Liver-Crushed: An Unusual Cause of Non-Traumatic Rhabdomyolysis

Abstract

Introduction: Cirrhosis (Ch) induced rhabdomyolysis (Rb) is an under diagnosed complication of liver failure that is associated with higher morbidity and mortality when compared to other causes of Rb. It is important to know when to suspect and properly diagnose this condition. Case Report: 54 year-old female with past medical history of esophageal cancer, alcohol-induced Ch and a three-week-old right ankle fracture presented to the Emergency Department with generalized weakness and muscle pain for three days. She denied recent falls or trauma. Physical exam showed muscle strength of +1, anasarca and cast in the right ankle with preserved pulses. On admission, her CK was 17,000U/L with a normal creatinine. She also had a macrocytic anemia and no proteniurea. Her ESR, CRP and TSH were normal. ANA and RF were negative. Carnitine levels were appropriate. Auto-immune myositis and paraneoplastic panel were also negative. She was a Child-Pugh B classification with a MELD of nine. There were no clinical or laboratorial signs of infection. After six days of IV hydration and protein supplementation the patient's CK decreased and her pain improved. Nonetheless, her weakness was unchanged. An EMG showed severe proximal myopathy with a normal MRI of spine. A spinal tap was unremarkable. The B12 level was 188pg/ml and intravenous B12 replacement was initiated and after the fourth day her strength improved to +4. After excluding other differentials, she was diagnosed with cirrhosis- induced Rb and weakness due to B12 deficiency, both complications of alcohol- induced cirrhosis. Discussion: Two percent of patients who are admitted to the hospitaldue to liver dysfunction have Rb due to Ch. Patient with Ch due to alcohol consumption are more prone to develop Rb. Patients with Rb due to Ch tend to have longer hospital stays (twenty days vs six) and mortality is significantly increased (31% vs 10%). In between the patient with Ch, Child-pugh classification has also been associated with differences in mortality (A 0%; B 16% and C 40%) and higher levels of CK. It is important to suspect Rb induced by Ch in patients presenting with Rb if all other causes are excluded. In cirrhotic patients admitted for a different medical issue, CKs should be tested if they present with worsening of chronic pain or weakness. The pathophysiology of Ch-induced Rb is still poorly understood and further studies are needed.