An Unusual Cause of Myoglobinuria

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Rhabdomyolysis is characterized by the acute breakdown of skeletal muscle, which can lead to AKI in severe cases. A number of etiologies have been identified in rhabdomyolysis with drugs and trauma accounting for the majority of cases. Rhabdomyolysis following a massage session is rare. We report a unique case of rhabdomyolysis with AKI following an aggressive massage session. A 57-year-old gentleman with a history of diabetes and hypertension presented with fever, breathlessness, and decreased urine output. On investigations, it was found that his serum creatinine was 5.7 mg%. Further investigations revealed a Hb of 12.7 gm% and the TLC was 21400/ cumm. His other blood tests showed: LDH 1095U/l, CPK 58928U/l with 100% of CPKMM form, potassium 6.7 mEq/l, creatinine 6.3mg/dl, and BUN 76 mg/dl. In view of the hyperkalemia and fluid overload, he was dialyzed once and the potassium was corrected. The qualitative test of urine for myoglobin was positive. The time concentration curve of CPK and LDH was similar to that of WBC and CRP levels. The downward trend of creatinine is also associated with a fall in CPK, LDH, CRP, and WBC levels. After 2 weeks, the patient was discharged with stable creatinine. To determine the etiology of raised CPK a detailed history was taken and he confessed that he regularly received body massage for 1 hour. However, a day prior, he received a prolonged body massage session for 2hours served by two masseurs simultaneously with higher intensity. Compression-induced rhabdomyolysis has been reported in a coma or immobilized patients, but it has rarely been associated with body massage. Myoglobinuria is a key player in the complex pathogenesis of AKI only in presence of hypovolemia, hypotension, and aciduria. Sivert et al. reported that AKI is not observed when nephrotoxic cofactors are absent. The people receiving body massages should drink an adequate amount of water to prevent rhabdomyolysis-associated AKI which is exacerbated by volume depletion.

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