Case ReportNontraumatic Exertional Rhabdomyolysis Leading toAcute Kidney Injury in a Sickle Trait Positive Individual onRenal Biopsy

Kalyana C. Janga ,1 Sheldon Greenberg ,1 Phone Oo,1

Kavita Sharma,2 and Umair Ahmed1

1Department of Nephrology, Maimonides Medical Center, Brooklyn, NY, USA2Department of Infectious Diseases, Maimonides Medical Center, Brooklyn, NY, USA

Correspondence should be addressed to Kalyana C. Janga; kjanga@maimonidesmed.org

Received 15 October 2017; Revised 7 February 2018; Accepted 4 March 2018; Published 15 April 2018

Academic Editor: Yoshihide Fujigaki

Copyright © 2018 KalyanaC. Janga et al.This is an open access article distributed under theCreativeCommonsAttribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

A 26-year-oldAfricanAmericanmale with a history of congenital cerebral palsy, sickle cell trait, and intellectual disability presentedwith abdominal pain that started four hours prior to the hospital visit. The patient denied fever, chills, diarrhea, or any localizedtrauma. The patient was at a party at his community center last evening and danced for 2 hours, physically exerting himself morethan usual. Labs revealed blood urea nitrogen (BUN) level of 41mg/dL and creatinine (Cr) of 2.8mg/dL which later increased to4.2mg/dL while still in the emergency room. Urinalysis revealed hematuria with RBC > 50 on high power field. Imaging of theabdomen revealed no acute findings for abdominal pain. With fractional excretion of sodium (FeNa) > 3%, findings suggestednonoliguric acute tubular necrosis. Over the next couple of days, symptoms of dyspepsia resolved; however, BUN/Cr continuedto rise to a maximum of 122/14mg/dL. With these findings, along with stable electrolytes, urine output matching the intake,and prior use of proton pump inhibitors, medical decision was altered for the possibility of acute interstitial nephritis. Steroidswere subsequently started and biopsy was taken. Biopsy revealed heavy deposits of myoglobin. Creatinine phosphokinase (CPK)levels drawn ten days later after the admission were found to be elevated at 334U/dl, presuming the levels would have been muchhigher during admission. This favored a diagnosis of acute kidney injury (AKI) secondary to exertional rhabdomyolysis. We heredescribe a case of nontraumatic exertional rhabdomyolysis in a sickle cell trait (SCT) individual that was missed due to findings ofmicroscopic hematuria masking underlying myoglobinuria and fractional excretion of sodium > 3%. As opposed to other causesof ATN, rhabdomyolysis often causes FeNa < 1%. The elevated fractional excretion of sodium in this patient was possibly due tothe underlying inability of SCT positive individuals to reabsorb sodium/water and concentrate their urine. Additionally, becauseof their inability to concentrate urine, SCT positive individuals are prone to intravascular depletion leading to renal failure as seenin this patient. Disease was managed with continuing hydration and tapering steroids. Kidney function improved and the patientwas discharged with a creatinine of 3mg/dL. A month later, renal indices were completely normal with persistence of microscopichematuria from SCT.

1. Introduction

Rhabdomyolysis is a condition characterized by muscle celldeath and the release of muscle cell constituents into thecirculation.The causes of rhabdomyolysis include trauma+/−muscle compression; nontraumatic, nonexertional causes(drugs, toxins, or infections); and nontraumatic, exertionalrhabdomyolysis [1]. The incidence of exertional rhabdomy-olysis is unknown; however, a recent retrospective cohort

study revealed that, out of all their rhabdomyolysis cases in aset amount of time, 35% were exertional [2]. Nontraumatic,exertional rhabdomyolysis can occur in extreme exertionor normal physical exertion in addition to risk factors thatimpair muscle oxygenation, ultimately leading to muscle celldeath. One of these risk factors includes individuals with thesickle cell trait (SCT).

Sickle cell trait is the heterozygous state (HBAS) of sicklecell disease [3]. SCT is a benign carrier state; it is by itself

HindawiCase Reports in NephrologyVolume 2018, Article ID 5841216, 5 pageshttps://doi.org/10.1155/2018/5841216

http://orcid.org/0000-0002-6930-0576http://orcid.org/0000-0003-3476-5434https://doi.org/10.1155/2018/5841216

2 Case Reports in Nephrology

(a) (b)

Figure 1: H&E stain. (a) Reddish tubular casts. Most tubules are preserved, mild interstitial fibrosis with tubular atrophy. (b) Glomeruli withcongestion.

not considered a disease [4]. SCT is present in 7–9% ofthe African American population. Additionally, a recentcross-sectional study reviewing hemoglobin phenotypes inAfrican Americans with end stage renal disease found thatSCT was twice as common among African Americans withend stage renal disease [5]. Although the overall effectsof SCT are benign, many studies and case reports haveidentified that individuals with SCT are at an increased riskfor rare conditions including exertional rhabdomyolysis withprolonged physical activity, compartment syndrome, andsudden cardiac death [6]. We report on an SCT patient withsymptoms of hematuria and isosthenuria developing stage IIInonoliguric AKI from exertional rhabdomyolysis.

2. Case Presentation

A 26-year-old African American male with a history ofcongenital cerebral palsy, sickle cell trait, and intellectualdisability presented with abdominal pain that started fourhours prior to the hospital visit. His only medication isoccasional proton pump inhibitors for indigestion and belch-ing. Abdominal pain was characterized as colicky, constant,and located in the epigastric region and was associated withsymptoms including nausea and two episodes of vomiting.The patient denied fever, chills, diarrhea, or any localizedtrauma. The patient was at a party at his community centerlast evening and danced for 2 hours, physically exertinghimself more than usual. Physical examination revealed mildepigastric tenderness upon palpation; skin was warm anddry with normal turgor. The buccal mucosa was moist.Blood work revealed BUN of 41mg/dL (reference range:7–18mg/dL) and creatinine of 2.8mg/dL (reference range:0.6–1.2mg/dL) which later increased to 4.2mg/dL whilestill in the emergency room. Additionally, liver enzymeswere minimally elevated. Urinalysis revealed microscopichematuria with RBC > 50 on high power field. Imagingof the abdomen was benign. Decision was made to admitthe patient based on abnormal liver enzymes and worseningkidney injury suggesting signs of nonoliguric acute tubularnecrosis.

Over the next couple of days, symptoms of dyspepsiaresolved; however, renal indices continued to worsen despiteadequate hydration and 1ml/kg/h bicarbonate infusion,

Figure 2: PAS stain. PAS stain showing tubular atrophy, glomerulicongestion, and normal capillary loops in the glomerulus.

Figure 3: Tubular casts are positive for myoglobin immunostain.

reaching a peak of creatinine of 14mg/dL. Due to thesefindings, stable electrolytes, urine outputmatching the intake,and prior use of occasional proton pump inhibitors, medicaldecision was altered for the possibility of allergic interstitialnephritis. Steroids were subsequently started and biopsy wastaken.

Biopsy revealed heavy deposits of myoglobin (Figures1–3). CPK levels were drawn shortly after the results (day10) and were found to be elevated at 334U/L. This favoreda diagnosis of AKI secondary to exertional rhabdomyolysis.Decision was made to continue hydration and taper steroids.Kidney function improved and the patient was dischargedwith a creatinine of 3mg/dL. A month later, renal indiceswere completely normal with persistence of microscopichematuria from SCT.

Case Reports in Nephrology 3

Table 1: Basic investigation for acute renal failure (∗tests can beordered if needed based on history and physical).

Blood tests

Complete blood counts with differentialsComplete metabolic profile

PhosphorusUric acidMyoglobin

Creatinine phosphokinaseLiver function tests

Brain natriuretic peptide∗ (BNP)Arterial blood gas

Urine tests

Urinalysis with microscopy and cultureUrine osmolalityUrine electrolytesUrine eosinophils∗

Urine protein/creatinine ratio (PCR)

Radiology tests Renal and bladder sonogramChest X-ray∗

3. Discussion

In this case, the patient initially presented with symptoms ofnonoliguric acute tubular necrosis (ATN). The patient hadabdominal pain, elevated liver enzymes, elevated BUN/Cr,and FeNa > 3%. Intrarenal AKI is characterized as dam-age to the major structures of the kidney including thetubules, glomeruli, interstitium, and the intrarenal bloodvessels [7]. Damage can be caused by toxins, contrast, drugs,myoglobin, and others (Table 1). Although the patient’ssymptoms resolved the next day, his BUN/Cr continued torise with hydration. Medical decision was altered for thepossibility of proton pump inhibitor induced acute interstitialnephritis. So, steroids were started and biopsy was taken,which revealed rhabdomyolysis.

Rhabdomyolysis is a condition characterized by musclecell death and the release of muscle cell constituents into thecirculation. Common symptoms of rhabdomyolysis includemuscle pain, rashes, weakness, and dark colored urine dueto myoglobinuria [8, 9]. Additional symptoms in severecases include fever, alteredmental status, nausea/vomiting, orabdominal pain which our patient had. Physical examinationfindings may include positive muscle tenderness, muscleswelling, and/or skin discolorations. Laboratory diagnosis isessential based on the measurement of biomarkers of muscleinjury, with creatinine phosphokinase being the biochemical“gold standard” for diagnosis and myoglobin the “goldstandard” for prognostication, especially in patients withnontraumatic rhabdomyolysis. Serum CPK levels are usuallyat least 5 times the upper limit of normal at presentation,reaching the peak within 24–72 hours and then decliningafter 3–5 days with cessation of muscle injury [9]. The CPKlevels are more sustained and long-lasting as compared tomyoglobin which has a short half-life due to faster elimina-tion kinetics. Most believe that CPK levels correlate with theamount of muscle injury and disease activity. Additional tests

such as muscle biopsy, kidney biopsy, MRI, and electromyog-raphy are usually not needed [8, 9]. The filtered myoglobinis degraded into a heme pigment which can damage thekidney in three different ways, that is, direct tubular cellinjury, vasoconstriction leading to decreased blood flow,and tubular obstruction [10]. However, in contrast to othercauses of intrarenal AKI, the fractional excretion of sodiumis often

4 Case Reports in Nephrology

Table 2: Renal biopsy indications.

Isolated glomerular hematuria Persistent and severe hematuria, hypertension, and elevatedcreatinineIsolated nonnephrotic syndrome Persistent and >1-gram proteinuria

Nephrotic syndromeRoutinely indicated in adults including diabetes, connective tissue

disorders, steroid-resistant nephrotic syndrome, and obesityException is first attack in children

Nephritic syndrome Connective tissue disorders, hepatitis, infection-related nephriticsyndrome, and rapidly progressive glomerulonephritisUnexplained acute kidney injury After clinical diagnosis failsUnexplained progressive chronic kidney disease Normal size kidneys and extent of kidney damage

Familial renal diseases Biopsy of one member can yield the diagnosis of other familymembersRenal transplant dysfunction Acute versus chronic rejection versus drug-induced renal failure

Small localized renal tumors/lesions Benign renal tumors, metastasis, lymphoma, and focal kidneyinfection

of suddendeath and exertional rhabdomyolysis occurring at ahigh rate in SCT positive military personnel, the Departmentof Defense developed screening guidelines in 1972 for thetesting of SCT in new recruits [16]. The increased risk ofexertional rhabdomyolysis found in SCT individuals maybe due to the underlying renovascular changes combinedwith the inability to concentrate the urine. The pathophys-iology behind this is that RBC sickling found in SCT maycause the congestion of the vasa recta. This may lead toischemia and retention of the medullary interstitium. Sincewater reabsorption is dependent on interstitial osmolality,there will be a decrease of reabsorption across antidiuretichormone stimulated collecting ducts [3]. With the inabilityto concentrate the urine, SCT positive individuals are moreinclined to dehydration and are unable flush out renal toxinsadequately.

Our patient had nontraumatic exertional rhabdomyol-ysis due to excessive physical exertion the night beforehis symptoms began. As discussed above, he was at anincreased risk of developing this condition because he hadthe sickle cell trait. The diagnosis of rhabdomyolysis wasmissed because of symptoms of hematuria, FeNa > 3%, andfailure to order CPK levels initially. Although he receivedthe proper treatment of fluid/electrolyte replacement, hiscondition took longer to recover because of the underlyingrenal disease found in SCT patients. Fortunately, this patientwas able to recover and his kidney function normalizedwithout the need for hemodialysis. Acute exertional rhab-domyolysis may lead to metabolic acidosis and electrolytedisturbances including hyperkalemia [17]. Severe cases maylead to renal failure and death. Although continued renalreplacement therapy and hemodialysis will improve creati-nine, BUN, andpotassiumand reduce the duration of oliguriaphase and length of hospital stay, no significant differenceswere found in mortality rates compared with conventionaltherapy in rhabdomyolysis. It is important to build aware-ness and counsel SCT positive patients and families onavoiding excessive physical exertion in order to avoid suchcomplications.

4. Conclusion

This case report describes the occurrence of nontraumaticexertional rhabdomyolysis in individuals that have the sicklecell trait. There is an increased risk of AKI secondary toexertional rhabdomyolysis in these individuals. The rhab-domyolysis was missed here due to no history of trauma,microscopic hematuria, and fractional excretion of sodium> 3%. Classic rhabdomyolysis subjects will have some type oftrauma, no microscopic hematuria, and fractional excretionof sodium < 1%. In summary, we recommend checkingCPK levels in all unknown causes of acute renal failure andrenal biopsy should remain the gold standard in determiningthe cause of unknown AKI (Table 2). We also recommendscreening of African American patients for SCT due to thehigh prevalence in this population. Early screening as donein military recruits will allow for proper counseling of theseindividuals in order to prevent complications including exer-tional rhabdomyolysis, which, through multiple publishedcase reports, have proved to be detrimental in some patients.It is important for physicians to counsel SCTpatients on theseincreased risks of kidney injury and advise them to avoidnephrotoxins, stay hydrated, and avoid excessive physicalexertion.

Conflicts of Interest

The authors declare that there are no conflicts of interestregarding the publication of this paper.

References

[1] M. L. Miller, I. N. Targoff, and M. S. Jeremy, Causesof rhabdomyolysis, in. UpToDate, https://www.uptodate.com/contents/causes-of-rhabdomyolysis.

[2] J. P. Alpers and L. K. Jones, “Natural history of exertionalrhabdomyolysis: A population-based analysis,”Muscle &Nerve,vol. 42, no. 4, pp. 487–491, 2010.

[3] K. A. Nath and R. P. Hebbel, “Sickle Cell Disease: renalmanifestations and mechanisms,” Nature Reviews Nephrology,

https://www.uptodate.com/contents/causes-of-rhabdomyolysishttps://www.uptodate.com/contents/causes-of-rhabdomyolysis

Case Reports in Nephrology 5

vol. 11, no. 3, pp. 161–171, 2015, https://www.ncbi.nlm.nih.gov/pubmed/25668001.

[4] R. P. Naik and C. Haywood, “Sickle cell trait diagnosis: clinicaland social implications,” International Journal of Hematology,vol. 2015, no. 1, pp. 160–167, 2015.

[5] V. K. Derebail, P. H. Nachman, N. S. Key, H. Ansede, R. J. Falk,and A. V. Kshirsagar, “High prevalence of sickle cell trait inAfrican Americans with ESRD,” Journal of the American Societyof Nephrology, vol. 21, no. 3, pp. 413–417, 2010.

[6] P. Saxena, C. Chavarna, and J. Thurlow, “Rhabdomyolysis in aSickle Cell Trait Positive Active Duty Male Soldier,” U.S. ArmyMedical Department Journal, vol. 20, no. 3, 2016, https://www.ncbi.nlm.nih.gov/pubmed/26874092.

[7] D. P. Basile,M.D.Anderson, andT.A. Sutton, “Pathophysiologyof acute kidney injury,” Comprehensive Physiology, vol. 2, no. 2,pp. 1303–1353, 2012.

[8] X. Bosch, E. Poch, and J. M. Grau, “Rhabdomyolysis andAcute Kidney Injury,” New England Journal of Medicine, vol.361, pp. 61–72, 2009, http://www.nejm.org/doi/full/10.1056/NEJMra0801327.

[9] M. L. Miller, I. N. Targoff, and M. S. Jeremy, Clinical Manifes-tations and diagnosis of rhabdomyolysis. 2016. In: UpToDate,Post TW, Waltham, MA https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-rhabdomyolysis?source=see link.

[10] M. A. Perazella, M. Rosner, P. Palevsky, and A. Sheridan,Clinical Features and diagnosis of heme pigment-inducedAKI. 2016. In: UpToDate, Post TW,Waltham, MA https://www.uptodate.com/contents/clinical-features-and-diagnosis-of-heme-pigment-induced-acute-kidney-injury?source=see link.

[11] R. S. Riley and R. McPherson, Basic Examination of Urine.Henry’s Clinical Diagnosis and Management by LaboratoryMethods.Chapter 28, 442-480.e3, https://www.clinicalkey.com/#!/content/book/3-s2.0-B9780323295680000280?scrollTo=%23hl0002163.

[12] D. Kim, E. Ko, H. Cho, P. Hyung, and S. Lee, “Spinning-induced Rhabdomyolysis: Eleven Case Reports and Reviewof the Literature,” Electrolytes and Blood Pressure, vol. 13, no.2, pp. 58–61, 2015, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4737663/.

[13] E. P. Vichinsky, D. H. Mahoney, and J. Tirnauer, Cell Trait. In:UpToDate, Post TW,Waltham,MAhttps://www.uptodate.com/contents/sickle-cell-trait?source=search result&search=sickle%20cell%20trait&selectedTitle=1∼108.

[14] U. Khan, L. Kleess, J. Yeh, C. Berko, and S. Kuehl, “Sickle celltrait: not as benign as once thought,” Journal of CommunityHospital Internal Medicine Perspectives (JCHIMP), vol. 4, no. 5,p. 25418, 2014.

[15] D. A. Nelson, P. Deuster, R. Carter, O. Hill, W. L. Wolcott, andL. Kurina, “Sickle Cell Trait, Rhabdomyolysis, and Mortalityamong U.S. Army Soldiers,” New England Journal of Medicine,vol. 375, no. 5, pp. 435–442, 2016, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5026312/.

[16] N.A. Raju, S. V. Rao, J. Chakravarthy Joel et al., “Predictive valueof serum myoglobin and creatine phosphokinase for devel-opment of acute kidney injury in traumatic rhabdomyolysis,”Indian Journal of Critical Care Medicine, vol. 21, no. 12, pp. 852–856, 2017.

[17] J. N. Makaryus, J. N. Catanzaro, and K. C. Katona, “Exertionalrhabdomyolysis and renal failure in patients with sickle celltrait: Is it time to change our approach?” International Journalof Hematology, vol. 12, no. 4, pp. 349–352, 2007.

https://www.ncbi.nlm.nih.gov/pubmed/25668001https://www.ncbi.nlm.nih.gov/pubmed/25668001https://www.ncbi.nlm.nih.gov/pubmed/26874092https://www.ncbi.nlm.nih.gov/pubmed/26874092http://www.nejm.org/doi/full/10.1056/NEJMra0801327http://www.nejm.org/doi/full/10.1056/NEJMra0801327https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-rhabdomyolysis?source=see_linkhttps://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-rhabdomyolysis?source=see_linkhttps://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-rhabdomyolysis?source=see_linkhttps://www.uptodate.com/contents/clinical-features-and-diagnosis-of-heme-pigment-induced-acute-kidney-injury?source=see_linkhttps://www.uptodate.com/contents/clinical-features-and-diagnosis-of-heme-pigment-induced-acute-kidney-injury?source=see_linkhttps://www.uptodate.com/contents/clinical-features-and-diagnosis-of-heme-pigment-induced-acute-kidney-injury?source=see_linkhttps://www.clinicalkey.com/#!/content/book/3-s2.0-B9780323295680000280?scrollTo=23hl0002163https://www.clinicalkey.com/#!/content/book/3-s2.0-B9780323295680000280?scrollTo=23hl0002163https://www.clinicalkey.com/#!/content/book/3-s2.0-B9780323295680000280?scrollTo=23hl0002163https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4737663/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4737663/https://www.uptodate.com/contents/sickle-cell-trait?source=search_result&search=sickle%20cell%20trait&selectedTitle=1~108https://www.uptodate.com/contents/sickle-cell-trait?source=search_result&search=sickle%20cell%20trait&selectedTitle=1~108https://www.uptodate.com/contents/sickle-cell-trait?source=search_result&search=sickle%20cell%20trait&selectedTitle=1~108https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5026312/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5026312/

Stem Cells International

Hindawiwww.hindawi.com Volume 2018

Hindawiwww.hindawi.com Volume 2018

MEDIATORSINFLAMMATION

of

EndocrinologyInternational Journal of

Hindawiwww.hindawi.com Volume 2018

Hindawiwww.hindawi.com Volume 2018

Disease Markers

Hindawiwww.hindawi.com Volume 2018

BioMed Research International

OncologyJournal of

Hindawiwww.hindawi.com Volume 2013

Hindawiwww.hindawi.com Volume 2018

Oxidative Medicine and Cellular Longevity

Hindawiwww.hindawi.com Volume 2018

PPAR Research

Hindawi Publishing Corporation http://www.hindawi.com Volume 2013Hindawiwww.hindawi.com

The Scientific World Journal

Volume 2018

Immunology ResearchHindawiwww.hindawi.com Volume 2018

Journal of

ObesityJournal of

Hindawiwww.hindawi.com Volume 2018

Hindawiwww.hindawi.com Volume 2018

Computational and Mathematical Methods in Medicine

Hindawiwww.hindawi.com Volume 2018

Behavioural Neurology

OphthalmologyJournal of

Hindawiwww.hindawi.com Volume 2018

Diabetes ResearchJournal of

Hindawiwww.hindawi.com Volume 2018

Hindawiwww.hindawi.com Volume 2018

Research and TreatmentAIDS

Hindawiwww.hindawi.com Volume 2018

Gastroenterology Research and Practice

Hindawiwww.hindawi.com Volume 2018

Parkinson’s Disease

Evidence-Based Complementary andAlternative Medicine

Volume 2018Hindawiwww.hindawi.com

Submit your manuscripts atwww.hindawi.com

https://www.hindawi.com/journals/sci/https://www.hindawi.com/journals/mi/https://www.hindawi.com/journals/ije/https://www.hindawi.com/journals/dm/https://www.hindawi.com/journals/bmri/https://www.hindawi.com/journals/jo/https://www.hindawi.com/journals/omcl/https://www.hindawi.com/journals/ppar/https://www.hindawi.com/journals/tswj/https://www.hindawi.com/journals/jir/https://www.hindawi.com/journals/jobe/https://www.hindawi.com/journals/cmmm/https://www.hindawi.com/journals/bn/https://www.hindawi.com/journals/joph/https://www.hindawi.com/journals/jdr/https://www.hindawi.com/journals/art/https://www.hindawi.com/journals/grp/https://www.hindawi.com/journals/pd/https://www.hindawi.com/journals/ecam/https://www.hindawi.com/https://www.hindawi.com/