Fatal Rhabdomyolysis in a Patient with Head Injury
A previously healthy 42-year-old man was referred to our emergency department due to a deteriorating mental status after a car accident. Emergency services reported decreased mental status and a Glasgow Coma Scale score of 7. There were no associated systemic injuries, muscle contusions, internal organ damage or swelling of the extremities. However, he showed decerebrated rigidity at both arms and legs. On admission, sodium, potassium, and osmolarity were 143 meq/L, 3.5 meq/L, and 335 mmol/L, respectively. Computed tomography (CT) showed diffuse cerebral swelling consistent with hemorrhagic contusion and epidural hematoma at right temporoparietal area (). 150 mL of mannitol solution (20%) every 4 hours was prescribed. However, despite treatment to lower intracranial pressure (ICP), that is, mannitol, mild hyperventilation, and extraventricular drainage (EVD), his mental status remained semicomatose and recurrent convulsive generalized tonic-clonic seizures developed, and thus, he was admitted to the neurosurgical intensive care unit for adequate hydration, anticonvulsant and correction of the metabolic derangement. Unfortunately, myoglobinuria developed 3 days after admission with a high serum creatine kinase (CK) level up to 48, 837 IU/L (normal 55-215 IU/L). At this time, his serum sodium, potassium, and osmolarity were 152 meq/L, 3.0 meq/L and 352 mmol/L. Acute renal failure developed 3 days after admission despite intensive fluid replacement and diuresis. CK level peaked at 52, 825 IU/L on day 5, and serum myoglobin exceeded 25 mg/dL (normally <2.5 mg/dL). Despite intensive supportive treatment, the patient became anuric 5 days after admission and required hemodialysis. No source of muscle breakdown was evident, but his condition deteriorated rapidly, culminating in cardiorespiratory arrest with dilated non-reactive pupils. He died 8 days after admission.