A Case of Exertional Rhabdomyolysis: A Cheer for Standardizing Inpatient Management and Prevention

Abstract

A 17-year-old girl presented to the emergency department with bilateral triceps pain, swelling, and stiffness after participating in 2 days of summer cheerleading camp in August 2015. Serum creatine kinase (CK) was measured at 32 531 IU/L. The patient was diagnosed with exertional rhabdomyolysis (ER). A full chemistry panel (serum electrolytes, serum urea nitrogen/creatinine, glucose, calcium, magnesium, phosphate), serum CK, and urinalysis with microscopy was obtained. The patient received 2 L normal saline (NS) by intravenous (IV) bolus in the emergency department and was admitted to the inpatient ward. As she was one of several patients subsequently admitted from her cheerleading training camp, the pediatric hospitalist and nephrology services created a standardized inpatient management protocol according to which all admitted patients were treated (Table 1). This protocol delineated admission criteria, approach to inpatient management with contingency planning, and discharge criteria. It is based on current adult and pediatric literature on rhabdomyolysis and clinician expertise. 1-5 Question What Is Currently Known About ER and Its Optimal Management? DISCUSSION Acute rhabdomyolysis is a potentially fatal illness, defined by the triad of muscle weakness, myalgias, and elevation in serum CK. 6 Causes of rhabdomyolysis include infectious, traumatic, medication-induced, exertional, metabolic, and genetic. 2 Viral infection is the most common cause in school-aged children, whereas in adolescents, trauma is the most common cause. 8 ER, or exercise-induced rhabdomyolysis, is a subset of rhabdomyolysis, and therefore a potential cause of acute kidney injury (AKI) and subsequent need for renal replacement therapy. Although the pathogenesis of ER is not completely understood, tissue injury is thought to occur when muscle energy requirements exceed maximal adenosine triphosphate production. Consequent muscle necrosis results in the release of intracellular calcium, potassium, and myoglobin, the latter of which causes AKI. 9