The patient was treated with observation, oral hydration, and restricted physical activity. She was seen in the clinic 10 d after her initial visit. Laboratories were drawn 4 and 10 d following her initial visit. Within 10 d of her first visit, her symptoms had completely abated. On day 10, she had no swelling on examination and her laboratory values returned to normal limits (Fig. 1c). She was able to resume normal activities by day 10, and at 6 months, she reported no further episodes or exacerbations.
There have been only a few reported cases of isolated upper extremity ER (9,10,14,19). Contrary to our case, all of these cases reported pain as a major symptom. Another important feature of this case was the presence of substantial amount of subcutaneous edema. Clinical presentation of edema has been reported in a few cases of rhabdomyolysis (9,10,12,15,18). However pain seemed to be present in all cases (9,10,12,15,18). Other causes of subcutaneous edema like congestive heart failure, cellulitis, thrombosis, myositis, and drug-induced myopathy should be considered in cases with clinical suspicion for ER.
Ultrasonic appearance of our case was consistent with a significant subcutaneous edema with no noticeable intramuscular edema or abnormality. Ultrasonic features of rhabdomyolysis include homogenous decreased echogenicity, areas of hyperechogenic foci, disorganized muscle fibers, and edema within the muscle (17,18). Lamminen et al. (11) examined the use of imaging modalities in the diagnosis of rhabdomyolysis and found out that the sensitivities of magnetic resonance imaging (MRI), computed tomography (CT), and ultrasound in the detection of rhabdomyolysis were 100%, 62%, and 42%, respectively. Presence of subcutaneous edema on MRI, CT, and ultrasound has been reported in few cases of rhabdomyolysis (9,11,12,15,18). However all of these cases showed substantial evidence of characteristic muscle damage on imaging modalities (9,11,12,15,18).
The complications of rhabdomyolysis can be severe and grave. Severe electrolyte imbalance (e.g., hyperkalemia and hypocalcemia), arrhythmia, and DIC are rare complications of rhabdomyolysis. AKI is a common and important complication of ER. The incidence of AKI in patients with rhabdomyolysis is approximately 5% to 7% (16). AKI occurs in the setting of rhabdomyolysis as a result of serum myoglobin levels exceeding 100 mg·dL−1 (16). At this level, tubule epithelial myoglobin metabolization capacity is overwhelmed and filtered myoglobin accumulates in the tubules leading to tubule damage, AKI, and myoglobinuria (1). Serum CK levels correlate with myoglobin levels, and CK is the preferred marker over myoglobin because of its longer half-life, cost, and laboratory properties (4,5,16). Myoglobinuria occurs when CK levels approach 70,000 U·L−1 (16).
The risk of AKI from any form of rhabdomyolysis is low when serum CK levels are less than 20,000 U·L−1 (4,6,7). Most reported cases of ER that result in AKI have occurred in patients with coexisting medical conditions (4,6,7). Underlying conditions that may increase the risk of AKI include dehydration, nonsteroidal anti-inflammatory drug (4) use, heat, and genetic conditions (1,4–7). Sickle cell trait is a major risk factor for ER (4,13). Repetitive sprints or timed laps may cause exertional sickling and eventually ischemia in athletes with sickle cell traits (7). Levels of serum CK up to 100,000 U·L−1 have been reported in healthy individuals with no renal complications (4). These findings suggest that elevated or extremely elevated CK levels in the setting of ER in healthy individuals may not be predictive of renal failure (1,4–6). There is no consensus on the CK serum level that will precipitate AKI and warrant hospital admission (1,2,4,6).
It remains unclear why the incidence of ER is relatively high among untrained individuals performing repetitive eccentric exercise (4). ER is a potential life-threatening syndrome that may present with nonspecific clinical features like muscle pain, tenderness, and swelling. Screening is performed with urine dipstick and microscopy. Early recognition and prompt management are critical to prevent potential complications. More scientific studies are needed to further understand the clinical course of ER.
Patients with ER can present variably, sometimes including minimal pain and normal renal function. Musculoskeletal ultrasound is an inexpensive rapid office diagnostic tool that can aid in evaluation of a patient suspected of having ER. Severe complications from ER in patients with no coexisting medical conditions are rare (8). Patients presenting with ER with no comorbidity can be managed in the outpatient setting, with close serial monitoring, oral hydration, and restricted physical activity. Complications of rhabdomyolysis can be severe in patients with underlying medical conditions, and clinical judgment must be exercised on a case-by-case basis when determining the management of a patient presenting with ER.
The authors declare no conflicts of interest and do not have any financial disclosures.
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