Rhabdomyolysis- See Your Doctor Before Your Body Spins Out of Control

A long-term patient of mine recently visited the clinic with an urgent presentation of coca-cola-coloured urine. She also complained of lower back and thigh muscle aches. In view of the unique presentation, the patient herself collected her urine in a bottle and showed it to me. 

Clinically, aside from mild lethargy and muscle aches and pain, she was feeling well. She was concerned about urinary tract infections and kidney stones. What do you think is wrong?

The reasonable thought process would be:
“Is there something wrong with my urinary filtration system’’

 “Is there an issue with my kidney or the bladder?’’

‘’ Do I have a urinary infection or a kidney stone, or even cancer?”’

Upon further history exploration, she stated that she had recently bought a new spin bike to work out at home and was immediately suspected of rhabdomyolysis after this revelation. In recent years, with an increase in spin class popularity and exercise bike workouts, a correlative trend of exercise-induced rhabdomyolysis has been observed– a condition less commonly heard of but can occur to anyone. 

The mention of “spin class” or “spin cycling” is sufficient to alert any experienced doctor about the possibility of rhabdomyolysis. I’m happy to report that the patient recovered uneventfully over time following the prompt diagnosis and treatment. 

What is rhabdomyolysis?

Simply put, rhabdomyolysis is a medical condition in which the breakdown of muscle tissues leads to a spike of protein in the bloodstream, subsequently clogging up the tubes in the kidney and leading to kidney injury or acute kidney failure. 

Clinical explanation of rhabdomyolysis

When the breakdown of the skeletal muscle occurs,  increased protein myoglobulin and creatinine kinase(CK) substances in the bloodstream cause kidney injury or kidney failure. A sudden rise of excessive myoglobulin and creatinine kinase proteins in the bloodstream clogs up the intricate tubing system of the kidneys, leading to kidney injury or acute kidney failure. 

These proteins are usually filtered and excreted through the kidney system. However, with an influx of these particles in the bloodstream, one can develop complications such as acute kidney injury/failure, electrolyte imbalance, heart rhythm abnormalities, disseminated intravascular coagulation (DIC) and other severe life-threatening medical risks.

What is exercise-induced (exertional) rhabdomyolysis?

Exercised-induced rhabdomyolysis happens when a person undergoes intense physical exercise leading to a sudden or excessive muscle contraction and breakdown of skeletal muscles. This breakdown subsequently releases skeletal muscle proteins Into the bloodstream. 

How common is exercise-induced rhabdomyolysis in Singapore? 

Exercise-induced rhabdomyolysis has been more commonly reported in the medical literature since 2004. In Singapore, following the increased popularity of spin cycling classes, more cases of exercise-induced rhabdomyolysis have been seen in the local hospital in recent years.

In 2020, 4 cases were noted locally, while the number of cases of exercise-induced rhabdomyolysis has increased to 10 cases in 2022. Some cases may even be missed as patients may be misdiagnosed as having urinary tract infections following the presentation of blood in the urine. If you suspect that you have developed rhabdomyolysis, please seek medical attention.

What are the signs and symptoms of rhabdomyolysis?

Symptoms to suggest a person has rhabdomyolysis include:

• Muscle cramps and pain that are out of proportion to your physical exertion
• Muscle weakness
• Acute dark-coloured/blood urine
• Lethargy/fatigue
• Dizziness, a fainting spell
• Nausea or vomiting
• Palpitation or irregular heartbeat
• Confusion and an altered mental state (severe cases)

What causes rhabdomyolysis?

Rhabdomyolysis can be categorised into exertional (exercise-induced) or non-exertional.

Non-exertional related rhabdomyolysis can be due to:

• Infection
• Blood vessels/vascular compromise
• Certain medications/drugs
• Injury/ trauma

What are the common medications that can cause rhabdomyolysis?

Do speak to your doctor before considering taking medication to understand the possible side effects and suitable doses of the medications.

Some of the common drugs that can cause rhabdomyolysis include :

• Antipsychotics and antidepressants
• Sedatives such as Benzodiazepines, Barbiturates
• Narcotics
• Tricyclic antidepressants
• Cholesterol medication– statin, fibrates
• Antihistamines– diphenhydramine, doxylamine
• Drug abuse with amphetamine, methadone, heroin, cocaine, LSD
• Alcohol
• Others such as narcotics, amphotericin B, azathioprine, pentaamine, quinidine salicylates, theophylline, thiazide etc.

What do I expect when I see my doctor for rhabdomyolysis?

Diagnosing rhabdomyolysis would involve a number of steps:

1. Your doctor will usually go through your medical history, and conduct a physical examination.
2. A blood test to screen for your kidney function and creatinine kinase (CK) will be ordered. 
3. A urine test would also be suggested to rule out other potential urinary system causes.
4. In acute or severe cases, your doctor may refer you to the hospital for further management of the condition.

What are the treatment options for rhabdomyolysis?

Thankfully, most patients with rhabdomyolysis recover uneventfully. The treatment goal involves early fluid resuscitation to maintain normal kidney function or to aid kidney function recovery over time. 

Treatment advice(s) include:

• Plenty of fluid hydration and rest.
• Avoid insulting causes– stop affecting medications, avoid exercise, heat/dehydration.
• In more pressing cases, intravenous fluid hydration may be offered in hospital settings.
• In severe cases with evidence of kidney injury, treatment options may include dialysis.

When should I go to the hospital if I have rhabdomyolysis?

If you develop acute symptoms such as feeling generally unwell, muscle aches, lethargy, or acute findings of dark, red, or brownish urine, please seek medical attention. Hitherto, there are no studies that evaluate the safety and any subsequent complication in the management of rhabdomyolysis as an outpatient. It is worthwhile seeing your doctor to get yourself checked and evaluated for further health advice.

How can I prevent rhabdomyolysis?

There are ways to avoid exposure to the risks of rhabdomyolysis.

These include: 

• Stay well-hydrated at all times, and avoid dehydration.

• Avoid excessive heat exposure or physical exertion.
• Avoid acute weight loss with the use of dietary protein supplements with creatinine, caffeine, ephedrine, and ephedra.
• Increase exercise intensity gradually, you may consider seeking advice from a personal trainer.
• Check with your doctor before taking medication, and avoid self-medicating.

Frequently asked questions

Can I treat and manage rhabdomyolysis at home?

In mild cases, one may be able to recover from symptoms with increased fluid hydration, though there is a lack of medical guidelines on the safety and possible complications following the management of rhabdomyolysis at home. 

Given the severity and dangers of the condition, self-diagnosis and attempts at self-management for recovery is advised against. If you ever suspect you may be dealing with rhabdomyolysis, please visit your doctor as soon as possible. 

Will I die from rhabdomyolysis?

In severe cases, mortality (death) from rhabdomyolysis is predicted to be at 59%.  However, these are not all exercise-induced rhabdomyolysis. Nevertheless, a risk of mortality does exist. 

Will I recover from rhabdomyolysis?

With prompt diagnosis and treatment, most patients with rhabdomyolysis recover without complication. Hence, you are advised to seek medical attention if you encounter any symptoms to give yourself the highest chance of recovery. 

How fast can I return back to physical activities after rhabdomyolysis?

Your doctor will usually evaluate your individual risk and medical possibilities of delayed recovery before advising you when you can return to your physical activities. Generally, you are advised to return to gradual sports 1-2 months after recovery with adequate rest, fluid hydration, and close monitoring of urine and blood tests.