Acute renal failure due to severe rhabdomyolysis: a rare clinical manifestation of atrial myxoma

Abstract

Rhabdomyolysis is usually caused by physical, infectious or toxic factors and may be complicated by acute renal failure (ARF) associated with a high mortality rate of more than 20% [1]. We report about a very unusual, but emergent cause of severe rhabdomyolysis due to peripheral embolism of a left atrial myxoma. A 36-year-old male patient was admitted to hospital due to lumbalgia. Patient’s history revealed neither traumatic injury nor intake of drugs. Clinical examination only showed right-sided weakness in ankle dorsiflexion, hip flexion and adduction. Vital parameters, ECG findings, X-ray and MRI of the lumbar spine were normal. Laboratory tests revealed highly elevated serum creatine phosphokinase (286,580 U/l, n: ≤270 U/l), myoglobin (56,000 μg/l, n: ≤75 μg/l), lactate dehydrogenase (4,926 U/l, n: ≤232 U/l), aspartate aminotransferase (4,263 U/l, n: ≤35 U/l), alanine aminotransferase (701 U/l, n: ≤45 U/l) levels and inflammation parameters (CRP 145 mg/l, n: ≤8 mg/l). Renal function was impaired (creatinine 173 μmol/l, n: 61–104 μmol/l; urea-N 5 mmol/l, n: 1.3–3.5 mmol/l; uric acid 655 μmol/l, n: 208–440 μmol/l; glomerular filtration rate 31 ml/min, n: 80–170 ml/min/1.73 m2). Kidney ultrasonography revealed no signs of hydronephrosis or perfusion defects. MRI of pelvis and thighs due to the development of acute myalgias in the right leg demonstrated compartment syndrome of the M. iliopsoas and femoral muscles. After emergent fasciotomy, transthoracic echocardiography performed due to hemodynamic instability demonstrated a left atrial inhomogenous mass (Fig. 1a). Furthermore, MRI angiography initiated due to signs of lower extremity vascular occlusion revealed a circumscribed perfusion defect at the aortic bifurcation (Fig. 1b). Surgical removal of the atrial mass and its aortic embolus was immediately performed and histopathology revealed a typical cardiac myxoma (Fig. 1c). Patient’s postoperative course was complicated by ARF, arrhythmias and serious infections. However, multiple organ dysfunction could completely be restored after 6 weeks of intensive care management. Fig. 1 Embolism of a left atrial cardiac myxoma a Echocardiography. Four-chamber image from ECG-gated line-balanced fast field echo pulse sequence showed an intra-atrial mass (arrow) with attachment to the inter-atrial septum. LA left atrial cavity, LV left ...