of injuries to the human body. We present a case report with a 24-year-old male football player, who survived prolonged cardiac arrest after a lighting strike and then presented with multiple organ dysfunction due to cellular swelling, extreme rhabdomyolysis and global hypoperfusion. We describe the clinical observations, therapy and injuries which may be expected. Furthermore, the pathophysiology and factors influencing the survival of this patient are discussed. PMID:21672467

Pedersen, Malene Lægdsgaard; Uslu, Bülent; Lind, Morten Nikolaj; Carl, Peder



Spotted black snake (Pseudechis guttatus) envenomation in a maned wolf (Chrysocyon brachyurus).  


Envenomation by a spotted black snake (Pseudechis guttatus), following multiple bites on the buccal mucosa of a captive maned wolf (Chrysocyon brachyurus), caused the animal's collapse, hemolysis, rhabdomyolysis, local tissue necrosis, hepatic and renal failure, and subsequent death. The wolf died despite intensive supportive care including antivenom administration, fluid support, and a blood transfusion. Gross necropsy findings included myocardial and intestinal hemorrhage, pulmonary congestion, hepatomegaly, and splenomegaly. Microscopic examination of formalin-fixed tissues demonstrated pulmonary and abdominal visceral hemorrhage, acute nephrosis with casts, multifocal hepatic necrosis, and splenic congestion. PMID:17939361

Portas, Timothy J; Montali, Richard J



Primary adenosine monophosphate (AMP) deaminase deficiency in a hypotonic infant.  


The spectrum of the adenosine monophosphate (AMP) deaminase deficiency ranges from asymptomatic carriers to patients who manifest exercise-induced muscle pain, occasionally rhabdomyolysis, and idiopathic hyperCKemia. However, previous to the introduction of molecular techniques, rare cases with congenital weakness and hypotonia have also been reported. We report a 6-month-old girl with the association of congenital muscle weakness and hypotonia, muscle deficiency of adenosine monophosphate deaminase, and the homozygous C to T mutation at nucleotide 34 of the adenosine monophosphate deaminase-1 gene. This observation indicates the possible existence of a primary adenosine monophosphate deaminase deficiency manifested by congenital muscle weakness and hypotonia. PMID:21343608

Castro-Gago, Manuel; Gómez-Lado, Carmen; Pérez-Gay, Laura; Eirís-Puñal, Jesús; Martínez, Elena Pintos; García-Consuegra, Inés; Martín, Miguel Angel



An Isolated Bee Sting Involving Multiple Cranial Nerves  

PubMed Central

Hymenoptera stings are self-limiting events or due to allergic reactions. Sometimes envenomation with Hymenoptera can cause rare complications such as acute encephalopathy, peripheral neuritis, acute renal failure, nephrotic syndrome, silent myocardial infarction, rhabdomyolysis, conjunctivitis, corneal infiltration, lens subluxation, and optic neuropathy. The mechanism of peripheral nervous system damage is not clearly known. In our studied case after bee sting on face between the eyebrows with little erythema and 1 × 1?cm in size, bilateral blindness developed and gradually improved. Lateral movement of eyes was restricted with no pain. Involvement of cranial nerves including II, V, and VI was found. With conservative therapy after a year significant improvement has been achieved.

Motamed, Hassan; Forouzan, Arash; Rasooli, Fatemeh; Majidi, Alireza; Maleki Verki, Mohammadreza



Fulminant and Fatal Multiple Organ Failure in a 12-Year-Old Boy With Mycoplasma pneumoniae Infection.  


Mycoplasma pneumoniae (Mp) is a unique pathogen that causes not only pulmonary but also extrapulmonary manifestations that must be rapidly diagnosed. A 12-year-old boy, with no relevant medical history, presented with fever, severe epigastric pain, and vomiting. Laboratory findings showed fulminant and cholestatic hepatitis, hemolytic anemia, thrombocytopenia, acute kidney injury, disseminated intravascular coagulopathy, acute myocardial infarction, and rhabdomyolysis. His clinical condition rapidly deteriorated during intubation and continuous renal replacement therapy. Despite intensive treatment, he did not recover. We report a case of fulminant and fatal multiple organ failure in a previously healthy boy with Mp infection, describing the possible pathomechanisms of multiple organ failure involved in the disease. PMID:22211173

Park, Se Jin; Pai, Ki Soo; Kim, Ah Reum; Lee, Jang Hoon; Shin, Jae Il; Lee, Soo Young



Oral Nanoparticulate Atorvastatin Calcium is More Efficient and Safe in Comparison to Lipicure ® in Treating Hyperlipidemia  

Microsoft Academic Search

Atorvastatin calcium (AC) is a second-generation 3-hydroxy-3-methylglutaryl-CoA reductase inhibitor approved for clinical\\u000a use as a lipid lowering agent. AC, the world’s best selling drug is associated with poor oral bioavailability and serious\\u000a adverse effects like rhabdomyolysis on chronic administration. A biodegradable nanoparticulate approach was introduced here\\u000a with a view to improving the efficacy and safety of AC. Poly lactide-co-glycolic acid

A. K. Meena; D. Venkat Ratnam; G. Chandraiah; D. D. Ankola; P. Rama Rao; M. N. V. Ravi Kumar



Acute renal failure following wasp sting.  


Wasp stings can result in multi system involvement ranging from intravascular hemolysis, rhabdomyolysis, acute renal failure cardiac involvement, hepatic dysfunction and occasionally thrombocytopenia and coagulopathy. We report here a case of eight year old boy presented with history of wasp sting followed by scanty micturation, generalized swelling and respiratory distress. After admission renal replacement therapy along with oral Prednisolone was started as serum creatinine level was gradually increasing. Kidney biopsy reveled Acute Interstitial Nephritis (AIN). Diagnosis was made of acute renal failure due to AIN following wasp stings. PMID:23982560

Jesmin, T; Muinuddin, G; Hossain, M M; Rahman, M H; Mamun, A A



[Diseases of the shipwrecked: apropos of 3 cases].  


Three men (31, 34, 36 yr old) were rescued after they had drifted for 50 hours on their wrecked catamaran. While their apparent clinical condition was not worrying, besides multiple bruises, marked dehydration, epigastralgias, mild hypothermia in one patient and 50, severe biological disorders were present in all four: haemoconcentration, functional renal insufficiency, metabolic acidosis, severe rhabdomyolysis, hepatic cytolysis. After intravenous rehydration for 24 hr hydroelectrolytic and acid-base anomalies were corrected. Pathophysiology of shipwreck casualties is recalled. Initial management in ICU is necessary. Psychological and emotional aspects should not be underrated. PMID:8087631

Dalger, J M; Belat, C; Le Marec, C; Genco, G; Le Guern, G



Anabolic androgenic steroid induced necrotising myopathy  

Microsoft Academic Search

We describe the case of a 23-year-old gentleman who developed a severe generalised necrotising myopathy. Initially presenting\\u000a with features of a virus-induced polymyositis, both symptomatic and biochemical improvements were initially achieved with\\u000a glucocorticoid-based immunosuppression. Subsequently he represented with evidence of severe generalised rhabdomyolysis (creatinine\\u000a kinase peaking at 210,000 U\\/L). Rendered anuric from the myogloburic assault, he required intensive care support from

Michael Hughes; Saleh Ahmed



New-generation Skulachev ions exhibiting nephroprotective and neuroprotective properties  

Microsoft Academic Search

A mitochondria-targeted chimeric compound consisting of a rhodamine derivative linked to a plastoquinone molecule (10-(6?-plastoquinonyl)decylrhodamine,\\u000a SkQR1) was studied under conditions of acute brain or kidney damage. A protective effect of this compound was demonstrated\\u000a in a model of focal brain ischemia, rat kidney ischemia\\/reperfusion, myoglobinuria (rhabdomyolysis, or crush syndrome), and\\u000a pyelonephritis. We found that a single intraperitoneal injection of SkQR1

E. Y. Plotnikov; D. N. Silachev; A. A. Chupyrkina; M. I. Danshina; S. S. Jankauskas; M. A. Morosanova; E. V. Stelmashook; A. K. Vasileva; E. S. Goryacheva; Y. A. Pirogov; N. K. Isaev; D. B. Zorov



A fatal overdose with 3,4-methylenedioxyamphetamine derivatives.  


Methylenedioxymethylamphetamine (MDMA or 'Ecstasy') is the best known of the 3,4-methylenedioxy ring-substituted amphetamines. Reports of serious adverse reactions and fatalities associated with its use emphasise hyperpyrexia, profuse sweating and subsequent rhabdomyolysis, although cardiac deaths and fatal accidents whilst intoxicated are also prominent. Other 3,4-methylenedioxy ring-substituted amphetamines are also available in the illicit market place and may have different spectra of activity. We report here a case of fatal ingestion of a variety of drugs of this group. PMID:7908887

Forrest, A R; Galloway, J H; Marsh, I D; Strachan, G A; Clark, J C



Overview of the muscular dystrophies.  


The muscular dystrophies are a clinically and genetically heterogeneous group of myopathies typically associated with progressive weakness. Weakness may be noted at birth or develop in late adult life. Some patients manifest with myalgias, rhabdomyolysis, or only raised serum creatine kinase levels without any symptoms or signs of weakness. The muscular dystrophies can be inherited in an X-linked, autosomal recessive, or autosomal dominant fashion and can result from mutations affecting structural proteins localizable to the sarcolemmal proteins, nuclear membrane, basement membrane, sarcomere, or nonstructural enzymatic proteins. This chapter provided a brief overview of the muscular dystrophies before later chapters discuss the individual subtypes in greater detail. PMID:21496621

Amato, Anthony A; Griggs, Robert C



A case of refeeding syndrome in a marine recruit.  


Refeeding syndrome is an under-recognized complication of starvation. Presented is a 26-year-old Marine recruit who was found to have hypothermia, mental status changes, and rhabdomyolysis after purposeful weight loss with calorie restriction in conjunction with an arduous exercise program. With rest and food, the patient developed refeeding syndrome, with hypophosphatemia requiring prolonged intravenous replacement. His case is unique in illustrating both malnutrition and refeeding syndrome in someone who appeared to be healthy and was exercising strenuously up to the point of hospital admission. PMID:23707842

Bunge, Paul D; Frank, Laura L



Case report of exercise and statin-fibrate combination therapy-caused myopathy in a patient with metabolic syndrome: contradictions between the two main therapeutic pathways  

PubMed Central

Background Lifestyle modifications including exercise are beneficial and fundamentally part of the therapy of metabolic syndrome, although in most of the cases medical interventions are also required to reach the target values in the laboratory parameters. Statin and fibrate combination therapy is considered to be safe and effective in dyslipidaemia and metabolic syndrome. However, increased physical activity can enhance the statin and fibrate-associated myopathy. Myositis and the rare but life-threatening rhabdomyolysis are causing a conflict between exercise and statin-fibrate therapy, which is yet to be resolved. Case presentation We present a case of a 43-year-old Caucasian man with metabolic syndrome who had the side-effect of exercise and drug-associated myositis. The patient had only transient moderate complaints and rhabdomyolysis could be avoided with the one-month creatine kinase control, a test which is not recommended routinely by the new guidelines. Conclusions We would like to turn the spotlight on the possible complications of statin-fibrate therapy and exercise, when strict follow-up is recommended. In this condition high number of patients can be affected and the responsibility of general practitioners is accentuated.



Proximal tubule H-ferritin mediates iron trafficking in acute kidney injury  

PubMed Central

Ferritin plays a central role in iron metabolism and is made of 24 subunits of 2 types: heavy chain and light chain. The ferritin heavy chain (FtH) has ferroxidase activity that is required for iron incorporation and limiting toxicity. The purpose of this study was to investigate the role of FtH in acute kidney injury (AKI) and renal iron handling by using proximal tubule–specific FtH-knockout mice (FtHPT–/– mice). FtHPT–/– mice had significant mortality, worse structural and functional renal injury, and increased levels of apoptosis in rhabdomyolysis and cisplatin-induced AKI, despite significantly higher expression of heme oxygenase-1, an antioxidant and cytoprotective enzyme. While expression of divalent metal transporter-1 was unaffected, expression of ferroportin (FPN) was significantly lower under both basal and rhabdomyolysis-induced AKI in FtHPT–/– mice. Apical localization of FPN was disrupted after AKI to a diffuse cytosolic and basolateral pattern. FtH, regardless of iron content and ferroxidase activity, induced FPN. Interestingly, urinary levels of the iron acceptor proteins neutrophil gelatinase–associated lipocalin, hemopexin, and transferrin were increased in FtHPT–/– mice after AKI. These results underscore the protective role of FtH and reveal the critical role of proximal tubule FtH in iron trafficking in AKI.

Zarjou, Abolfazl; Bolisetty, Subhashini; Joseph, Reny; Traylor, Amie; Apostolov, Eugene O.; Arosio, Paolo; Balla, Jozsef; Verlander, Jill; Darshan, Deepak; Kuhn, Lukas C.; Agarwal, Anupam



Proximal tubule H-ferritin mediates iron trafficking in acute kidney injury.  


Ferritin plays a central role in iron metabolism and is made of 24 subunits of 2 types: heavy chain and light chain. The ferritin heavy chain (FtH) has ferroxidase activity that is required for iron incorporation and limiting toxicity. The purpose of this study was to investigate the role of FtH in acute kidney injury (AKI) and renal iron handling by using proximal tubule-specific FtH-knockout mice (FtHPT-/- mice). FtHPT-/- mice had significant mortality, worse structural and functional renal injury, and increased levels of apoptosis in rhabdomyolysis and cisplatin-induced AKI, despite significantly higher expression of heme oxygenase-1, an antioxidant and cytoprotective enzyme. While expression of divalent metal transporter-1 was unaffected, expression of ferroportin (FPN) was significantly lower under both basal and rhabdomyolysis-induced AKI in FtHPT-/- mice. Apical localization of FPN was disrupted after AKI to a diffuse cytosolic and basolateral pattern. FtH, regardless of iron content and ferroxidase activity, induced FPN. Interestingly, urinary levels of the iron acceptor proteins neutrophil gelatinase-associated lipocalin, hemopexin, and transferrin were increased in FtHPT-/- mice after AKI. These results underscore the protective role of FtH and reveal the critical role of proximal tubule FtH in iron trafficking in AKI. PMID:24018561

Zarjou, Abolfazl; Bolisetty, Subhashini; Joseph, Reny; Traylor, Amie; Apostolov, Eugene O; Arosio, Paolo; Balla, Jozsef; Verlander, Jill; Darshan, Deepak; Kuhn, Lukas C; Agarwal, Anupam



Increased toxicity when fibrates and statins are administered in combination--a metabolomics approach with rats.  


Combination therapies with fibrates and statins are used to treat cardiovascular diseases, because of their synergistic effect on lowering plasma lipids. However, fatal side-effects like rhabdomyolysis followed by acute renal necrosis sometimes occur. To elucidate biochemical changes resulting from the interaction of fibrates and statins, doses of 100 mg/kg fenofibrate, 50mg/kg clofibrate, 70 mg/kg atorvastatin and 200 mg/kg pravastatin as well as combinations thereof were administered to Crl:Wi(Han) rats for 4 weeks. Plasma metabolome profile was measured on study days 7, 14 and 28. Upon study termination, clinical pathology parameters were measured. In a separate experiment plasmakinetic data were measured in male rats after 1 week of drug administration in monotherapy as well as in combinations. Lowering of blood lipid levels as well as toxicological effects, like liver cell degradation (statins) and anemia (fibrates) and distinct blood metabolite level alterations were observed in monotherapy. When fibrates and statins were co-administered metabolite profile interactions were generally underadditive or at the utmost additive according to the linear mixed effect model. However, more metabolite levels were significantly altered during combination therapy. New effects on the antioxidant status and the cardiovascular system were found which may be related to a development of rhabdomyolysis. Accumulation of drugs during the combination therapy was not observed. PMID:22484644

Strauss, V; Mellert, W; Wiemer, J; Leibold, E; Kamp, H; Walk, T; Looser, R; Prokoudine, A; Fabian, E; Krennrich, G; Herold, M; van Ravenzwaay, B



A hyperbaric oxygen therapy approach to heat stroke with multiple organ dysfunction.  


Here in we report the case of a patient who displayed a classic heat stroke with multiple organ dysfunction and hypercoagulable state resistant to conventional whole body cooling and antipyretic therapy, and necessitating the use of hyperbaric oxygen therapy (HBOT) to rescue him from death. A 49-year-old male laborer, suffering from heat stroke syndromes (e.g., hyperpyrexia, seizure and coma, and hypotension), was admitted to an emergency unit of a medical center hospital. The patient displayed multiple organ dysfunction with rhabdomyolysis, hepatic, renal, respiratory, and cerebral dysfunction, and disseminated intravascular coagulation (DIC). Both hyperpyrexia and multiple organ dysfunction were resistant to conventional treatment measures. HBOT was adopted to rescue the patient from heat stroke-induced death. Before HBOT, analyses of serum revealed hypercoagulable state or DIC as well as signs of rhabdomyolysis, and renal and hepatic failure. In addition, pulmonary edema, coma, hypotension, and hyperpyrexia occurred. HBOT was used successfully to combat these syndromes and to rescue the patient from heat stroke death. This case suggests that HBOT is useful for treatment of heat stroke with multiple organ dysfunction. PMID:19777803

Niu, Ko-Chi; Chang, Chen-Kuei; Lin, Mao-Tsun; Huang, Kuo-Fong



How electroshock weapons kill!  

NASA Astrophysics Data System (ADS)

Growing numbers of law enforcement officers now carry an electroshock weapon (ESW). Over 500 U.S. deaths have followed ESW use in the past 26 years; over 450 of these deaths followed use of an electromuscular disruptor in the past 9 years. Most training courses teach that ESWs are safe; that they can kill only by the direct effect of electric current on the heart; and that a death following use of an ESW always has some other cause. All these teachings are false! The last was disproved by Lundquist.^1 Williams^2 ruled out direct electrical effects as a cause of almost all the 213 deaths he studied, leaving disruption of normal physiological processes as the only alternative explanation. Careful study of all such deaths identifies 4 different ways that death has or could have been brought about by the ESW: kidney failure following rhabdomyolysis [rare]; cardiac arrest from hyperkalemia following rhabdomyolysis [undocumented]; lactic acid-induced ventricular fibrillation [conclusive proof impossible]; and [most common] anoxia from so much lactic acid in the circulating blood that it acts as an oxygen scavenger, continuously depleting the blood of oxygen until most of the lactate has been metabolized. ^1M. Lundquist, BAPS 54(1) K1.270(2009). ^2Howard E. Williams, Taser Electronic Control Devices and Sudden In-Custody Death, 2008.

Lundquist, Marjorie



Dantrolene for the treatment of MDMA toxicity.  


MDMA (3,4-methylenedioxymethamphetamine), popularly known as “Ecstasy,” was first introduced and patented by Merck & Co., Inc., in 1914 as an appetite suppressant. Currently, its primary role is as an illegal stimulant used to produce a euphoric effect during parties. This case report de scribes a 31-year-old man who, after taking 3 tablets of Ecstasy, presented to an emergency department with a decreased level of consciousness and became progressively hyperthermic and rigid. During the course of his acute illness, his temperature reached 42.2°C rectally. He was given mechanical ventilation. He was aggressively cooled and dantrolene was initiated. Soon after the administration of dantrolene his temperature decreased and his rigidity began to resolve. The only complication was rhabdomyolysis with a creatine kinase level increasing to over 150 ?kat/L. This did not progress to acute renal failure. The patient made a full recovery and was discharged to psychiatry for assessment. PMID:20925170

Grunau, Brian E; Wiens, Matthew O; Greidanus, Marc



Paraphenylenediamine poisoning.  


Hair dye containing paraphenylenediamine (PPD) is widely used in India because of its free availability and low cost. PPD produces local as well as systemic toxic effects when applied topically and/or ingested. It is highly toxic when taken by mouth and the outcome depends mainly on the dose taken. Important clinical manifestations are angioedema leading to dysphasia and respiratory distress, rhabdomyolysis, intravascular hemolysis, acute renal failure and hepatic necrosis. Myocarditis or fatal arrhythmia may also occur in PPD poisoning. Mainstay of management is early recognition and supportive measures as there is no specific antidote. We hereby report a young female who presented to us with features of angioedema, cardiac manifestation and hepatic dysfunction after ingesting PPD, which was treated successfully. In the absence of laboratory facilities, clinical features like angioedema and chocolate brown-colored urine could be suggestive of PPD poisoning. PMID:23563473

Chaudhary, S C; Sawlani, K K; Singh, K


Bench-to-bedside review: mechanisms and management of hyperthermia due to toxicity.  


Body temperature can be severely disturbed by drugs capable of altering the balance between heat production and dissipation. If not treated aggressively, these events may become rapidly fatal. Several toxins can induce such non-infection-based temperature disturbances through different underlying mechanisms. The drugs involved in the eruption of these syndromes include sympathomimetics and monoamine oxidase inhibitors, antidopaminergic agents, anticholinergic compounds, serotonergic agents, medicaments with the capability of uncoupling oxidative phosphorylation, inhalation anesthetics, and unspecific agents causing drug fever. Besides centrally disturbed regulation disorders, hyperthermia often results as a consequence of intense skeletal muscle hypermetabolic reaction. This leads mostly to rapidly evolving muscle rigidity, extensive rhabdomyolysis, electrolyte disorders, and renal failure and may be fatal. The goal of treatment is to reduce body core temperature with both symptomatic supportive care, including active cooling, and specific treatment options. PMID:18096088

Eyer, Florian; Zilker, Thomas



Scintigraphic evaluation of muscle damage following extreme exercise: concise communication  

SciTech Connect

Total body Tc-99m pyrophosphate scintigraphy was performed on 11 ''ultramarathon'' runners to assess the ability of nuclear medicine techniques to evaluate skeletal-muscle injury due to exercise. We found increased muscle radionuclide concentration in 90% of the runners. The pattern of muscle uptake correlated with the regions of maximum pain. The detection of exercise-induced rhabdomyolysis appeared to be best when scintigraphy was performed within 48 hr after the race, and to be almost undetectable after about a week. It was possible to differentiate muscle injury from joint and osseous abnormalities such as bone infarct or stress fracture. Although 77% of the runners had elevated serum creatine kinase MB activity, cardiac scintigraphy showed no evidence of myocardial injury.

Matin, P.; Lang, G.; Carretta, R.; Simon, G.



Distributive shock due to systemic capillary leak syndrome treated with high-dose immunosuppression.  


A female patient in her 60s presented with a history of malaise, chills, headache and vomiting. She was in shock on presentation with a high haematocrit and a low albumin with evidence of rhabdomyolysis. Severe limb and truncal oedema developed with worsening hypotension leading to intensive care unit admission for multiple organ support. Extensive radiological, microbiological and immunological work up was negative with the exception of a monoclonal gammopathy. A review of patient investigations led to a diagnosis of Clarkson's disease. Treatment with high-dose methylprednisolone and intravenous immunoglobulins led to a rapid decline in the creatine kinase (CK) level and vasopressor requirements. The patient was discharged home on long-term terbutaline and has made a good recovery. PMID:23576661

Sheehan, James Robert; Keating, Liza; Chan, Antoni; Walden, Andrew



An isolated bee sting involving multiple cranial nerves.  


Hymenoptera stings are self-limiting events or due to allergic reactions. Sometimes envenomation with Hymenoptera can cause rare complications such as acute encephalopathy, peripheral neuritis, acute renal failure, nephrotic syndrome, silent myocardial infarction, rhabdomyolysis, conjunctivitis, corneal infiltration, lens subluxation, and optic neuropathy. The mechanism of peripheral nervous system damage is not clearly known. In our studied case after bee sting on face between the eyebrows with little erythema and 1 × 1?cm in size, bilateral blindness developed and gradually improved. Lateral movement of eyes was restricted with no pain. Involvement of cranial nerves including II, V, and VI was found. With conservative therapy after a year significant improvement has been achieved. PMID:23970981

Motamed, Hassan; Forouzan, Arash; Rasooli, Fatemeh; Majidi, Alireza; Maleki Verki, Mohammadreza



[Clinical case of acute renal failure revealing an autoimmune hypothyroidism].  


Although the clinic picture is often indicative of muscle manifestations in patients with hypothyroidism, signs and symptoms of this condition are variable from simple elevation of serum muscle enzymes with myalgia, muscle weakness, cramps to rhabdomyolysis with acute renal failure which remains a rare event. Thyroid hormones affect the function of almost every body organ, and thyroid dysfunction produces a wide range of metabolic disturbances. Hypothyroidism is associated with significant effects on the kidney which the pathophysiology seems to be multifactorial, but the exact mechanisms remain poorly understood. Hypothyroidism as a cause of renal impairment is usually overlooked, leading to unnecessary diagnostic procedures. The main objective of our observation is to report a case of acute renal failure revealing an autoimmune hypothyroidism in which thyroid hormone substitution led to a significant improvement in muscular, thyroid and renal disorders. PMID:20185381

Montasser, Dina Ibrahim; Hassani, Mohamed; Zajjari, Yassir; Bahadi, Abdelali; Alayoud, Ahmed; Hamzi, Amine; Hassani, Kawtar; Moujoud, Omar; Asseraji, Mohamed; Kadiri, Moncif; Aatif, Taoufik; El Kabbaj, Driss; Benyahia, Mohamed; Allam, Mustapha; Akhmouch, Ismail; Oualim, Zouhir



Statin induced myotoxicity.  


Statins are an effective treatment for the prevention of cardiovascular diseases and used extensively worldwide. However, myotoxicity induced by statins is a common adverse event and a major barrier to maximising cardiovascular risk reduction. The clinical spectrum of statin induced myotoxicity includes asymptomatic rise in creatine kinase concentration, myalgia, myositis and rhabdomyolysis. In certain cases, the cessation of statin therapy does not result in the resolution of muscular symptoms or the normalization of creatine kinase, raising the possibility of necrotizing autoimmune myopathy. There is increasing understanding and recognition of the pathophysiology and risk factors of statin induced myotoxicity. Careful history and physical examination in conjunction with selected investigations such as creatine kinase measurement, electromyography and muscle biopsy in appropriate clinical scenario help diagnose the condition. The management of statin induced myotoxicity involves statin cessation, the use of alternative lipid lowering agents or treatment regimes, and in the case of necrotizing autoimmune myopathy, immunosuppression. PMID:22560377

Sathasivam, Sivakumar



McArdle disease: a case report and review.  


McArdle disease (glycogen storage disease type V) is a pure myopathy caused by an inherited deficit of myophosphorylase. The disease exhibits clinical heterogeneity, but patients typically experience exercise intolerance, acute crises of early fatigue, and contractures, sometimes with rhabdomyolysis and myoglobinuria, triggered by static muscle contractions or dynamic exercise. We present the case of a 54-year-old man with a lifelong history of fatigability, worsening on exertion. Laboratory evaluation revealed significant elevations in levels of creatine kinase (7924 U/L), lactate dehydrogenase (624 U/L), and myoglobulin (671 ng/mL). A muscle biopsy confirmed the presence of McArdle disease. This case report illustrates how, due to embarrassment, the patient hid his symptoms for many years and was eventually extremely relieved and "liberated" once McArdle disease was diagnosed 40 years later. PMID:23754915

Leite, Alberto; Oliveira, Narciso; Rocha, Manuela



Malignant hyperthermia and its implications in general dentistry.  


Malignant hyperthermia (MH) is an uncommon and potentially life-threatening pharmacogenetic disorder. This abnormality in muscle metabolism can be triggered by a variety of agents (particularly general anesthetics and stress), resulting in a rapid heart rate increase, muscle rigidity, acidosis, temperature elevation, rhabdomyolysis, and renal failure. Immediate discontinuing of triggering agents, oxygenation, cooling, and dantrolene are necessary to treat an episode. MH-susceptible patients often indicate a positive family history of experiencing an adverse event during anesthesia. Few diagnostic tests are available to screen patients; the most accurate test is a skeletal muscle biopsy. MH-susceptible patients can undergo surgical procedures as necessary. Careful exploration of the medical history will allow the clinician to make the necessary modifications to treat and manage an episode expediently. PMID:19819813

Reifenstahl, Erik F; Rowshan, Henry H


A hypokalemic muscular weakness after licorice ingestion: a case report.  


A 21-year-old male presented to the emergency department with the complaint of muscle weakness. The patient had used a powderized over-the-counter product named 'Tekumut' for 2 weeks to quit smoking. The granulated product was studied and determined to contain 'licorice' containing glycyrrhizic acid.Licorice (a plant which contain glycyrrhizic acid) -induced hypokalemia usually has a mild progression. However, it may cause a critical failure in physical action by means of weakness followed by paralysis and may cause rhabdomyolysis or ventricular fibrillation, leading to death, when left untreated.This report has presented the first case with hypocalemia due to licorice consumption in granulated form from Turkey. In addition, the report has aimed to emphasize the importance of obtaining the detailed history of a patient in diagnosis. PMID:20181204

Meltem, Akkas Camkurt; Figen, Coskun; Nalan, Metin Aksu; Mahir, Kunt; Sebnem, Bozkurt; Mehlika, Isildak; Kasim, Kilic Ahmet; Miyase, Bayraktar



Exacerbation of acetazolamide-responsive sodium channel myotonia by uterotonic agents.  


The symptoms of myotonia can worsen during pregnancy and tocolysis with ritodrine has been associated with rhabdomyolysis. We describe a patient with myotonia who developed hypertonus immediately following the administration of uterotonic agents. A 24-year-old, G2P1 at 31 weeks of gestation with a history of acetazolamide-responsive myotonia presented with premature rupture of membranes. During cesarean delivery she experienced significant hypertonus of the upper limbs, shoulders, fingers, and mouth immediately after intravenous administration of oxytocin 5 IU and methylergometrine maleate 0.2mg. The mechanism underlying increased muscle tone in response to these drugs remains unclear. Anesthesiologists should be especially attentive to the administration of uterotonic drugs during the management of pregnant myotonia patients. PMID:21074404

Fujii, K; Iranami, H; Hatano, Y



Recurrent myoglobinuria and deranged acylcarnitines due to a mutation in the mtDNA MT-CO2 gene.  


Mitochondrial myopathies commonly present with exercise intolerance typified by breathlessness and fatigue on exercise. In contrast, exercise-induced rhabdomyolysis and myoglobinuria occur rarely. We present a 43-year-old man with a lifelong history of exercise intolerance associated with myalgia and recurrent episodes of exercise-induced myoglobinuria. From early childhood, he had weekly episodes of myoglobinuria, which became infrequent (every 3 months) as an adult. Carnitine transporter defect was suspected, because carnitine levels were low in muscle. During childhood, he was treated with carnitine (4-5 g daily), but without effect. With the advent of acylcarnitines, profiles mimicking but not diagnostic for multiple acyl-CoA dehydrogenase deficiency (MADD) were found. This led to treatment with riboflavin (100 mg/day for 3 years), again without effect. Clinical examination, including echocardiography, revealed no signs of involvement from other organs, and all relatives were asymptomatic. PMID:23616164

Vissing, Christoffer Rasmus; Duno, Morten; Olesen, Jess Have; Rafiq, Jabin; Risom, Lotte; Christensen, Ernst; Wibrand, Flemming; Vissing, John



Anesthesia in neuromuscular diseases.  


Neuromuscular diseases raise a lot of anesthesia related problems. The first is the hitherto unknown disease discovered by an unexpected adverse reaction to anesthetics or/and muscle relaxants up to a life-threatening incident. A second problem is the probable, suspected or proven disposition to malignant hyperthermia in patients with other neuromuscular diseases. Furthermore, severe rhabdomyolysis can be induced in myopathic muscle by the application of succinylcholine alone or in combination with inhalational anesthetics resulting in hyperkalemia, myoglobinuria and CK-elevation, sometimes followed by cardiac arrest. Cardiomyopathy is a common feature in many neuromuscular diseases. All cardiodepressant agents must be avoided. Specific problems with muscle relaxants arise in myasthenia gravis and in the myotonias. In the later stages of severe neuromuscular diseases the main problem concerning anesthesia is respiratory failure. The individual risk of every patient has to be evaluated before anesthesia. Recommendations for the anesthetic management are given. PMID:2196754

Breucking, E; Mortier, W



[Recurrent macroscopic hematuria and heterozygote drepanocytosis].  


The sickle cell trait may result in recurrent macroscopic haematuria which can cause severe anaemia. Despite normal intravenous urography and CAT, the haemorrhage probably occurs in the renal medulla due to the operative physiopathogenic conditions. A proliferative mesangial glomerulonephritis with IgG, IgA, IgM and complement deposits, which has a controversial relationship with sickle cell disease, may be discovered by renal biopsy. The severity of the anaemia may necessitate treatment with epsilon-aminocaproic acid which cures the haematuria but may provoke rhabdomyolysis. This case report is followed by a review of the literature of the different types of renal involvement in sickle cell trait and sickle cell anemia. PMID:3592455

Nedelec, G; Didelot, F; Giudicelli, C P; Perrot, S; Debord, T; Brouard, R; Rougier, Y



Phosphoglycerate kinase San Francisco: a new variant associated with hemolytic anemia but not with neuromuscular manifestations.  


Phosphoglycerate kinase deficiency is a rare, x-linked glycolytic defect that, when severe, can be associated with hemolytic anemia, rhabdomyolysis, or neurological disorders. We report here a new phosphoglycerate kinase variant discovered in a boy with severe hemolytic anemia but no evidence of neuromuscular disease or developmental delay. The biochemical properties of the variant enzyme (greatly increased kmATP and km3-phosphoglycerate; normal pH optimum, electrophoretic mobility, and substrate specificity; resistance to heat inactivation) establish its uniqueness. Separation of light and dense red cells by centrifugation showed no greater loss of phosphoglycerate kinase activity in dense ("old") variant cells than in normal cells. We postulate that the striking stability of the variant enzyme allows cells capable of protein synthesis to accumulate sufficient enzyme to limit neuromuscular sequelae. PMID:3605066

Guis, M S; Karadsheh, N; Mentzer, W C



Possible fatal acetaminophen intoxication with atypical clinical presentation.  


Acetaminophen or paracetamol, a commonly used over-the-counter analgesic, is known to elicit severe adverse reactions when taken in overdose, chronically at therapeutic dosage or, sporadically, following single assumptions of a therapeutic dose. Damage patterns including liver damage and, rarely, acute tubular necrosis or a fixed drug exanthema. We present a case of fatal acetaminophen toxicity with postmortem blood concentration 78 ?g/mL and unusual clinical features, including a visually striking and massive epidermolysis and rhabdomyolysis, disseminated intravascular coagulation and myocardial ischemia. This case is compared with the most similar previous reports in terms of organ damage, clinical presentation, and cause of death. We conclude that a number of severe patterns of adverse effects to acetaminophen are emerging that were previously greatly underestimated, thus questioning the adequacy of the clinical spectrum traditionally associated with acetaminophen intoxication and leading to the need to review this spectrum and the associated diagnostic criteria. PMID:23822653

De-Giorgio, Fabio; Lodise, Maria; Chiarotti, Marcello; d'Aloja, Ernesto; Carbone, Arnaldo; Valerio, Luca



Spontaneous bilateral compartment syndrome of the legs: A case report and review of the literature  

PubMed Central

INTRODUCTION Bilateral acute compartment syndrome of the legs is a rare presentation requiring emergent surgical intervention. PRESENTATION OF CASE We report the case of 41-year-old woman who presented with acute bilateral compartment syndrome of the legs, complicated by rhabdomyolysis and acute renal failure. DISCUSSION There are very few previously reported cases of bilateral compartment syndrome of the legs. In the present case, despite any clear causative factor, we suggest that the aetiology is related to inadvertent posture during sleep. CONCLUSION The diagnosis of acute bilateral compartment syndrome of the legs requires a high index of suspicion, particularly in the absence of obvious aetiology. A successful outcome can be achieved with early diagnosis, prompt surgical intervention and a multidisciplinary approach.

Khan, T.; Lee, G.H.; Alvand, A.; Mahaluxmivala, J.S.



Emergency Endovascular Treatment of an Acute Traumatic Rupture of the Thoracic Aorta Complicated by a Distal Low-Flow Syndrome  

SciTech Connect

We report the case of a patient who suffered major trauma following a motorcycle accident that resulted in multiple fractures, bilateral hemopneumothorax, pulmonary contusions, and an isthmic rupture of the aorta with a pseudoaneurysm compressing the descending aorta. This compression was responsible for distal hypotension and low flow, leading to acute renal insufficiency and massive rhabdomyolysis. Due to the critical clinical status of the patient, which prevented any type of open thoracic surgery, endovascular treatment was performed. An initial stent-graft permitted alleviation of the compression and the re-establishment of normal hemodynamic conditions, but its low position did not allow sufficient coverage of the rupture. A second stent-graft permitted total exclusion of the pseudoaneurysm while preserving the patency of the left subclavian artery.

Bruninx, Guy; Wery, Didier; Dubois, Eric; El Nakadi, Badih; Dueren, Eric van; Verhelst, Guy; Delcour, Christian [Unite Vasculaire Integree, CHU de Charleroi, 92 Blvd. P. Janson, B-6000 Charleroi (Belgium)



Operative care and surveillance in severe trauma patients. Interference between resuscitation treatments and anaesthesiology, and consequence on immunity.  


Major trauma remains a worldwide cause of morbi-mortality. Early mortality is the consequence of hemorrhagic shock and traumatic brain injury. During early resuscitation, anaesthesia is often mandatory to perform surgery. It is mandatory to master the hemodynamic effects of hypnotic drugs in order to anticipate their potential deleterious effects in the setting of hemorrhagic shock. After early resuscitation, trauma patients present a high prevalence of nosocomial pneumonia, which sustains major morbidity. Nosocomial pneumonia are the consequence of an overwhelming systemic inflammatory response syndrome (SIRS) as well as a trauma-related immunosuppression. The administration of hemisuccinate of hydrocortisone modulates the SIRS and reduces the risk of nosocomial pneumonia as well as the length of mechanical ventilation. Finally in the operating theatre, fighting against hypothermia and un-anatomical positions, which can aggravate rhabdomyolysis, are both mandatory. PMID:23916514

Cinotti, R; Roquilly, A; Mahé, P-J; Demeure-Dit-Latte, D; Chupin, A-M; Josse-Chatel, N; Peneau, C; Paulus, J; Lejus, C; Asehnoune, K



Atypical presentation of distal renal tubular acidosis in two siblings.  


Primary distal renal tubular acidosis (dRTA) is an inherited disease characterized by the inability of the distal tubule to lower urine pH <5.50 during systemic acidosis. We report two male siblings who presented with severe hyperchloremic metabolic acidosis, high urinary pH, nephrocalcinosis, growth retardation, sensorineural hearing loss, and hypokalemic paralysis. Laboratory investigations revealed proximal tubular dysfunction (low molecular weight proteinuria, generalized hyperaminoaciduria, hypophosphatemia with hyperphosphaturia, and hypouricemia with hyperuricosuria). There was significant hyperoxaluria and laboratory evidence for mild rhabdomyolysis. Under potassium and alkali therapy, proximal tubular abnormalities, muscular enzymes, and oxaluria normalized. A homozygous mutation in the ATP6V1B1 gene, which is responsible for dRTA with early hearing loss, was detected in both siblings. In conclusion, proximal tubular dysfunction and hyperoxaluria may be found in children with dRTA and are reversible under appropriate therapy. PMID:18386070

Tasic, Velibor; Korneti, Petar; Gucev, Zoran; Hoppe, Bernd; Blau, Nenad; Cheong, Hae Il



Mass envenomations by honey bees and wasps.  

PubMed Central

Stinging events involving honey bees and wasps are rare; most deaths or clinically important incidents involve very few stings (< 10) and anaphylactic shock. However, mass stinging events can prove life-threatening via the toxic action of the venom when injected in large amounts. With the advent of the Africanized honey bee in the southwestern United States and its potential for further spread, mass envenomation incidents will increase. Here we review the literature on mass stinging events involving honey bees and wasps (i.e., yellowjackets, wasps, and hornets). Despite different venom composition in the two insect groups, both may cause systemic damage and involve hemolysis, rhabdomyolysis, and acute renal failure. Victim death may occur due to renal failure or cardiac complications. With supportive care, however, most victims should be able to survive attacks from hundreds of wasps or approximately 1000 honey bees.

Vetter, R S; Visscher, P K; Camazine, S



[Preoperative evaluation, preparation and outcome prediction. II: preface and comments].  


In this special issue, essential points in preoperative evaluation are presented on the basis of up-to-date information. Myasthenia gravis should be evaluated according to individual severity. Muscular dystrophies may lead to rhabdomyolysis perioperatively. Schizophrenia is predisposed to developing torsade de pointes. Depression could be a risk factor of acute myocardial infarction. Infants may be influenced by anesthesia with respect to brain development. Elderly patients should be evaluated on the basis of age, physiological states, coexisting diseases and the type of surgery. Difficult airway management can be predicted by Mallanpati classification and thyromental distance. Jehovah's Witness of ages below 15 should be informed about the policy of life-saving blood transfusion. Oral contraceptive is associated with a fivefold-increased risk of perioperative venous thromboembolism. PMID:20857660

Sumikawa, Koji



[Acute renal injury in polytrauma patients].  


Acute Kidney Injury (AKI) in trauma is, in most cases, multifactorial. Factors related to the initial ressuscitation protocol, degree of the systemic inflamatory response to trauma, contrast nephropathy in diagnostic procedures, rhabdomyolysis and abdominal compartment syndrome are some of those factors. Nowadays a uniformization in diagnostic criteria for AKI has been proposed by the Acute Kidney Injury Network (AKIN) and as a result the incidence of AKI and its impact in outcomes in trauma patients also needs to be reconsider. In this review we aim to approach epidemiologic, physiologic and clinical relevant data in the critical care of patients victims of trauma and also to expose the risks of indiscriminate use of volume expanders and the interaction between renal replacement theraphy and intracranial hypertension. PMID:23598752

Romano, Thiago Gomes; Tierno, Paulo Fernando Guimarães Morando Marzocchi


Role of transcranial magnetic stimulation in differentiating motor nervous tract disorders from other causes of recumbency in four horses and one donkey.  


Transcranial magnetic stimulation and measurement of the magnetic motor-evoked potentials (MMEPs) in the thoracic and pelvic limbs of four recumbent horses and one recumbent donkey were used to assess the integrity of the descending motor pathways, in order to confirm or exclude a descending motor tract lesion as the cause of the recumbency. In two of the animals abnormal MMEPs were recorded; in one of the horses a lesion along the cervical spinal cord due to a fracture of the fifth cervical vertebra was diagnosed and confirmed by radiography and postmortem examination; in another horse, damage to the peripheral nerves of the left forelimb was diagnosed and confirmed postmortem when a large abscess was found to have been compressing the peripheral nerves at the level of the last cervical vertebra. In the three other animals, normal MMEPs were recorded, and laminitis, rhabdomyolysis and physitis were diagnosed as the causes of the recumbency. PMID:16299367

Nollet, H; Vanschandevijl, K; Van Ham, L; Vanderstraeten, G; Deprez, P



[Multiorgan failure associated with hyperthermia in an infant with Prader-Willi syndrome. Case report].  


Heat stroke is a medical emergency characterized primarily by an elevated core temperature associated with a systemic inflammatory response, which causes multiple organ dysfunction in which encephalopathy predominates. If it is not early treated has high mortality. The Prader-Willi syndrome is a multisystem genetic disorder secondary to an abnormality in long arm chromosome 15 (15q11-q13), characterized by neonatal central hypotonia, developmental delay, hypogonadism, hyperphagia and obesity. These patients are susceptible to developing thermoregulatory problems. We report the case of a 5-month-old infant, in whom a diagnosis of Prader-Willi syndrome was established in the course of a febrile episode without known focus, who developed multiorganic failure and rhabdomyolysis secondary to hyperthermia. PMID:24092035

Donoso, Alejandro; Arriagada, Daniela; Campbell, Stephanie; Cruces, Pablo



[Treatment of heat stroke].  


Immediate cooling and support of organ-system function are the two main therapeutic objectives in patients with heat stroke. When cooling is rapidly initiated and both the body temperature and cognitive function return to the normal range within an hour of onset of symptoms, most patients recover fully. Immersion in an ice-water bath is the most effective cooling method, and evaporative cooling is a rapid and effective alternative. To prevent the development of rhabdomyolysis-induced acute renal failure, aggressive IV rehydration should be continued for first 24 to 72 hours with the goal of maintaining a minimum urine output of 2 mL/kg/h. Treatment of heat cramps also consists of fluid and salt replacement (PO or IV) and rest in a cool environment. In severe cases, IV magnesium sulphate may be effective to relieve muscle cramping. PMID:22690601

Yagi, Keiichi; Kim, Soong-Ho



Recommendations for anesthesia and perioperative management of patients with neuromuscular disorders.  


Patients with neuromuscular disorders are at high risk of intraoperative and postoperative complications. General anesthesia in these patients may exacerbate respiratory and cardiovascular failure due to a marked sensitivity to several anesthetic drugs. Moreover, succinylcholine and halogenated agents can trigger life-threatening reactions, such as malignant hyperthermia, rhabdomyolysis and severe hyperkalemia. Therefore, regional anesthesia should be used whenever possible. If general anesthesia is unavoidable, special precautions must be taken. In particular, for patients at increased risk of respiratory complications (i.e., postoperative atelectasis, acute respiratory failure, nosocomial infections), noninvasive ventilation associated with aggressive airway clearance techniques can successfully treat upper airway obstruction, hypoventilation and airway secretion retention, avoiding prolonged intubation and tracheotomy. Anesthesia and perioperative management of patients with neuromuscular disorders are described in this article. To grade the strength of recommendations and the quality of evidence we adopted the GRADE approach. In case of low-quality evidence, these recommendations represent the collective opinion of the expert panel. PMID:23419334

Racca, F; Mongini, T; Wolfler, A; Vianello, A; Cutrera, R; Del Sorbo, L; Capello, E C; Gregoretti, C; Massa, R; De Luca, D; Conti, G; Tegazzin, V; Toscano, A; Ranieri, V M



Statin-associated myopathy and its exacerbation with exercise.  


3-Hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) are a common and effective treatment for hypercholesterolemia, with a low overall rate of side-effects. The most common complication is some degree of skeletal muscle myopathy, ranging from painless serum creatine kinase elevations to rhabdomyolysis. Unfortunately, the likelihood and/or severity of complications increases with the combination of statin treatment and physical activity. The specific pathways that mediate statin-associated myopathy are unclear, and research directly addressing the exacerbation with exercise is limited. Potential mechanisms include the induction of skeletal muscle fiber apoptosis, alterations in ubiquitin-proteasome pathway activity, mitochondrial dysfunction, and terpenoid depletion. In this review we provide an overview of research that specifically addresses the combination of statin-associated myopathy and physical activity and highlight some deficiencies in the available literature, as well as future directions for this important subset of statin-associated myopathy. PMID:20878737

Meador, Benjamin M; Huey, Kimberly A



[Patient with encephalitis presenting with olanzapine-responsive malignant catatonia].  


We report the case of a 29-year-old man, who could not remember some words of Kanji and showed emotional instability. Magnetic resonance imaging (MRI) scan of his brain appeared normal. Cerebrospinal fluid (CSF) analysis showed lymphocytic pleocytosis. An electroencephalogram (EEG) showed slow activities in both frontal regions of the brain. He was diagnosed as acute encephalitis. On his fourth hospital day, he was found to be catatonic and showed mutism, akinetism, and catalepsy. On the ninth day, he showed hyperpyrexia, muscle rigidity, difficulty in swallowing, respiratory insufficiency, and rhabdomyolysis (creatine phosphokinase (CK), 3038 IU/l). He was diagnosed as malignant catatonia. Intravenous administration of acyclovir, high-dose methylprednisolone, antibiotics, diazepam, and dantrolene sodium was not effective. After initiating oral administration of olanzapine, his condition improved. PMID:20535983

Suzuki, Hayato; Fukushima, Takao; Makino, Kunihiko; Kuwabara, Takeo



MDEA related death in Crete: a case report and literature review.  


"Designer drugs" are derivatives of approved drugs abused for recreational effect and created by underground laboratories to circumvent legal restriction. By far the most controversial drug has been MDMA (3,4-methylenedioxymethamphetamine) and the newer derivative MDEA (3,4-methylenedioxymethamphetamine) often called "Eve". MDEA-related deaths have not been reported in the US, but there have been a death of MDMA and MDEA severe poisonings. Convulsions, collapse, hyperpyrexia, disseminated intravascular coagulation rhabdomyolysis, and acute liver and renal damage result from the ingestion of the drug. Complications may occur and severity and death possibly result. The case of a 31-y-old male, the first victim of MDEA in Greece, is reported. Blood MDEA was 3.1 micrograms/mL; MDEA concentrations in liver, lung and kidney were 4.8, 5.2, and 4.8 micrograms/g respectively. PMID:9251177

Tsatsakis, A M; Michalodimitrakis, M N; Patsalis, A N



Acute Kidney Injury in HIV- Infected Patients  

PubMed Central

Acute kidney injury is common in HIV-infected patients, and has been associated with increased morbidity and mortality. Prior to the introduction of effective antiretroviral therapy, acute kidney injury in HIV-positive patients was most commonly the result of volume depletion, septicemia, or nephrotoxic medications. Acute kidney injury remains a significant problem in the antiretroviral era, and is still commonly attributed to infection or nephrotoxic medications. Less common causes such as direct infectious insults, immune restoration inflammatory syndrome, rhabdomyolysis, and obstruction should be considered when the underlying process is not obvious. In addition to advanced HIV disease, several other patient characteristics have emerged as potential risk factors for acute kidney injury in the antiretroviral era, including older age, diabetes, pre-existing chronic kidney disease, and hepatitis co-infection or liver disease.

Kalim, Sahir; Szczech, Lynda A.; Wyatt, Christina M.



Excited delirium: Consideration of selected medical and psychiatric issues  

PubMed Central

Excited delirium, sometimes referred to as agitated or excited delirium, is the label assigned to the state of acute behavioral disinhibition manifested in a cluster of behaviors that may include bizarreness, aggressiveness, agitation, ranting, hyperactivity, paranoia, panic, violence, public disturbance, surprising physical strength, profuse sweating due to hyperthermia, respiratory arrest, and death. Excited delirium is reported to result from substance intoxication, psychiatric illness, alcohol withdrawal, head trauma, or a combination of these. This communication reviews the history of the origins of excited delirium, selected research related to its causes, symptoms, management, and the links noted between it and selected medical and psychiatric conditions. Excited delirium involves behavioral and physical symptoms that are also observed in medical and psychiatric conditions such as rhabdomyolysis, neuroleptic malignant syndrome, and catatonia. A useful contribution of this communication is that it links the state of excited delirium to conditions for which there are known and effective medical and psychiatric interventions.

Samuel, Edith; Williams, Robert B; Ferrell, Richard B



Statin-induced apoptosis and skeletal myopathy.  


Over 100 million prescriptions were filled for statins (3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors) in 2004. Statins were originally developed to lower plasma cholesterol in patients with hypercholesterolemia and are the most effective drugs on the market in doing so. Because of the discovered pleiotropic effects of statins, the use has expanded to the treatment of many other conditions, including ventricular arrythmias, idiopathic dilated cardiomyopathy, cancer, osteoporosis, and diabetes. The elderly population is growing. Therefore, it is estimated that the number of statin users will also increase. Fortunately, the use of statins is relatively safe with few side effects. Myopathy is the most common side effect with symptoms ranging from fatigue, weakness, and pain to symptoms associated with rhabdomyolysis which is a life-threatening condition. The development of statin-induced rhabdomyolysis is rare occurring in approximately 0.1% of patients; however, the occurrence of less severe symptoms is underreported and may be 1-5% or more. Physical exercise appears to increase the likelihood for the development of myopathy in patients taking statins. It is thought that as many as 25% of statin users who exercise may experience muscle fatigue, weakness, aches, and cramping due to statin therapy and potentially dismissed by the patient and physician. The mechanisms causing statin-induced myopathy have not been elucidated; however, research efforts suggest that apoptosis of myofibers may contribute. The mitochondrion is considered a regulatory center of apoptosis, and therefore its role in the induction of apoptosis will be discussed as well as the mechanism of statin-induced apoptosis and myopathy. PMID:16885396

Dirks, Amie J; Jones, Kimberly M



A past Haff disease outbreak associated with eating freshwater pomfret in South China  

PubMed Central

Background Haff disease is unexplained rhabdomyolysis caused by consumption of fishery products in the previous 24 h. It was first identified in Europe in 1924 but the condition is extremely rare in China. Here we describe a past outbreak of acute food borne muscle poisoning that occurred in Guangdong Province (South China) in 2009. Methods The first full outbreak of Haff disease reported in Jiangsu Province (East China) in 2010, indicated that the incidence of the disease may be increasing in China. We, therefore first retrospectively reviewed epidemiologic, trace-back, environmental studies, and laboratory analyses, including oral toxicity testing to ascertain risk and chemical analysis to identify toxin(s), from the 2009 Guangdong outbreak. Then we compared data from the 2009 outbreak with data from all other Haff disease outbreaks that were available. Results Clinical symptoms and laboratory findings indicated that the 2009 Guangdong outbreak disease was consistent with rhabdomyolysis. Epidemiologic, trace-back, environmental studies and laboratory analyses implied that the disease was caused by freshwater Pomfrets consumed prior to the onset of symptoms. We also identified common factors between the 2009 Guangdong outbreak and previous Haff disease outbreaks reported around the world, while as with other similar outbreaks, the exact etiological factor(s) of the disease remains unknown. Conclusions The 2009 Guangdong outbreak of ‘muscle poisoning’ was retrospectively identified as an outbreak of Haff disease. This comprised the highest number of cases reported in China thus far. Food borne diseases emerging in this unusual form and the irregular pattern of outbreaks present an ongoing public health risk, highlighting the need for improved surveillance and diagnostic methodology.



Statin-Associated Muscular and Renal Adverse Events: Data Mining of the Public Version of the FDA Adverse Event Reporting System  

PubMed Central

Objective Adverse event reports (AERs) submitted to the US Food and Drug Administration (FDA) were reviewed to assess the muscular and renal adverse events induced by the administration of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) and to attempt to determine the rank-order of the association. Methods After a revision of arbitrary drug names and the deletion of duplicated submissions, AERs involving pravastatin, simvastatin, atorvastatin, or rosuvastatin were analyzed. Authorized pharmacovigilance tools were used for quantitative detection of signals, i.e., drug-associated adverse events, including the proportional reporting ratio, the reporting odds ratio, the information component given by a Bayesian confidence propagation neural network, and the empirical Bayes geometric mean. Myalgia, rhabdomyolysis and an increase in creatine phosphokinase level were focused on as the muscular adverse events, and acute renal failure, non-acute renal failure, and an increase in blood creatinine level as the renal adverse events. Results Based on 1,644,220 AERs from 2004 to 2009, signals were detected for 4 statins with respect to myalgia, rhabdomyolysis, and an increase in creatine phosphokinase level, but these signals were stronger for rosuvastatin than pravastatin and atorvastatin. Signals were also detected for acute renal failure, though in the case of atorvastatin, the association was marginal, and furthermore, a signal was not detected for non-acute renal failure or for an increase in blood creatinine level. Conclusions Data mining of the FDA's adverse event reporting system, AERS, is useful for examining statin-associated muscular and renal adverse events. The data strongly suggest the necessity of well-organized clinical studies with respect to statin-associated adverse events.

Sakaeda, Toshiyuki; Kadoyama, Kaori; Okuno, Yasushi



Malignant hyperthermia  

PubMed Central

Malignant hyperthermia (MH) is a pharmacogenetic disorder of skeletal muscle that presents as a hypermetabolic response to potent volatile anesthetic gases such as halothane, sevoflurane, desflurane and the depolarizing muscle relaxant succinylcholine, and rarely, in humans, to stresses such as vigorous exercise and heat. The incidence of MH reactions ranges from 1:5,000 to 1:50,000–100,000 anesthesias. However, the prevalence of the genetic abnormalities may be as great as one in 3,000 individuals. MH affects humans, certain pig breeds, dogs, horses, and probably other animals. The classic signs of MH include hyperthermia to marked degree, tachycardia, tachypnea, increased carbon dioxide production, increased oxygen consumption, acidosis, muscle rigidity, and rhabdomyolysis, all related to a hypermetabolic response. The syndrome is likely to be fatal if untreated. Early recognition of the signs of MH, specifically elevation of end-expired carbon dioxide, provides the clinical diagnostic clues. In humans the syndrome is inherited in autosomal dominant pattern, while in pigs in autosomal recessive. The pathophysiologic changes of MH are due to uncontrolled rise of myoplasmic calcium, which activates biochemical processes related to muscle activation. Due to ATP depletion, the muscle membrane integrity is compromised leading to hyperkalemia and rhabdomyolysis. In most cases, the syndrome is caused by a defect in the ryanodine receptor. Over 90 mutations have been identified in the RYR-1 gene located on chromosome 19q13.1, and at least 25 are causal for MH. Diagnostic testing relies on assessing the in vitro contracture response of biopsied muscle to halothane, caffeine, and other drugs. Elucidation of the genetic changes has led to the introduction, on a limited basis so far, of genetic testing for susceptibility to MH. As the sensitivity of genetic testing increases, molecular genetics will be used for identifying those at risk with greater frequency. Dantrolene sodium is a specific antagonist of the pathophysiologic changes of MH and should be available wherever general anesthesia is administered. Thanks to the dramatic progress in understanding the clinical manifestation and pathophysiology of the syndrome, the mortality from MH has dropped from over 80% thirty years ago to less than 5%.

Rosenberg, Henry; Davis, Mark; James, Danielle; Pollock, Neil; Stowell, Kathryn



The pharmacology and toxicology of "ecstasy" (MDMA) and related drugs  

PubMed Central

Abtract "Ecstasy" (MDMA) and related drugs are amphetamine derivatives that also have some of the pharmacological properties of mescaline. They have become popular with participants in "raves," because they enhance energy, endurance, sociability and sexual arousal. This vogue among teenagers and young adults, together with the widespread belief that "ecstasy" is a safe drug, has led to a thriving illicit traffic in it. But these drugs also have serious toxic effects, both acute and chronic, that resemble those previously seen with other amphetamines and are caused by an excess of the same sympathomimetic actions for which the drugs are valued by the users. Neurotoxicity to the serotonergic system in the brain can also cause permanent physical and psychiatric problems. A detailed review of the literature has revealed over 87 "ecstasy"-related fatalities, caused by hyperpyrexia, rhabdomyolysis, intravascular coagulopathy, hepatic necrosis, cardiac arrhythmias, cerebrovascular accidents, and drug-related accidents or suicide. The toxic or even fatal dose range overlaps the range of recreational dosage. The available evidence does not yet permit an accurate assessment of the size of the problem presented by the use of these drugs.

Kalant, Harold



Basic principles of nuclear medicine techniques for detection and evaluation of trauma and sports medicine injuries.  


Nuclear medicine skeletal imaging is a very sensitive technique for evaluating bone and muscle abnormalities because it can detect minor changes in metabolism and blood flow. The specificity of bone imaging, however, depends on the ability of the nuclear medicine physician to make a differential diagnosis. To aid in making a specific diagnosis, this article describes the various patterns of abnormality in stress fractures, tibial stress syndrome (shin splints), compartment syndrome, enthesopathy, and traumatic fractures. The characteristic scintigraphic appearance of joint injuries, muscle injuries (rhabdomyolysis), and radionuclide arthrography is discussed and the way the scan patterns change with time in these various disorders is described. A brief summary of the basic anatomy and physiology of bone and muscle in normal and injured tissue is presented and the basic mechanisms which cause the various abnormal scan patterns is postulated. In addition, a staging system for stress fractures is presented to help direct the referring physician toward the proper management of the injured patient. In most cases, nuclear medicine skeletal imaging can be used to differentiate between acute muscle injury, tibial stress syndrome, skeletal injury (periosteal reaction, stress fracture, and traumatic fracture) or an abnormality that is entirely associated with the joint or connective tissue. This differential diagnosis is easier if the nuclear medicine procedure is performed within a few days after the onset of injury. PMID:3291129

Matin, P



Complications and outcomes of brown recluse spider bites in children.  


Brown recluse spider bites may cause severe local and systemic morbidity, but data regarding morbidity in children are limited. This study reviewed inpatient medical records (n = 26; 10 years) with a discharge diagnosis of "spider bite" from a tertiary pediatric hospital. The majority (85%) of children had an inflammatory response accompanying necrosis, usually with signs of secondary cellulitis (77%). Hemolytic anemia (50%), rhabdomyolysis (27%), and acute renal failure (12%) were the most prevalent systemic effects. Hemolytic anemia was bimodal in distribution relative to the time-of-onset of the bite (early, 2.2 ± 0.4; late, 6.9 ± 1.5 days postbite, respectively; P = .004). Although no fatalities occurred in the population, 65% of children had major morbidity, including wound complications requiring surgical care and acute orbital compartment syndrome. The findings emphasize the importance of anticipatory patient/family education for outpatients and careful monitoring for systemic morbidity in inpatients. Timely and appropriate supportive care should yield favorable outcomes in most cases. PMID:21307081

Hubbard, Jonathan J; James, Laura P



Methadone-Induced Delayed Posthypoxic Encephalopathy: Clinical, Radiological, and Pathological Findings  

PubMed Central

Objective. To describe the clinical, radiological and pathological findings in a patient with methadone-induced delayed posthypoxic encephalopathy (DPHE). Case Report. A Thirty-eight-year-old man was found unconscious for an unknown duration after methadone and diazepam ingestion. His initial vitals were temperature 104 degree Fahrenheit, heart rate 148/minute, respiratory rate 50/minute, and blood pressure 107/72?mmhg. He developed renal failure, rhabdomyolysis, and elevated liver enzymes which resolved completely in 6 days. After 2 weeks from discharge he had progressive deterioration of his cognitive, behavioral and neurological function. Brain MRI showed diffuse abnormal T2 signal in the corona radiata, centrum semiovale, and subcortical white matter throughout all lobes. Extensive work up was negative for any metabolic, infectious or autoimmune disorder. Brain biopsy showed significant axonal injury in the white matter. He was treated successfully with combination of steroids and antioxidants. Follow up at 2 year showed no residual deficits. Conclusion. Our observation suggests that patients on methadone therapy should be monitored for any neurological or psychiatric symptoms, and in suspected cases MRI brain may help to make the diagnosis of DPHE. A trial of steroids and antioxidants may be considered in these patients.

Mittal, Manoj; Wang, Yunxia; Reeves, Alan; Newell, Kathy



Cardiovascular, haematological and neurological effects of the venom of the Papua New Guinean small-eyed snake (Micropechis ikaheka) and their neutralisation with CSL polyvalent and black snake antivenoms.  


Cardiovascular and haematological effects of venom of the small-eyed Snake (Micropechis ikaheka) were examined in ventilated anaesthetised piglets. Neurotoxic effects were examined in chick biventer cervicis nerve-muscle preparations. Immunoreactivity of venom was tested against the monovalent antivenom components in a CSL Ltd Venom Detection Kit. Neutralisation was tested in vivo and in vitro with CSL Ltd polyvalent snake and Black Snake (Pseudechis australis) antivenoms. Venom in 0.1% bovine serum albumin in saline was infused into piglets in doses 1-2000 microg/kg. Pulmonary hypertension (P= 0.0007) and depression of cardiac output (P= 0.002) were observed up to 3 h after 150-160 microg/kg. The concentration of plasma free-haemoglobin increased more than 50-fold, indicating haemolysis. Neither coagulopathy nor thrombocytopenia occurred. Creatine phosphokinase and serum potassium levels did not increase suggesting absence of acute rhabdomyolysis. The venom caused post-synaptic neurotoxicty. Immunoreactivity of venom with Black Snake antivenom was observed at very high venom concentrations. Cardiovascular effects were absent and haemolysis was less after venom was pre-incubated at 37 degrees C for 30 min with polyvalent antivenom. Neutralisation by Black Snake antivenom was less effective. The neurotoxicity was neutralised by polyvalent or Black Snake antivenoms. Human envenomation may be treated with CSL Ltd polyvalent snake antivenom. PMID:14602120

Tibballs, J; Kuruppu, S; Hodgson, W C; Carroll, T; Hawdon, G; Sourial, M; Baker, T; Winkel, K



Anuric renal failure in a dog after red-bellied black snake (Pseudechis porphyriacus) envenomation.  


A case of Red-bellied Black snake envenomation resulting in intravascular haemolytic anaemia, rhabdomyolysis and anuric renal failure is described in the dog. A 12-year-old female desexed Golden Retriever was presented with a 15 hour history of profuse salivation, progressive lethargy, obtundence, inappetence and collapse. Significant findings on clinical examination were pallor, icterus, tachypnoea and dyspnoea with increased respiratory sounds and crackles in all lung fields. Generalised abdominal and muscular pain was apparent and dark red-brown urine was present around the perineal region. A diagnosis of Red-bellied Black snake (Pseudechis porphyriacus) envenomation was made and the dog was treated with intravenous fluid therapy, Tiger/Brown snake antivenom, packed red cell transfusions and Intermittent Positive Pressure Ventilation. Continued clinical deterioration occurred and a diagnosis of acute renal failure secondary to myohaemoglobinuric pigmenturia was made 12 hours after admission. Intensive treatment was attempted with diuresis and volume expansion. Oliguria and subsequent anuria ensued and the dog was euthanased due to a grave prognosis and lack of clinical response to treatment. Necropsy examination revealed muscular necrosis, accumulation of fluid in the thoracic and peritoneal cavities, and marked renal tubular necrosis with intraluminal occlusion secondary to pigmentary casts. PMID:16739524

Heller, J; Bosward, K L; Hodgson, D R; Pottie, R



Malignant hyperthermia.  

PubMed Central

Malignant hyperthermia is a rare autosomal dominant trait that predisposes affected individuals to great danger when exposed to certain anaesthetic triggering agents (such as potent volatile anaesthetics and succinylcholine). A sudden hypermetabolic reaction in skeletal muscle leading to hyperthermia and massive rhabdomyolysis can occur. The ultimate treatment is dantrolene sodium a nonspecific muscle relaxant. Certain precautions should be taken before anaesthesia of patients known to be susceptible to malignant hyperthermia. These include the prohibition of the use of triggering agents, monitoring of central body temperature and expired CO2, and immediate availability of dantrolene. In addition, careful cleansing of the anaesthesia machine of vapours of halogenated agents is recommended. If these measures are taken, the chances of an MH episode are greatly reduced. When malignant hyperthermia-does occur in the operating room, prompt recognition and treatment usually prevent a potentially fatal outcome. The most reliable test to establish susceptibility to malignant hyperthermia is currently the in vitro caffeine-halothane contracture test. It is hoped that in the future a genetic test will be available.

Ben Abraham, R.; Adnet, P.; Glauber, V.; Perel, A.



A patient with heatstroke associated with consciousness disturbance secondary to hyponatremia: a case report  

PubMed Central

Introduction Little information is available on the pathogenesis of heatstroke without strenuous exercise in younger patients. Here, we report the case of a 31-year-old man who developed heatstroke secondary to hyponatremia. His condition was initially misdiagnosed as classic heatstroke. We hope the detailed description of our patient’s case will provide valuable information for medical professionals faced with similar cases in the future. Case presentation A 31-year-old Japanese man who was regularly taking anti-hypertensive agents, including a thiazide, was admitted to our hospital owing to consciousness disturbance and a high-grade fever. A thorough examination revealed mild renal dysfunction, rhabdomyolysis, a hyper-coagulable state, and severe hyponatremia (114mEq/L). Because he worked in a hot environment, an initial diagnosis of heatstroke was established. His general condition improved rapidly with supportive measures, and he was discharged on the fourth day after admission. Interestingly, he did not recognize feeling hot while working in a hot environment. These findings suggest that the consciousness disturbance, which was probably attributable to acute hyponatremia caused by the thiazide, preceded the onset of the heatstroke. Conclusions Clinicians should consider the presence of underlying diseases, especially consciousness disturbance, when younger individuals develop heatstroke in the absence of strenuous exercise.



Anesthetic- and heat-induced sudden death in calsequestrin-1-knockout mice.  


Calsequestrin-1 (CASQ1) is a moderate-affinity, high-capacity Ca(2+)-binding protein in the sarcoplasmic reticulum (SR) terminal cisternae of skeletal muscle. CASQ1 functions as both a Ca(2+)-binding protein and a luminal regulator of ryanodine receptor (RYR1)-mediated Ca(2+) release. Mice lacking skeletal CASQ1 are viable but exhibit reduced levels of releasable Ca(2+) and altered contractile properties. Here we report that CASQ1-null mice exhibit increased spontaneous mortality and susceptibility to heat- and anesthetic-induced sudden death. Exposure of CASQ1-null mice to either 2% halothane or heat stress triggers lethal episodes characterized by whole-body contractures, elevated core temperature, and severe rhabdomyolysis, which are prevented by prior dantrolene administration. The characteristics of these events are remarkably similar to analogous episodes observed in humans with malignant hyperthermia (MH) and animal models of MH and environmental heat stroke (EHS). In vitro studies indicate that CASQ1-null muscle exhibits increased contractile sensitivity to temperature and caffeine, temperature-dependent increases in resting Ca(2+), and an increase in the magnitude of depolarization-induced Ca(2+) release. These results demonstrate that CASQ1 deficiency alters proper control of RYR1 function and suggest CASQ1 as a potential candidate gene for linkage analysis in families with MH/EHS where mutations in the RYR1 gene are excluded. PMID:19237502

Dainese, Marco; Quarta, Marco; Lyfenko, Alla D; Paolini, Cecilia; Canato, Marta; Reggiani, Carlo; Dirksen, Robert T; Protasi, Feliciano



Patient with Hypertriglyceridemia, Type 2 Diabetes, and Chronic Kidney Disease Treated with Atorvastatin and Omega-3 Fatty Acid Ethyl Esters  

PubMed Central

This is a case report that describes a 67-year-old woman with mixed hyperlipidemia and diabetic nephropathy. She was initially prescribed a combination of simvastatin plus gemfibrozil by her general practitioner (GP). When referred to our cardiovascular unit, we further diagnosed the patient to have mixed hyperlipidemia and rhabdomyolysis. Because of concerns with her chronic kidney disease (CKD), we temporarily stopped all her drug treatments and started insulin treatment for her type 2 diabetes (T2D). A month later when her T2D was stabilised, we prescribed atorvastatin and an omega-3 fatty acid ethyl ester supplement to treat her hypertriglyceridemia. Within two months her blood lipids were within the recommended range. In patients with stage 3–5 CKD, it is not advisable to prescribe the fibrate gemfibrozil, particularly in combination with a statin that is metabolised predominantly in the kidneys. To minimise adverse events without compromise on efficacy, we used a combination of omega-3 fatty acid ethyl esters, which are not metabolised in the kidneys, with a statin that is minimally metabolised in the kidneys for the treatment of her hyperlipidemia.

Athyros, Vasilios G; Mikhailidis, Dimitri P



Pharmacologically-induced metabolic acidosis: a review.  


Metabolic acidosis may occasionally develop in the course of treatment with drugs used in everyday clinical practice, as well as with the exposure to certain chemicals. Drug-induced metabolic acidosis, although usually mild, may well be life-threatening, as in cases of lactic acidosis complicating antiretroviral therapy or treatment with biguanides. Therefore, a detailed medical history, with special attention to the recent use of culprit medications, is essential in patients with acid-base derangements. Effective clinical management can be handled through awareness of the adverse effect of certain pharmaceutical compounds on the acid-base status. In this review, we evaluate relevant literature with regard to metabolic acidosis associated with specific drug treatment, and discuss the clinical setting and underlying pathophysiological mechanisms. These mechanisms involve renal inability to excrete the dietary H+ load (including types I and IV renal tubular acidoses), metabolic acidosis owing to increased H+ load (including lactic acidosis, ketoacidosis, ingestion of various substances, administration of hyperalimentation solutions and massive rhabdomyolysis) and metabolic acidosis due to HCO3- loss (including gastrointestinal loss and type II renal tubular acidosis). Determinations of arterial blood gases, the serum anion gap and, in some circumstances, the serum osmolar gap are helpful in delineating the pathogenesis of the acid-base disorder. In all cases of drug-related metabolic acidosis, discontinuation of the culprit medications and avoidance of readministration is advised. PMID:20397738

Liamis, George; Milionis, Haralampos J; Elisaf, Moses



Neuroleptic malignant syndrome or a statin drug reaction? A case report.  


A 60-year-old woman with a long psychiatric history presented with delirium and mutism. She was febrile, with marked limb rigidity and elevated creatinine kinase (CK) level. Current medications included pericyazine. Current or recent use of dopamine-blocking agents, such as pericyazine, together with a disturbance in conscious state, autonomic dysfunction, and an elevated CK level may be suggestive of neuroleptic malignant syndrome (NMS). The diagnosis was confirmed as NMS, and she was successfully treated with bromocriptine. Eight years later, she represents with symptoms suggesting recurrence of NMS including elevated CK level and myalgia, however, without limb rigidity. Current medications include quetiapine, lithium, simvastatin, and a recent course of clarithromycin. Macrolide antibiotics such as clarithromycin inhibit the metabolic pathway of statins via the cytochrome CYP450 3A4 hepatic enzyme system and may result in elevated CK level, myopathy, or rhabdomyolysis producing symptoms that may be confused with NMS. Simvastatin was ceased with rapid decrease in CK level and resolution of symptoms. This case highlights the importance of considering other diagnoses in any patient presenting with a disturbance in conscious state, autonomic dysfunction, and an elevated CK level. Particularly in a patient with a history of NMS, a thorough medication history is essential to aid diagnosis and avoid confusion with presenting symptoms and medical history. PMID:19952877

Cooper, Joyce M; Jones, Alison L


[Muscle problems due to statins: underestimated].  


Statin-associated muscle problems are more common than the 1-5% prevalence reported in large clinical trials. Observational studies show a prevalence of about 10%. Muscle problems can occur anytime during statin treatment, but usually occur in the first 6 months. The occurrence of rhabdomyolysis is rare. Depletion of isoprenoids due to HMG-CoA reductase inhibition is probably the main cause of the myopathy. Statin-associated myopathy is treated by prevention and treatment of risk factors. The main risk factors are multiple drug treatment, alcohol abuse, hypothyroidism and a family history of muscle problems due to statin therapy. The first step in the treatment of muscle problems or of elevated creatine kinase levels is lowering or stopping the statin. The chance of another type of statin not having the same muscular effects is about 40%.The benefit of Q10 or other supplements is unproven thus far. In the presence of recurrent creatine kinase elevation or muscle problems, other cholesterol-lowering agents can be considered. PMID:21435278

Janssen, Stan P; Smulders, Yvo M; Gerdes, Victor E; Visseren, Frank L J



The lightning heart: a case report and brief review of the cardiovascular complications of lightning injury.  


Lightning strike is a rare natural phenomenon, which carries a risk of dramatic medical complications to multiple organ systems and a high risk of fatality. The known complications include but are not limited to: myocardial infarction, arrhythmia, cardiac contusion, stroke, cutaneous burns, respiratory disorders, neurological disorders, acute kidney injury and death. We report a case of a healthy young man who suffered a lightning injury and discuss the cardiovascular complications of lightning injury, ranging from ECG changes to death. The patient in our case, a 27-year old previously healthy male, developed a syndrome of rhabdomyolysis and symptomatic cardiogenic pulmonary edema. Electrocardiographic findings included transient T-wave inversions, late transition shift and long QT. His clinical condition improved with supportive measures.Early recognition of lightning injury syndromes and anticipation of complications may help us improve outcomes for these patients. Evaluation of patients having experienced a lightning injury should include a minimum of a detailed history and physical examination, 12-lead ECG and drawing of baseline troponins. Prolonged electrocardiographical monitoring (for monitoring of ventricular arrhythmias) and assessment for signs and symptoms of hemodynamic compromise may be warranted. PMID:20930961

McIntyre, William F; Simpson, Christopher S; Redfearn, Damian P; Abdollah, Hoshiar; Baranchuk, Adrian



Mimicry between mitochondrial disorder and multiple sclerosis.  


Under certain conditions or at certain stages of the disease course, multiple sclerosis (MS) and mitochondrial disorder (MID) may be differential diagnoses and thus may be confused with each other. In a 30 years old female MS was diagnosed at age 16 year upon recurrent sensory disturbances of the right lower leg, an "inflammatory" cerebrospinal fluid, and a cerebral MRI with multiple non-enhancing white matter lesions. Steroids were repeatedly given but because of rapid deterioration treatment was switched to interferon and mitoxantrone, without improvement. Fourteen years after onset the patient additionally presented with a history of rhabdomyolysis, hypothyroidism, ophthalmoparesis, anarthria, tetraspasticity, tetraparesis, and joint contractures. After MID had been diagnosed in her mother she was re-evaluated and elevated resting lactate, axonal polyneuropathy, and empty sella were additionally found. Muscle biopsy revealed myophagy, fat deposition, and type-II predominance, and biochemical investigations showed a deficiency of complex I and IV of the respiratory chain. MID was diagnosed also in the index patient. It is concluded that even if CSF investigations or imaging studies suggest MS, differentials such as MIDs need to be excluded before prescribing medication possibly toxic to a MID. An "inflammatory CSF" may also occur in MIDs. PMID:22311611

Finsterer, Josef; Höftberger, Romana; Stöllberger, Claudia; Rolinski, Boris



A physiologic-based approach to the evaluation of a patient with hypokalemia.  


Hypokalemia is a common electrolyte disorder. Transient causes of hypokalemia are due to cell shift, whereas sustained hypokalemia is caused by either inadequate intake or excessive potassium loss. Evaluation of the intake, distribution, and excretion of potassium should include the following: (1) a careful history, including use of drugs, medications, and the presence of vomiting or diarrhea; (2) physical examination, including orthostatic changes in blood pressure and heart rate; and (3) measurement of urine and plasma electrolytes. Urinary potassium wasting is caused by pathophysiologic conditions that couple increased distal sodium delivery with increased plasma aldosterone levels or aldosterone-like effects. If urinary potassium loss is identified, the next step is to determine whether the loss is caused by a primary increase in distal delivery of sodium or a primary increase in mineralocorticoid level. A primary increase in distal delivery should be associated with volume depletion, whereas a primary increase in mineralocorticoid level generally is associated with volume expansion and hypertension. In patients with a primary increase in mineralocorticoid activity, it is useful to measure plasma renin activity and plasma aldosterone levels. Complications of hypokalemia include muscle weakness, rhabdomyolysis, cardiac arrhythmias, impaired urinary concentrating ability, and glucose intolerance. PMID:20828906

Palmer, Biff F




PubMed Central

Background The use of long-chain fatty acids (LCFAs) for energy is inhibited in inherited disorders of long-chain fatty acid oxidation (FAO). Increased energy demands during exercise can lead to cardiomyopathy and rhabdomyolysis. Medium-chain triglycerides (MCTs) bypass the block in long-chain FAO and may provide an alternative energy substrate to exercising muscle. Objectives To determine the influence of isocaloric MCT versus carbohydrate (CHO) supplementation prior to exercise on substrate oxidation and cardiac workload in participants with carnitine palmitoyltransferase 2 (CPT2), very long-chain acyl-CoA dehydrogenase (VLCAD) and long-chain 3-hydroxyacyl CoA dehydrogenase (LCHAD) deficiencies. Design Eleven subjects completed two 45-minute, moderate intensity, treadmill exercise studies in a randomized crossover design. An isocaloric oral dose of CHO or MCT-oil was administered prior to exercise; hemodynamic and metabolic indices were assessed during exertion. Results When exercise was pretreated with MCT, respiratory exchange ratio (RER), steady state heart rate and generation of glycolytic intermediates significantly decreased while circulating ketone bodies significantly increased. Conclusions MCT supplementation prior to exercise increases the oxidation of medium chain fats, decreases the oxidation of glucose and acutely lowers cardiac workload during exercise for the same amount of work performed when compared with CHO pre-supplementation. We propose that MCT may expand the usable energy supply, particularly in the form of ketone bodies, and improve the oxidative capacity of the heart in this population.

Behrend, Annie M; Harding, Cary O; Shoemaker, James D; Matern, Dietrich; Sahn, David J; Elliot, Diane L; Gillingham, Melanie B



Long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency.  


Long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency is one of the recently discovered defects of mitochondrial fatty acid beta-oxidation. As a group, the beta-oxidation defects are among the most common inherited metabolic disorders, and LCHAD deficiency appears to be the most frequently diagnosed beta-oxidation defect in Finland. In the vast majority of patients, LCHAD deficiency is caused by a common autosomal recessive mutation G1528C. Like several beta-oxidation defects, it presents during infancy with hypoglycemic coma, hepatic steatosis, and hypocarnitinemia. Other manifestations are cardiomyopathy and rhabdomyolysis, which are frequent in defects of long-chain fatty acid oxidation. In addition, LCHAD deficiency has specific features, namely peripheral neuropathy and chorioretinopathy. Female carriers of LCHAD deficiency are prone to have preeclampsia-related pregnancy complications. Diagnosis is suggested by 3-hydroxylated acylcarnitine species in blood and the definitive diagnosis can be made by measuring intermediates of fatty acid beta-oxidation in fibroblasts or by detecting disease causing mutations. Analysis of the frequency of the G1528C mutation in Finland revealed carrier frequency of 1:240. Because of therapeutic and prenatal diagnostic opportunities in LCHAD deficiency, it is important to recognize this severe disorder early in its course. PMID:10229030

Tyni, T; Pihko, H



[Case of imported scrub typhus contracted in Myanmar].  


Scrub typhus is widespread in rural south and southeastern Asia and the western Pacific. The scrub typhus incidence is the highest among vector-borne diseases in Japan, but imported cases are extremely rare. A 49-year-old man admitted for persistent fever, headache, and rash after returning from Myanmar had been exposed to mosquito and tick bites while doing a 12-day forest inventory in Myanmar. On admission, he had a generalized maculopapular rash but no apparent eschars characteristic of scrub typhus. Blood examination and abdominal ultrasonography showed elevated liver enzymes, thrombocytopenia, and hepatosplenomegaly. Repeated blood smears and blood cultures were negative for malaria infection and bacteremia. Dengue fever was denied by both PCR and serology. The patient deteriorated on the ninth day and suffered complications of rhabdomyolysis, pneumonia, and enteritis. Based on a tentative diagnosis of typhoid fever or rickettiosis, we administratered ceftriaxone and minocycline, which dramatically reduced clinical signs and symptoms. After discharge on day 19, immunofluorescence assay showed significantly increased antibodies for Orienta tsutsugamushi serotype Gilliam, first discovered in Myanmar. All serological results were negative for other rickettioses, leptospirosis and Q fever. Given the many travelers from Japan visiting endemic scrub typhus areas, we must recognize cases of imported scrub typhus among those travelers with fever and rash returning from endemic areas. PMID:19522310

Matsumura, Yasufumi; Shimizu, Tsunehiro



The significance of genetic polymorphisms in modulating the response to lipid-lowering drugs.  


The response to lipid-lowering drugs is modified by a number of factors like age, gender, concomitant disease and genetic determinants. Even within homogenous groups of patients, individual responses vary greatly. Until now, no clinical or biochemical parameter exists which predicts whether a subject will respond well to a particular lipid-lowering drug or, in the extreme case, will develop adverse, life-threatening effects (e.g., myositis or rhabdomyolysis). The recent advances in the human genome project promises to have a great impact on our understanding of lipid and lipoprotein metabolism and of the individual response to lipid-lowering drugs. Monogenetic disorders of the lipid metabolism produce severe clinical phenotypes, such as Tangier disease, but have a minor role in the evaluation of cardiovascular risk in the general population. On the other hand, several polymorphisms in genes involved in lipoprotein metabolism (e.g., apolipoprotein E) are associated with the plasma levels of lipoproteins, explaining a substantial fraction of the variance of LDL or HDL concentrations. In combination, the knowledge of these polymorphisms, further variants yet to be discovered and variants within the genes involved in the metabolism of lipid-lowering drugs will in the future allow these drugs to be selected according to the patients needs and thus increase both efficacy and cost-effectiveness of lipid-lowering regimes. PMID:11368750

Hoffmann, M M; Winkelmann, B R; Wieland, H; März, W



[Cardiac complications of dermatopolymyositis. Apropos of 56 cases].  


A retrospective study was conducted on 58 patients hospitalized for dermato- or polymyositis between 1967 and 1986, with the view of determining the cardiovascular complications specific to these diseases. The patients' mean age was 51 years, less than 6 months had elapsed between first symptoms and diagnosis, and 31 p. 100 of the patients had died. The electrocardiogram was considered normal in 46 patients, none of whom presented with the slighted clinical evidence of cardiovascular involvement. ECG abnormalities were present in 10 cases, including 5 with disorders of conduction. Five cases of cardiovascular pathology with clinical manifestations were discovered. A 36-year old woman had severe myocardial pathology with marked rhabdomyolysis (CPK greater than 100,000) and complete atrio-ventricular block requiring emergency pacemaker implantation. Three years after the onset of the disease, and whilst the clinical signs of polymyositis had regressed, this patient still had complete AVB and moderately dilated congestive cardiomyopathy. This study shows that cardiac complications of dermato-polymyositis are rare and predominantly consist of disorders of conduction which may become permanent and associated with alterations of left ventricular kinetics. The authors suggest that a high-risk category for patients with disorders of conduction and cardiomyopathy can be identified by echocardiography, but this examination needs mainly be performed in cases when ECG abnormalities are present, since no clinical cardiac pathology was observed in patients of this series with normal electrocardiogram. PMID:3118837

Brottier, L; Coste, P; Combe, C; Bruchère, C; Bonnet, J; Bricaud, H



Effects of marathon running on platelet activation markers : direct evidence for in vivo platelet activation.  


We used the ADVIA 2120 Hematology System (Bayer HealthCare, Diagnostics Division, Tarrytown, NY) to study the effects of vigorous exercise on CBC count, WBC differential, RBC fragmentation, and platelet activation parameters in 32 healthy participants in a 26.2-mile (42.2-km) marathon. The runners demonstrated increases in hematocrit and platelet count consistent with dehydration and leukocytosis indicative of demargination of neutrophils or inflammation secondary to tissue destruction (eg, rhabdomyolysis). The number of RBC fragments was increased after the race (P = .008), consistent with exercise-induced hemolysis. The mean platelet component, a measure of platelet granularity, was decreased (P < .0001), and the number of platelet clumps was increased (P = .0026), providing evidence for in vivo platelet activation during the marathon. By using direct measurement of platelet granularity, our study confirms the in vivo activation of platelets by vigorous exercise and establishes the usefulness of automated cell counters for the assessment of platelet activation and of RBC fragmentation in this setting. PMID:16393676

Kratz, Alexander; Wood, Malissa J; Siegel, Arthur J; Hiers, Jennifer R; Van Cott, Elizabeth M



Effect of marathon running on hematologic and biochemical laboratory parameters, including cardiac markers.  


Participants in marathon races may require medical attention and the performance of laboratory assays. We report the changes in basic biochemical parameters, cardiac markers, CBC counts, and WBC differentials observed in participants in a marathon before, within 4 hours, and 24 hours after a race. The concentrations of glucose, total protein, albumin, uric acid, calcium, phosphorus, serum urea nitrogen, creatinine, bilirubin, alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, total creatine kinase, creatine kinase-MB, myoglobin, and the anion gap were increased after the race, consistent with the effects of exertional rhabdomyolysis and hemolysis. The increase in WBC counts was due mainly to neutrophilia and monocytosis, with a relative decrease in circulating lymphocytes, consistent with an inflammatory reaction to tissue injury. A significant percentage of laboratory results were outside the standard reference ranges, indicating that modified reference ranges derivedfrom marathon runners might be more appropriatefor this population. We provide a table of modified reference ranges (or expected ranges) for basic biochemical, cardiac, and hematologic laboratory parameters for marathon runners. PMID:12472278

Kratz, Alexander; Lewandrowski, Kent B; Siegel, Arthur J; Chun, Kelly Y; Flood, James G; Van Cott, Elizabeth M; Lee-Lewandrowski, Elizabeth



Measurement of a plasma stroke biomarker panel and cardiac troponin T in marathon runners before and after the 2005 Boston marathon.  


We report changes in cardiac troponin-T (TnT) and a new plasma stroke biomarker panel (D-dimer, B-natriuretic peptide [BNP], matrix metalloproteinase-9 [MMP-9], S-100 b, Biosite Diagnostics, San Diego, CA) in 30 nonprofessional marathon runners before and immediately after the 2005 Boston Marathon. Following competition, there was a statistically significant increase in MMP-9 (P < .001) and D dimer (P < .001). Nonsignificant changes in S-100 b and BNP were observed. Premarathon and postmarathon values for a multimarker stroke index increased from 0.97 (normal) to 3.5 (low risk or more; P < .001). Two subjects had index values more than the high-risk cutoff value. Mean TnT premarathon and postmarathon levels increased (from <0.01 to 0.03 ng/mL; P < .0001). After the marathon, with a cutoff value of 0.05 ng/mL, 7 runners (23%) had values above the manufacturer's recommended cutoff for myocardial damage. Although biochemical evidence of myocardial damage following strenuous exercise may reflect myocardial stunning or subclinical ischemia, the changes in the stroke index and values for individual stroke markers may reflect a systemic inflammatory response to exertional rhabdomyolysis which is common, but the possibility of subclinical central nervous system damage cannot be excluded. PMID:16891191

Saenz, Adam J; Lee-Lewandrowski, Elizabeth; Wood, Malissa J; Neilan, Tomas G; Siegel, Arthur J; Januzzi, James L; Lewandrowski, Kent B



Elevated serum cardiac markers in asymptomatic marathon runners after competition: is the myocardium stunned?  


Prolonged strenuous exercise may trigger acute myocardial infarction (AMI), as exemplified by the occurrence of sudden cardiac death during marathon running. Serum creatine kinase MB (CK-MB) may be elevated in asymptomatic marathon runners after competition from exertional rhabdomyolysis of skeletal muscle altered by training, limiting its utility for evaluating acute cardiac injury in such athletes. Myoglobin and CK-MB2 isoform levels are emerging as earlier markers of AMI and troponin subunits as more specific than serum CK-MB mass. We tested runners before and sequentially after the 1995 Boston Marathon for conventional and newer markers including myoglobin, CK-MB mass and isoforms, cardiac troponin T, and cardiac troponin I using standard laboratory methods and rapid format assays if available. The mean serum values for myoglobin, CK-MB mass, CK-MB/myoglobin rapid panel tests, and CK-MB2 isoforms were normal or negative pre-race and elevated or positive 4 and 24 h after competition. These markers lack specificity for acute cardiac injury in trained runners. While the mean serum values for cardiac troponins T and I remained normal, 9 of 45 runners (20%) showed an increase in subunits by first-generation assays. All runners remained asymptomatic for cardiac disease and completed subsequent marathons 1 year later, making reversible myocardial injury or stunning unlikely. Elevated values of serum markers for AMI, including first-generation assays for both troponin subunits should be interpreted with caution in trained runners. PMID:9397299

Siegel, A J; Sholar, M; Yang, J; Dhanak, E; Lewandrowski, K B


Normal post-race antimyosin myocardial scintigraphy in asymptomatic marathon runners with elevated serum creatine kinase MB isoenzyme and troponin T levels. Evidence against silent myocardial cell necrosis.  


Recent epidemiologic studies confirm that heavy physical exertion can trigger myocardial infarction. Diagnosis of acute myocardial injury in marathon runners is complicated by elevations of serum creatine kinase MB isoenzyme activity in asymptomatic finishers with normal post-race infarct-avid myocardial scintigraphy. Such isoenzyme elevations can arise from exertional rhabdomyolysis of skeletal muscle biochemically altered by training, from silent injury to the myocardium or from a combined tissue source. To assess silent myocardial cell necrosis in marathon runners, we performed quantitative anti-myosin myocardial scintigraphy after competition with serum immunoassays for creatine kinase MB isoenzyme and troponin T. Therefore, 8 male marathon runners with a mean age of 52 years underwent quantitative antimyosin myocardial scintigraphy immediately following the 1988 and 1993 Boston Marathons. Serum immunoassays for creatine kinase MB isoenzyme by a chemiluminescent method (CLIA) and troponin T by an enzyme-linked immunosorbent assay were performed in 4 runners after the 1993 race. Quantitative antimyosin myocardial scintigraphy was normal in all runners including 3 who participated after both races 5 years apart. Post-race serum creatine kinase MB isoenzyme and/or troponin T levels were in a range otherwise diagnostic of acute myocardial infarction in 3 of 4 subjects. Normal quantitative antimyosin myocardial imaging in asymptomatic marathon runners excludes silent myocardial cell necrosis as the source of elevated serum protein markers. Such imaging may be the optimal diagnostic modality for detection of myocardial cell necrosis in symptomatic athletes when results of conventional testing are inconclusive. PMID:7585754

Siegel, A J; Lewandrowski, K B; Strauss, H W; Fischman, A J; Yasuda, T



Omacor and Omega-3 Fatty Acids for Treatment of Coronary Artery Disease and the Pleiotropic Effects.  


Omega-3 polyunsaturated fatty acids are found in fish oil and they have been shown to mitigate the risk of cardiovascular disease. Omega-3 fatty acids are essential fatty acids because they cannot be synthesized de novo and must be consumed from dietary sources such as marine fish. It reduces fatal and nonfatal myocardial infarction, stroke, coronary artery disease, sudden cardiac death, and all-cause mortality. It also has beneficial effects in mortality reduction after a myocardial infarction. Omacor is a highly potent form of Omega-3 fatty acids that lowers plasma triglycerides. In patients with severe hypertriglyceridemia who are refractory to statins, it helps augment triglyceride reduction. Omacor also increases high-density lipoprotein and decreases low-density lipoprotein levels. It is well tolerated with minimal adverse effects and no known interactions causing rhabdomyolysis. In high doses, Omacor has pronounced cardiovascular benefits with improvement of triglycerides and various lipid parameters. Omega-3 fatty acids have also been shown to have beneficial effects on arrhythmias, inflammation, and heart failure. It may also decrease platelet aggregation and induce vasodilation. Omega-3 fatty acids also reduce atherosclerotic plaque formation and stabilize plaques preventing plaque rupture leading to acute coronary syndrome. Moreover, omega-3 fatty acids may have antioxidant properties that improve endothelial function and may contribute to its antiatherosclerotic benefits. In this review, we sought to provide the current literature on the use of omega-3 fatty acids and the potent formulation Omacor in the treatment of coronary artery disease. PMID:21975796

Kar, Subrata



A review of deep tissue injury development, detection, and prevention: shear savvy.  


Pressure ulcer prevention strategies include the prevention, and early recognition, of deep tissue injury (DTI), which can evolve into a Stage III or Stage IV pressure ulcer. In addition to their role in pressure-induced ischemia, shearing forces are believed to contribute substantially to the risk of DTI. Because the visual manifestation of a DTI may not occur until many hours after tissues were damaged, research to explore methods for early detection is on-going. For example, rhabdomyolysis is a common complication of deep tissue damage; its detection via blood chemistry and urinalysis is explored as a possible diagnostic tool of early DTI in anatomical areas where muscle is present. Substances released from injured muscle cells have a predictable time frame for detection in blood and urine, possibly enabling the clinician to estimate the time of the tissue death. Several small case studies suggest the potential validity and reliability of ultrasoun for visualizing soft tissue damage also deserve further research. While recommendations to reduce mechanical pressure and shearing damage in high-risk patients remain unchanged, their implementation is not always practical, feasible, or congruent with the overall plan of patient care. Early detection of existing tissue damage will help clinicians implement appropriate care plans that also may prevent further damage. Research to evaluate the validity, reliability, sensitivity, and specificity of diagnostic studies to detect pressure-related tissue death is warranted. PMID:23388395

Gefen, Amit; Farid, Karen J; Shaywitz, Ira



Bacterial, Fungal, Parasitic, and Viral Myositis  

PubMed Central

Infectious myositis may be caused by a broad range of bacterial, fungal, parasitic, and viral agents. Infectious myositis is overall uncommon given the relative resistance of the musculature to infection. For example, inciting events, including trauma, surgery, or the presence of foreign bodies or devitalized tissue, are often present in cases of bacterial myositis. Bacterial causes are categorized by clinical presentation, anatomic location, and causative organisms into the categories of pyomyositis, psoas abscess, Staphylococcus aureus myositis, group A streptococcal necrotizing myositis, group B streptococcal myositis, clostridial gas gangrene, and nonclostridial myositis. Fungal myositis is rare and usually occurs among immunocompromised hosts. Parasitic myositis is most commonly a result of trichinosis or cystericercosis, but other protozoa or helminths may be involved. A parasitic cause of myositis is suggested by the travel history and presence of eosinophilia. Viruses may cause diffuse muscle involvement with clinical manifestations, such as benign acute myositis (most commonly due to influenza virus), pleurodynia (coxsackievirus B), acute rhabdomyolysis, or an immune-mediated polymyositis. The diagnosis of myositis is suggested by the clinical picture and radiologic imaging, and the etiologic agent is confirmed by microbiologic or serologic testing. Therapy is based on the clinical presentation and the underlying pathogen.

Crum-Cianflone, Nancy F.



Normal results of post-race thallium-201 myocardial perfusion imaging in marathon runners with elevated serum MB creatine kinase levels  

SciTech Connect

Elevated cardiac enzyme values in asymptomatic marathon runners after competition can arise from skeletal muscle through exertional rhabdomyolysis, silent injury to the myocardium, or a combined tissue source. Peak post-race levels of the MB isoenzyme of creatine kinase are similar to values in patients with acute myocardial infarction. Previously reported normal results of infarct-avid myocardial scintigraphy with technetium 99m pyrophosphate in runners after competition suggest a non-cardiac source but cannot exclude silent injury to the myocardium. Therefore, thallium 201 myocardial perfusion imaging was performed in runners immediately after competition together with determination of sequential cardiac enzyme levels. Among 15 runners tested, the average peak in serum MB creatine kinase 24 hours after the race was 128 IU/liter with a cumulative MB creatine kinase release of 117 IU/liter; these values are comparable to those in patients with acute transmural myocardial infarction. Thallium 201 myocardial scintigraphic results were normal in five runners randomly selected from those who volunteered for determination of sequential blood levels. It is concluded that elevations of serum MB creatine kinase in marathon runners arise from a skeletal muscle source and that thallium 201 myocardial scintigraphy is useful to assess runners for myocardial injury when clinical questions arise.

Siegel, A.J.; Silverman, L.M.; Holman, B.L.



Phase I study of oral S-1 and concurrent radiotherapy in patients with head and neck cancer  

PubMed Central

This study investigated the maximum tolerated dose (MTD) of S-1 with concurrent radiotherapy in patients with head and neck cancer, based on the frequency of dose-limiting toxicities (DLT). S-1 was administered orally at escalating doses from 40 mg/m2 b.i.d. on the days of delivering radiotherapy, which was given at a total dose of 64–70 Gy in 32–35 fractions over 6–7 weeks. A total of 12 patients (3 patients at 40 mg/m2, 6 patients at 60 mg/m2, and 3 patients at 80 mg/m2) were enrolled in this trial. At the dose of 80 mg/m2, two of the three patients developed DLT (Grade 3 anorexia and rhabdomyolysis) due to S-1, so the MTD was determined to be 80 mg/m2. Among the 12 enrolled patients, 9 (75%) showed a complete response and 3 (25%) showed a partial response. The overall response rate was 100%. The recommended dose of S-1 with concurrent radiotherapy is 60 mg/m2.

Nakata, Kensei; Sakata, Koh-ichi; Someya, Masanori; Miura, Katsutoshi; Hayashi, Junichi; Hori, Masakazu; Takagi, Masaru; Himi, Tetsuo; Kondo, Atsushi; Hareyama, Masato



Phase I study of oral S-1 and concurrent radiotherapy in patients with head and neck cancer.  


This study investigated the maximum tolerated dose (MTD) of S-1 with concurrent radiotherapy in patients with head and neck cancer, based on the frequency of dose-limiting toxicities (DLT). S-1 was administered orally at escalating doses from 40 mg/m(2) b.i.d. on the days of delivering radiotherapy, which was given at a total dose of 64-70 Gy in 32-35 fractions over 6-7 weeks. A total of 12 patients (3 patients at 40 mg/m(2), 6 patients at 60 mg/m(2), and 3 patients at 80 mg/m(2)) were enrolled in this trial. At the dose of 80 mg/m(2), two of the three patients developed DLT (Grade 3 anorexia and rhabdomyolysis) due to S-1, so the MTD was determined to be 80 mg/m(2). Among the 12 enrolled patients, 9 (75%) showed a complete response and 3 (25%) showed a partial response. The overall response rate was 100%. The recommended dose of S-1 with concurrent radiotherapy is 60 mg/m(2). PMID:23292146

Nakata, Kensei; Sakata, Koh-Ichi; Someya, Masanori; Miura, Katsutoshi; Hayashi, Junichi; Hori, Masakazu; Takagi, Masaru; Himi, Tetsuo; Kondo, Atsushi; Hareyama, Masato



Pathophysiology of fatty acid oxidation disorders and resultant phenotypic variability.  


Fatty acids are a major fuel for the body and fatty acid oxidation is particularly important during fasting, sustained aerobic exercise and stress. The myocardium and resting skeletal muscle utilise long-chain fatty acids as a major source of energy. Inherited disorders affecting fatty acid oxidation seriously compromise the function of muscle and other highly energy-dependent tissues such as brain, nerve, heart, kidney and liver. Such defects encompass a wide spectrum of clinical disease, presenting in the neonatal period or infancy with recurrent hypoketotic hypoglycaemic encephalopathy, liver dysfunction, hyperammonaemia and often cardiac dysfunction. In older children, adolescence or adults there is often exercise intolerance with episodic myalgia or rhabdomyolysis in association with prolonged aerobic exercise or other exacerbating factors. Some disorders are particularly associated with toxic metabolites that may contribute to encephalopathy, polyneuropathy, axonopathy and pigmentary retinopathy. The phenotypic diversity encountered in defects of fat oxidation is partly explained by genotype/phenotype correlation and certain identifiable environmental factors but there remain many unresolved questions regarding the complex interaction of genetic, epigenetic and environmental influences that dictate phenotypic expression. It is becoming increasingly clear that the view that most inherited disorders are purely monogenic diseases is a naive concept. In the future our approach to understanding the phenotypic diversity and management of patients will be more realistically achieved from a polygenic perspective. PMID:23674167

Olpin, Simon E



[Necrotizing autoimmune myopathies].  


Necrotizing autoimmune myopathies are included in the spectrum of inflammatory myopathies, together with polymyosis, dermatopolymyosis and inclusion body myositis, despite the characteristic feature of marked muscular necrosis without inflammatory infiltrates. The clinical presentation is highly variable, often similar to the other inflammatory myopathies. The most common finding is nevertheless the severe form with rhabdomyolysis. The creatine kinase level is elevated (around 10,000IU/l) and electromyography shows myopathic changes with increased spontaneous activities reflecting the importance of the muscular necrosis. Muscle biopsy is required for diagnosis, revealing active necrosis of the muscle fibers without inflammatory invasion by CDA+ or CD8+ T-cells. Deposition of a microvascular membrane attack complex (C5b9) is often noted, whereas the upregulation of MHC class 1 is rarely detected. Signs of endomysial microangiopathy are frequently reported. Necrotizing autoimmune myopathies can be associated with antisignal recognition particle (SRP) antibodies or more rarely with the usual inflammatory myopathy antibodies. Paraneoplasic forms are described but remain exceptional. Lastly, necrotizing autoimmune myopathies, sometimes associated with statin therapy, have been recently described. They are linked with an antibody directed against 3-hydroxy-3-methyglutaryl-coenzyme A. Treatment is based on corticosteroid therapy, immunosuppressive drugs or intravenous immunoglobulins. Response is variable, depending on the clinical form. PMID:23999024

Petiot, P; Choumert, A; Hamelin, L; Devic, P; Streichenberger, N



Detection of pharmacovigilance-related adverse events using electronic health records and automated methods.  


Electronic health records (EHRs) are an important source of data for detection of adverse drug reactions (ADRs). However, adverse events are frequently due not to medications but to the patients' underlying conditions. Mining to detect ADRs from EHR data must account for confounders. We developed an automated method using natural-language processing (NLP) and a knowledge source to differentiate cases in which the patient's disease is responsible for the event rather than a drug. Our method was applied to 199,920 hospitalization records, concentrating on two serious ADRs: rhabdomyolysis (n = 687) and agranulocytosis (n = 772). Our method automatically identified 75% of the cases, those with disease etiology. The sensitivity and specificity were 93.8% (confidence interval: 88.9-96.7%) and 91.8% (confidence interval: 84.0-96.2%), respectively. The method resulted in considerable saving of time: for every 1 h spent in development, there was a saving of at least 20 h in manual review. The review of the remaining 25% of the cases therefore became more feasible, allowing us to identify the medications that had caused the ADRs. PMID:22713699

Haerian, K; Varn, D; Vaidya, S; Ena, L; Chase, H S; Friedman, C



Changes in urine composition after trauma facilitate bacterial growth  

PubMed Central

Background Critically ill patients including trauma patients are at high risk of urinary tract infection (UTI). The composition of urine in trauma patients may be modified due to inflammation, systemic stress, rhabdomyolysis, life support treatment and/or urinary catheter insertion. Methods Prospective, single-centre, observational study conducted in patients with severe trauma and without a history of UTIs or recent antibiotic treatment. The 24-hour urine samples were collected on the first and the fifth days and the growth of Escherichia coli in urine from patients and healthy volunteers was compared. Biochemical and hormonal modifications in urine that could potentially influence bacterial growth were explored. Results Growth of E. coli in urine from trauma patients was significantly higher on days 1 and 5 than in urine of healthy volunteers. Several significant modifications of urine composition could explain these findings. On days 1 and 5, trauma patients had an increase in glycosuria, in urine iron concentration, and in the concentrations of several amino acids compared to healthy volunteers. On day 1, the urinary osmotic pressure was significantly lower than for healthy volunteers. Conclusion We showed that urine of trauma patients facilitated growth of E. coli when compared to urine from healthy volunteers. This effect was present in the first 24 hours and until at least the fifth day after trauma. This phenomenon may be involved in the pathophysiology of UTIs in trauma patients. Further studies are required to define the exact causes of such modifications.



Imaging the pH evolution of an acute kidney injury model by means of iopamidol, a MRI-CEST pH-responsive contrast agent.  


PURPOSE: To investigate in vivo possible pH level alterations following an acute renal failure disease using a MRI-CEST pH responsive contrast agent. The impact of functional evolution in different renal compartments over time was also investigated. METHODS: a mouse model of acute kidney injury was obtained by glycerol-induced rhabdomyolysis. pH maps were obtained using Iopamidol (0.75 g iodine/kg b.w. corresponding to 2.0 mmol/kg) in a control group (n = 3) and in the acute kidney injury group (n = 6) at 1, 3, 7, 14, and 21 days after the damage induction at 7T. Histology assessment of renal damage and blood urea nitrogen levels were compared with pH maps. RESULTS: during the acute kidney injury, there was a robust increase of pH values, which peaked after 3 days, compared with the predamage situation. In addition, it was possible to detect changes in contrast detection between the different functional regions of the damaged kidneys. Moreover, a slow restoration of normal pH values was observed three weeks after the glycerol injection. CONCLUSIONS: pH appears to be a good parameter to assess the early detection of kidney injury as well as it acts as a reporter of the recovery toward the physiologic functionality. Magn Reson Med, 2012. © 2012 Wiley Periodicals, Inc. PMID:23059893

Longo, Dario Livio; Busato, Alice; Lanzardo, Stefania; Antico, Federica; Aime, Silvio



The Lightning Heart: A Case Report and Brief Review of the Cardiovascular Complications of Lightning Injury  

PubMed Central

Lightning strike is a rare natural phenomenon, which carries a risk of dramatic medical complications to multiple organ systems and a high risk of fatality. The known complications include but are not limited to: myocardial infarction, arrhythmia, cardiac contusion, stroke, cutaneous burns, respiratory disorders, neurological disorders, acute kidney injury and death. We report a case of a healthy young man who suffered a lightning injury and discuss the cardiovascular complications of lightning injury, ranging from ECG changes to death. The patient in our case, a 27-year old previously healthy male, developed a syndrome of rhabdomyolysis and symptomatic cardiogenic pulmonary edema. Electrocardiographic findings included transient T-wave inversions, late transition shift and long QT. His clinical condition improved with supportive measures. Early recognition of lightning injury syndromes and anticipation of complications may help us improve outcomes for these patients. Evaluation of patients having experienced a lightning injury should include a minimum of a detailed history and physical examination, 12-lead ECG and drawing of baseline troponins. Prolonged electrocardiographical monitoring (for monitoring of ventricular arrhythmias) and assessment for signs and symptoms of hemodynamic compromise may be warranted.

McIntyre, William F; Simpson, Christopher S; Redfearn, Damian P; Abdollah, Hoshiar; Baranchuk, Adrian



Toxicity and death following recreational use of 2-pyrrolidino valerophenone.  


Abstract Background. Consumption of substituted cathinones, frequently called 'legal highs' or 'designer drugs', is increasing in the European Union. In July 2012, the French Medicine Agency listed the substituted cathinone's chemical family as narcotic and psychotropic substances, to restrict their use and distribution. We present, here, the first documented cases of recreational use of 2-pyrrolidino valerophenone (PVP) associated with death for one patient, with post-mortem toxicological analysis. Case reports. Two men purchased the legal high Energy-3 (NRG-3). It can be sold as laboratory reagent and is available from Internet. The oldest died of sudden cardiac arrest. The other experienced visual hallucinations and psychotic symptoms for 24 h. He also presented bilateral mydriasis, sinus tachycardia and rhabdomyolysis. He reported an occasional intranasal use of NRG-3. Analysis of the powder and blood and urine from both men revealed the presence of PVP. Discussion and conclusion. PVP belongs to the substituted cathinones chemical family. These cases highlight the need for emergency physicians, toxicologists and networks of toxicovigilance to control the use of these substances and their dangers, quickly identify cases of severe poisoning associated with the use of new drugs and to develop detection methods. PMID:24111554

Eiden, Celine; Mathieu, Olivier; Cathala, Philippe; Debruyne, Daniele; Baccino, Eric; Petit, Pierre; Peyriere, Helene



Safety evaluation of trabectedin in treatment of soft-tissue sarcomas.  


Introduction: Trabectedin gained the approval by the European Medicines Agency (EMA) in 2007 for the treatment of patients affected by soft-tissue sarcomas (STS). Its safety and activity profiles have been assessed in many clinical trials as well as in standard clinical practice for > 10 years. Areas covered: This article extensively reviews the most common and specific adverse events associated with trabectedin. Moreover, we compare these toxicity data with other drugs active in STS such as doxorubicin and ifosfamide. Also, we provide a comprehensive view of the special mechanism of action of this drug and its clinical applications. Additionally, we discuss the current role of trabectedin in the treatment of STS and give a future perspective with the review of ongoing clinical trials and potential new indications. Expert opinion: Trabectedin is, in general, a well-tolerated drug with a favorable toxicity profile. The majority of its side effects are mild and easily manageable. Specific adverse events such as liver toxicity and rhabdomyolysis do not usually have a significant clinical impact. Overall, trabectedin is a safe and active treatment option in STS. PMID:23937190

Martin-Liberal, Juan; Judson, Ian



Increased serum creatine phosphokinase in a child with bruising due to physical abuse.  


Bruising is a frequent and often sentinel injury in children who are victims of physical abuse. Children who are evaluated in an emergency department for bruising, which may be due to abuse, present a challenge to physicians; the injuries themselves are medically minor and their severity can only be described qualitatively with photographs. Nonetheless, bruising in an infant or bruising in unusual locations in young children can indicate violence and risk. These children also present a challenge to the Child Protective Services system because the injuries generally resolve quickly without medical treatment and do not result in long-term sequelae. Creatine phosphokinase (CPK) is released from injured muscle and results in increased serum CPK concentrations. We report on a case of isolated bruising due to child physical abuse in which serum CPK concentrations were markedly increased, demonstrating clinically unsuspected rhabdomyolysis. The increased serum CPK concentrations provided important quantitative information about the seriousness of the bruising. A subsequent chart review of children evaluated by our hospital's child protection team for isolated bruising during a 6-year period demonstrated that there were other children with bruising due to abuse who also had increased serum CPK concentrations. This information suggests that increased serum CPK in children with bruising due to abuse may be more common than previously thought and that this information may have the potential to be used to provide quantitative, objective information about the seriousness of the bruising. We recommend that physicians consider measuring serum CPK in children with bruising due to physical abuse. PMID:23222104

Sussman, Stephanie; Squires, Janet; Stitt, Rodger; Zuckerbraun, Noel; Berger, Rachel P



Detection of Pharmacovigilance-Related adverse Events Using Electronic Health Records and automated Methods  

PubMed Central

Electronic health records (EHRs) are an important source of data for detection of adverse drug reactions (ADRs). However, adverse events are frequently due not to medications but to the patients’ underlying conditions. Mining to detect ADRs from EHR data must account for confounders. We developed an automated method using natural-language processing (NLP) and a knowledge source to differentiate cases in which the patient’s disease is responsible for the event rather than a drug. Our method was applied to 199,920 hospitalization records, concentrating on two serious ADRs: rhabdomyolysis (n = 687) and agranulocytosis (n = 772). Our method automatically identified 75% of the cases, those with disease etiology. The sensitivity and specificity were 93.8% (confidence interval: 88.9-96.7%) and 91.8% (confidence interval: 84.0-96.2%), respectively. The method resulted in considerable saving of time: for every 1 h spent in development, there was a saving of at least 20 h in manual review. The review of the remaining 25% of the cases therefore became more feasible, allowing us to identify the medications that had caused the ADRs.

Haerian, K; Varn, D; Vaidya, S; Ena, L; Chase, HS; Friedman, C



Investigation of the relationship between serum creatine kinase and genetic polymorphisms in military recruits.  


Genetic polymorphisms may explain why certain individuals will develop exertional rhabdomyolysis (ER) or markedly elevated serum creatine kinase (CK) levels following exertion, while others in the same environment, performing the same exertion, do not. Prospectively, 499 recruits were evaluated during the initial fortnight of Army basic training. Serum CK levels were determined before and during that time. Eleven candidate genetic polymorphisms were studied and compared to CK levels. No subjects developed ER. Baseline CK was significantly greater in interleukin-6 G174C GG and myosin light chain kinase 2 (MLCK 2) AA subjects. Intertraining levels were significantly greater in angiotensin I-converting enzyme D/D and interleukin-6 GG subjects. Among African-Americans, those with MLCK2 AA had greater baseline CK (1,352 +/- 1,102.8 IU/L) than AC and CC genotypes (536.9 +/- 500.6). African-American men have the highest baseline levels and are more likely to have MLCK AA genotype. Whether this finding is associated with an increased incidence of ER requires further study. PMID:23198514

Landau, Mark E; Kenney, Kimbra; Deuster, Patricia; Gonzalez, Rodney S; Contreras-Sesvold, Carmen; Sambuughin, Nyamkhishig; O'Connor, Francis G; Campbell, William W



Myo- and hepatotoxic effects of cultivated mushrooms in mice.  


Mushrooms are currently examined for their potential as functional foods. At the same time, novel types of mushroom intoxications, such as rhabdomyolysis after prolonged consumption, have been described in edible species. The aim of the present study was to perform an acute toxicity test to establish if the most commonly cultivated species would have myo- or hepatotoxic effects. Mice (n=6/group) were exposed to 3, 6 or 9 g Agaricus bisporus, Lentinus edodes or Pleurotus ostreatus kg body mass(-1) d(-1) for 5 d with 6 controls. Food and water intakes, plasma clinical chemistry and liver and muscle histology were evaluated. While A. bisporus caused significantly increased plasma bilirubin concentrations, L. edodes elicited also increased plasma creatine kinase activities at 9 g kg(-1) d(-1). P. ostreatus decreased dramatically the food intake but increased the water intake and caused significantly increased plasma alanine aminotransferase activities at 9 g kg(-1) d(-1). While there were no pathological findings in the histological samples, it seems that the doses and time periods required for the potential benefits of mushroom consumption to appear are similar to those causing undesirable effects. This should be taken into consideration if mushrooms are to be used as functional foods. PMID:18976689

Nieminen, Petteri; Kärjä, Vesa; Mustonen, Anne-Mari



Equine botulism and acute pasture myodystrophy: new soil-borne emerging diseases in Switzerland?  


In Switzerland, the incidence of equine botulism and acute pasture myodystrophy have remarkably increased in the last five years. Equine fodder-borne botulism in Europe is most likely caused by Clostridium botulinum types C and D that produce the toxins BoNT/C and BoNT/D. Horses showing signs suggestive of botulism (muscle weakness and tremors, reduced tongue tone, slow chewing, salivation and difficulties swallowing, drooping eyelids, mydriasis), especially patients that have fed on suspect fodder (mostly haylage), must be treated with anti-serum as soon as possible. They also need intensive care, which is often difficult to provide and always expensive in the face of a guarded to poor prognosis. Therefore, prevention (high standards of forage quality and vaccination) is all the more important. Pasture myodystrophy is an acute disease with signs of rhabdomyolysis and lethality rate over 90%. It affects grazing horses under frosty, windy and rainy conditions. Preliminary results indicate that Clostridium sordellii and Clostridium bifermentans producing lethal toxin may play a role in pasture myodystrophy. Our efforts concentrate on developing a new subunit vaccine for equine botulism and understanding the ethiology and pathogenesis of pasture myodystrophy with the goal of improving prevention against these highly fatal diseases that present a significant risk to our horse population. PMID:17076463

Gerber, V; Straub, R; Frey, J



Metabolic neuropathies and myopathies.  


Inborn errors of metabolism may impact on muscle and peripheral nerve. Abnormalities involve mitochondria and other subcellular organelles such as peroxisomes and lysosomes related to the turnover and recycling of cellular compartments. Treatable causes are ?-oxidation defects producing progressive neuropathy; pyruvate dehydrogenase deficiency, porphyria, or vitamin B12 deficiency causing recurrent episodes of neuropathy or acute motor deficit mimicking Guillain-Barré syndrome. On the other hand, lysosomal (mucopolysaccharidosis, Gaucher and Fabry diseases), mitochondriopathic (mitochondrial or nuclear mutations or mDNA depletion), peroxisomal (adrenomyeloneuropathy, Refsum disease, sterol carrier protein-2 deficiency, cerebrotendinous xanthomatosis, ?-methylacyl racemase deficiency) diseases are multisystemic disorders involving also the heart, liver, brain, retina, and kidney. Pathophysiology of most metabolic myopathies is related to the impairment of energy production or to abnormal production of reactive oxygen species (ROS). Main symptoms are excercise intolerance with myalgias, cramps and recurrent myoglobinuria or limb weakness associated with elevation of serum creatine kinase. Carnitine palmitoyl transferase deficiency, followed by acid maltase deficiency, and lipin deficiency, are the most common cause of isolated rhabdomyolysis. Metabolic myopathies are frequently associated to extra-neuromuscular disorders particularly involving the heart, liver, brain, retina, skin, and kidney. PMID:23622366

D'amico, Adele; Bertini, Enrico



Mild uncoupling of respiration and phosphorylation as a mechanism providing nephro- and neuroprotective effects of penetrating cations of the SkQ family.  


It is generally accepted that mitochondrial production of reactive oxygen species is nonlinearly related to the value of the mitochondrial membrane potential with significant increment at values exceeding 150 mV. Due to this, high values of the membrane potential are highly dangerous, specifically under pathological conditions associated with oxidative stress. Mild uncoupling of oxidative phosphorylation is an approach to preventing hyperpolarization of the mitochondrial membrane. We confirmed data obtained earlier in our group that dodecylrhodamine 19 (C(12)R1) (a penetrating cation from SkQ family not possessing a plastoquinone group) has uncoupling properties, this fact making it highly potent for use in prevention of pathologies associated with oxidative stress induced by mitochondrial hyperpolarization. Further experiments showed that C(12)R1 provided nephroprotection under ischemia/reperfusion of the kidney as well as under rhabdomyolysis through diminishing of renal dysfunction manifested by elevated level of blood creatinine and urea. Similar nephroprotective properties were observed for low doses (275 nmol/kg) of the conventional uncoupler 2,4-dinitrophenol. Another penetrating cation that did not demonstrate protonophorous activity (SkQR4) had no effect on renal dysfunction. In experiments with induced ischemic stroke, C(12)R1 did not have any effect on the area of ischemic damage, but it significantly lowered neurological deficit. We conclude that beneficial effects of penetrating cation derivatives of rhodamine 19 in renal pathologies and brain ischemia may be at least partially explained by uncoupling of oxidation and phosphorylation. PMID:23157263

Plotnikov, E Y; Silachev, D N; Jankauskas, S S; Rokitskaya, T I; Chupyrkina, A A; Pevzner, I B; Zorova, L D; Isaev, N K; Antonenko, Y N; Skulachev, V P; Zorov, D B



Animal models of acute renal failure.  


The animal models are pivotal for understanding the characteristics of acute renal failure (ARF) and development of effective therapy for its optimal management. Since the etiology for induction of renal failure is multifold, therefore, a large number of animal models have been developed to mimic the clinical conditions of renal failure. Glycerol-induced renal failure closely mimics the rhabdomyolysis; ischemia-reperfusion-induced ARF simulate the hemodynamic changes-induced changes in renal functioning; drug-induced such as gentamicin, cisplatin, NSAID, ifosfamide-induced ARF mimics the renal failure due to clinical administration of respective drugs; uranium, potassium dichromate-induced ARF mimics the occupational hazard; S-(1,2-dichlorovinyl)-L-cysteine-induced ARF simulate contaminated water-induced renal dysfunction; sepsis-induced ARF mimics the infection-induced renal failure and radiocontrast-induced ARF mimics renal failure in patients during use of radiocontrast media at the time of cardiac catheterization. Since each animal model has been created with specific methodology, therefore, it is essential to describe the model in detail and consequently interpret the results in the context of a specific model. PMID:22580518

Singh, Amrit Pal; Junemann, Anselm; Muthuraman, Arunachalam; Jaggi, Amteshwar Singh; Singh, Nirmal; Grover, Kuldeep; Dhawan, Ravi



Metformin induced severe hypophosphatemia in a patient on hemodialysis.  


A 67-year-old diabetic and hypertensive woman presented to us with very low serum phosphate levels (PO?? =1.1 mg/dL) about 40 days after initiation of hemodialysis (HD). The phosphate binders were discontinued, because they were thought to be the cause of hypophosphatemia. However, the serum phosphate levels continued to remain low during subsequent follow-up visits over one month (PO???? = 0.7 and 0.6 mg/dL respectively). The patient had been started on metformin hydrochloride (850 mg thrice a day) about 18 days after the beginning of HD. The drug was stopped immediately (approximately 50 days after it was started) and the serum phosphate levels increased progressively, reaching 4.3 mg/dL. During the period with hypophosphatemia, the patient suffered from very intense fatigue and weakness (she was unable to walk), anorexia, diarrhea and tenesmus. There were no features suggestive of rhabdomyolysis, hemolysis, low blood pressure or hypoglycemia; she had low white blood cell and platelet counts. The patient was in good clinical condition 2-3 days after the discontinuation of metformin and she recovered totally 15 days later. This case is presented due to its rarity as well as the observation that despite the patient having severe hypophosphatemia, she showed only side effects of metformin. Hypophosphatemia caused only intense fatigue and no other symptoms. PMID:20814133

Tsitsios, Tilemachos; Sotirakopoulos, Nikolaos; Armentzioiou, Karmen; Kalogiannidou, Irini; Kolaggis, Alexandros; Mavromatidis, Konstantinos



Envenomations by Bothrops and Crotalus Snakes Induce the Release of Mitochondrial Alarmins  

PubMed Central

Skeletal muscle necrosis is a common manifestation of viperid snakebite envenomations. Venoms from snakes of the genus Bothrops, such as that of B. asper, induce muscle tissue damage at the site of venom injection, provoking severe local pathology which often results in permanent sequelae. In contrast, the venom of the South American rattlesnake Crotalus durissus terrificus, induces a clinical picture of systemic myotoxicity, i.e., rhabdomyolysis, together with neurotoxicity. It is known that molecules released from damaged muscle might act as ‘danger’ signals. These are known as ‘alarmins’, and contribute to the inflammatory reaction by activating the innate immune system. Here we show that the venoms of B. asper and C. d. terrificus release the mitochondrial markers mtDNA (from the matrix) and cytochrome c (Cyt c) from the intermembrane space, from ex vivo mouse tibialis anterior muscles. Cyt c was released to a similar extent by the two venoms whereas B. asper venom induced the release of higher amounts of mtDNA, thus reflecting hitherto some differences in their pathological action on muscle mitochondria. At variance, injection of these venoms in mice resulted in a different time-course of mtDNA release, with B. asper venom inducing an early onset increment in plasma levels and C. d. terrificus venom provoking a delayed release. We suggest that the release of mitochondrial ‘alarmins’ might contribute to the local and systemic inflammatory events characteristic of snakebite envenomations.

Zornetta, Irene; Caccin, Paola; Fernandez, Julian; Lomonte, Bruno; Gutierrez, Jose Maria; Montecucco, Cesare



Case report: fatal poisoning with Colchicum autumnale  

PubMed Central

Introduction Colchicum autumnale, commonly known as the autumn crocus, contains alkaloid colchicine with antimitotic properties. Case report A 76-year-old man with a history of alcoholic liver disease and renal insufficiency, who mistakenly ingested Colchicum autumnale instead of wild garlic (Aliium ursinum), presented with nausea, vomiting and diarrhea 12 hours after ingestion. On admission the patient had laboratory signs of dehydration. On the second day the patient became somnolent and developed respiratory insufficiency. The echocardiogram showed heart dilatation with diffuse hypokinesia with positive troponin I. The respiratory insufficiency was further deteriorated by pneumonia, confirmed by chest X-ray and later on by autopsy. Laboratory tests also revealed rhabdomyolysis, coagulopathy and deterioration of renal function and hepatic function. The toxicological analysis disclosed colchicine in the patient's urine (6 ?g/l) and serum (9 ?g/l) on the second day. Therapy was supportive with hydration, vasopressors, mechanical ventilation and antibiotics. On the third day the patient died due to asystolic cardiac arrest. Discussion and conclusion Colchicine poisoning should be considered in patients with gastroenterocolitis after a meal of wild plants. Management includes only intensive support therapy. A more severe clinical presentation should be expected in patients with pre-existing liver and renal diseases. The main reasons for death are cardiovascular collapse, respiratory failure and leukopenia with infection.

Brvar, Miran; Ploj, Tom; Kozelj, Gordana; Mozina, Martin; Noc, Marko; Bunc, Matjaz




PubMed Central

Hypophosphatemia is a common laboratory abnormality that occurs in a wide variety of disorders. When severe and prolonged, it may be associated with rhabdomyolysis, brain dysfunction, myocardial failure and certain defects of erythrocyte function and structure. Other disorders ascribed to hypophosphatemia, including platelet dysfunction and thrombocytopenia, liver dysfunction, renal tubular defects, peripheral neuropathy, metabolic acidosis and leukocyte dysfunction are less well documented. In quantitative terms, the most severe phosphate deficiency is seen in patients who consume a phosphate-deficient diet in conjunction with large amounts of phosphate-binding antacids, in persons with severe, chronic alcoholism and in patients with wasting illnesses who are refed with substances containing an inadequate amount of phosphate. When severe hypophosphatemia occurs in such a setting, the clinical effects appear to be much more pronounced. While there have been some advances in our understanding of the pathophysiology of phosphate depletion and hypophosphatemia, much remains to be learned. Treatment of hypophosphatemia is controversial; however, there is little question that it is indicated in alcoholic patients and those with severe phosphate deficiency.

Knochel, James P.



Drugs, muscle pallor, and pyomyositis.  


A 33-year-old athletic male was unexpectedly found dead in his bed. For several days prior to his death he complained of tenderness and swelling of his right buttock. The post-mortem examination revealed unilateral pale gluteal muscles and pustular impetiginized skin lesions of the right lower leg. The muscle histology demonstrated pronounced acute inflammation and limited necrosis of muscle fibers confined to the right gluteal muscles. Vascular occlusion and renal abnormalities were excluded by post-mortem angiography and histology respectively, and the diagnosis of non-tropical pyomyositis, possibly originating from the dermatological infection, was made. Toxicological testing revealed a potentially lethal intoxication with fentanyl and morphine. Pyomyositis is etiologically attributed to an infection and predominantly affects large limb or trunk muscles. Males are affected more frequently than females. Histologically, it is dominated by acute inflammatory infiltrates and may lead to sepsis and subsequent death. Although occurring less frequently, pyomyositis must be considered in the differential diagnosis of macroscopic localized muscle pallor, together with vascular occlusion and rhabdomyolysis. In such cases, only the examination of fresh frozen muscle tissue samples from different locations, together with the histological examination of the internal organs, particularly the kidneys, will facilitate the confirmation of the correct diagnosis. PMID:23864208

Kubat, Bela



Pituitary metastasis presenting as ischemic pituitary apoplexy following heparin-induced thrombocytopenia.  


Pituitary apoplexy (PA) typically results from infarction or hemorrhage in a pituitary adenoma, while PA in nonadenomatous pituitary gland is uncommon. Prothrombotic states have never been recognized as precipitating factors for PA. The authors report a case of an elderly female who received prophylactic fractionated heparin therapy due to sepsis, consequent rhabdomyolysis, and overt disseminated intravascular coagulation. On the seventh day of heparin therapy, she reported sudden vision loss, ptosis, diplopia, and severe headache. Severe thrombocytopenia and positive antibodies to the complex of platelet factor 4 and heparin confirmed heparin-induced thrombocytopenia type 2 (HIT). Magnetic resonance imaging disclosed a homogenous pituitary tumor mass with pronounced sphenoid sinus mucosa thickening and two hypointense zones within the tumor mass on contrast-enhanced images consistent with focal ischemic necrosis. The tumor was confirmed to be squamous cell carcinoma with no signs of necrosis. Ischemic necrosis was found within marginal pituitary tissue. This is the first reported case of ischemic PA associated with pituitary metastasis and the first case in which HIT triggered PA. Our case demonstrates that prothrombotic states such as HIT can precipitate ischemic PA. Pituitary metastasis can present with ischemic PA, but radiological features differ from those described in pituitary adenomas. Segregated low-signal intensity zones within the tumor mass on postcontrast images indicate partial infarction of the tumor, which could be a special feature of ischemic PA in pituitary metastasis and has never been described in pituitary adenomas. These are all novel findings and might enlighten the pathogenesis of PA. PMID:23129546

Kruljac, Ivan; Cerina, Vatroslav; Pe?ina, Hrvoje Ivan; Pažanin, Leo; Mati?, Tomas; Božikov, Velimir; Vrkljan, Milan



Pathophysiologic changes due to TASER® devices versus excited delirium: potential relevance to deaths-in-custody?  


The syndrome of excited delirium has been implicated in some deaths-in-custody which also involved the use of electronic control devices (ECDs) (including those manufactured by TASER International) on subjects. This review is an update on recent studies of pathophysiologic changes related to these two separate but parallel topics: a) first, the use of ECDs during law-enforcement activities; and b) second, the occurrence of excited delirium during such activities. This is a narrative review of elements that may be of use in generating hypotheses relating to potential similarities or differences between the two topics. Differences between changes in most factors due to excited delirium versus those of ECD applications were not readily apparent in most cases. These factors include: direct and indirect effects on the cardiovascular system, respiration, rhabdomyolysis and muscle enzymes, hyperkalemia, acidosis, hyperglycemia, and increased hematocrit. One factor that may exhibit consistent differences, however, is increased body temperature, which is often evident during excited delirium (versus a lack of increase temperature during ECD exposures). Thus, on the basis of this review, a more detailed delineation of this factor could be a major focus for future forensic investigations of deaths-in-custody involving either excited delirium or ECD exposures. PMID:21550562

Jauchem, James R



Neuroleptic malignant syndrome from central nervous system insult: 4 cases and a novel treatment strategy. Clinical article.  


Neuroleptic malignant syndrome (NMS) is a potentially life-threatening entity characterized by hyperthermia, autonomic deregulation, decreased mental status, increased muscle tone, and, frequently, by renal failure due to rhabdomyolysis. Classically, it follows administration of antipsychotic medication. The authors report on 4 patients (2 children and 2 adults) in whom NMS was diagnosed after a CNS insult. No patient was receiving antipsychotic medication. The patients' hospital and clinic charts, radiographic data, and follow-up telephone conversations were reviewed retrospectively. All 4 patients met diagnostic criteria for NMS. Three patients presented with shunt failure, and 1 patient had undergone a functional hemispherectomy 2 days earlier. One patient with shunt failure received the diagnosis retrospectively. An endoscopic third ventriculostomy alleviated his shunt failure and he remains free of NMS. The other 2 patients underwent treatment for shunt failure, but NMS remained. These 2 patients and the one who had undergone hemispherectomy underwent a trial of intrathecal baclofen, and the NMS resolved. Subsequently, an intrathecal baclofen infusion device was placed in all 3 patients, and the NMS resolved. The 2 patients in shunt failure had a lumbar intrathecal baclofen infusion device. The patient who had undergone hemispherectomy had an intracranial baclofen catheter. Neuroleptic malignant syndrome is a rare, life-threatening disorder that can occur without the administration of neuroleptic medications. Alleviation of any CNS insult is the first order of treatment. Some patients with persistent symptoms of NMS may benefit from intrathecal delivery of baclofen. PMID:19772404

Wait, Scott D; Ponce, Francisco A; Killory, Brendan D; Wallace, Donna; Rekate, Harold L



Influence of 3-hydroxy-3-methylglutaryl-CoA (HMG-CoA) reductase inhibitors on endothelial nitric oxide synthase and the formation of oxidants in the vasculature.  


HMGCoA reductase inhibitors (statins) can have effects outside the target tissue, liver, including serious side-effects such as rhabdomyolysis as well as beneficial pleiotrophic effects. One such effect is upregulation of endothelial nitric oxide synthase (e-NOS) which generally leads to vasorelaxation. However, changing the balance between localized NO and O(2-) fluxes can also lead to oxidant stress and cellular injury through formation of reactive secondary oxidants such as peroxynitrite. We compared different statins for e-NOS subcellular localization, formation of pro-oxidants, and endothelial-dependent vascular function. Vascular relaxation in aortas of statin-dosed rats was inhibited with simvastatin (sevenfold higher EC50 for acetyl-choline induced relaxation) and atorvastatin (twofold increase) but not pravastatin. Ex vivo oxidation of the fluorescent redox probe dihydrorhodamine-123 (DHR-123) was increased in aortas from simvastatin treated rats, indicating increased reactive nitrogen and oxygen species. Human aortic endothelial cells incubated with simvastatin exhibited up to threefold higher intracellular oxidation of DHR-123 along with a twofold increase in total e-NOS protein. The elevated e-NOS was found in the Golgi/mitochondrial fraction and not in the plasma membrane, and using immunofluorescence greater e-NOS was observed proximal to Golgi and cytoskeletal structures and away from plasma membrane in simvastatin-treated cells. The data suggest that the action of lipophilic statins in endothelium can shift e-NOS localization towards intracellular domains, thereby increasing the encounter with metabolically generated O(2-) to produce peroxynitrite and related oxidants. Thus, under some conditions the direct action of lipophilic HMGCoA reductase inhibitors may unbalance NO and O(2-) fluxes and promote oxidant stress, compromising potentially beneficial vascular effects of e-NOS upregulation and increasing the potential for damage to muscle and other tissues. PMID:12860247

Parker, Rex A; Huang, Qi; Tesfamariam, Belay



The controversies of statin therapy: weighing the evidence.  


The debate whether statins, 3-hydroxymethyl-3-methylglutaryl coenzyme A reductase inhibitors, are safe to use has been raging since their introduction in 1987. Statins are generally well tolerated and are believed to have minimal adverse effects. However, individual, specific rare adverse events have been reported, such as elevations of liver enzymes, muscle aches, and very rarely, rhabdomyolysis. Discontinuation and/or reduction in the dose of the statin usually leads to resolution of these side effects. Recently, however, debate has focused on the possible negative long-term effects of statin treatment on cognitive decline, the incidence of cancer, and the development of diabetes mellitus. Recently, the U.S. Food and Drug Administration has expanded the warning for statins with a statement that statin use may lead to cognitive impairment. In this review, we discuss all levels of evidence, from case reports to large randomized controlled clinical trials, for the possible adverse effects of statins on cognitive decline, cancer, and diabetes. After careful consideration of all discussed scientific evidence, we conclude that there is no increased risk of cognitive decline or cancer with statin use. However, statin use is related to a small increased risk of type 2 diabetes mellitus. In view of the overwhelming benefit of statins in the reduction of cardiovascular events, we believe the small absolute risk for development of diabetes is outweighed by the cardiovascular benefits in patients for whom statin therapy is recommended. We, therefore, suggest that clinical practice for statin therapy should not be changed on the basis of the most recent Food and Drug Administration informational warnings. PMID:22902202

Jukema, J Wouter; Cannon, Christopher P; de Craen, Anton J M; Westendorp, Rudi G J; Trompet, Stella



Species-dependent variations in the in vitro myotoxicity of death adder (Acanthophis) venoms.  


Based on early studies on Acanthophis antarcticus (common death adder) venom, it has long been thought that death adder snake venoms are devoid of myotoxicity. However, a recent clinical study reported rhabdomyolysis in patients following death adder envenomations, in Papua New Guinea, by a species thought to be different to A. antarcticus. Subsequently, a myotoxic phospholipase A2 component was isolated from A. rugosus (Irian Jayan death adder) venom. The present study examined the venoms of A. praelongus (northern), A. pyrrhus (desert), A. hawkei (Barkly Tableland), A. wellsi (black head), A. rugosus, A. sp. Seram and the regional variants of A. antarcticus for in vitro myotoxicity. Venoms (10-50 microg/ml) were examined for myotoxicity using the chick directly (0.1 Hz, 2 ms, supramaximal V) stimulated biventer cervicis nerve-muscle preparation. A significant contracture of skeletal muscle and/or inhibition of direct twitches were considered signs of myotoxicity. This was confirmed by histological examination. All venoms displayed high phospholipase A2 activity. The venoms (10-50 microg/ml) of A. sp. Seram, A. praelongus, A. rugosus,and A. wellsi caused a significant inhibition of direct twitches and an increase in baseline tension compared to the vehicle (n=4-6; two-way ANOVA, p<0.05). Furthermore, these venoms caused dose-dependent morphological changes in skeletal muscle. In contrast, the venoms (10-50 microg/ml; n=3-6) of A. hawkei, A. pyrrhus, and regional variants of A. antarcticus were devoid of myotoxicity. Prior incubation (10 min) of CSL death adder antivenom (5 U/ml) prevented the myotoxicity caused by A. sp. Seram, A. praelongus, A. rugosus, and A. wellsi venoms (50 microg/ml; n=4-7). In conclusion, clinicians may need to be mindful of possible myotoxicity following envenomations by A. praelongus, A. rugosus, A. sp. Seram, and A. wellsi species. PMID:12773755

Wickramaratna, Janith C; Fry, Bryan G; Hodgson, Wayne C



Knock-in mice for the R50X mutation in the PYGM gene present with McArdle disease.  


McArdle disease (glycogenosis type V), the most common muscle glycogenosis, is a recessive disorder caused by mutations in PYGM, the gene encoding myophosphorylase. Patients with McArdle disease typically experience exercise intolerance manifested as acute crises of early fatigue and contractures, sometimes with rhabdomyolysis and myoblobinuria, triggered by static muscle contractions or dynamic exercises. Currently, there are no therapies to restore myophosphorylase activity in patients. Although two spontaneous animal models for McArdle disease have been identified (cattle and sheep), they have rendered a limited amount of information on the pathophysiology of the disorder; therefore, there have been few opportunities for experimental research in the field. We have developed a knock-in mouse model by replacing the wild-type allele of Pygm with a modified allele carrying the common human mutation, p.R50X, which is the most frequent cause of McArdle disease. Histochemical, biochemical and molecular analyses of the phenotype, as well as exercise tests, were carried out in homozygotes, carriers and wild-type mice. p.R50X/p.R50X mice showed undetectable myophosphorylase protein and activity in skeletal muscle. Histochemical and biochemical analyses revealed massive muscle glycogen accumulation in homozygotes, in contrast to heterozygotes or wild-type mice, which did not show glycogen accumulation in this tissue. Additional characterization confirmed a McArdle disease-like phenotype in p.R50X/p.R50X mice, i.e. they had hyperCKaemia and very poor exercise performance, as assessed in the wire grip and treadmill tests (6% and 5% of the wild-type values, respectively). This model represents a powerful tool for in-depth studies of the pathophysiology of McArdle disease and other neuromuscular disorders, and for exploring new therapeutic approaches for genetic disorders caused by premature stop codon mutations. PMID:22730558

Nogales-Gadea, Gisela; Pinós, Tomàs; Lucia, Alejandro; Arenas, Joaquín; Camara, Yolanda; Brull, Astrid; de Luna, Noemí; Martín, Miguel A; Garcia-Arumí, Elena; Martí, Ramon; Andreu, Antoni L



Movement disorder emergencies in childhood.  


The literature on paediatric acute-onset movement disorders is scattered. In a prospective cohort of 52 children (21 male; age range 2mo-15y), the commonest were chorea, dystonia, tremor, myoclonus, and Parkinsonism in descending order of frequency. In this series of mainly previously well children with cryptogenic acute movement disorders, three groups were recognised: (1) Psychogenic disorders (n = 12), typically >10 years of age, more likely to be female and to have tremor and myoclonus (2) Inflammatory or autoimmune disorders (n = 22), including N-methyl-d-aspartate receptor encephalitis, opsoclonus-myoclonus, Sydenham chorea, systemic lupus erythematosus, acute necrotizing encephalopathy (which may be autosomal dominant), and other encephalitides and (3) Non-inflammatory disorders (n = 18), including drug-induced movement disorder, post-pump chorea, metabolic, e.g. glutaric aciduria, and vascular disease, e.g. moyamoya. Other important non-inflammatory movement disorders, typically seen in symptomatic children with underlying aetiologies such as trauma, severe cerebral palsy, epileptic encephalopathy, Down syndrome and Rett syndrome, include dystonic posturing secondary to gastro-oesophageal reflux (Sandifer syndrome) and Paroxysmal Autonomic Instability with Dystonia (PAID) or autonomic 'storming'. Status dystonicus may present in children with known extrapyramidal disorders, such as cerebral palsy or during changes in management e.g. introduction or withdrawal of neuroleptic drugs or failure of intrathecal baclofen infusion; the main risk in terms of mortality is renal failure from rhabdomyolysis. Although the evidence base is weak, as many of the inflammatory/autoimmune conditions are treatable with steroids, immunoglobulin, plasmapheresis, or cyclophosphamide, it is important to make an early diagnosis where possible. Outcome in survivors is variable. Using illustrative case histories, this review draws attention to the practical difficulties in diagnosis and management of this important group of patients. PMID:21835657

Kirkham, F J; Haywood, P; Kashyape, P; Borbone, J; Lording, A; Pryde, K; Cox, M; Keslake, J; Smith, M; Cuthbertson, L; Murugan, V; Mackie, S; Thomas, N H; Whitney, A; Forrest, K M; Parker, A; Forsyth, R; Kipps, C M



Analytical investigations of toxic p-phenylenediamine (PPD) levels in clinical urine samples with special focus on MALDI-MS/MS.  


Para-phenylenediamine (PPD) is a common chromophoric ingredient in oxidative hair-dyes. In some African countries like Sudan, Egypt and Morocco but also in India this chemical is used alone or in combination with colouring extracts like Henna for dyeing of the hair or the skin. Excessive dermal exposure to PPD mainly leads to the N-mono- and N,N'-diacetylated products (MAPPD, DAPPD) by N-acetyltransferase 1 and 2 (NAT1 and 2) catalyzed reactions. Metabolites and PPD are mainly excreted via renal clearance. Despite a low risk of intoxication when used in due form, there are numerous cases of acute intoxication in those countries every year. At the ENT Hospital - Khartoum (Sudan) alone more than 300 cases are reported every year (~10% fatal), mostly caused by either an accidental or intended (suicidal) high systemic exposure to pure PPD. Intoxication leads to a severe clinical syndrome including laryngeal edema, rhabdomyolysis and subsequent renal failure, neurotoxicity and acute toxic hepatitis. To date, there is no defined clinical treatment or antidote available and treatment is largely supportive. Herein, we show the development of a quick on-site identification assay to facilitate differential diagnosis in the clinic and, more importantly, the implementation of an advanced analytical platform for future in-depth investigations of PPD intoxication and metabolism is described. The current work shows a sensitive (~25 µM) wet chemistry assay, a validated MALDI-MS/MS and HPLC-UV assay for the determination of PPD and its metabolites in human urine. We show the feasibility of the methods for measuring PPD over a range of 50-1000 µM. The validation criteria included linearity, lower limit of quantification (LLOQ), accuracy and precision, recovery and stability. Finally, PPD concentrations were determined in clinical urine samples of cases of acute intoxication and the applied technique was expanded to identify MAPPD and DAPPD in the identical samples. PMID:21829608

Hooff, Gero P; van Huizen, Nick A; Meesters, Roland J W; Zijlstra, Eduard E; Abdelraheem, Mohamed; Abdelraheem, Waleed; Hamdouk, Mohamed; Lindemans, Jan; Luider, Theo M



Clinical spectrum of dengue fever in a tertiary care centre with particular reference to atypical presentation in the 2012 outbreak in Kolkata.  


During the summer of 2012, dengue fever epidemic has emerged in Kolkata and spread throughout West Bengal. During the epidemic period, wide spectrum of atypical presentations of dengue fever has been observed. Here, in this study, the spectrum of dengue fever was analysed in 300 patients who were found to have dengue serology positive (NS1, IgM, IgG). The study was done in the department of medicine, RG Kar Medical College, Kolkata. The patients were classified according to age, gender, duration of symptoms on admission, associated comorbidities and coinfections, complications that developed after admission, the final outcome and duration till death after symptoms developed. The dengue fever cases started to appear from April but it attained its peak during August-September this year. All ages were affected but the brunt was borne maximally by those between 15 and 40 years. Females were more affected than males. It may be concluded from the study that 30% had no complications while 70% cases developed complications, 4% cases had underlying comorbidities and coinfections, 68% developed thrombocytopenia and other haemorrhagic features, 55% serositis, 25% acalculous cholecystitis, 20% myocarditis, 15% pancreatitis, 5% had central nervous system involvement, 0.66% rhabdomyolysis and myositis, 0.33% secondary vasculitis and death occurred in 3% cases. More number of patients were having multiple and atypical complications requiring hospitalisation. Mortality was more common in patients with associated comorbidities and coinfection. Awareness, early treatment with aggressive fluid replacement therapy with close monitoring, supportive management andpatient education showed promising results. PMID:23936956

Majumdar, Ritwika; Jana, Chanchal Kumar; Ghosh, Sandip; Biswas, Uttam



Anesthetic- and heat-induced sudden death in calsequestrin-1-knockout mice  

PubMed Central

Calsequestrin-1 (CASQ1) is a moderate-affinity, high-capacity Ca2+-binding protein in the sarcoplasmic reticulum (SR) terminal cisternae of skeletal muscle. CASQ1 functions as both a Ca2+-binding protein and a luminal regulator of ryanodine receptor (RYR1)-mediated Ca2+ release. Mice lacking skeletal CASQ1 are viable but exhibit reduced levels of releasable Ca2+ and altered contractile properties. Here we report that CASQ1-null mice exhibit increased spontaneous mortality and susceptibility to heat- and anesthetic-induced sudden death. Exposure of CASQ1-null mice to either 2% halothane or heat stress triggers lethal episodes characterized by whole-body contractures, elevated core temperature, and severe rhabdomyolysis, which are prevented by prior dantrolene administration. The characteristics of these events are remarkably similar to analogous episodes observed in humans with malignant hyperthermia (MH) and animal models of MH and environmental heat stroke (EHS). In vitro studies indicate that CASQ1-null muscle exhibits increased contractile sensitivity to temperature and caffeine, temperature-dependent increases in resting Ca2+, and an increase in the magnitude of depolarization-induced Ca2+ release. These results demonstrate that CASQ1 deficiency alters proper control of RYR1 function and suggest CASQ1 as a potential candidate gene for linkage analysis in families with MH/EHS where mutations in the RYR1 gene are excluded.—Dainese, M., Quarta, M., Lyfenko, A. D., Paolini, C., Canato, M., Reggiani, C., Dirksen, R. T., Protasi, F. Anesthetic- and heat-induced sudden death in calsequestrin-1-knockout mice.

Dainese, Marco; Quarta, Marco; Lyfenko, Alla D.; Paolini, Cecilia; Canato, Marta; Reggiani, Carlo; Dirksen, Robert T.; Protasi, Feliciano



Lessons from calsequestrin-1 ablation in vivo: much more than a Ca(2+) buffer after all.  


Calsequestrin type-1 (CASQ1), the main sarcoplasmic reticulum (SR) Ca(2+) binding protein, plays a dual role in skeletal fibers: a) it provides a large pool of rapidly-releasable Ca(2+) during excitation-contraction (EC) coupling; and b) it modulates the activity of ryanodine receptors (RYRs), the SR Ca(2+) release channels. We have generated a mouse lacking CASQ1 in order to further characterize the role of CASQ1 in skeletal muscle. Contrary to initial expectations, CASQ1 ablation is compatible with normal motor activity, in spite of moderate muscle atrophy. However, CASQ1 deficiency results in profound remodeling of the EC coupling apparatus: shrinkage of junctional SR lumen; proliferation of SR/transverse-tubule contacts; and increased density of RYRs. While force development during a twitch is preserved, it is nevertheless characterized by a prolonged time course, likely reflecting impaired Ca(2+) re-uptake by the SR. Finally, lack of CASQ1 also results in increased rate of SR Ca(2+) depletion and inability of muscle to sustain tension during a prolonged tetani. All modifications are more pronounced (or only found) in fast-twitch extensor digitorum longus muscle compared to slow-twitch soleus muscle, likely because the latter expresses higher amounts of calsequestrin type-2 (CASQ2). Surprisingly, male CASQ1-null mice also exhibit a marked increased rate of spontaneous mortality suggestive of a stress-induced phenotype. Consistent with this idea, CASQ1-null mice exhibit an increased susceptibility to undergo a hypermetabolic syndrome characterized by whole body contractures, rhabdomyolysis, hyperthermia and sudden death in response to halothane- and heat-exposure, a phenotype remarkably similar to human malignant hyperthermia and environmental heat-stroke. The latter findings validate the CASQ1 gene as a candidate for linkage analysis in human muscle disorders. PMID:22130610

Protasi, Feliciano; Paolini, Cecilia; Canato, Marta; Reggiani, Carlo; Quarta, Marco



A Detailed Epidemiological and Clinical Description of 6 Human Cases of Avian-Origin Influenza A (H7N9) Virus Infection in Shanghai  

PubMed Central

Background The world’s first reported patient infected with avian influenza H7N9 was treated at the Fifth People’s Hospital of Shanghai. Shortly thereafter, several other cases emerged in the local area. Here, we describe the detailed epidemiological and clinical data of 6 cases of avian influenza H7N9. Methods and Findings We analyzed the epidemiologic and clinical data from clustered patients infected with H7N9 in the Minhang District of Shanghai during a 2-week period. Of the 6 patients, 2 were from a single family. In addition, 3 patients had a history of contact with poultry; however, all 6 patients lived in the proximity of 2 food markets where the H7N9 virus was detected in chickens and pigeons. The main symptoms were fever, cough, and hemoptysis. At onset, a decreased lymphocyte count and elevated creatine kinase, lactate dehydrogenase, procalcitonin, and C-reactive protein levels were observed. As the disease progressed, most patients developed dyspnea and hypoxemia. Imaging studies revealed lung consolidation and multiple ground-glass opacities in the early stage, rapidly extending bilaterally. All patients were treated with oseltamivir tablets beginning on days 3–8 after onset. The main complications were as follows: acute respiratory distress syndrome (ARDS; 83.3%), secondary bacterial infection (66.7%), pleural effusion (50%), left ventricular failure (33.3%), neuropsychiatric symptoms (33.3%), and rhabdomyolysis (16.7%). Of the 6 patients, 4 died of ARDS, with 2 patients recovering from the infection. Conclusions An outbreak of H7N9 infection occurred in the Minhang District of Shanghai that easily progressed to acute respiratory distress syndrome. Two cases showed family aggregation, which led us to identify the H7N9 virus and indicated that human transmission may be involved in the spread of this infection.

Hu, Yunwen; He, Yanchao; Huang, Qihui; Leng, Beizheng; He, Wei; Sheng, Ying; Li, Fangming; Song, Yuanlin; Bai, Chunxue; Gu, Yong; Jie, Zhijun



[Mushroom poisoning--the dark side of mycetism].  


Most mushroom intoxications become evident within 12 hours with vomiting and diarrhea. They can be divided into incidents with a short latency (less than four hours) and incidents with a long latency (longer than four hours). As a rule of thumb amatoxin poisonings must be considered in case of symptoms appearing with a long latency (8-12-18 h), especially after consumption of non-controlled wild mushrooms. Shorter latencies do not exclude amatoxin poisoning. Large meals of mushrooms, which are rich in chitin, mixed meals and individual factors, may shorten latency and disguise amatoxin poisoning. Any vomiting and diarrhea after mushroom consumption is suspicious. Unless the mushrooms are not to be identified within 30 minutes by an expert, specific treatment for amatoxin poisoning must be started. Identification shall be achieved by macroscopic or microscopic means; and urine analysis for amatoxins are crucial. By commencing treatment before analysis, mortality rates may be as low as 5%. Current standards in amatoxin poisoning treatment can be obtained at the Swiss Toxicological Information Centre (Phone 145), where contacts to mycologists are available as well. Emergency mycologists are listed on the website Of the 18 different syndromes we present the most common and most important in Switzerland. In an overview all of them are listed. Early gastrointestinal syndrome with its short latency of less than 4 h and indigestion with a very variable latency are the most common. Psychotropic symptoms after consumptions of fly agaric and panther cap are rare, in case of psilocybin-containing mushrooms, symptoms are frequent, but hardly ever lead to medical treatment. In case of renal failure and rhabdomyolysis of unknown origin, completing a patient's history by questioning nutritional habits might reveal causal relationship with ingestion of orellanin-containing mushrooms or tricholoma equestre respectively. Mushrooms in the backyard are attractive for children. We discuss possible approaches. PMID:19401986

Flammer, René; Schenk-Jäger, Katharina M



Hyperglycemic hyperosmolar syndrome at the onset of type 2 diabetes mellitus in an adolescent male.  


Hyperglycemic hyperosmolar state (HHS) is rare in the paediatric population. The diagnosis and management of HHS presents a challenge in paediatric patients who may present with a mixed picture of HHS and diabetic ketoacidosis (DKA).A 15-year-old obese African American male was brought to the emergency department following a two-day history of feeling unwell. The patient was obtunded, hypotensive and tachypneic. Initial investigations revealed the following: pH 6.97 (normal 7.35 to 7.41), HCO(3) (-) 5 mEq/L (normal 20 mEq/L to 25 mEq/L), glucose 90.9 mmol/L (normal 3.4 mmol/L to 6.3 mmol/L), serum osmolality 454 mOsm/kg (normal 275 mOsm/kg to 295 mOsm/kg), Na(+) 141 mEq/L (normal 135 mEq/L to 145 mEq/L), corrected Na(+) 165 mEq/L, K(+) 8.4 mEq/L (normal 3.5 mEq/L to 5.0 mEq/L), urinalysis revealed 1+ ketones and 4+ glucose. The patient's clinical course was complicated by severe hyperkalemia, acute renal failure, refractory status epilepticus, rhabdomyolysis, pancreatitis and hypertension.The present case emphasizes the complexity of managing patients with a mixed DKA/HHS presentation and associated morbidities. It is very important to disseminate and implement screening guidelines for type 2 diabetes mellitus, so as to prevent this potentially devastating complication. PMID:23277751

Tsai, Sarah L; Hadjiyannakis, Stasia; Nakhla, Meranda



[Myoglobinuria due to enzyme abnormalities in glycolytic pathway--especially lactate dehydrogenase M subunit deficiency].  


Glycolysis is an important energy productive system. Enzyme abnormalities the in glycolytic pathway, which cause myoglobinuria, are deficiencies of phosphofructokinase, phosphoglycerate kinase, phosphoglycerate mutase, and lactate dehydrogenase (LDH). Common symptoms of these enzyme abnormalities are muscle cramp, muscle pain, and rhabdomyolysis after strenuous exercise. Acute renal failure owing to myoglobinuria is the most noteworthy symptom. In daily life, symptoms are rarely observed and prognosis is usually good. Correct and fast diagnosis of such latent symptomatic disorders is important to prevent a turn for the worse of these symptoms. LDH M subunit deficiency was first discovered by urinary discoloration and a discrepancy of laboratory data. Since then, only four cases have been reported in the Japanese population. The response to ischemic forearm work is characteristic (an increase of venous lactate concentration after ischemic work is not observed and a marked increase of venous pyruvate is found). The increase of pyruvate concentration is specific in LDH-M subunit deficiency, and is not observed in other abnormalities of the glycolytic pathway. Glycolysis was markedly retarded in the patient's muscle in the glyceraldehyde 3-phosphate dehydrogenase (GA3PD) step, possibly due to the impaired reoxidation of NADH produced by GA3PD activity. Then, the excess NADH is reoxidized by alpha-glycerophosphate dehydrogenase and triose phosphates are drained to alpha-glycerophosphate and glycerol. Therefore ATP production is significantly impaired and muscle tissue is damaged. A genetical study revealed a deletion of 20 base-pairs in exon 6 in LDH-M subunit deficiency. This mutation results in a frame-shift translation and premature termination. PMID:1828277

Maekawa, M; Kanno, T; Sudo, K



A case of fatal caffeine poisoning.  


Caffeine is a natural alkaloid methylxanthine that is found in various plants such as coffee or tea. Symptoms of a severe overdose may present with hypokalemia, hyponatremia, ventricular arrhythmias, hypertension followed by hypotension, respiratory failure, seizures, rhabdomyolysis, ventricular fibrillation and finally circulatory collapse. A 21-year-old woman called for the ambulance herself soon after the ingestion of about 10,000 mg of caffeine. At the arrival of the ambulance, the patient went into cardiac arrest almost immediately. After a total resuscitation period of 34 min including seven counter-shocks and 2 mg epinephrine, the patient was stable enough to be transferred to the hospital. The patient soon went into VF again and received two more counter-shocks and 1 mg epinephrine and finally an intravenous bolus dose of 300 mg amiodarone. The initial arterial blood gas showed pH at 6.47, lactate at 33 mmol/l and potassium level at 2.3 mmol/l. Unfortunately, no blood samples for caffeine analysis were taken. Three days after hospital admission, the patient developed myoclonus, which did not respond to medical treatment. Excessive intake of caffeine may produce arrhythmias and pronounced hypokalemia and ensuing ventricular fibrillation. In case of counter-shock-resistant VF, it can be necessary to give an early loading dose of amiodarone. Furthermore, it may be beneficial to replace the potassium as early as possible. Epinephrine and buffer solutions used during resuscitation may further decrease blood potassium levels and should be administrated cautiously. Epinephrine can be replaced by other vasopressor drugs, such as vasopressin without effects on beta-receptors. PMID:20096021

Rudolph, T; Knudsen, K



The influence of acute renal injury on arginine and methylarginines metabolism.  


Abstract Arginine (ARG) and its methylated analogs (methylarginines) are the crucial regulators of nitric oxide (NO) bioavailability. ARG is the substrate for NO synthesis, whereas monomethylarginine (MMA) and asymmetric dimethylarginine (ADMA) are potent inhibitors. Symmetric dimethylarginine (SDMA) does not interfere with NO synthesis, but competes with ARG for the intracellular transport. The kidneys play the major role in ARG and methylarginines metabolism. They synthesize ARG de novo and eliminate methylarginines by excretion into urine and also by enzyme dimethylarginine dimethylaminohydrolase (DDAH) degrading only ADMA and MMA. Acute renal injury (ARI) is known to be accompanied by reduced NO production in the body. This study aimed to investigate the influence of ARI on ARG and methylarginines metabolism, and to establish the relationship between disturbances in the latter and reduced NO bioavailability in ARI. The rhabdomyolysis-related ARI model in rats was used. ARI reduced renal synthesis of ARG and its level in circulation as well as renal DDAH activity. However, ADMA did not accumulate because of its increased urinary excretion. Whole-body production of SDMA was increased significantly, whereas whole-body metabolism of MMA did not change. ARG and methylarginines content in renal tissue was decreased. Moreover, the balance between the substrate and inhibitors for NO synthesis was changed in favor of the inhibitors in renal tissue as well as in blood, and daily urinary excretion of NO metabolites was significantly decreased. Thus, ARI provokes severe disturbances in ARG and methylarginines metabolism that results in reduced NO bioavailability in the kidney and the whole body. PMID:23991715

Sukhovershin, Roman A; Gilinsky, Mikhail A



Quantitative Structure Activity Relationship for Inhibition of Human Organic Cation/Carnitine Transporter (OCTN2)  

PubMed Central

Organic cation/carnitine transporter (OCTN2; SLC22A5) is an important transporter for L-carnitine homeostasis, but can be inhibited by drugs, which may cause L-carnitine deficiency and possibly other OCTN2-mediated drug-drug interactions. One objective was to develop a quantitative structure–activity relationship (QSAR) of OCTN2 inhibitors, in order to predict and identify other potential OCTN2 inhibitors and infer potential clinical interactions. A second objective was to assess two high renal clearance drugs that interact with OCTN2 in vitro (cetirizine and cephaloridine) for possible OCTN2-mediated drug-drug interactions. Using previously generated in vitro data of 22 drugs, a 3D quantitative pharmacophore model and a Bayesian machine learning model were developed. The four pharmacophore features include two hydrophobic groups, one hydrogen-bond acceptor, and one positive ionizable center. The Bayesian machine learning model was developed using simple interpretable descriptors and function class fingerprints of maximum diameter 6 (FCFP_6). An external test set of 27 molecules, including 15 newly identified OCTN2 inhibitors, and a literature test set of 22 molecules were used to validate both models. The computational models afforded good capability to identify structurally diverse OCTN2 inhibitors, providing a valuable tool to predict new inhibitors efficiently. Inhibition results confirmed our previously observed association between rhabdomyolysis and Cmax/Ki ratio. The two high renal clearance drugs cetirizine and cephaloridine were found not to be OCTN2 substrates and their diminished elimination by other drugs is concluded not to be mediated by OCTN2.

Diao, Lei; Ekins, Sean; Polli, James E.



Metabolic control during exercise with and without medium-chain triglycerides (MCT) in children with long-chain 3-hydroxy acyl-CoA dehydrogenase (LCHAD) or trifunctional protein (TFP) deficiency  

PubMed Central

Exercise induced rhabdomyolysis is a complication of long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) and mitochondrial trifunctional protein (TFP) deficiency that frequently leads to exercise avoidance. Dietary therapy for most subjects includes medium-chain triglyceride (MCT) supplementation but analysis of diet records indicates that the majority of patients consume oral MCT only with breakfast and at bedtime. We hypothesized that MCT immediately prior to exercise would provide an alternative fuel source during that bout of exercise and improve exercise tolerance in children with LCHAD deficiency. Nine subjects completed two 45 min moderate intensity (60–70% predicted maximum heart rate (HR)) treadmill exercise tests. Subjects were given 4 oz of orange juice alone or orange juice and 0.5 g MCT per kg lean body mass, 20 min prior to exercise in a randomized cross-over design. ECG and respiratory gas exchange including respiratory quotient (RQ) were monitored. Blood levels of acylcarnitines, creatine kinase, lactate, and ?-hydroxybutyrate were measured prior to and immediately after exercise, and again following 20min rest. Creatine kinase and lactate levels did not change with exercise. There was no significant difference in RQ between the two exercise tests but there was a decrease in steady-state HR following MCT supplementation. Cumulative long-chain 3-hydroxyacylcarnitines were 30% lower and ?-hydroxybutyrate was three-fold higher after the MCT-pretreated exercise test compared to the test with orange juice alone. Coordinating MCT supplementation with periods of increased activity may improve the metabolic control of children with LCHAD and TFP deficiency following exercise.

Gillingham, Melanie B.; Scott, Bradley; Elliott, Diane; Harding, Cary O.



Growth factor delivery from hydrogel particle aggregates to promote tubular regeneration after acute kidney injury.  


Local delivery of growth factors (GFs) can accelerate regeneration of injured tissue, but for many medical applications, injectable GF delivery systems are required for clinical success. Viscoelastic, injectable aggregates of micrometer-sized hydrogel particles made of multiarmed polyethylene glycol (starPEG) and heparin were prepared and tested for site-specific paracrine stimulation of tissue regeneration. Heparin was used as it binds, protects and releases numerous GFs. Hydrogel based delivery of basic fibroblast growth factor (bFGF) and murine epidermal growth factor (EGF) was monitored utilizing enzyme-linked immunosorbent assay (ELISA). bFGF was released slowly because of its high affinity to the heparin while the significantly higher release of the non-specific binding EGF was controlled by diffusion only. To investigate GF delivery in vivo, a hydrogel loaded with murine EGF or bFGF was injected subcapsularly into the left kidney of mice with experimental acute kidney injury caused by glycerol induced rhabdomyolysis. Visual examination confirmed sustained stability of the injected gel aggregates during the timescale of the experiment. The number of proliferating kidney tubular epithelial cells was quantified both in the injected kidney and the non-injected contralateral kidney. bFGF delivery from hydrogels induced a significant increase in cell proliferation in the injected kidney, although small effects were also seen in the non-injected kidney due to a systemic effect. EGF delivery strongly increased cell proliferation for both kidneys, but also showed a local effect on the injected kidney. The hydrogel without loaded GFs was used as a control and showed no increase in cell proliferation. Our results suggest that this novel starPEG-heparin hydrogel system can be an effective approach to deliver GFs locally. PMID:23395667

Tsurkan, Mikhail V; Hauser, Peter V; Zieris, Andrea; Carvalhosa, Raquel; Bussolati, Benedetta; Freudenberg, Uwe; Camussi, Giovanni; Werner, Carsten



Simvastatin impairs ADP-stimulated respiration and increases mitochondrial oxidative stress in primary human skeletal myotubes  

PubMed Central

Statins, the widely prescribed cholesterol-lowering drugs for the treatment of cardiovascular disease, cause adverse skeletal muscle side effects ranging from fatigue to fatal rhabdomyolysis. The purpose of this study was to determine the effects of simvastatin on mitochondrial respiration, oxidative stress, and cell death in differentiated primary human skeletal muscle cells (i.e. myotubes). Simvastatin induced a dose dependent decrease in viability of proliferating and differentiating primary human muscle precursor cells, and a similar dose-dependent effect was noted in differentiated myoblasts and myotubes. Additionally, there were decreases in myotube number and size following 48 h of simvastatin treatment (5 µM). In permeabilized myotubes, maximal ADP-stimulated oxygen consumption, supported by palmitoyl-carnitine + malate (PCM, complex I and II substrates) and glutamate + malate (GM, complex I substrates), was 32–37% lower (P<0.05) in simvastatin treated (5 µM) vs. control myotubes, providing evidence of impaired respiration at complex I. Mitochondrial superoxide and hydrogen peroxide generation were significantly greater in the simvastatin treated human skeletal myotube cultures compared to control. In addition, simvastatin markedly increased protein levels of Bax (pro-apoptotic, +53%) and Bcl-2 (anti-apoptotic, +100%, P<0.05), mitochondrial PTP opening (+44%, P<0.05), and TUNEL-positive nuclei in human skeletal myotubes, demonstrating up-regulation of mitochondrial-mediated myonuclear apoptotic mechanisms. These data demonstrate that simvastatin induces myotube atrophy and cell loss associated with impaired ADP-stimulated maximal mitochondrial respiratory capacity, mitochondrial oxidative stress, and apoptosis in primary human skeletal myotubes, suggesting mitochondrial dysfunction may underlie human statin-induced myopathy.

Kwak, Hyo-Bum; Thalacker-Mercer, Anna; Anderson, Ethan J.; Lin, Chien-Te; Kane, Daniel A.; Lee, Nam-Sihk; Cortright, Ronald N.; Bamman, Marcas M.; Neufer, P. Darrell



Statins as a Potential Risk Factor for Autoimmune Diseases: A Case Report and Review.  


Association of statins with autoimmune disorders is rarely reported. We report a case of an apparently healthy 76-year-old woman who was on long-term statin therapy presenting with severe rhabdomyolysis, autoimmune hepatitis, and positive lupus antibodies. Patient presented with complaints of worsening fatigue, leg cramps, and progressive weakening of lower extremities over 3 weeks. The patient was on simvastatin daily for several years. Clinical examination on admission included muscle tenderness, lower extremity edema, and ascites. Her laboratory values on admission showed elevated creatine kinase and transaminases. Immunologic workup revealed positive ANA, anti-dsDNA and anti-SSA antibodies. F-actin antibody was also positive at high titer. Magnetic resonance imaging of the lower extremities showed findings consistent with myositis. Patient underwent biopsy of the thigh muscles, which showed inflammatory myositis. Liver biopsy was characteristic of autoimmune hepatitis. Patient responded well to immunosuppressive therapy with azathioprine and prednisone. Although statins are generally considered safe, recent data from long-term follow-up on patients who are on statins for long duration suggest that prolonged exposure to statins may trigger autoimmune reactions. The exact mechanism of statin-induced autoimmune reaction is unclear. Statins, as proapoptotic agents, release nuclear antigen into the circulation and may induce the production of pathogenic autoantibodies. The role of statins in inducing an endoplasmic reticular stress response with associated upregulation of major histocompatibility complex-1 expression and antigen presentation by muscle fibers has also been reported. Systemic immunosuppressive therapy has proven to be effective in many reported cases. PMID:23782756

John, Santhosh G; Thorn, Jennifer; Sobonya, Richard



Some kinetic considerations in high cut-off hemodiafiltration for acute myoglobinuric renal failure.  


The kinetics of myoglobin in severe rhabdomyolysis and dialysis-dependent myoglobinuric acute kidney injury (Mb-AKI) is still not well elucidated, and more detailed knowledge could improve the now empiric use of rapid extracorporeal myoglobin removal by high cut-off (HCO) hemodialysis treatments. Eighteen adult patients with severe dialysis-dependent Mb-AKI (median serum concentration of myoglobin 57.4?mg/L) participated in the prospective clinical study, assessing myoglobin kinetics during HCO hemodiafiltration (HCO HDF). High initial serum concentrations of myoglobin (median 57.4?mg/L), together with protracted myoglobin appearance in the blood, indicated a large accumulation of myoglobin in body fluids. Extra-renal endogenous metabolic myoglobin clearance was delayed, with a slow exponential fall in serum myoglobin (t½ 35?h). A mean myoglobin clearance of 90-94?mL/min, a reduction ratio of 80%, and a rapid exponential fall (t½ 1?h) in serum and dialysate myoglobin were achieved by HCO HDF. Half of the cumulative myoglobin removal was accomplished in 3-5?h, with an additional removal of 7% each hour thereafter. A 2.4-fold rebound in serum myoglobin followed the HCO procedures. Large amounts of myoglobin are released into the circulation, and its endogenous metabolic clearance in dialysis-dependent Mb-AKI is slow. Owing to its rapid and highly efficient myoglobin elimination, HCO HDF may represent a valuable tool in the initial management of severe Mb-AKI, with a potential for earlier application in the future. PMID:23931878

Premru, Vladimir; Kova?, Janko; Buturovi?-Ponikvar, Jadranka; Ponikvar, Rafael



Integration of biosensors and drug delivery technologies for early detection and chronic management of illness.  


Recent advances in biosensor design and sensing efficacy need to be amalgamated with research in responsive drug delivery systems for building superior health or illness regimes and ensuring good patient compliance. A variety of illnesses require continuous monitoring in order to have efficient illness intervention. Physicochemical changes in the body can signify the occurrence of an illness before it manifests. Even with the usage of sensors that allow diagnosis and prognosis of the illness, medical intervention still has its downfalls. Late detection of illness can reduce the efficacy of therapeutics. Furthermore, the conventional modes of treatment can cause side-effects such as tissue damage (chemotherapy and rhabdomyolysis) and induce other forms of illness (hepatotoxicity). The use of drug delivery systems enables the lowering of side-effects with subsequent improvement in patient compliance. Chronic illnesses require continuous monitoring and medical intervention for efficient treatment to be achieved. Therefore, designing a responsive system that will reciprocate to the physicochemical changes may offer superior therapeutic activity. In this respect, integration of biosensors and drug delivery is a proficient approach and requires designing an implantable system that has a closed loop system. This offers regulation of the changes by means of releasing a therapeutic agent whenever illness biomarkers prevail. Proper selection of biomarkers is vital as this is key for diagnosis and a stimulation factor for responsive drug delivery. By detecting an illness before it manifests by means of biomarkers levels, therapeutic dosing would relate to the severity of such changes. In this review various biosensors and drug delivery systems are discussed in order to assess the challenges and future perspectives of integrating biosensors and drug delivery systems for detection and management of chronic illness. PMID:23771157

Ngoepe, Mpho; Choonara, Yahya E; Tyagi, Charu; Tomar, Lomas Kumar; du Toit, Lisa C; Kumar, Pradeep; Ndesendo, Valence M K; Pillay, Viness



Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis: an etiology worth considering in the differential diagnosis of delirium.  


Abstract Background. Medical toxicologists are frequently consulted when young patients present with delirium attributed to suspected poisoning. Medical toxicologists should be aware of non-toxicological mimics of delirium. We describe two patients ultimately diagnosed with anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis for which a toxicological consultation was requested to evaluate for neuroleptic malignant syndrome (NMS). Case 1. A 21 year old male was sent from a psychiatric facility for new, worsening psychotic symptoms. He had autonomic instability, confusion, and hyper-reflexia. He was treated for NMS without improvement, and after an extensive workup was unrevealing, he was discharged home with significant cognitive dysfunction. Stored CSF later tested positive for anti-NMDAR antibodies. Case 2. A 27 year old female was sent from a psychiatric facility for a seizure and new psychiatric symptoms. She was agitated and had violent, alternating extremity flexion and extension along with autonomic instability. She was treated for NMS, rhabdomyolysis, and rabies before analysis of CSF demonstrated anti-NMDAR antibodies. Treatment included surgical resection of a suspicious ovarian cyst, steroids and IVIG, with moderate improvement. Discussion. Autoimmune syndromes of the central nervous system result from receptor dysfunction after an antibody response to extracellular or intracellular antigens, such as subunits of the NMDA receptor. The NMDA subunits NR2b and NR2a, in addition to the N-terminal region of the glycine binding NR1 subunit, have been implicated. Typical features such as memory loss, movement disorders, and hallucinations reflect the density and distribution of neuronal NDMA receptors. As young people, particularly young women, are predominantly affected, initial symptoms may be attributed to encephalopathy from drug abuse or schizophrenia. Toxicologists may be consulted as many features mimic NMS. Serum and cerebrospinal fluid can be checked for anti-NMDAR antibodies as part of a paraneoplastic or meningioencephalitis panel. Effective treatments have been described and include surgical resection and immunosuppressive medications. PMID:23962100

Punja, M; Pomerleau, A C; Devlin, J J; Morgan, B W; Schier, J G; Schwartz, M D



Protection of rat skeletal muscle fibers by either L-carnitine or coenzyme Q10 against statins toxicity mediated by mitochondrial reactive oxygen generation  

PubMed Central

Mitochondrial redox imbalance has been implicated in mechanisms of aging, various degenerative diseases and drug-induced toxicity. Statins are safe and well-tolerated therapeutic drugs that occasionally induce myotoxicity such as myopathy and rhabdomyolysis. Previous studies indicate that myotoxicity caused by statins may be linked to impairment of mitochondrial functions. Here, we report that 1-h incubation of permeabilized rat soleus muscle fiber biopsies with increasing concentrations of simvastatin (1–40 ?M) slowed the rates of ADP-or FCCP-stimulated respiration supported by glutamate/malate in a dose-dependent manner, but caused no changes in resting respiration rates. Simvastatin (1 ?M) also inhibited the ADP-stimulated mitochondrial respiration supported by succinate by 24% but not by TMPD/ascorbate. Compatible with inhibition of respiration, 1 ?M simvastatin stimulated lactate release from soleus muscle samples by 26%. Co-incubation of muscle samples with 1 mM L-carnitine, 100 ?M mevalonate or 10 ?M coenzyme Q10 (Co-Q10) abolished simvastatin effects on both mitochondrial glutamate/malate-supported respiration and lactate release. Simvastatin (1 ?M) also caused a 2-fold increase in the rate of hydrogen peroxide generation and a decrease in Co-Q10 content by 44%. Mevalonate, Co-Q10 or L-carnitine protected against stimulation of hydrogen peroxide generation but only mevalonate prevented the decrease in Co-Q10 content. Thus, independently of Co-Q10 levels, L-carnitine prevented the toxic effects of simvastatin. This suggests that mitochondrial respiratory dysfunction induced by simvastatin, is associated with increased generation of superoxide, at the levels of complexes-I and II of the respiratory chain. In all cases the damage to these complexes, presumably at the level of 4Fe-4S clusters, is prevented by L-carnitine.

La Guardia, P. G.; Alberici, L. C.; Ravagnani, F. G.; Catharino, R. R.; Vercesi, A. E.



Metabolic control during exercise with and without medium-chain triglycerides (MCT) in children with long-chain 3-hydroxy acyl-CoA dehydrogenase (LCHAD) or trifunctional protein (TFP) deficiency.  


Exercise induced rhabdomyolysis is a complication of long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) and mitochondrial trifunctional protein (TFP) deficiency that frequently leads to exercise avoidance. Dietary therapy for most subjects includes medium-chain triglyceride (MCT) supplementation but analysis of diet records indicates that the majority of patients consume oral MCT only with breakfast and at bedtime. We hypothesized that MCT immediately prior to exercise would provide an alternative fuel source during that bout of exercise and improve exercise tolerance in children with LCHAD deficiency. Nine subjects completed two 45 min moderate intensity (60-70% predicted maximum heart rate (HR)) treadmill exercise tests. Subjects were given 4 oz of orange juice alone or orange juice and 0.5 g MCT per kg lean body mass, 20 min prior to exercise in a randomized cross-over design. ECG and respiratory gas exchange including respiratory quotient (RQ) were monitored. Blood levels of acylcarnitines, creatine kinase, lactate, and beta-hydroxybutyrate were measured prior to and immediately after exercise, and again following 20 min rest. Creatine kinase and lactate levels did not change with exercise. There was no significant difference in RQ between the two exercise tests but there was a decrease in steady-state HR following MCT supplementation. Cumulative long-chain 3-hydroxyacylcarnitines were 30% lower and beta-hydroxybutyrate was three-fold higher after the MCT-pretreated exercise test compared to the test with orange juice alone. Coordinating MCT supplementation with periods of increased activity may improve the metabolic control of children with LCHAD and TFP deficiency following exercise. PMID:16876451

Gillingham, Melanie B; Scott, Bradley; Elliott, Diane; Harding, Cary O



Chimeric maternal cells in offspring do not respond to renal injury, inflammatory or repair signals.  


Maternal microchimerism (MMc) can persist for years in a child, and has been implicated in the pathogenesis of chronic inflammatory autoimmune diseases. Chimeric cells may either contribute to disease by acting as immune targets or expand in response to signals of injury, inflammation or repair. We investigated the role of maternal cells in tissue injury in the absence of autoimmunity by quantifying MMc by quantitative PCR in acute and chronic models of renal injury: (1) reversible acute renal injury, inflammation and regeneration induced by rhabdomyolysis and (2) chronic injury leading to fibrosis after unilateral ureteral obstruction. We found that MMc is common in the mouse kidney. In mice congenic with their mothers neither acute nor chronic renal injury with fibrosis influenced the levels or prevalence of MMc. Maternal cells expressing MHC antigens not shared by offspring (H2(b/d)) were detected at lower levels in all groups of homozygous H2(b/b) or H2(d/d) offspring, with or without renal injury, suggesting that partial tolerance to low levels of alloantigens may regulate the homeostatic levels of maternal cells within tissues. Maternal cells homozygous for H2(b) were lost in H2(b/d) offspring only after acute renal failure, suggesting that an inflammatory stimulus led to loss of tolerance to homozygous maternal cells. The study suggests that elevated MMc previously found in association with human autoimmune diseases may not be a response to non-specific injury or inflammatory signals, but rather a primary event integral to the pathogenesis of autoimmunity. PMID:21912718

López-Guisa, Jesús M; Howsmon, Rebecca; Munro, Andrew; Blair, Kendall M; Fisher, Edward; Hermes, Heidi; Zager, Richard; Stevens, Anne M



Pediatric and neonatal tetanus: a hospital based study at eastern Nepal.  


A prospective hospital based study of childhood (<15 yrs) and neonatal tetanus cases from July 2004 - May 2006 was done to study the demography, clinical features and outcome of pediatric and neonatal tetanus cases at BPKIHS. During the study, 24 cases of tetanus were admitted from 9 districts including 5 neonatal tetanus. Among children with tetanus, 31.5% received 3 doses of DPT and 10.5% received TT vaccine as tetanus prophylaxis. In 16.0% children there was no recognizable injury preceding the disease. Otitis media preceded tetanus in 16.0%. All neonatal tetanus cases occurred following umbilical sepsis. Despite their mothers receiving 2 doses of TT during pregnancy, 2 neonates developed tetanus. A neonate delivered in hospital also developed neonatal tetanus. Average incubation period was 7.7 days and average onset time was 16.9 hours. Short onset time predicted the favorable outcome (p=0.005). Generalized tetanus cases were 75.0%, neonatal tetanus 21.0% and cephalic tetanus 4.0%. Generalized spasm was present in all cases. Common autonomic dysfunctions were fever, tachycardia and hypotension. Respiratory failure, aspiration pneumonia, rhabdomyolysis and seizure were common complications. Only one case received Intensive Care Unit (ICU) care. Survival rate was 21.1% for childhood tetanus and 40.0% for neonatal tetanus. Respiratory failure was the cause of death in majority. Study finds tetanus as an important disease in eastern Nepal, with substantial morbidity and mortality, primarily affecting the unvaccinated and inadequately vaccinated individuals. Despite lack of adequate resources, we can still manage tetanus cases with comparable outcome to other case series reported in the literatures. PMID:19253861

Poudel, P; Singh, R; Raja, S; Budhathoki, S



Stress-induced cardiomyopathy caused by heat stroke.  


Heat stroke is defined by central nervous system abnormalities and failure of proper maintenance of thermoregulation as a result of high core body temperature ensuing from exposure to high environmental temperatures or strenuous exercise. Common complications include acute respiratory distress syndrome, disseminated intravascular coagulation, acute renal injury, hepatic injury, and rhabdomyolysis. Myocardial injury may also occur during heat stroke, resulting in cardiac enzyme increase and ST-segment changes on the ECG. Such findings might behave as diagnostic pitfalls by mimicking the presentation of coronary artery occlusive myocardial infarction. A previous case report described a patient with heat stroke and ST-segment elevation, in which the definite cause of the ST-segment elevation was unclear; however, acute myocardial infarction caused by coronary artery disease was ruled out according to the clinical signs, serial ECG changes, and serum level of cardiac biomarkers. Stress-induced cardiomyopathy (Takotsubo cardiomyopathy) was suspected, but it could not be confirmed because of the lack of coronary angiography. We herein report a case of heat stroke presenting with ST-segment elevation and cardiogenic shock. Coronary angiography was performed and coronary artery occlusive myocardial infarction was ruled out because of the presence of patent coronary arteries. Left ventriculography showed midventricular and apical hypokinesis, and stress-induced cardiomyopathy was then determined to be the appropriate diagnosis. Heat stroke causes increase of serum catecholamine levels, in which oversecretion and abnormal responses to catecholamines are a possible cause of stress-induced cardiomyopathy. Catecholamines may therefore be the key in linking heat stroke and stress-induced cardiomyopathy. PMID:22153997

Chen, Wei-Ta; Lin, Cheng-Hsin; Hsieh, Ming-Hsiung; Huang, Chun-Yao; Yeh, Jong-Shiuan



Analytical Investigations of Toxic p-Phenylenediamine (PPD) Levels in Clinical Urine Samples with Special Focus on MALDI-MS/MS  

PubMed Central

Para-phenylenediamine (PPD) is a common chromophoric ingredient in oxidative hair-dyes. In some African countries like Sudan, Egypt and Morocco but also in India this chemical is used alone or in combination with colouring extracts like Henna for dyeing of the hair or the skin. Excessive dermal exposure to PPD mainly leads to the N-mono- and N,N?-diacetylated products (MAPPD, DAPPD) by N-acetyltransferase 1 and 2 (NAT1 and 2) catalyzed reactions. Metabolites and PPD are mainly excreted via renal clearance. Despite a low risk of intoxication when used in due form, there are numerous cases of acute intoxication in those countries every year. At the ENT Hospital - Khartoum (Sudan) alone more than 300 cases are reported every year (?10% fatal), mostly caused by either an accidental or intended (suicidal) high systemic exposure to pure PPD. Intoxication leads to a severe clinical syndrome including laryngeal edema, rhabdomyolysis and subsequent renal failure, neurotoxicity and acute toxic hepatitis. To date, there is no defined clinical treatment or antidote available and treatment is largely supportive. Herein, we show the development of a quick on-site identification assay to facilitate differential diagnosis in the clinic and, more importantly, the implementation of an advanced analytical platform for future in-depth investigations of PPD intoxication and metabolism is described. The current work shows a sensitive (?25 µM) wet chemistry assay, a validated MALDI-MS/MS and HPLC-UV assay for the determination of PPD and its metabolites in human urine. We show the feasibility of the methods for measuring PPD over a range of 50–1000 µM. The validation criteria included linearity, lower limit of quantification (LLOQ), accuracy and precision, recovery and stability. Finally, PPD concentrations were determined in clinical urine samples of cases of acute intoxication and the applied technique was expanded to identify MAPPD and DAPPD in the identical samples.

Hooff, Gero P.; van Huizen, Nick A.; Meesters, Roland J. W.; Zijlstra, Eduard E.; Abdelraheem, Mohamed; Abdelraheem, Waleed; Hamdouk, Mohamed; Lindemans, Jan; Luider, Theo M.



[Sedation and analgesia for the brain-injured patient].  


Sedation-analgesia occupies an essential place in the specific therapeutic arsenal of the brain-injured patients. The maintenance of the perfusion of the brain, its relaxation and its protection are the fundamental objectives whose finality is to avoid the extension of the lesions and to preserve the neuronal capital. Sedation is instituted when patients are severely agitated or present a deterioration of their state of consciousness (GCS< or =8). Under cover of mechanical ventilation, sedation is the first line treatment of intracranial hypertension, a common pathway of various acute brain diseases of traumatic, vascular or other origin. The use of the combination of hypnotic and opioids is the rule. The combined action of these two classes reinforces and improves their sedative effects. Midazolam is the 2 benzodiazepine of reference. Propofol is more and more frequently added to the combination of hypnotic and opioids. The "propofol infusion syndrome" is a severe limitation to its long term administration in particular among patients presenting a severe septic or inflammatory state. Propofol will be imperatively stopped in the event of metabolic acidosis, rhabdomyolysis, acute renal insufficiency, hyperkaliemia or increase in the blood triglyceride levels. The use of thiopental is restricted to the most severe cases. Its use as a monotherapy at high doses is abandoned to the profit of a co-administration with midazolam or even with the combination of midazolam and propofol. Thiopental overdose is very frequent in the event of associated hypothermia. Etomidate does not have its place apart from induction in fast sequence. The neuro-protective effects of ketamine require to be demonstrated in man before being recommended routinely. Withdrawal of sedation can be responsible for a state of agitation which can be controlled by neuroleptics. PMID:18619762

Abdennour, L; Puybasset, L



In vivo evidence suggesting reciprocal renal hypoxia-inducible factor-1 upregulation and signal transducer and activator of transcription 3 activation in response to hypoxic and non-hypoxic stimuli.  


In vitro studies suggest that combined activation of hypoxia-inducible factor (HIF) and signal transducer and activator of transcription 3 (STAT3) promotes the hypoxia response. However, their interrelationship in vivo remains poorly defined. The present study investigated the possible relationship between HIF-1 upregulation and STAT3 activation in the rodent kidney in vivo. Activation of HIF-1 and STAT3 was analysed by immunohistochemical staining and western blot analysis in: (i) models of hypoxia-associated kidney injury induced by radiocontrast media or rhabdomyolysis; (ii) following activation of STAT3 by the interleukin (IL)-6-soluble IL-6 receptor complex; or (iii) following HIF-1? stabilization using hypoxic and non-hypoxic stimuli (mimosine, FG-4497, CO, CoCl(2)) and in targeted von Hippel-Lindau-knockout mice. Western blot analysis and immunostaining revealed marked induction of both transcription factors under all conditions tested, suggesting that in vivo STAT3 can trigger HIF and vice versa. Colocalization of HIF-1? and phosphorylated STAT3 was detected in some, but not all, renal cell types, suggesting that in some cells a paracrine mechanism may be responsible for the reciprocal activation of the two transcription factors. Nevertheless, in several cell types spatial concordance was observed under the majority of conditions tested, suggesting that HIF-1 and STAT3 may act as cotranscription factors. These in vivo studies suggest that, in response to renal hypoxic-stress, upregulation of HIF-1 and activation of STAT3 may be both reciprocal and cell type dependent. PMID:23384058

Nechemia-Arbely, Yael; Khamaisi, Mogher; Rosenberger, Christian; Koesters, Robert; Shina, Ahuva; Geva, Carmit; Shriki, Anat; Klaus, Stephen; Rosen, Seymour; Rose-John, Stefan; Galun, Eithan; Axelrod, Jonathan H; Heyman, Samuel N



Recovery from Glycerol-Induced Acute Kidney Injury Is Accelerated by Suramin  

PubMed Central

Acute kidney injury (AKI) is a common and potentially life-threatening complication after ischemia/reperfusion and exposure to nephrotoxic agents. In this study, we examined the efficacy and mechanism(s) of suramin in promoting recovery from glycerol-induced AKI, a model of rhabdomyolysis-induced AKI. After intramuscular glycerol injection (10 ml of 50% glycerol per kilogram) into male Sprague-Dawley rats, serum creatinine maximally increased at 24 to 72 h and then decreased at 120 h. Creatinine clearance (CrCl) decreased 75% at 24 to 72 h and increased at 120 h. Suramin (1 mg/kg i.v.) administered 24 h after glycerol accelerated recovery of renal function as demonstrated by increased CrCl, decreased renal kidney injury molecule-1, and improved histopathology 72 h after glycerol injection. Suramin treatment decreased interleukin-1? (IL-1?) mRNA, transforming growth factor-?1 (TGF-?1), phospho-p65 of nuclear factor-?B (NF-?B), and cleaved caspase-3 at 48 h compared with glycerol alone. Suramin treatment also decreased glycerol-induced activation of intracellular adhesion molecule-1 (ICAM-1) and leukocyte infiltration at 72 h. Urinary/renal neutrophil gelatinase-associated lipocalin 2 (NGAL) levels, hemeoxygenase-1 expression, and renal cell proliferation were increased by suramin compared with glycerol alone at 72 h. Mechanistically, suramin decreases early glycerol-induced proinflammatory (IL-1? and NF-?B) and growth inhibitory (TGF-?1) mediators, resulting in the prevention of late downstream inflammatory effects (ICAM-1 and leukocyte infiltration) and increasing compensatory nephrogenic repair. These results support the hypothesis that delayed administration of suramin is effective in abrogating apoptosis, attenuating inflammation, and enhancing nephrogenic repair after glycerol-induced AKI.

Korrapati, Midhun C.; Shaner, Brooke E.



Status dystonicus resembling the intrathecal baclofen withdrawal syndrome: a case report and review of the literature  

PubMed Central

Introduction Status dystonicus is a rare but life-threatening disorder characterized by increasingly frequent and severe episodes of generalized dystonia that may occur in patients with primary or secondary dystonia. Painful and repetitive spasms interfere with respiration and may cause metabolic disturbances such as hyperpyrexia, dehydration, respiratory insufficiency, and acute renal failure secondary to rhabdomyolysis. Intrathecally administered baclofen, delivered by an implantable pump system, is widely used for the treatment of refractory spasticity. Abrupt cessation of intrathecal baclofen infusion has been associated with a severe withdrawal syndrome comprised of dystonia, autonomic dysfunction, hyperthermia, end-organ failure and sometimes death. The aetiology of this syndrome is not well understood. Status dystonicus describes the episodes of acute and life-threatening generalized dystonia, which occasionally manifest themselves in patients with dystonic syndromes. Case presentation We present the case of a nine-year-old Caucasian boy who experienced a severe episode of status dystonicus with no known cause and clinical features resembling those described in intrathecal baclofen withdrawal. Our patient subsequently underwent the placement of an intrathecal baclofen pump without incident. Conclusion The similarity between the clinical features of the case we present and those reported in connection to abrupt withdrawal of intrathecal baclofen is emphasized. Several drugs, although not intrathecal baclofen withdrawal, have previously been associated with status dystonicus. The similarity between the life-threatening dystonic episode experienced by our patient, and those reported in intrathecal baclofen withdrawal, highlights the possibility that, rather than representing a true physiological withdrawal syndrome, abrupt withdrawal of intrathecal baclofen may simply precipitate an episode of status dystonicus in susceptible individuals. The clinical similarities between the intrathecal baclofen withdrawal syndrome and status dystonicus have not previously been highlighted.



Detection and management of the neuroleptic malignant syndrome.  


Two patients who developed the neuroleptic malignant syndrome (NMS) are described, and pertinent literature is reviewed. A 30-year-old man developed NMS, apparently as a result of haloperidol treatment of chronic undifferentiated schizophrenia. Treatment with cooling blankets, acetaminophen, dantrolene sodium, and bromocriptine mesylate decreased abnormal vital signs, but catatonia continued. After 30 treatments with electroconvulsive therapy over a one-month period, the patient's catatonia was resolved, and he was discharged on no medication with the schizophrenia in remission. The second patient was a 22-year-old woman who developed NMS after five weeks of therapy with haloperidol and thiothixene for an acute episode of abnormal behavior. She did not respond to therapy with cooling blankets, acetaminophen, antibiotics, and amobarbital sodium. Dantrolene sodium therapy produced no improvement except for some relief of muscular rigidity. Electroconvulsive therapy (22 treatments over one month) successfully decreased the patient's elevated liver enzymes and leukocyte count, but periodic temperature elevations and catatonia continued. Prompt diagnosis and treatment of NMS are essential, as the mortality rate is 20%. Acute lethal catatonia and malignant hyperthermia are considered in differential diagnosis. Both central and peripheral pathophysiologic mechanisms are probably involved in NMS, and most cases are seen in patients with psychiatric illness. Onset of NMS does not seem related to duration of neuroleptic therapy and, in susceptible persons, additional factors may be required to trigger onset of NMS. Symptoms, including diffuse muscular rigidity, akinesia, and fever, develop within 24-72 hours. Neurologic symptoms may develop or worsen, and leukocytosis and elevated levels of liver enzymes occur. Death can result from respiratory or cardiovascular failure, and rhabdomyolysis can lead to acute renal failure.(ABSTRACT TRUNCATED AT 250 WORDS) PMID:6145537

Bond, W S


Acute kidney injury in scrub typhus.  


BACKGROUND: We studied the urinary abnormalities and acute kidney injury (AKI) as per RIFLE criteria in scrub typhus. METHODS: A prospective case record-based study of scrub typhus was carried out from January 2009 to December 2010 in a tertiary hospital in South India. Patients were followed up until renal recovery or for at least 3 months after discharge. Univariate, chi-squared tests and multivariate logistic regression analyses were performed to identify the predictors of AKI. RESULTS: Scrub typhus was diagnosed in 259 patients. Urinary abnormalities were seen in 147 patients (56.7 %) with 60 patients (23.2 %) having AKI. All AKI patients had urinary abnormalities and 17 (28.3 %) were oliguric. Applying RIFLE (risk, injury, failure, loss, end-stage kidney disease) criteria, R, I, F were present in 23 (38.33 %), 13 (21.67 %), and 24 patients (40 %), respectively. Creatine phosphokinase (CPK) was raised in 33 patients (55 %) and hemodialysis was required in 6 patients (10 %). The case fatality rate in this study was 2 out of 259 (0.77 %), both having AKI and others recovering clinically. Significant predictors of AKI were tachycardia [odds ratio (OR) 2.28], breathlessness (OR 2.281), intensive care requirement (OR 2.43), mechanical ventilation (OR 3.33), thrombocytopenia (OR 2.90) and CPK >80 U/L (OR 1.76) by univariate analysis and intensive care requirement (adjusted OR 2.89) and thrombocytopenia (AOR 2.28) by multivariable logistic regression. CONCLUSION: Scrub typhus should be part of the differential diagnosis of acute febrile illness with AKI. AKI in scrub typhus is usually mild, non-oliguric, and renal recovery occurs in most patients. Rhabdomyolysis may be contributory to AKI. Thrombocytopenia and intensive care requirement are significant predictors of AKI in scrub typhus. PMID:23292176

Attur, Ravindra Prabhu; Kuppasamy, Sujatha; Bairy, Manohar; Nagaraju, Shankar Prasad; Pammidi, Nageswara Reddy; Kamath, Veena; Kamath, Asha; Rao, Lakshmi; Bairy, Indira



Renal disease in the inner city.  


For various ethnic and socioeconomic reasons the pattern of renal disease in the inner city displays distinctive features. Hypertension is frequent, often intractable, and generally conditioned by salt sensitivity and a high sodium intake. Chronic hypertensive nephrosclerosis, found predominantly in African Americans, comprises marked cardiomegaly, renal shrinkage, and hypertensive retinopathy. It has been overdiagnosed in the past, but actually accounts for less than 20% of end-stage renal disease (ESRD) in African Americans. Malignant hypertension, less frequent nowadays, may cause renal shutdown, which is reversible in a few cases; the heart and kidneys are often of normal size. Idiopathic focal segmental glomerulosclerosis is the most common cause of the primary nephrotic syndrome in blacks, but its incidence has also been rising in whites and Hispanics; it does not respond well to treatment, and almost one half of the patients develop ESRD within 10 years. Systemic lupus erythematosus is also more common in African Americans, in whom the severe proliferative forms of lupus nephritis pursue a more virulent course: one half of such patients develop ESRD in 5 years. Cocaine, the use of which has assumed epidemic proportions, may cause accelerated hypertension, acute renal failure from rhabdomyolysis, and progression of preexisting renal disease. Heroin nephropathy has all but disappeared and has been replaced by human immunodeficiency virus (HIV) nephropathy. The prognosis of HIV-infected patients maintained by dialysis has greatly improved. Sickle glomerulopathy, consisting of mesangial expansion, basement membrane duplication, and the absence of immune deposits, may cause the nephrotic syndrome in 4% of patients with severe sickle cell anemia, heralding death within 2 years in one half of patients and ESRD in two thirds; survival has not improved with dialysis. Diabetes is now the most common cause of ESRD. Familial aggregation of ESRD is frequently encountered. Interventions useful in the general population, such as vascular bypass procedures, should be undertaken with great caution and restraint in dialysis patients. PMID:11455521

Bakir, A A; Dunea, G



[Acute renal failure due to multiple stings by Africanized bees. Report on 43 cases].  


This study reports on acute renal failure (ARF) due to multiple stings by Africanized bees (AB) occurring in 43 cases collected between 1982 and 2007 (at the Nephrology Section, University of Antioquia School of Medicine and San Vicente de Paul University Hospital, Medellin, Colombia). No intervention on patient care was performed except for responding the Nephrology consult and prescribing dialysis. Data obtained from the medical records included demography; clinical presentation; laboratory results on admission; evolution of renal function to document improvement and normalization; intervals between stings and outcomes; number of dialysis sessions; length of follow-up and hospitalization; survival; and mortality. Not all patients had complete data and therefore, the number of observations is included where required. Mean age was 56 ± 26 yr (range 2-96); 37 (86%) were men; 38 (of 41 cases) came from rural areas (91%); 22 (of 39) were farmers (56.4%); 33 (of 41) lived in Medellin or in the department of Antioquia (80.5%). Number of stings per patient: ~ 900. Interval between stings and ARF < 48 hours: in 31 cases (72.1%; mean 2.6 ± 2.6 days; range 1-12); 37 (of 43) required dialysis (86%); mean number of sessions: 4.7 ± 3.3 (range 1-12). Survival occurred in 36 cases (83.7%) and mortality, in 7, all > 60 yr (16.3%). At last follow-up, renal function improvement was documented in 36 (83.7%) and normalization in 15 of them (41.7%). Interval until initiation of diuresis: 10.6 ± 6.8 days (range 1-25). Duration of hospitalization: 16.9 ± 8.7 days (range 1-39). Follow-up: 25.2 ± 18.3 days (range 1-75). Hematuria and oliguria occurred before 24 hours; there was an increase of CPK in 90%, of ALT in 96%, of AST in 89%, of DHL in 95%, and of BUN and creatinine in 100%. Based on our findings and on the review of the available information, we propose that this type of ARF occurs as a result of rhabdomyolysis with subsequent myoglobinuria, which lead to nephrotoxic acute tubular necrosis; a variable degree of direct nephrotoxicity, not quantifiable with current diagnostic methods, is also probably involved. A better knowledge of this entity by the medical community could improve care and prognosis of the patients who develop it. PMID:20613852

Mejía Vélez, G



Sports haematology.  


While the crucial role of haemoglobin in aerobic exercise has been well accepted, there is still a great deal of controversy about the optimal haematological parameters in the athletic population. The initial part of this review will examine the question of anaemia in athletes. The most common finding in athletes is a dilutional pseudoanaemia that is caused by a plasma volume expansion, rather than an actual blood loss. It is not a pathological state and normalises with training cessation in 3 to 5 days. This entity should be distinguished from conditions associated with lowered blood counts, such as intravascular haemolysis or iron deficiency anaemia. The evaluation of true anaemia states in the athlete must take into account not only blood losses secondary to exercise, such as foot strike haemolysis or iron losses through sweat, but non-athletic causes as well. Depending on the age and sex of the athlete, consideration must be given to evaluation of the gastrointestinal or genitourinary systems for blood loss. Finally, a comprehensive nutritional history must be taken, as athletes, especially women, are frequently not consuming adequate dietary iron. The second section of the paper will deal with the very contentious issue of sickle cell trait. While there have been studies demonstrating an increased risk of sudden death in people with sickle cell trait, it is still quite rare and should not be used as a restriction to activity. Further, studies have demonstrated that patients with sickle cell trait have an exercise capacity that is probably normal or near normal. However, in the cases of sudden death, it has been secondary to rhabdomyolysis occurring among sickle cell trait athletes performing at intense exertion under hot conditions, soon after arriving at altitude. The recommendations are that athletes with sickle cell trait adhere to compliance with the general guidelines for fluid replacement and acclimatisation to hot conditions and altitude. The final section of the paper examines the issue of haematological manipulation for the purposes of ergogenic improvement. Although experiments with blood doping revealed improvements in running time to exhaustion and maximal oxygen uptake, the introduction of recombinant erythropoietin has rendered blood doping little more than a historical footnote. However, the improvements in performance are not without risk, and the use of exogenous erythropoietin has the potential for increased viscosity of the blood and thrombosis with potentially fatal results. Until a definitive test is developed for detection of exogenous erythropoietin, it will continue to be a part of elite athletics. PMID:10688281

Shaskey, D J; Green, G A



A molecular contribution to the assessment of the Tricholoma equestre species complex.  


In recent years, interest in the Tricholoma equestre species complex has increased because of several cases of severe and sometimes fatal rhabdomyolysis reported in France and Poland. These occurred after repeated consumption of large portions of T. equestre sporophores during consecutive meals, despite the fact that this species is renowned as a tasty edible wild mushroom. The T. equestre species complex includes three ectomycorrhizal species Tricholoma flavovirens (Pers.) S. Lundell, Tricholoma auratum (Paulet) Gillet, and T. equestre (L.) P. Kummer. All these species produce sporophores with intense yellow gills but are difficult to distinguish by morphological analyses at both the macroscopic and microscopic levels. In T. equestre, two additional varieties are recognized: T. equestre var. populinum (Christensen & Noordeloos) associated with Populus sp. and/or Betula sp. trees and sometimes recognized as Tricholoma frondosae (Kalamees & Shchukin) and T. equestre var. pallidifolia characterized by pale to white gills, frequently recognized as Tricholoma joachimii (Bon & Riva). To explore the taxonomic (species delimitation), ecological, and geographical extent and limits of the T. equestre species complex, we have carried out a molecular comparison of worldwide strains belonging to this complex by using sequences of two molecular markers: the internal transcript spacer (ITS)1/5.8S/ITS2 region of the nuclear ribosomal unit and the 5' part of the mitochondrial cox1 gene. Phylogenetic analyses support the placement of European T. equestre, T. flavovirens, and T. auratum strains as representatives of a single species. This species appears associated with various conifers trees, depending on the geographic origin (Pinus pinaster for T. auratum, Pinus sylvestris or Abies alba for T. equestre and T. flavovirens). However, in the context of a single T. equestre species, the geographical location could lead to the characterization of sub-species or varieties, as suggested by the gathering of the four Asian (Japanese) T. auratum strains in a strongly supported distinct phylogenetic clade. Moreover, our analysis strongly argues for considering T. joachimii and the synonymised T. equestre var. pallidifolia as two representatives of a different species not belonging to the T. equestre group. This species would be phylogenetically related to the Tricholoma columbetta species with which they share white gills. Similarly, the phylogenetic analysis of the molecular data and the lack of gene flow between the strains associated with broad-leaved trees and those of the T. equestre complex, rather argues for two distinct species depending on the ecological niche: T. frondosae under broad-leaved trees and T. equestre under conifers. PMID:23452952

Moukha, Serge; Férandon, Cyril; Beroard, Erika; Guinberteau, Jacques; Castandet, Benoît; Callac, Philippe; Creppy, Edmond; Barroso, Gérard



Characterization of Statin-Associated Myopathy Case Reports in Thailand Using the Health Product Vigilance Center Database.  


BACKGROUND: HMG-CoA reductase inhibitors [statins], a widely prescribed cholesterol-lowering