Updated: 12/2/2021


Review Topic
  • Snapshot
    • A 26-year-old woman has just finished running a full marathon. She did not stop as often as she would have liked for water to rehydrate during her 26.2 mile run. She reports feeling lightheaded and has mild muscle soreness. When she went to use the restroom, she noticed that her urine was dark – almost like tea. At an urgent care clinic, her serum creatine kinase is found to be elevated. An ECG is shown here.
  • Introduction
    • Clinical definition
      • skeletal muscle breakdown and necrosis
        • releases intracellular contents of the cells into circulation
        • causes severe complications including acute kidney injury, compartment syndrome, cardiac arrest, or respiratory failure
  • Epidemiology
    • Risk factors
      • intense physical exercise under heat or humidity
      • diuretic abuse
      • marathon running
  • Etiology
    • Common associations
      • trauma
      • crush injury
      • alcohol abuse
      • cocaine abuse
      • statins and fibrates together
      • neuroleptic malignant syndrome
    • Pathogenesis
      • mechanism
        • muscle cell injury causes intracellular contents to be released including:
          • potassium
          • myoglobin
          • uric acid
          • sarcoplasmic contents
            • creatine kinase
            • alanine aminotransferase (ALT)
            • aspartate aminotransferase (AST)
      • cocaine-induced rhabdomyolysis
        • prolonged vasoconstriction can lead to ischemia and necrosis of muscle cells
      • acute kidney injury
        • high levels of myoglobin precipitates in kidneys and cause tubular obstruction
        • metabolites of myoglobin also directly causes damage to tubules
  • Presentation
    • Symptoms
      • primary symptoms
        • classic triad
          • muscle pain
          • weakness and swelling of muscle
          • tea-colored urine (myoglobinuria)
      • nausea
      • emesis
      • oliguria or anuria
      • may be asymptomatic
    • Physical exam
      • fever
      • tachycardia
      • muscle weakness
  • Studies
    • Labs
      • ↑ serum creatine kinase (CK)
      • ↑ serum myoglobin
        • because of its short half-life they are not as sensitive as CK
      • ↑ serum creatinine
      • electrolyte abnormalities
        • ↑ potassium
        • ↑ phosphate
        • ↓ calcium (most common disturbance)
        • ↑ uric acid
      • ↑ liver function tests
    • Urine dipstick
      • myoglobinuria
    • Urinalysis
      • protein
      • brown casts
      • uric acid crystals
      • red blood cells
    • Electrocardiogram (ECG)
      • monitor for cardiac arrhythmias from electrolyte abnormalities
      • first step in evaluating a patient with suspected rhabdomyolysis
    • Diagnostic criteria
      • elevated serum CK
  • Differential
    • Hemolysis causing hemoglobinuria (dark urine)
      • normal CK
  • Treatment
    • Conservative
      • fluid hydration and mannitol
        • indications
          • for all patients to help treat or prevent acute kidney injury
    • Medical
      • sodium bicarbonate
        • indications
          • to alkalinize the urine
      • insulin and glucose
        • indications
          • if rhabdomyolysis causes hyperkalemia
            • calcium gluconate if peaked T-waves on EKG
  • Complications
    • Acute kidney injury
    • Cardiac arrest from hyperkalemia
  • Prognosis
    • generally good with early detection, supportive care, and careful monitoring
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(M2.RL.17.4754) A 25-year-old Greek college student presents to the emergency department with wine-colored urine. He states that the change in urine color came on suddenly, and this has never happened to him before. Aside from the dark urine, he complains of minor muscle pain and soreness that is related to his training. The patient states he ran in a marathon today that he has been training for for the past year. The patient does not have a significant past medical history and is currently taking a multivitamin, fish oil, and a whey protein supplement. Urine dipstick is positive for red blood cells. An EKG is obtained and seen in Figure A. Urine toxicology is performed and returns positive for amphetamines and cocaine. On physical exam, you note an excitable young man who has no abnormal findings. Urine microscopy reveals an absence of red blood cells. Which of the following is the next best step in management?

QID: 108980

Renal ultrasound



CT scan



IV fluids



Observation and wait for the patient to metabolize illicit substances



Phlebotomy and chloroquine



M 7 C

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Evidence (4)
Private Note