ANASARCA - COMPETITIVE BODY BUILDING

Abstract

1490 HISTORY - An 18-year-old competitive weight-lifter with known insulin dependent diabetes mellitus presented with weight gain of 40 pounds, severe edema in upper and lower extremities, joint pain, paresthesia, and oliguria. He competed in a body-building competition one week prior to presentation. His pre-competition regime included nine weeks of short and long acting anabolic steroids, diuretics, stimulants, natural supplements, and altered diet. His insulin requirements decreased during training until 2 days prior to competition. At that time, insulin requirements reached 3-4 times his usual dosage. He was treated two days prior to admission with diuretics with no noted effect. Along with the above symptoms, he was complaining of mild dyspnea, orthopnea, arthralgias, myalgia, urinary urgency and hesitancy. PHYSICAL EXAM - Alert and oriented. Vital signs were stable. No acute distress. No periorbital edema. No JVD. Lungs - clear. Heart regular rhythm without murmur or extra heart sounds. No hepatosplenomegaly or ascities. Bounding peripheral arterial pulses. Strength 5/5. Sensation intact. Skin appeared tense over the forearms with tenderness to palpation in the forearms and posterior lower extremities. 2-3+ pitting edema noted distal to knees bilaterally. DIFFERENTIAL DIAGNOSIS - I. Anasarca secondary to hypernatremia from dietary overload post-competition, steroid and/or diuretic induced sodium retention; insulin edema; acute renal failure; hypoproteinemia. II. Cardiomyopathy secondary to steroid abuse and/or diabetes leading to congestive heart failure. III. Compartment syndrome in upper and lower extremities. IV. Insulin resistance secondary to steroid abuse. V. Acute renal failure due to rhabdomyolysis; urinary tract infection; dehydration. TESTS AND RESULTS - ECG normal. Echocardiogram - small amount of retrocardiac effustion. Chest x-ray - increased vascular markings. Blood glucose of 165 mg/dl, sodium 146 mg/dl, BUN 21 mg/dl, creatinine 1.2 mg/dl, CPK 1658 mg/dl. Cardiac enzymes normal. Myoglobinuria. Forearm compartment pressures 27-30 mm Hg. FINAL/WORKING DIAGNOSES - Rhabdomyolysis, mild dehydration, prerenal azotemia, insulin-dependent diabetes mellitus with insulin resistance, anasarca of multiple etiologies. TREATMENT - Diuretics, alkalinization of urine with sodium bicarbonate and fluid hydration, low sodium, 3000 calorie American Diabetes Association diet, decreased insulin dosage, and sulfonylureas. Discontinued use of anabolic steroids, ergogenic supplements, stimulants, and pathologic dietary behaviors.