What Causes Rhabdomyolysis?

Rhabdomyolysis happens when severely damaged muscles (such as from intense physical activity or some medical condition) release protein molecules into the bloodstream that are too large and complex for the kidneys to break down.

Rhabdomyolysis (“rhabdo”) occurs when muscle tissue becomes severely damaged and proteins and electrolytes from inside the muscle cells leak out into the blood. 

Rhabdomyolysis can range from asymptomatic and mild to severe and life-threatening.

Rhabdomyolysis may cause no symptoms in some people. When symptoms of rhabdomyolysis occur, they may include:

• Muscle pain, cramps, or aches
• Muscle tenderness, swelling, and bruising 
• Dark urine (red, brown, or tea-colored)
• Muscle weakness
• Tiredness
• Inability to complete job tasks or finish a workout
• Fever
• Nausea
• Vomiting
• Feeling unwell (malaise)
• Confusion
• Agitation
• Delirium
• Not urinating

Causes of rhabdomyolysis and muscle tissue damage include:

• Muscle injury
  • Surgery 
  • Trauma
  • Electrical shock injury
  • Crush injury
• Extremely intense exercise
  • Marathon running
  • Physical overexertion in untrained athletes
• Lying in the same position for a very long time, such as being in a coma
• Extensive third-degree burns
• Heatstroke
• Certain infections
  • Viruses: influenza virus B, parainfluenza virus, adenovirus, coxsackievirus, echovirus, herpes simplex virus, cytomegalovirus, Epstein-Barr virus, human immunodeficiency virus (HIV)
  • Bacteria: Streptococcus, Salmonella, Legionella, Staphylococcus, and Listeria species
• Certain medicines 
  • HMG-CoA reductase inhibitors, especially in combination with fibrate-derived lipid-lowering agents such as niacin (nicotinic acid; Nicolar)
  • Cyclosporine (Sandimmune) 
  • Itraconazole (Sporanox)
  • Erythromycin 
  • Colchicine 
  • Zidovudine (Retrovir)
  • Corticosteroids
  • Alcohol
  • Central nervous system depressants
  • Neuromuscular blocking agents 
  • Amphetamines 
  • Cocaine 
  • Ecstasy (MDMA) 
  • LSD 
• Inflammatory causes
  • Polymyositis
  • Dermatomyositis
  • Capillary leak syndrome
  • Snake bites (mostly in South America, Asia and Africa)
• Some poisons
• Some congenital muscle problems 

Rhabdomyolysis cannot be diagnosed by a patient history or physical examination alone. Tests used to diagnose rhabdomyolysis include: 

• Blood tests for creatine kinase (CK or creatine phosphokinase [CPK]), a muscle protein
  • When muscles are damaged, CK levels increase
  • Repeated tests are needed to determine if CK levels are rising or falling
• Urine dipstick tests to check for myoglobin, a muscle cell component

Treatment for rhabdomyolysis depends on the cause and severity. The underlying cause of the rhabdomyolysis needs to be treated when possible. Much of the time, hospitalization is needed. 

Treatment for milder cases of rhabdomyolysis may include: 

• Drinking fluids
• Getting out of the heat
• Rest

Treatment for moderate to severe cases of rhabdomyolysis includes:

• Intravenous (IV) fluids to help the body flush out the substances from muscle cells
• Medicines to correct salt levels 
• Treatment to support the kidneys until they can function normally again
  • Medications 
  • Diet changes
  • Renal replacement therapy
    • Hemodialysis: a machine to moves the blood through a filter outside the body to remove waste
    • Peritoneal dialysis: the lining of the abdomen is used to filter the blood inside the body to remove waste
• Kidney transplant, if kidney function does not recover
• Emergency surgery to cut open muscles and relieve abnormal build-up of pressure 

Rhabdomyolysis can lead to serious complications including:

• Kidney damage or kidney failure
• Dangerous arrhythmias
• Seizures
• Nausea and vomiting
• Permanent disability
• Compartment syndrome 
• Death 

Not all cases of rhabdomyolysis can be prevented, but the risk of developing rhabdomyolysis can be reduced by:

• Staying hydrated
• Taking breaks 
• Avoiding activities involving exertion and/or heat exposure when possible 
• Knowing the signs and symptoms of heat-related illnesses and take steps to prevent overheating
• Becoming acclimatized to physical activity levels and heat before working for long periods of time
• Staying home when you’re sick