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An Unexpected Course of Rhabdomyolysis
Page, S. DO, MPH and Daoud, E. MD
Kent Hospital, Emergency Medicine Residency Program, Warwick, RI
Background: Rhabdomyolysis is a clinical syndrome that results from acute
necrosis of skeletal muscle fibers and leakage of cellular contents into circulation.
Aggressive treatment and monitoring are required as in some cases injury is
irreversible, potentially leading to significant morbidity including chronic renal
insufficiency and even death. This otherwise healthy patient presented in acute
renal failure secondary to rhabdomyolysis, without a clear cause, and had a
quickly declining course.
Case: A 32 year-old male presents to the emergency department with inability to
void, decreased urine output and tea colored urine. The symptoms began 2 days
prior. He complains of associated fever, chills, abdominal pain, low back pain,
and nausea and vomiting. A Foley catheter is placed in the ED with 300ml of
dark urine output. Pt denies any trauma, recent injury, drug use or strenuous
exercise. Past medical history includes anxiety, depression, ADHD, GERD, and
opioid abuse. Pt is a smoker, denies alcohol use, and denies recent illicit drug
use. On admission vitals include temperature of 37.1, BP 141/81, Pulse 120,
respirations 15, and oxygen saturation of 95% on room air. Patient is alert and
oriented in mild distress due to pain. Physical exam is benign except for
tachycardia and mild abdominal distention with tenderness in the RUQ and lower
quadrants bilaterally. Lab results include CK 73,859, Creatinine 3.06, AST 1548,
ALT 421, troponin .05, UA 3+ Blood, 100-299 protein, and trace ketones. EKG
shows sinus tachycardia. CXR and CT are normal. Toxicology screen is positive
for opiates. Patient is admitted for rhabdomyolysis and acute renal failure and
started on IV fluids. On hospital day two a rapid response is called when patient
was found sedated. At this time he was found to have oxycontin pills in his hand.
He was transferred to ICU step down on non-invasive positive pressure
ventilation due to respiratory distress. On hospital day three the patient became
anuric with creatinine elevating to 6.46. He was transferred to the Intensive Care
Unit where he was subsequently intubated and emergent hemodialysis was
performed. Repeat chest x-ray showed extensive bilateral pulmonary infiltrates.
Despite hemodialysis his renal function worsened and he remained difficult to
oxygenate. On hospital day six he suffered cardiac arrest and expired.
Discussion: This young, otherwise healthy male presented with rhabdomyolysis
resulting in acute kidney injury. History and toxicology make opioid abuse the
likely culprit. Rhabdomyolysis is most often thought of in the ED after crush injury
or trauma. When the history or physical exam does not match the diagnosis
medications, both illicit and prescription must also be considered as an
underlying cause. A patient presenting in acute renal failure is more likely to need
dialysis and is at an increased risk for mortality.