A 25-year-old man suffers from serious muscle injury after exercise. A case of rare but life-threatening severe rhabdomyolysis after training!
Vigorous exercise can lead to massive rhabdomyolysis. Since creatinine kinase levels are the most accurate indicator of the severity of the muscle injury, it is imperative to monitor the CK levels and manage to reduce the levels to avoid acute kidney injury. Muscle injury after exercise, that is rhabdomyolysis, can elevate the CK levels to anywhere from 10.000 to 300.000. However, levels up to 1.400.000 are rarely seen in otherwise healthy individuals, making this case one of its kind.
What are the risk factors of rhabdomyolysis?
Although rhabdomyolysis can occur with normal physical activity, the factors that increase the risk include impaired sweating, untrained persons, exertion in extremely humid weather, sickle cell trait coupled with hypoxia for example affected individuals exercising at high altitude, and enzymatic deficiencies.
Preserving the renal function is the primary aim along with managing electrolyte imbalances. The latter can lead to cardiac arrhythmias, disseminated intravascular coagulation, etc. Intravenous hydration (IV) remains the mainstay of management. Unresponsive patient may need haemodialysis.
Case of muscle injury after exercise:
A 25-year-old male presented to the emergency department with complaints of dark urine and swelling of the left thigh for the past 1 day. He revealed that he resumed physical activity 2 days back after a gap of the last six months. During the past 6 months, he did not do any physical training. However, for the past 2 days, he got active again. He began with very heavy leg work-out without warming up first. He tried to force his left leg more as the left knee had undergone a surgery 12 months earlier due to an anterior cruciate ligament injury.
After 2 days of physical activity, he developed dark urine and left thigh swelling. Therefore, he presented to the emergency department.
Past medical and surgical history was unremarkable, except for the left knee surgery. The patient was a non-smoker. Moreover, he denied using any illicit drugs, alcohol, dietary supplements, steroids, or hormones.
Rest of the history was unremarkable with no significant findings in the family, social, or sexual histories.
On examination, the patient had a mild left thigh swelling when compared to the right thigh. Moreover, on deep palpation, there was tenderness over his left quadriceps. Neurological and vascular examinations were unremarkable with bilateral palpable pulses. The doctors excluded compartment syndrome by performing Doppler Ultrasound.
Serological investigations were normal except creatine kinase (CK) level of 1,454,952 UI, Alanine Aminotranseferase (ALT) of 555, and Aspartate Aminotransferase (AST) of 2292. Additionally, urinalysis was unremarkable and urine toxicology screening was negative for alcohol, and drugs including amphetamines, barbiturates, benzodiazepines, cocaine, methadone, opiates, and phencyclidine.
The patient received a diagnosis of exertion-induced rhabdomyolysis.
Since rhabdomyolysis can lead to electrolyte imbalances, the doctors repeated labs after 4 hours which revealed CK level of 1,423,878 and normal creatinine and potassium.
Management:
The doctors started the patient on vigorous hydration with 0.9% NaCl intravenous fluid (IV) at a rate of 500 ml/hr, reaching a urinary output > 200 ml/hr.
Approximately 12 hours later, the CK level dropped to 321.244 UI and the patient showed no complications. On day 2 of treatment, the CK level further dropped to 299.148, and on day 3 the CK was 181.196. The treatment with IV fluids was continued on the 4th day therefore, the CK levels further decreased to 95.870. Moreover, his left thigh swelling also resolved.
The patient was doing well by the 5th day with a CK of 52.476 and creatinine of 0.9, therefore, he was discharged with an advice to follow up in the outpatient department after every 2 days so his CK level and renal function tests can be performed and monitored.
After 8 days, his CK was less than 1000 with a normal creatinine 0.9.
Reference:
Casares, P., Marull, J. Over a millon Creatine Kinase due to a heavy work-out: A case report. Cases Journal 1, 173 (2008). https://doi.org/10.1186/1757-1626-1-173
