SESSION TITLE: Fellows Critical Care Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Rhabdomyolysis is a common clinical syndrome that can result from a variety of insults that are generally evident, and well-described. We report a patient with rhabdomyolysis associated with an unusual inciting event. CASE PRESENTATION: A 44-year-old gentleman presented to the hospital with upper extremity myalgias. About 48 hours prior to presentation, he received an upper body massage at a commercial spa over a 30-60 minute duration. Hours after, he sustained a fall from standing via a relatively low mechanism of injury. After waking from sleep the following day his symptoms worsened and he developed dark-brown urine discoloration, prompting his presentation to the hospital. He denied any new medications, excessive physical exertion, or prior similar episodes in himself or relatives. His medication list included gabapentin, oxycodone, and doxepin, without concurrent anabolic steroid use, or illicit drug use. On examination, he was mildly tachycardic but otherwise hemodynamically normal. He had a general muscular build, and bilateral deltoid, upper arm, and forearm edema and tenderness. There was no evidence of neurovascular compromise. Workup showed an elevated creatine phosphokinase (CPK) (66,100 U/L), myoglobinuria (3+ blood, 0-5 RBCs), with unremarkable potassium, phosphate, urine drug screen, and plain films of the affected extremities. The patient was admitted to the medical ICU for hydration and neurovascular monitoring. His serial CPK levels gradually improved over days (1,483 U/L) and he was discharged home. DISCUSSION: Rhabdomyolysis occurs when injured myocytes release their intracellular contents into the extracellular space, which results in subsequent myoglobinuria. Supporting diagnostic features include elevated serum muscle enzymes (CPK =500-1000 U/L), myoglobinuria, proteinuria, hyperkalemia, hyperphosphatemia, and acute kidney injury. Insults include physical, ischemic, chemical and biologic causes. Physical insults such as prolonged exertion and immobilization are established causes for rhabdomyolysis. However, only one previously published report has implicated massage therapy, in which an elderly man developed rhabdomyolysis after a 120-minute massage by two therapists. While massage remains a common Complementary and Alternative Medicine modality, serious adverse events rarely may occur. CONCLUSIONS: Our patient's course highlights a rare encounter which associates deep-tissue massage and rhabdomyolysis by close temporal association, anatomic distribution, and lack of other significant contributing causes. Reference #1: Zimmerman JL, Shen MC. Rhabdomyolysis. Chest. 2013 Sep;144(3):1058-1065. doi: 10.1378/chest.12-2016. Review. PubMed PMID: 24008958. Reference #2: Lai MY, Yang SP, Chao Y, Lee PC, Lee SD. Fever with acute renal failure due to body massage-induced rhabdomyolysis. Nephrol Dial Transplant. 2006 Jan;21(1):233-4. Epub 2005 Oct 4. PubMed PMID: 16204282. Reference #3: Yin P, Gao N, Wu J, Litscher G, Xu S. Adverse events of massage therapy in pain-related conditions: a systematic review. Evid Based Complement Alternat Med. 2014;2014:480956. doi: 10.1155/2014/480956. Epub 2014 Aug 12. Review. PubMed PMID: 25197310; PubMed Central PMCID: PMC4145795. DISCLOSURES: No relevant relationships by Jason Stankiewicz, source=Web Response No relevant relationships by Nevins Todd, source=Web Response
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