The patient was in agreement with these recommendations. Education on the causes, symptoms and complications of rhabdomyolysis was reviewed with the patient, and cessation of any nutritional supplements, especially fat burners, was strongly recommended prior to discharge. The patient was taking in adequate oral fluids, and the intravenous hydration was discontinued. After an additional 12 h, it was noted that the CPK had fallen below 500 U/L, and the patient's creatinine was at baseline. After approximately 12 h, this was decreased to 100 mL/h in light of decreasing CPK and stable creatinine. After baseline electrolytes returned to the normal range, the patient was started on a maintenance intravenous infusion of normal saline at 150 mL/h. The patient, who had otherwise normal cardiovascular and renal function, was given a 1 L bolus of normal saline in the emergency department. The patient's basic metabolic panel was unremarkable except for mildly elevated creatinine, which ameliorated the need to pursue correction of any metabolic abnormalities. The underlying cause was assumed to be intense exercise or a drug, and so the patient's exercise history, outpatient medications and substance abuse history were reviewed in the emergency department. Treatment of rhabdomyolysis is primarily concerned with treating its underlying cause, correcting metabolic abnormalities and preventing acute kidney injury. The basic metabolic panel and urinalysis were helpful in determining that a mild acute kidney injury accompanied the rhabdomyolysis. Liver pathology was ruled out with a nearly normal liver function panel, especially considering the need to evaluate bilirubin levels in the setting of dark urine. Rhabdomyolysis was considered more likely in the setting of markedly increased CPK. An ischaemic embolic event was lower on our differential in the setting of a normal cardiovascular and extremity examination. A basic metabolic panel excluded electrolyte abnormalities, and an inflammatory myopathy was considered less likely in the setting of a negative family history and normal sedimentation rate. Traumatic injury was ruled out via history, while spinal cord impingement was ruled out by an unremarkable neurological examination. On further inquiry for other possible causes of rhabdomyolysis, he denied any recent trauma to his lower extremities or back, recent illness, drug use or any family history of myopathies.įor a middle-aged man presenting with bilateral lower extremity and lower back muscular cramping and dark urine, rhabdomyolysis, spinal cord impingement, embolic events, traumatic injury, electrolyte abnormalities such as hypocalcaemia, inflammatory myopathies, acute kidney injury and liver pathology must be considered. The patient did mention the use of a new supplement known as ‘Fat Burn X’, which he had begun taking 2 days prior, shortly before the cramping started. He denied any recent changes to his medication regimen, which included 100 mg sildenafil as needed, 25 mg hydrochlorothiazide four times a day for hypertension, 20 mg omeprazole four times a day for heartburn, codeine 30 mg/acetaminophen 300 mg two times a day for osteoarthritis and 50 mg hydroxyzine as needed for sleep. He admitted to some muscle soreness after working out, but described the current lower extremity and lower back cramping as severe, and something he had never experienced previously. The patient was noted to be of a muscular build, and endorsed daily exercise, which had not changed in intensity or duration in the past 2 months. In brief, dietary and nutritional supplements can pose a serious risk to patients, and patient awareness and health literacy in this area remains poor.Ī 50-year-old man with a medical history of hypertension, gastro-oesophageal reflux disease, osteoarthritis and insomnia presented with a 2-day history of bilateral lower extremity and lower back cramping, and some subjective darkening of urine. 2 3 It is likely that adverse events caused by unregulated nutritional supplements are under-reported since their use is not always reported by the patient, even when specifically asked about medication and supplement use. 1 Also, this is not the first instance of a nutritional supplement contributing to a case of rhabdomyolysis-additional cases have been described in the literature. As the use of herbal and nutritional supplements increases in the USA, the number of adverse events and drug interactions is increasing. The responsibility for insuring that the product is safe for consumption and that advertising claims are accurate falls on the company producing the nutritional supplement. Under the Dietary Supplement Health and Education Act of 1994, companies producing nutritional supplements do not need official review by the Food and Drug Administration prior to marketing their product in the USA.
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