Arm Swelling - Weight Lifting

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HISTORY: A 26-year old female presented to clinic with bilateral arm swelling after exercise. Symptoms started 1 year prior after a crossfit workout that involved upper arm weight training exercises. She developed significant swelling of the upper arms 2 days later with difficulty extending her arms and an associated feeling of tightness in the upper arms. The swelling improved after 1 week with residual pain in the upper arms for about 2 weeks. She saw a physician and was noted to have an elevated C-reactive protein that resolved after several days. She resumed upper body workouts 2 months prior to her clinic visit and again developed swelling in bilateral arms 2 days later. She reported having a total of 4 episodes of swelling and pain in the arms, each occurring after upper extremity exercises and resolving with rest and NSAIDs after 1-2 weeks. She denied any swelling or pain in the lower extremities at rest or after exercise, and she ran regularly. No family history of myopathy or neuromuscular disorders. PHYSICAL EXAMINATION: Examination of the upper extremities revealed no visible ecchymosis, erythema or swelling over the bilateral upper extremities. There was normal muscle bulk of the arms. There was tenderness to palpation of the distal biceps muscle. There was full active and passive range of motion of the elbow and shoulder bilaterally. Strength was 4+/5 with elbow extension bilaterally, otherwise full strength in the upper extremities. Sensation was intact to light touch and reflexes were equal and symmetric in bilateral upper extremities. DIFFERENTIAL DIAGNOSIS: 1. Recurrent exertional rhabdomyolysis 2. Inflammatory Myopathy 3. Mitchondrial disorder 4. Lipid or carbohydrate storage disorder TEST AND RESULTS: EMG/Nerve Conduction Study: abnormalities in upper limbs consistent with myopathic process, with short duration, polyphasic motor units, early recruitment. CRP: 4.2 CPK: 5117 (day after upper arm resistance exercise routine) FINAL WORKING DIAGNOSIS: Recurrent exertional rhabdomyloysis affecting the upper extremities TREATMENT AND OUTCOMES: 1. Activity as tolerated 2. Avoid exercises that causes arms to swell or be painful afterwards 3. Referral to Neurology for assessment of myopathy or related disorder 4. Subsequent muscle biopsy, myoglobinuria panel normal. Negative CPT2 genetic testing.