林昌民、闕舜仁、白彝維、陳永泰、陳日昇、陳欣宏

基督復臨安息日會醫療財團法人臺安醫院 外科部 泌尿科

Chang-Min Lin, Leonard S. Chuech, Yi-Wei Pai,

Tung-Tai Chen, Jih-Sheng Chen, Shin-Hong Chen

Divisions of Urology, Department of Surgery, Taiwan Adventist Hospital, Taipei, Taiwan

 

We report a patient with rhabdomyolysis presented with renal colic with hematuria initially.

A 41-year-old man had a history of left renal stone and received Extracorporeal shock wave lithotripsy twice 5 years ago. He suffered from sudden onset of severe left flank pain in the morning and went to our outpatient department immediately. His blood pressure, pulse rate, and temperature were 125/67 mmHg, 68 per minute, and 36.7°C. Abdominal examination found no distention or tenderness but severe knocking tenderness over left costovertebral angle. Renal ultrasonography shower mild hydronephrosis of left kidney. Urinalysis revealed microscopic hematuria (RBC:16-30 /HPF, WBC:5-7/HPF). Because no improvement to his colicky pain with oral analgesic agent, he was admitted later. Laboratory results were leukocytosis (white blood count was 13,100 cells/mm³) and poor liver function (AST: 143 IU/L; ALT: 70 IU/L).

On abdominal CT scan, the patient had one stone caused obstruction of the left upper ureter. On account of his general weakness, we re-inquired his history and he denied any hepatic disease or habit of alcohol drinking. He told us that he had went to gym for at least 3 hours every day in these three weeks eventually and he did not do any exercise before. The following high CK level (4171 IU/L) was found, and rhabdomyolysis was confirmed. Then he received treatment with osmotic agent (mannitol) and fluid hydration immediately. After his weakness was improved and CK level was decreased four days later, he received ureteroscopic lithotripsy for his left ureteral stone. The patient recovered and discharged and there was not stone recurrence during follow up at outpatient department 6 months after discharge. 

Rhabdomyolysis is a relatively rare condition, but its clinical consequences are frequently dramatic in terms of both morbidity and mortality. Although no consensus has been reached so far about the precise definition of this condition, the term rhabdomyolysis describes a rapid breakdown of striated muscle. The conventional triad of symptoms includes muscle pain, weakness and dark urine. The laboratory diagnosis of rhabdomyolysis is essentially based on the measurement of serum CK, which is considered the most sensitive test. Although there is no established cut-off threshold, a concentration five to ten times the URL (i.e., ~1000 U/L) is commonly used. CK has a half-life of 1.5 days. As a consequence, blood levels remain increased longer than for myoglobin, which has a half-life of 2–4 h. Myoglobin values tend to normalize within 6–8 h following the event. After establishing a definitive diagnosis of rhabdomyolysis, or even when is strongly suspected it (e.g., in case of crush syndrome), fluid infusion should be promptly initiated, with the goal of maintaining a urinary flow of 200–300 mL/h. Acute kidney injury is a potential and serious complication of severe exertional rhabdomyolysis and the prognosis is worse if renal failure develops. When we meet one patient with renal colic, the possibility of rhabdomyolysis should be always kept in our mind especially the patient has poor liver function. Misdiagnosis of hematuria caused by rhabdomyolysis will lead to life-threatening acute renal failure in those patients with renal colic even when they have only one side ureteral obstruction.