Rhabdomyolysis

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Basics

Description

  • Breakdown of skeletal muscle with systemic release of intracellular contents
  • Rhabdomyolysis typically presents with muscle pain, weakness, and reddish brown (tea-colored) urine. Up to 50% of patients are asymptomatic.

Epidemiology

Incidence
26,000 hospitalizations annually in United States

Etiology and Pathophysiology

Risk factors

  • Direct muscle trauma (most common cause)
    • Crush injuries
    • Extended periods of muscle pressure (during surgery, unconscious from alcohol ingestion)
    • Burns, electrocution, lightning strike
  • Muscle exertion
    • Intense and/or prolonged physical exercise (marathon runners, athletes, contact sports)
    • Seizures
    • Delirium tremens
  • Drugs and toxins
    • Alcohol
    • Cocaine (most common recreational drug), methamphetamine, phencyclidine, heroin, bath salts (1)[B]; synthetic marijuana has been associated with severe rhabdomyolysis.
    • Antipsychotics (due to neuroleptic malignant syndrome, malignant hyperthermia, and dystonia)
    • Zidovudine
    • Antimalarials
    • HMG-CoA reductase inhibitors (statins) (risk <0.01%—elevated with higher doses and in combination with fibrates)
    • Colchicine
    • Corticosteroids
    • Carbon monoxide
    • Snake envenomation
  • Muscle ischemia
    • Thrombosis, embolism, sickle cell disease
    • Compartment syndrome
    • Tourniquets
  • Infections
    • Viral: influenza A and B, coxsackievirus, HIV, varicella
    • Bacterial: Streptococcus or Staphylococcus sepsis, gas gangrene, necrotizing fasciitis, Salmonella, Legionella
    • Malaria
  • Hypothermia
  • Hyperthermia
  • Autoimmune disorders
    • Polymyositis, dermatomyositis
  • Metabolic and endocrinologic:
    • Hypothyroidism or thyrotoxicosis
    • Electrolyte imbalances (e.g., hyponatremia, hypernatremia, hypokalemia, hypocalcemia, hypophosphatemia)
    • Diabetic ketoacidosis
    • Hyperosmolar state
Genetics

Hereditary causes of rhabdomyolysis are rare but should be suspected in children; patients with recurrent attacks; or patients who have attacks after minimal exertion, mild illness, or starvation.

  • Genetic disorders (1)[C]
    • Muscular dystrophies
    • Disorders of lipid metabolism (e.g., carnitine palmitoyltransferase deficiency)
    • Disorders of carbohydrate metabolism (i.e., phosphofructokinase deficiency, phosphoglycerate mutase, myophosphorylase deficiency, a.k.a. McArdle disease/deficiency)
    • Glycogen storage diseases (e.g., phosphorylase B kinase deficiency) and others (e.g., lactate dehydrogenase A deficiency)
    • Mitochondrial disorders

General Prevention

  • Avoid excessive exertion; ensure adequate hydration.
  • Avoid precipitating drugs, metabolic and electrolyte abnormalities.

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Basics

Description

  • Breakdown of skeletal muscle with systemic release of intracellular contents
  • Rhabdomyolysis typically presents with muscle pain, weakness, and reddish brown (tea-colored) urine. Up to 50% of patients are asymptomatic.

Epidemiology

Incidence
26,000 hospitalizations annually in United States

Etiology and Pathophysiology

Risk factors

  • Direct muscle trauma (most common cause)
    • Crush injuries
    • Extended periods of muscle pressure (during surgery, unconscious from alcohol ingestion)
    • Burns, electrocution, lightning strike
  • Muscle exertion
    • Intense and/or prolonged physical exercise (marathon runners, athletes, contact sports)
    • Seizures
    • Delirium tremens
  • Drugs and toxins
    • Alcohol
    • Cocaine (most common recreational drug), methamphetamine, phencyclidine, heroin, bath salts (1)[B]; synthetic marijuana has been associated with severe rhabdomyolysis.
    • Antipsychotics (due to neuroleptic malignant syndrome, malignant hyperthermia, and dystonia)
    • Zidovudine
    • Antimalarials
    • HMG-CoA reductase inhibitors (statins) (risk <0.01%—elevated with higher doses and in combination with fibrates)
    • Colchicine
    • Corticosteroids
    • Carbon monoxide
    • Snake envenomation
  • Muscle ischemia
    • Thrombosis, embolism, sickle cell disease
    • Compartment syndrome
    • Tourniquets
  • Infections
    • Viral: influenza A and B, coxsackievirus, HIV, varicella
    • Bacterial: Streptococcus or Staphylococcus sepsis, gas gangrene, necrotizing fasciitis, Salmonella, Legionella
    • Malaria
  • Hypothermia
  • Hyperthermia
  • Autoimmune disorders
    • Polymyositis, dermatomyositis
  • Metabolic and endocrinologic:
    • Hypothyroidism or thyrotoxicosis
    • Electrolyte imbalances (e.g., hyponatremia, hypernatremia, hypokalemia, hypocalcemia, hypophosphatemia)
    • Diabetic ketoacidosis
    • Hyperosmolar state
Genetics

Hereditary causes of rhabdomyolysis are rare but should be suspected in children; patients with recurrent attacks; or patients who have attacks after minimal exertion, mild illness, or starvation.

  • Genetic disorders (1)[C]
    • Muscular dystrophies
    • Disorders of lipid metabolism (e.g., carnitine palmitoyltransferase deficiency)
    • Disorders of carbohydrate metabolism (i.e., phosphofructokinase deficiency, phosphoglycerate mutase, myophosphorylase deficiency, a.k.a. McArdle disease/deficiency)
    • Glycogen storage diseases (e.g., phosphorylase B kinase deficiency) and others (e.g., lactate dehydrogenase A deficiency)
    • Mitochondrial disorders

General Prevention

  • Avoid excessive exertion; ensure adequate hydration.
  • Avoid precipitating drugs, metabolic and electrolyte abnormalities.

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