eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics
Rhabdomyolysis
Updated: Aug 14, 2008
Introduction
Background
Rhabdomyolysis was first described in the victims of crush injury during the 1940-1941 London, England blitzkrieg bombing raids of World War II.1 It has many etiologies.
Pathophysiology
Rhabdomyolysis is the breakdown of muscle fibers with leakage of potentially toxic cellular contents into the systemic circulation. The final common pathway of rhabdomyolysis may be a disturbance in myocyte calcium homeostasis.2
Clinical sequelae of rhabdomyolysis include the following:
- Hypovolemia (sequestration of plasma water within injured myocytes)
- Hyperkalemia (release of cellular potassium into the systemic circulation)
- Metabolic acidosis (release of cellular phosphate and sulfate)
- Acute renal failure (nephrotoxic effects of liberated myocyte components)
- Disseminated intravascular coagulation (DIC)
Frequency
United States
Rhabdomyolysis accounts for an estimated 8-15% of cases of acute renal failure.
Mortality/Morbidity
The overall mortality rate for patients with rhabdomyolysis is approximately 5%; however, the mortality rate of any single patient is dependent upon the underlying etiology and any existing comorbidities.
Sex
Incidence is higher in males than in females, especially in the subgroups of trauma and inherited enzyme deficiencies.
Age
Rhabdomyolysis is more common in adults, though it may occur in infants, toddlers, and adolescents who have inherited enzyme deficiencies of carbohydrate or lipid metabolism or who have inherited myopathies, such as Duchenne muscular dystrophy and malignant hyperthermia.
Clinical
History
The clinical presentation is often subtle, underscoring the need for a high index of suspicion.
- In a 1982 study of 87 episodes of rhabdomyolysis in adults, Gabow found that only 50% of patients initially complained of muscle pain. A minority of patients reported dark discoloration of the urine.
- In Gabow's series, 97% of patients reported at least 1 risk factor for rhabdomyolysis. Fifty-nine percent reported multiple risk factors.
- Common risk factors included alcohol abuse (67%), recent soft tissue compression (39%), and seizure activity (24%).
- Other causative factors included trauma (17%), drug abuse (15%), metabolic derangements (8%), hypothermia (4%), flulike illness (3%), sepsis (2%), and gangrene (1%).3
- Ward's 1988 review of 157 patients found the following predisposing factors:
- Trauma (38%)
- Ischemia (14%)
- Polymyositis (8%)
- Drug overdose (7%)
- Exertion (6%)
- Seizures (5%)
- Burns (5%)
- Sepsis (3%)
- Hereditary disorders (3%)
- Viral illness (1%)4
- More recently, Fernandez et al reviewed 97 adult patients who presented to a university emergency department with rhabdomyolysis and found that the most common risk factors were cocaine use (30), exercise (29), and immobilization (18). Direct trauma, seizures, and alcohol withdrawal each accounted for 4 cases.5
- In a review of 191 pediatric patients with rhabdomyolysis, Mannix et al studied presenting symptoms, causative factors, and incidence of acute renal failure. The average age was 11 years.
- The most common documented symptoms were muscle pain (45%), fever (40%), and symptoms of viral infection (39%).
- The most common causes of rhabdomyolysis in this pediatric population were viral myositis (38%), trauma (26%), and connective tissue disease (5%). CK levels greater than 6000 IU/L were more likely to be associated with undiagnosed dermatomyositis or hereditary muscle disease than levels less than 6000 IU/L.
- Acute renal failure occurred in 4.7% of patients, all of whom had urinary heme dipstick results of at least 2+.6
- Patients with statin-induced rhabdomyolysis typically present with flulike symptoms, fatigue, or progressive low back pain and proximal muscle weakness. The average duration of statin therapy is approximately 1 year.7
Physical
- Focal or diffuse skeletal muscle swelling is rare. In Gabow's series, only 5% of the patients presented with muscle edema.
- Tense and tender muscle compartments suggest compartment syndrome; peripheral pulses that are within reference range do not rule out compartment syndrome because loss of distal pulses is a very late sign.
Causes
The etiologies may be subdivided into traumatic, exercise induced, toxicologic, environmental, metabolic, infectious, immunologic, and inherited classifications.
- Rhabdomyolysis may occur after traumatic events, including the following:
- Significant blunt trauma or crush injury8
- High-voltage electrical injury
- Extensive burns
- Near drowning
- Prolonged immobilization (eg, after excess alcohol or drug consumption, after an unwitnessed incapacitating stroke, following prolonged surgical procedures)
- Rhabdomyolysis may occur after excessive muscular activity, such as the following:
- Toxin-mediated rhabdomyolysis may result from substance abuse, including abuse of the following:
- Ethanol
- Methanol
- Ethylene glycol
- Isopropanol
- Heroin
- Methadone
- Barbiturates
- Cocaine
- Amphetamine
- Phencyclidine
- 3,4-methylenedioxymethamphetamine (MDMA, ecstasy)
- Lysergic acid diethylamide (LSD)
- Toxic-mediated rhabdomyolysis may result from prescription and nonprescription medications, including the following:
- Antihistamines
- Salicylates
- Caffeine12
- Fibric acid derivatives (eg, bezafibrate, clofibrate, fenofibrate, gemfibrozil)
- Neuroleptics
- Anesthetic and paralytic agents (the malignant hyperthermia syndrome)
- Amphotericin B
- Quinine
- Corticosteroids
- Atorvastatin
- Fluvastatin
- Lovastatin
- Pitavastatin (marketed in Japan, South Korea, India)
- Pravastatin
- Rosuvastatin
- Simvastatin
- Cerivastatin (recalled from US market)
- Theophylline
- Cyclic antidepressants
- Selective serotonin reuptake inhibitors (the serotonin syndrome)
- Aminocaproic acid
- Phenylpropanolamine (recalled from US market)
- Propofol (Continuous infusion)13
- Rhabdomyolysis may be caused by other toxins, including the following:
- Carbon monoxide14
- Toluene
- Hemlock herbs from quail (Rhabdomyolysis after the consumption of quail is well known in the Mediterranean region; it occurs as the result of intoxication by hemlock herbs that the quails consume.)
- Snake, spider (eg, black widow spider), and massive envenomations of Africanized honey bees
- Environmental causes of rhabdomyolysis include the following:
- Hyperthermia
- Hypothermia15
- Metabolic causes of rhabdomyolysis include the following:
- Viral infectious disease agents may cause rhabdomyolysis, including the following:19
- Bacterial infectious agents may cause rhabdomyolysis, including the following:19
- Francisella tularensis24
- Streptococcus pneumoniae
- Group B streptococci
- Streptococcus pyogenes
- Staphylococcus epidermidis
- Escherichia coli
- Borrelia burgdorferi
- Clostridium perfringens
- Clostridium tetani
- Viridans streptococci
- Plasmodium species
- Rickettsia species
- Salmonella species
- Listeria species
- Legionella species25
- Mycoplasma species26
- Vibrio species
- Brucella species
- Bacillus species
- Leptospira species27
- Fungal infectious agents may cause rhabdomyolysis, including the following:19
- Candida species
- Aspergillus species
- Causative connective tissue diseases that can cause rhabdomyolysis include the following:
- Polymyositis
- Dermatomyositis
- Inherited disorders may cause rhabdomyolysis, including the following:
- Enzyme deficiencies of carbohydrate or lipid metabolism
- Myopathies28
- Rhabdomyolysis also has been reported in patients with sickle cell anemia and has mistakenly been identified as a pain crisis.
More on Rhabdomyolysis |
 Overview: Rhabdomyolysis |
| Differential Diagnoses & Workup: Rhabdomyolysis |
| Treatment & Medication: Rhabdomyolysis |
| Follow-up: Rhabdomyolysis |
| References |
| Next Page » |
References
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Further Reading
Keywords
hypovolemia, hyperkalemia, metabolic acidosis, acute renal failure, disseminated intravascular coagulation, DIC, Duchenne muscular dystrophy, malignant hyperthermia, hyperthermia, alcohol abuse, drug abuse, metabolic derangements, hypothermia, flulike illness, trauma, ischemia, polymyositis, drug overdose, exertion, seizures, high-voltage electrical injury, extensiveburns, near drowning, prolonged immobilization, excessive muscular activity, strenuous exercise, status epilepticus, status asthmaticus, severe dystonia, acute psychosis, dermatomyositis, myopathies, sicklecell anemia
