INTRODUCTION AND EPIDEMIOLOGY
Rhabdomyolysis is the destruction of skeletal muscle, caused by any mechanism that results in injury to myocytes and their membranes. Direct muscle injury and genetic and biochemical factors can predispose to rhabdomyolysis. Acute necrosis of skeletal muscle fibers and the leakage of cellular contents into the circulation result in myoglobinuria.
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 89-1 lists commonly recognized conditions associated with rhabdomyolysis. 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.1,2 A host of drugs and toxins have been identified that are associated with or causative of rhabdomyolysis.3 Multiple causes are present in more than half of patients.1 In children, rhabdomyolysis is less common and is thought to be more benign.3 In one study of children, the most common causes of nonrecurrent rhabdomyolysis were trauma, viral myositis, and connective tissue disease.4 For adults and children, inherited metabolic disorders should be suspected with recurrent episodes of rhabdomyolysis, especially if associated with exercise intolerance.
TABLE 89-1Common Conditions Associated with Rhabdomyolysis in Adults ||Download (.pdf) TABLE 89-1 Common Conditions Associated with Rhabdomyolysis in Adults
|Trauma ||Immunologic diseases involving muscle ||Ischemic injury |
| Crush injury || Dermatomyositis || Compartment syndrome |
| Electrical or lightning injury || Polymyositis || Compression |
|Drugs of abuse ||Bacterial infection ||Medications |
| Amphetamines [including ecstasy (3,4-methylenedioxymethamphetamine)] || Clostridium || Antipsychotics |
| || Group A β-hemolytic streptococci || Barbiturates |
| Caffeine || Legionella || Benzodiazepines |
| Cocaine || Salmonella || Clofibrate |
| Ethanol || Shigella || Colchicine |
| Heroin || Staphylococcus aureus || Corticosteroids |
| Lysergic acid diethylamide || Streptococcus pneumoniae || Diphenhydramine |
| Methamphetamines || Viral infection || Isoniazid |
| Opiates || Coxsackievirus || Lithium |
| Phencyclidine || Cytomegalovirus || Monoamine oxidase inhibitors |
|Environment and excessive muscular activity || Epstein-Barr virus || Narcotics |
| Contact sports || Enterovirus || Neuroleptic agents |
| Delirium tremens || Hepatitis virus || Phenothiazines |
| Dystonia || Herpes simplex virus || Propofol |
| Psychosis || Human immunodeficiency virus || Salicylates |
| Seizures || Influenza virus (A and B) || Selective serotonin reuptake inhibitors |
| Marathons, military basic training || Rotavirus || Statins |
| Heat stroke || Mycoplasma || Theophylline |
|Genetic disorders || || Tricyclic antidepressants |
| Glycolysis and glycogenolysis disorders || || Zidovudine |
| Fatty acid oxidation disorders || || Some novel cancer chemotherapeutic agents |
| Mitochondrial and respiratory chain metabolism disorders || || |
Patients in coma are at risk for rhabdomyolysis from unrelieved pressure on gravity-dependent body parts. 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 most cases of rhabdomyolysis in adults.1 Drugs of abuse are commonly implicated in acute rhabdomyolysis, and many commonly prescribed medications have been associated as well.2 Statin-related myopathies include myalgias with or without elevation of creatine kinase level, ...