Chapter 92

Rhabdomyolysis is a clinical and biochemical syndrome that results from acute necrosis of skeletal muscle fibers and the leakage of cellular contents into the circulation. Several classification systems have been developed to characterize the numerous causes of rhabdomyolysis. None of these systems is universally recognized, and each has its limitations. Table 92-1 lists commonly recognized causes. In general, the most common causes of rhabdomyolysis in adults appear to be alcohol and drugs of abuse, followed by medications, muscle diseases, trauma, neuroleptic malignant syndrome, seizures, immobility, infection, strenuous physical activity, and heat-related illness.1 Multiple causes are present in more than half of patients.1 In children, rhabdomyolysis is less common and is thought to be more benign.2 In one study of children, the most common causes of nonrecurrent rhabdomyolysis were trauma, viral myositis, and connective tissue disease.2 For adults and children, inherited metabolic disorders should be suspected with recurrent episodes of rhabdomyolysis, especially if associated with exercise intolerance.

Table 92-1 Common Causes of Rhabdomyolysis in Adults

Patients in coma are at risk for development of rhabdomyolysis due to immobility from unrelieved pressure on gravity-dependent body parts. In one study, the positions most commonly leading to rhabdomyolysis were the lateral decubitus, lithotomy, sitting, knee-to-chest, and prone positions.3 Alcohol consumption can result in rhabdomyolysis secondary to coma-induced muscle compression and a direct toxic effect. Nutritional compromise, hypokalemia, hypomagnesemia, and hypophosphatemia, all common in alcoholics, increase the risk of rhabdomyolysis. Alcohol and drugs are thought to play a role in up to 80% of cases of rhabdomyolysis in adults.1,4,5 Drugs of abuse that have commonly been implicated in acute rhabdomyolysis include cocaine, amphetamines [including Ecstasy (3,4-methylenedioxymethamphetamine)], lysergic acid diethylamide (LSD), heroin, and phencyclidine. Commonly prescribed medications associated with the development of rhabdomyolysis include antipsychotics, lipid-lowering agents (i.e., statins and clofibrate), selective serotonin reuptake inhibitors, narcotics, zidovudine, colchicine, lithium, and antihistamines.2 Statin-related myopathies include myalgias with or without elevation of creatine kinase (CK) level, muscle weakness, and rhabdomyolysis. Statin-related rhabdomyolysis is rare, varies with the particular statin (0.04% ...

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