eMedicine Specialties > Pediatrics: General Medicine > Rheumatology

Rhabdomyolysis: Differential Diagnoses & Workup

Author: Eyal Muscal, MD, Assistant Professor, Section of Pediatric Rheumatology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital
Coauthor(s): Marietta Morales de Guzman, MD, Assistant Professor, Department of Pediatrics, Baylor College of Medicine; Consulting Staff, Section of Pediatric Rheumatology, Department of Pediatrics, Texas Children's Hospital, Ben Taub General Hospital
Contributor Information and Disclosures

Updated: Nov 16, 2009

Differential Diagnoses

Burns, Electrical
Sepsis
Carnitine Deficiency
Systemic Inflammatory Response Syndrome
Child Abuse & Neglect, Physical Abuse
Systemic Lupus Erythematosus
Dermatomyositis
Thromboembolism
Multisystem Organ Failure of Sepsis
Toxic Shock Syndrome
Myoglobinuria
Toxicity, Ethanol
Neuroleptic Malignant Syndrome

Other Problems to Be Considered

Traumatic injuries
Viral infections
Myalgias from other etiologies
Bacterial infections
Pyomyositis
Heatstroke
Cold exposure
Snakebite
Malignant hyperthermia
Muscle phosphorylase deficiency
Phosphofructokinase deficiency
Carnitine palmityl transferase deficiency
Phosphoglycerate mutase deficiency
Other inborn errors of metabolism
Hyperosmotic conditions
Guillain-Barré syndrome
Inflammatory myositis

Workup

Laboratory Studies

  • Creatinine kinase (CK) tests
    • The diagnosis of rhabdomyolysis can be confirmed using certain laboratory studies. The most reliable and sensitive indicator of muscle injury is CK. Assessing CK levels is most useful because of its ease of detection in serum and its presence in serum immediately after muscle injury.
    • The CK levels rise within 12 hours of muscle injury, peak in 24-36 hours, and decrease at a rate of 36-40% per day. The serum half-life of CK is approximately 36 hours. CK levels decline 3-5 days after resolution of muscle injury.10
    • Failure of CK levels to decrease suggests ongoing muscle injury. The peak CK level, especially when more than 15,000 U/L, may be predictive of renal failure.
    • CK levels 5 times the reference range suggest rhabdomyolysis. CK levels in rhabdomyolysis are frequently as much as or more than 100 times the reference range.
  • Myoglobin tests10
    • Plasma myoglobin measurements are not reliable because the half-life of myoglobin is 1-3 hours and it is cleared from plasma within 6 hours. Myoglobin levels not measured at the right time may produce a false-negative result. A positive test result may help to confirm the diagnosis.
    • Urine myoglobin is presumed if the urine is positive for blood but negative for RBCs. A urine myoglobin assay is helpful in patients with coexisting hematuria (confirmed with microscopic examination) when myoglobin presence is suspected.
  • Other tests: CBC count including hemoglobin, hematocrit, and platelets; serum chemistries including BUN, creatinine, glucose, calcium, phosphate, uric acid, and liver function tests; prothrombin time (PT); activated partial thromboplastin time (aPTT); serum aldolase; and lactate dehydrogenase are other useful laboratory tests that should be included. Renal failure and disseminated intravascular coagulation often develop 12-72 hours after initial muscle damage.

Imaging Studies

  • Obtain radiographs when fractures are suspected.
  • Head CT scanning may be necessary on a case-by-case basis when a patient with an altered sensorium is evaluated.32
    • Patients with significant head trauma may require head CT scanning.
    • A head CT scan may also be obtained in patients with first-time seizure activity or prolonged seizures or in patients with neurologic deficits of unknown etiology.

Other Tests

  • Obtain an ECG initially to evaluate for cardiac dysrhythmias related to hyperkalemia or hypocalcemia.
  • Specific disease testing may be indicated to determine definitive etiologies during or after short-term management of rhabdomyolysis.

Procedures

  • Measure compartment pressures in patients with suspected compartment syndromes.
  • A fasciotomy may be needed if compartment pressures are high.5

Histologic Findings

  • Histology demonstrates necrotic muscle fibers in patients with rhabdomyolysis.
  • A muscle biopsy may be required to demonstrate immunohistochemical features of necrosis only if underlying muscle disease is a concern. Immunoblotting, immunofluorescence, and genetic studies may be necessary to find evidence of inflammatory conditions or dystrophinopathies.10

More on Rhabdomyolysis

Overview: Rhabdomyolysis
Differential Diagnoses & Workup: Rhabdomyolysis
Treatment & Medication: Rhabdomyolysis
Follow-up: Rhabdomyolysis
Multimedia: Rhabdomyolysis
References
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References

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Further Reading

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Keywords

rhabdomyolysis, muscle weakness, myalgia, dark urine, myoglobinuria, sarcolemma, acute renal failure, myoglobin-induced acute renal failure, nephrotoxicity, malignant hyperthermia, crush injury, disseminated intravascular coagulation, treatment, diagnosis

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Contributor Information and Disclosures

Author

Eyal Muscal, MD, Assistant Professor, Section of Pediatric Rheumatology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital
Eyal Muscal, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Rheumatology, and Clinical Immunology Society
Disclosure: Nothing to disclose.

Coauthor(s)

Marietta Morales de Guzman, MD, Assistant Professor, Department of Pediatrics, Baylor College of Medicine; Consulting Staff, Section of Pediatric Rheumatology, Department of Pediatrics, Texas Children's Hospital, Ben Taub General Hospital
Marietta Morales de Guzman, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Rheumatology, and Texas Pediatric Society
Disclosure: Nothing to disclose.

Medical Editor

Barry L Myones, MD, Associate Professor, Departments of Pediatrics and Immunology, Pediatric Rheumatology Section, Baylor College of Medicine; Director of Research, Pediatric Rheumatology Center, Texas Children's Hospital
Barry L Myones, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American College of Rheumatology, American Heart Association, American Society for Microbiology, Clinical Immunology Society, and Texas Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Herbert S Diamond, MD, Professor of Medicine, Temple University School of Medicine; Chairman Emeritus, Department of Internal Medicine, Western Pennsylvania Hospital
Herbert S Diamond, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology, American Medical Association, and Phi Beta Kappa
Disclosure: medifocus Honoraria Review panel membership; health dialogs Honoraria Consulting; West Penn Allegheny Health System None Board membership

CME Editor

Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine
Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine
Disclosure: Baxter Honoraria Consulting

Chief Editor

Lawrence K Jung, MD, Chief, Division of Pediatric Rheumatology, Children's National Medical Center
Lawrence K Jung, MD is a member of the following medical societies: American Association for the Advancement of Science, American Association of Immunologists, American College of Rheumatology, Clinical Immunology Society, and New York Academy of Sciences
Disclosure: Nothing to disclose.

 
 
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