Life-threatening exertional rhabdomyolysis in a 35-year-old ultramarathon runner – case report
Creators: name: Piechota, Mariusz
name: Bernas, Szymon
name: Mirkiewicz, Krzysztof
Publisher: name: F1000Research
Year: 2017

description: Introduction: Exertional rhabdomyolysis in long-distance runners has been reported since the late 1970s as a condition precipitated by overheating, significant physical exertion and dehydration. The case report concerns a 35-year-old man who was admitted to the ICU at the 27th hour after completing a 24-hour ultramarathon race during which he ran a distance of about 205 km, after staying for a few hours in the Cardiac Department where the man was admitted for bradycardia (ventricular rhythm rate: 25 bpm), considerable fatigue and whole body pain. During hospitalization in the Cardiac Department, the patient was diagnosed with left ventricular hypokinesis with the EF of 40%, marked hyperkalaemia (8.41 mmol/l) accompanied by hyponatraemia (123 mmol/l) and hypochloraemia (86 mmol/l) as well as elevated levels of creatinine (6.18 mg/dl), urea (220 mg/dl), liver enzymes (AST – 6,799 U/I, ALT – 2,030 U/I), CK (332,900 U/l), CK-MB mass (&gt;300 ng/ml), troponin T (0.109 ng/ml), and anuria. The level of myoglobin determined on day 2 of the patient’s ICU stay was &gt; 30,000 ng/ml.<br><br>Methods: Aside from standard treatment, with a view to managing hyperkalaemia and protecting the kidneys from further damage, CVVHD CiCa haemodialysis with an EMIC2 filter was performed, leading to a rapid stabilization of the patient’s clinical condition including sinus rhythm recovery. The EMIC2 filter and/or the CVVHD CiCa kit was/were initially replaced every 12-24 hours. At the same time, the patient, who was monitored haemodynamically, despite anuria received fluid therapy so as to achieve mild arterial hypertension due to hypervolaemia (fluid delivery rate: 4,000 ml/day). The rate of ultrafiltration was adjusted to the patient’s hydration level.<br><br>Results: The treatment administered to the patient led to establishing a diuresis of over 400 ml/day on day 6 after admission. CVVHD was discontinued on day 11 of hospitalization, when the patient’s spontaneous diuresis was 1,600 ml/day. Following CVVHD discontinuation, diuresis was aided by the intake of mannitol and the continuous infusion of furosemide. The AST, CK and ALT levels returned to the normal range on days 11, 12 and 21 of hospitalization, respectively. The level of myoglobin decreased steadily, and was 233.4 ng/ml, 149.6 ng/ml and 72.57 ng/ml on hospitalization days 8, 11 and 15, respectively. The patient was discharged on day 17 of hospitalization, in the polyuric phase of up to 9,300 ml/day (eGFR 17.40 ml/min/1.73 m<sup>2</sup>), for further treatment in the Nephrology Unit. A week later, upon being discharged from the Nephrology Unit, the patient’s renal function was satisfactory (eGFR 72.3 ml/min/1.73 m<sup>2</sup>).<br><br>Conclusions: A combination of intensive fluid therapy provided under haemodynamic monitoring with continuous renal replacement therapy using a large pore filter ensuring myoglobin filtration in patients with acute renal failure caused by exertional rhabdomyolysis is a safe method of patient management which may reduce kidney damage and speed up the recovery of normal renal function after exercise-induced rhabdomyolysis. Also, it appears beneficial to determine the CK and myoglobin levels in the blood on a routine basis during the first 12 hours after the end of ultramarathons.