A case of rhabdomyolysis due to immobilization and compression

Abstract

To the Editor Rhabdomyolysis is a complex clinical picture characterized by damage to skeletal muscles participation of intracellular elements in the systemic circulation and clinical and laboratory findings which develop in relation 1 Rhabdomyolysis has traumatic and non traumatic causes Traumatic causes include earthquakes traffic and mine accidents electric shock excessive exercise and staying in certain positions for a long time In the pathogenesis of rhabdomyolysis related to traumatic causes compression on the muscle baromyopathy has a major role The clinical picture ranges from transient mild hyperpotassemia and increased creatinine phosphokinase CK level to ldquo;Crush rdquo; syndrome characterized by life threatening shock cardiac arrhythmias and acute renal failure ARF 2 Here a pediatric case of rhabdomyolysis and related acute renal failure possibly due to an uncomfortable and long travel is presented A seven year old male patient presented with complaints including weakness and pain in the arms and legs inability to walk and dark colored urine a few hours after an overnight bus trip during which he was stuck between two people His personal and familial histories were natural His physical examination was normal except for a decrease in muscle strength and deep tendon reflexes predominantly in the lower extremities and marked myalgia The initial laboratory tests revealed a urinalysis as follows: density: 1029 pH:6 protein blood 3 leucocytes nitrite no cells on microscopic examination Complete blood count erythrocyte sedimentation rate and C reactive protein were found to be normal Biochemical tests were as follows: alanine aminotransferase 668 IU L aspartate aminotransferase 3264 IU L CK 242 694 IU L blood urea nitrogen BUN 48 mg dL creatinine 1 9 mg dL albumin 1 9 g dL electrolytes: normal A diagnosis of acute renal failure related to rhabdomyolysis was made because of increased muscle enyzme levels and renal dysfunction in the patient who had weakness and myalgia which started suddenly Hydration and alkalization treatment was started Since renal dysfunction increased gradually hypertension developed and urine output decreased in the follow up hemodialysis was started In addition mechanical ventilation was started since respiratory distress developed and blood gases deteriorated gradually Since no traumatic cause including traffic accident electric shock or excessive exercise was found thryoid function tests autoimmune and viral serology urinary and blood amino acid chromatography and carnitine and homocysteine levels were investigated in the patient for conditions which might have caused rhabdomyolysis and found to be normal Electromyelography revealed primary muscle fiber involvement and muscle biopsy revealed an appearance compatible with rhabdomyolysis Rhabdomyolysis secondary to staying in the same position for a long time during an uncomfortable trip a short time before the complaints began was considered and the treatment was continued Hemodialysis and mechanical ventilation treatment were discontinued when renal function tests and blood pressure returned to normal and respiratory findings improved in the follow up The patient was discharged in a short time with a good general status Rhabdomyolysis develops due to traumatic or non traumatic causes 3 In the pathogenesis of rhabdomyolysis which develops as a result of traumatic causes baromyopathy has a major role In baromyopathy the permeabilty of the sarcolemma is disturbed substances including potassium myoglobin CK and creatinine which are found in high amounts in the muscle get outside the cell while sodium chloride water and calcium flow into the cell Thus edema is developed in the cell This edema leads to compartment syndrome clinically 1 Rhabdomyolysis due to a traumatic cause was considered in our patient who had increased potassium muscle enzymes and creatinine because of history of a long trip during which the patient was stuck in the same position In traumatic rhabdomyolysis systemic findings show variance in different stages of the disease though local symptoms myalgia muscle weakness muscle rigidity and pain are predominant These systemic findings include hypotension shock cardiac arrhythmia cardiac and respiratory failure hypovolemia and acute renal failure 3 4 5 6 Our patient had muscle weakness and developed acute renal failure and respiratory failure in the follow up The most common laboratory findings in patients with rhabdomyolysis include increase in muscle enzymes myoglobinuria findings of prerenal renal failure anemia leucocytosis thrombocytopenia hyperpotassemia hyperphosphatemia hypocalcemia hypoalbuminemia and metabolic acidosis 6 7 However a serum CK level 5 fold higher than the normal value is enough for a diagnosis of rhabdomyolysis 2 8 Our patient had increased muscle enzymes CK level 5 fold higher than the normal value increased potassium BUN and creatinine levels myoglubinuria and hypoalbuminemia In rhabdomyolysis one of the most important complications which affects the prognosis is acute renal failure Even if acute renal failure develops complete recovery is the rule unless the patient is lost as a result of complications including hyperpotassemia heart failure and infections and no persistent damage is expected in the kidneys in the long term 9 In our patient acute renal failure regressed in a short time Conclusively trauma is important in the etiology of rhabdomyolysis as well as infections and toxic causes Trauma is not necessarly severe As observed in our case it may occur as a result of an uncomfortable interurban travel and lead to serious problems including acute renal failure Ad shy;dress for Cor shy;res shy;pon shy;den shy;ce: Meral Torun Bayram MD Dr Behçet Uz Pediatric Diseases and Pediatric Surgery Education and Reseach Hospital İzmir Turkey E mail: meralt bayram@yahoo com tr Re shy;cei shy;ved: 05 07 2012 Ac shy;cep shy;ted: 05 20 2012 References 1 Slater MS Mullins RJ Rhabdomyolysis and myoglobinuric renal failure in trauma and surgical patients: Areview J Am Coll Surg 1998; 186: 693 716 2 MacLean JG Barrett DS Rhabdomyolysis: a neglected priority in the early management of severe limb trauma Injury 1993; 24: 205 207 3 Al B Güllü MN Kaplan M Güloğlu C Aldemir M Crush Sendromu Tıp Araştırmaları Dergisi 2006; 4: 31 38 4 Holt S Moore K Pathogenesis of renal failure in rabdomyolysis: the role of miyoglobin Exp Nephrol 2000; 8: 72 76 5 Al Ismaili Z Piccioni M Zappitelli M Rhabdomyolysis: pathogenesis of renal injury and management Pediatr Neprol 2011; 26 10 : 1781 1788 6 Elsayed EF Reilly RF Rhabdomyolysis: a review with emphasis on the pediatric population Pediatr Nephrol 2010; 25 1 : 7 18 7 Saluzzo RF Rhabdomyolysis Rosen PL Emergency medicine concepts and clinical practice Mosby Year Book St Louis 3rd ed 1992: 2232 2241 8 Vanholder R Sever MS Erek E Lameire N Acute renal failure related to crush syndrome: towards an era of seismo nephrology? Nephrol Dial Transplant 2000; 15 10 : 517 521 9 Shimazu T Yoshioka T Nakata Y Ishikawa K Mizushima Y Morimoto F Kishi M Takaoka M Tanaka H Iwai A Hiraide A Fluid resuscitation and systemic complications in Crush sydrome: 14 Hanshin Awaji earthquake patients J Trauma 1997; 42 4 : 641 646

Keywords

• -

İmmobilizasyon ve basıya bağlı gelişen rabdomiyoliz olgusu

Öz

Rabdomiyoliz, çizgili kasların hasara uğraması, ardından hücre içi oluşumların sistemik dolaşıma katılması ve buna bağlı olarak gelişen klinik ve laboratuvar bulgularını içeren karmaşık bir tablodur (1). Rabdomiyolizin travmatik ve travma dışı nedenleri vardır. Travmatik nedenler arasında depremler, trafik ve maden kazaları, elektrik çarpmaları, aşırı egzersiz yanında belirli pozisyonlarda uzun süre kalma bulunmaktadır. Travmatik sebeplere bağlı rabdomiyolizin patojenezinde kasın baskı altında kalması (baromiyopati) temel rol oynar. Klinik tablo geçici hafif hiperpotasemi ve yüksek kreatinin fosfokinaz (CK) düzeyinden hayatı tehdit eden hipovolemik şok, kardiyak aritmiler ve akut böbrek yetersizliği (ABY) ile belirgin “Crush” sendromuna kadar değişkenlik gösterebilir (2). Burada olası konforsuz ve uzun süren bir yolculuğa bağlı rabdomiyoliz ve ilişkili akut böbrek yetersizliği gelişen bir çocuk olgu sunulmuştur.

Anahtar Kelimeler

• İmmobilizasyon
• rabdomiyoliz
• olgusu

References

1. Slater MS, Mullins RJ. Rhabdomyolysis and myoglobinuric renal failure in trauma and surgical patients: Areview. J Am Coll Surg 1998; 186: 716.
2. MacLean JG, Barrett DS. Rhabdomyolysis: a neglected priority in the early management of severe limb trauma. Injury 1993; 24: 205-7.
3. Al B, Güllü MN, Kaplan M, Güloğlu C, Aldemir M. Crush Sendromu. Tıp Araştırmaları Dergisi 2006; 4: 31-8.
4. Holt S, Moore K. Pathogenesis of renal failure in rabdomyolysis: the role of miyoglobin. Exp Nephrol 2000; 8: 72-6.
5. Al-Ismaili Z, Piccioni M, Zappitelli M. Rhabdomyolysis: pathogenesis of renal injury and management. Pediatr Neprol 2011; 26(10): 1781-8.
6. Elsayed EF, Reilly RF. Rhabdomyolysis: a review, with emphasis on the pediatric population. Pediatr Nephrol 2010; 25(1): 7-18.
7. Saluzzo RF. Rhabdomyolysis. Rosen PL. Emergency medicine concepts and clinical practice. Mosby Year Book, St Louis, 3 rded. : 2232-41.
8. Vanholder R, Sever MS, Erek E, Lameire N. Acute renal failure related to crush syndrome: towards an era of seismo-nephrology? Nephrol Dial Transplant 2000; 15(10): 517-21.

9. Shimazu T, Yoshioka T, Nakata Y, et al. Fluid resuscitation and systemic complications in Crush sydrome: 14 Hanshin-Awaji earthquake patients. J Trauma 1997; 42(4): 641-6. Türk Ped Arfl 2012; 47: 232-3 Turk Arch Ped 2011; 47: 232-3 Apa ve ark.
10. İmmobilizasyon ve basıya bağlı gelişen rabdomiyoliz olgusu/A case of rhabdomyolysis due to immobilization and compression