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Rhabdomyolysis

  • Rhabdomyolysis facts
  • What is rhabdomyolysis?
  • What causes rhabdomyolysis?
  • What are the symptoms of rhabdomyolysis?
  • What should I do if I think I have rhabdomyolysis?
  • How is rhabdomyolysis diagnosed?
  • What are the complications of rhabdomyolysis?
  • How is rhabdomyolysis treated?
  • What is the prognosis for rhabdomyolysis?
  • Medical Author:

    Siamak N. Nabili, MD, MPH

    Siamak N. Nabili, MD, MPH

    Siamak N. Nabili, MD, MPH

    Dr. Nabili received his undergraduate degree from the University of California, San Diego (UCSD), majoring in chemistry and biochemistry. He then completed his graduate degree at the University of California, Los Angeles (UCLA). His graduate training included a specialized fellowship in public health where his research focused on environmental health and health-care delivery and management.

  • Medical Editor:

    William C. Shiel Jr., MD, FACP, FACR

    William C. Shiel Jr., MD, FACP, FACR

    William C. Shiel Jr., MD, FACP, FACR

    Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.

  • Rhabdomyolysis Center
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  • Patient Comments: Rhabdomyolysis – Describe Your Experience
  • Patient Comments: Rhabdomyolysis – Symptoms
  • Patient Comments: Rhabdomyolysis – Diagnosis
  • Patient Comments: Rhabdomyolysis – Treatment
  • Rhabdomyolysis facts
  • What is rhabdomyolysis?
  • What causes rhabdomyolysis?
  • What are the symptoms of rhabdomyolysis?
  • What should I do if I think I have rhabdomyolysis?
  • How is rhabdomyolysis diagnosed?
  • What are the complications of rhabdomyolysis?
  • How is rhabdomyolysis treated?
  • What is the prognosis for rhabdomyolysis?

Rhabdomyolysis facts

  • Rhabdomyolysis is the rapid destruction of skeletal muscle resulting in
    leakage into the urine of the muscle protein myoglobin.
  • Rhabdomyolysis has many causes.
  • Medications can cause muscle injury and rhabdomyolysis.
  • Rhabdomyolysis can cause muscle pain and
    weakness .
  • Blood levels of muscle enzymes, including CPK, SGOT, SGPT, and LDH, as well
    as blood and urine myoglobin are used to diagnose and monitor rhabdomyolysis.
  • Hospitalization is sometimes required to treat rhabdomyolysis.

What is rhabdomyolysis?


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Rhabdomyolysis (RAB-DOE-MY-O-LIE-SIS) is the rapid destruction of skeletal muscle resulting in
leakage into the urine of the muscle
protein myoglobin.

There are three different types of muscle in the human body ;

  1. smooth muscle,
  2. skeletal
    muscle, and
  3. heart muscle .

The
skeletal muscle is the muscle of movement of the body (moving the skeleton at the joints). Skeletal muscle is affected by
rhabdomyolysis.

Myoglobin is a protein component of the muscle cells that is released into
the blood when the skeletal muscle is destroyed in rhabdomyolysis.
Creatine
kinase is an enzyme (a protein that facilitates chemical reactions in the body)
also in the muscle cells. The level of each of these proteins can be
measured in blood to monitor the degree of muscle injury from rhabdomyolysis. Myoglobin can
also be measured in samples of urine.

Rhabdomyolysis Symptoms and Causes

What are the symptoms of rhabdomyolysis?

The muscle damage causes inflammation leading to tenderness, swelling, and weakness of the affected muscles. The dark urine color is due to myoglobin being excreted in the urine by the kidney as it tries to rid the body of the muscle breakdown products.

Symptoms related to the expected complications of rhabdomyolysis include:

  • symptoms of kidney failure, which may include swelling of the hands and feet;
  • shortness of breath as excess fluid builds up in the lungs,
  • lethargy;
  • weakness;
  • symptoms of hyperkalemia (elevations in potassium in the blood) such as weakness, nausea, lightheadedness, and palpitations due to heart rhythm disturbances); and
  • disseminated intravascular coagulation, a disruption of the normal blood clotting process, may occur as unexplained bleeding.
Read more about these the causes and symptoms of rhabdomyolysis »

What causes rhabdomyolysis?

Rhabdomyolysis has many causes. Some of the common ones include:

  • Muscle trauma or crush injury
  • Severe burns
  • Physical torture or child abuse
  • Prolonged lying down on the ground (people who fall or are unconscious and are unable to get up for several hours)
  • Prolonged coma
  • Severe muscle contractions from prolonged seizures
  • Cocaine use with related hyperthermia (increased body temperature)
  • Extreme physical activity ( running a marathon, extreme workouts)
  • Drug and alcohol intoxication
  • Low circulating phosphate, potassium, or magnesium levels in the blood ( electrolytes )
  • Genetic muscle diseases (familial paroxysmal rhabdomyolysis)
  • Prolonged drowning or hypothermia (low core body temperature)
  • Medications: most notably statins used to treat high cholesterol ( simvastatin [ Zocor ], atorvastatin [ Lipitor ], pravastatin [Pravachol], or lovastatin [ Mevacor ]) and other medications such as Parkinson’s medication, psychiatric medications, anesthesia medications, HIV medications, colchicine
  • Variety of viruses and some bacteria
  • Severe hypothyroidism (low thyroid level), especially if the person is also taking statin drugs for cholesterol
  • Lack of blood perfusion to a limb
  • Some inflammatory disorders of the muscle, called myopathies, ( myositis , dermatomyositis , polymyositis )
  • Venom from certain snake bites (mainly in Africa, Asia, and South America)

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What are the symptoms of rhabdomyolysis?


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Rhabdomyolysis may not cause any symptoms at all. Muscle aches and pain ( myalgia ), stiffness, and muscle weakness can occur with rhabdomyolysis, and is especially common with severe muscle damage. Rhabdomyolysis may cause a darkening of the urine color. Myoglobin is released from the muscles when they break down and is excreted into the urine. This can cause a red or cola color of the urine.

What should I do if I think I have rhabdomyolysis?

If you have signs and symptoms suggestive of rhabdomyolysis, your doctor
needs to be notified promptly. It is important to realize that these symptoms
are not specific for rhabdomyolysis as they may be caused by other conditions.

How is rhabdomyolysis diagnosed?


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Rhabdomyolysis is suggested by the history of recent and past events and the physical examination. It is confirmed by blood and urine testing. An important part of diagnosing rhabdomyolysis is a comprehensive medical history and physical examination.

The medical history may include questions about any medication use, drug and alcohol use, other medical conditions, any trauma or accident, etc. Blood tests include a complete blood count ( CBC ), a metabolic panel, muscle enzymes, and urinalysis .

The diagnosis of rhabdomyolysis is confirmed by detecting elevated muscle enzymes in blood, which include creatine phosphokinase (CPK), SGOT, SGPT, and LDH . The levels of these enzymes rise as the muscle is destroyed in rhabdomyolysis.

While the SGOT, SGPT, and LDH enzymes are found in muscles, they are more frequently associated with the liver . Therefore, elevations of SGOT and SGPT, without elevated CPK, are more typically indications of liver damage.

Of note, CPK is also in heart muscle ( cardiac muscle ) and brain. The laboratory is usually able to distinguish between the different components of this enzyme. For example, the fraction coming from skeletal muscle is referred to as CK-MM and the one from heart muscle is designated as CK-MB. There are small amounts of the CK-MB component in the skeletal muscle as well.

The levels of myoglobin can be elevated in blood and urine

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What are the complications of rhabdomyolysis?

One of the dreaded complications of rhabdomyolysis is kidney failure . This can occur for a variety of reasons. Direct injury to the kidney and plugging of the filtering tubes of the kidneys by the muscle proteins are among the causes of kidney function impairment in the setting of rhabdomyolysis.

Another serious complication of rhabdomyolysis is called the compartment syndrome  where muscle injury leads to swelling and increased pressure in a confined space (a compartment). This leads to compromised circulation which can endanger the affected tissue. The compartment syndrome is most common after injury in the lower leg, arms, or the muscles of the abdominal wall and can require emergency surgery.

Rhabdomyolysis can also cause abnormality of electrolytes in the blood. Because of muscle injury, the contents of the muscle cells can be released into the blood causing high levels of potassium ( hyperkalemia ) and phosphorus (hyperphosphatemia).

How is rhabdomyolysis treated?


  • Readers Comments 4

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The treatment of rhabdomyolysis depends on its cause and severity.

If a cause for rhabdomyolysis is identified, it is addressed; for example:

  • discontinuing a toxic medication,
  • replacing electrolytes, or
  • treating an
    underlying muscle disease.

In cases of mild rhabdomyolysis without any evidence of complications,
management can take place at home by simply recognizing the cause and correcting
it, such as discontinuing a medication and rehydration.

In more
severe cases, or if home therapy is not possible, hospitalization may be required. Prompt initiation
of hydration with intravenous fluids, in
addition to the removal the provoking factor(s), is an essential part of the
treatment of rhabdomyolysis. Monitoring and managing kidney dysfunction, correcting any disturbance in the electrolytes,
and monitoring the muscle enzyme levels (CPK, SGOT, SGPT, LDH) are most
effectively done in the hospital when rhabdomyolysis is severe.

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What is the prognosis for rhabdomyolysis?

The overall prognosis of rhabdomyolysis is favorable as long
as it is recognized and treated promptly. Most causes of rhabdomyolysis
reversible. Severe cases of rhabdomyolysis may be associated with kidney damage
and electrolyte imbalance and hospitalization and even dialysis can be required.

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References
Medically reviewed by Joseph Palermo, DO; American Osteopathic Board Certified Internal Medicine

REFERENCE:

Clinical manifestations and diagnosis of rhabdomyolysis.



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Rhabdomyolysis: Causes, Symptoms, and Diagnosis

Medically reviewed by Graham Rogers, MD on July 18, 2016 — Written by Christine Case-Lo and Erica Cirino

Overview

Rhabdomyolysis is the breakdown of damaged skeletal muscle.

Muscle breakdown causes the release of myoglobin into the bloodstream. Myoglobin is the protein that stores oxygen in your muscles. If you have too much myoglobin in your blood, it can cause kidney damage.

About 26,000 cases of rhabdomyolysis are reported in the United States each year. Most people with rhabdomyolysis are treated with fluids given through their veins in an intravenous (IV) drip. Some people may require dialysis or hemofiltration to address kidney damage in more severe cases.

Recognizing the symptoms

The initial symptoms of rhabdomyolysis can be subtle. They’re not specific and may mimic other conditions. The symptoms of rhabdomyolysis include:

  • muscle weakness
  • low urine output
  • fatigue
  • soreness
  • bruising
  • dark, tea-colored urine
  • infrequent urination
  • a fever
  • a sense of malaise, or feeling sick
  • nausea
  • vomiting
  • confusion
  • agitation

What causes rhabdomyolysis?

Rhabdomyolysis is always triggered by muscle injury. This injury can have physical, chemical or genetic causes. Anything that damages the muscles can cause this condition. Possible causes include the following:

Trauma, heat, and exertion

Causes in this category include:

  • a crush injury, which can occur when something heavy falls on you
  • a heatstroke
  • a third-degree burn
  • blocked blood vessels
  • a lightning strike
  • intense shivering
  • an ischemic limb injury, which occurs when your tissue lacks an adequate blood supply
  • pathological muscle exertion
  • a car accident
  • intense exercise, such as marathon running

Genetic and metabolic disorders

Some people develop rhabdomyolysis because of genetic conditions such as problems with metabolism of

  • lipids, or fats
  • carbohydrates
  • purines, which are in certain foods, such as sardines, liver, asparagus

Metabolic problems, such as the following, can also trigger rhabdomyolysis:

  • hypothyroidism or low thyroid hormone levels
  • diabetic ketoacidosis, or a buildup of ketones in the body
  • electrolyte imbalances

Genetic disorders that can lead to rhabdomyolysis include:

  • a carnitine deficiency
  • McArdle’s disease
  • a lactate dehydrogenase deficiency
  • Duchenne muscular dystrophy

Infection and inflammation

Many types of infection and inflammation can cause rhabdomyolysis, including:

  • viral infections
  • bacterial infections
  • polymyositis
  • dermatomyositis
  • snakebites

Medications and toxins

One important cause of rhabdomyolysis is statin medications, which are cholesterol-lowering drugs that many people take. Statins include:

  • atorvastatin (Lipitor)
  • rosuvastatin (Crestor)
  • pravastatin (Pravachol)

Although rhabdomyolysis only occurs in a few people who take statins, so many people take these medications that it’s important to be aware of the risk.

The condition can also occur due to exposure to other drugs, certain toxins, and high levels of alcohol. Other drugs that can cause rhabdomyolysis include:

  • cyclosporine
  • erythromycin
  • colchicine
  • cocaine
  • amphetamines
  • ecstasy
  • LSD

Many other potential causes exist in these four categories beyond the ones listed.

How is rhabdomyolysis diagnosed?

Your doctor will look and feel the larger skeletal muscles in your body, especially any that ache, to check for tenderness. They may also perform urine and blood tests to confirm a diagnosis of rhabdomyolysis.

Tests to determine muscle and kidney health may include determining levels of:

  • creatine kinase, which is an enzyme found in the skeletal muscles, the brain, and the heart
  • myoglobin in blood and urine, which is a protein that’s a byproduct of muscle breakdown
  • potassium, which is another important mineral that may leak from injured bone and muscles
  • creatinine in blood and urine, which is a breakdown product created by muscle that’s normally removed from the body by the kidneys

Elevated levels of these substances are signs of muscle damage.

Treatments options for rhabdomyolysis

If discovered early in its progression, rhabdomyolysis can be successfully treated without long-term damage to the kidneys.

Fluid recovery

Getting enough fluid into your body is the first and most important treatment. They must start IV fluids quickly. This fluid should contain bicarbonate, which helps flush the myoglobin out of your kidneys.

Medications

Your doctor may prescribe medications such as bicarbonate and certain kinds of diuretics to help keep your kidneys functioning.

They can also treat high potassium levels in the blood, or hyperkalemia, and low blood calcium levels, or hypocalcemia, with appropriate IV fluids.

Dialysis

If kidney damage and acute renal failure have already started, you may need to receive dialysis. During dialysis, blood is taken out of the body and cleaned in a special machine in order to remove waste products.

Home remedies

In mild cases of rhabdomyolysis, home treatment can help aid in the recovery process. The goals of at-home treatment include resting the body so muscles can recover and rehydration to help prevent further kidney damage.

When you’re feeling fatigued, recline in a comfortable position and try to relax. Drink plenty of water and other clear liquids, such as light broth and sports drinks.

Long-term outlook

Your long-term outlook depends on the degree of kidney damage. If rhabdomyolysis is caught early, you may be able to avoid major complications and return to normal health in a few weeks. Even then, however, you may still have some lingering weakness and pain in your muscles.

If major kidney damage occurs, your kidneys may be permanently damaged.

Several of the symptoms and complications of rhabdomyolysis are serious and may result in death if you don’t get treatment for them.

Tips for preventing rhabdomyolysis

You can prevent rhabdomyolysis by drinking plenty of fluids before and after strenuous exercise. This will dilute your urine and help your kidneys eliminate any myoglobin that your muscles may have released during exercise.

If you have an existing degenerative muscle condition or have sustained damage to your muscle after a recent trauma, you can prevent rhabdomyolysis by staying well-hydrated at all times. Carry a full refillable water bottle with you at all times so you can make sure you’ll have access to something to drink. Drink whenever you begin to feel thirsty, and don’t wait until your thirst increases.

See your doctor when you suspect you may be sick or have an infection. Addressing illness as soon as possible can help prevent the muscle damage that may lead to rhabdomyolysis.

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Medically reviewed by Graham Rogers, MD on July 18, 2016 — Written by Christine Case-Lo and Erica Cirino

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