Rhabdomyolysis





Acute rhabdomyolysis is a medical emergency that often requires hospitalization for infusion of intravenous fluids to protect from renal injury. In the acute period, the cause of rhabdomyolysis and the risk of recurrent episodes are often unknown. Many patients unnecessarily avoid exertion to prevent recurrence. An evaluation of baseline strength and creatine kinase (CK) once the patient has recovered from the acute episode will guide the diagnostic evaluation and prognosis.



  • A.

    Substantial trauma or prolonged immobilization causing diffuse muscle injury can lead to rhabdomyolysis. These events are often known at the time of presentation but should be screened for in the initial evaluation. Specific events of concern include falls resulting in prolonged immobilization, coma, compartment syndromes, and electrical injury from lightning or other high-voltage sources. In the presence of a substantial trauma or prolonged immobilization, further workup is not required and the patient may resume physical activity as tolerated.


  • B.

    Many toxic exposures have been associated with rhabdomyolysis, though much of the literature is limited to isolated case reports. Here we have included exposures with a clear and consistent association with rhabdomyolysis. In the presence of a clear toxic exposure, further workup is not required and the patient may resume physical activity as tolerated.


  • C.

    In the absence of trauma or toxic exposure, a thorough examination of motor strength is necessary to assess for baseline weakness. Additionally, a CK level should be drawn. Patients should refrain from strenuous exercise for one week to avoid artificially elevated CK levels. If the patient’s strength is impaired or the CK is elevated at baseline, further testing is required to assess for acquired or inherited causes of myopathy.


  • D.

    In patients with subacute progressive weakness or skin changes concerning for dermatomyositis, a biopsy should be performed to exclude rhabdomyolysis in the setting of an acquired myopathy. In the setting of skin changes, a skin biopsy of an affected region can also be performed. If biopsy findings are not consistent with an inflammatory process, then inherited myopathies should be considered, although if there is clear subacute progression of weakness, concurrent empiric treatment may be warranted due to the risk of sampling error. It is important to note that biopsies performed within several months of an episode of rhabdomyolysis are likely to demonstrate fiber necrosis and regeneration related to the acute episode of muscle breakdown.


  • E.

    In patients with a single episode of rhabdomyolysis with preserved strength and a normal baseline CK level, further evaluation is not recommended, and these patients are encouraged to resume their prior level of activity. Education should be provided regarding signs of recurrent rhabdomyolysis, including muscle pain, constitutional symptoms, and dark urine, which would require immediate medical assessment.


  • F.

    Advances in genetic testing have revolutionized the assessment of various inherited myopathies. The use of next-generation sequencing (NGS) allows a large number of genes to be tested in a single disease panel. Some panels are focused on particular disease sets (e.g., “metabolic” vs. “muscular dystrophy”) while others are broad and cover multiple disease categories (“comprehensive myopathy panels”). It is important to understand the strengths and weakness of individual panels. It is also important to know if large gene deletions and duplications are examined in the panel. Finally, NGS technology does not assess the two most common adult-onset muscular dystrophies, fascioscapulohumeral muscular dystrophy and myotonic dystrophy. It is important to consider these specific presentations, as they require separate specific genetic testing.


May 3, 2021 | Posted by in NEUROLOGY | Comments Off on Rhabdomyolysis

Full access? Get Clinical Tree

Get Clinical Tree app for offline access