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A3343 - High-Intensity Interval Strength Training Induced Rhabdomyolysis
Author Block: T. A. Cox, C. Castaneda, S. Hapangama; Internal Medicine, New York- Presbyterian/ Queens, Flushing, NY, United States.
Introduction: Although rhabdomyolysis was traditionally described after muscle injury from trauma, a non- traumatic or exertional rhabdomyolysis can occur.
Case Report: A 26 year old female rowing coach presented with severe pain in her upper limbs and dark urine five days after she reportedly completed a high- intensity workout. The patient rowed one mile, completed 100 pull-ups, and 200 sit-ups within 45 minutes. The next day pain worsened and she developed symmetrical upper extremity swelling limiting passive range of movement. On admission upper extremities were markedly swollen, tender and pulses were barely palpable. Her creatine kinase (CK) was 148, 224 U/L, lactate dehydrogenase >2140 U/L, BUN 26 mg/dL, serum Cr 1.44 mg/dL, potassium 5.2 mmol/L, transaminases AST 2,266 U/L and ALT 586 U/L, and urine dipstick with blood. Patient was admitted to the Intensive Care Unit for rhabdomyolysis, acute kidney injury and possible compartment syndrome. Aggressive fluid resuscitation with sodium bicarbonate drip at 200-250 cc/hour was started. By hospital day 8, CK trended down to 7781 U/L. The Orthopedics team measured compartment pressures, 13mmHg in anterior arm, 15mmHg in posterior arm, 20mmHg in dorsal forearm, 16mmHg in volar forearm and 14mmHg in lateral forearm. No fasciotomy was required. Pain and range of motion improved and she was counselled on adequate hydration and gradual return to physical activity.
Discussion: Exercise induced or exertional rhabdomyolysis though uncommon with an incidence rate ~29.9 per 100,000 patient years, results in muscle injury, myoglobin release and accumulation in the kidneys[1]. Myoglobin’s toxicity in acidic urine is reduced with sodium bicarbonate per expert opinion although unproven by current studies[2]. The increasing popularity of group based high intensity strength training may lead to an increased incidence of this potentially fatal condition. All participants, regardless of activity type, without proper physical conditioning should know to seek medical intervention immediately if muscle pain is severe, extremities are swollen or urine becomes dark from myoglobinuria, as with our patient who presented after several days with a CK 741 times upper limit of normal. Intensivists should be cognizant of rhabdomyolysis and its complications especially with the rapidly growing population of group based high intensity fitness enthusiasts.
Footnotes [1] Tietze BC and Borchers J, “Exertional rhabdomyolysis in the athlete: a clinical review,” Sports Health: A Multidisciplinary Approach, vol. 6, no. 4, pp. 336- 339, 2014. [2] Stanley M and Adigun R, “Rhabdomyolysis” NCBI Bookshelf. Aug 2, 2017.