Evidence from desensitization studies for distinct receptors for ATP and UTP on the rat superior cervical ganglion

A 44-year-old woman with scleroderma and Sj?gren's syndrome developed altered consciousness, acute renal failure, and rhabdomyolysis. She had no history of trauma, seizures, alcohol abuse, hyperthermia, or other possible causative factors for rhabdomyolysis. A high serum salicylate level indicated a diagnosis of salicylate intoxication. Medical history after recovery revealed chronic salicylate ingestion for severe headaches. This is possibly the first reported case of rhabdomyolysis caused by chronic salicylate intoxication. Continuous hemodiafiltration early in hospitalization was an effective treatment.     

Salt wastage, plasma volume contraction and hypokalemic paralysis in self-induced water intoxication

Eleven episodes of severe hyponatremia secondary to hiccup-induced potomania were recorded in 3 years in a man who had essential hypertension, a low protein intake and a normal diluting ability. Paradoxical increase in hematocrit and plasma protein with acute extensive natriuresis was associated as well as urine potassium loss and hypokalemia producing paralysis in 1 episode. During a chronic water loading test, the defect in water excretion was related to a low urine solute delivery which was partially reverted by the natriuretic response to plasma volume expansion, promoting water diuresis. In acute water intoxication, this natriuretic response was exaggerated, producing a brisk water diuresis. Plasma volume was rapidly normalized but without any improvement in plasma sodium due to the concomitant negative sodium balance. Thus, water diuresis persisted until plasma volume was significantly contracted. Potassium loss appeared to be related to sodium excretion. Metabolic disturbances have not reoccurred despite persistent hiccup and potomania during 2 years of urea therapy.     

Recurrent liver failure with severe rhabdomyolysis after liver transplantation for carbon tetrachloride intoxication

Acute liver failure due to intoxication is a rare indication for liver transplantation which a usually has a good prognosis. We herein report the case of a young male, who underwent orthotopic liver transplantation for acute liver failure due to carbon tetrachloride intoxication. Apart from hepatic and renal failure, the patient also developed severe rhabdomyolysis, which has not thus far been described as a toxic effect of this chemical agent. Despite forced hyperventilation, which is known to be the most effective means of eliminating the specifically lipophylic agent, as well as excessive plasma exchange following intravenous administration of fat emulsions, liver failure recurred when blood carbon tetrachloride concentrations were already at non-toxic levels. Retransplantation of the liver together with a kidney was only temporarily successful, since the patient died due to aspergillus sepsis. Based on this experience, we would recommend that whenever possible in patients with carbon tetrachloride intoxication, liver transplant should be delayed until most of the toxic agent has been eliminated in order to prevent fatal graft damage.     

Fine-needle aspiration biopsy of colonic masses

A 46-year-old-male developed acute renal failure (ARF) secondary to hypokalemic rhabdomyolysis. Potassium supplementation restored renal function following improvement of the rhabdomyolysis. After recovery from ARF, further evaluation disclosed he had hypokalemic metabolic alkalosis, normotensive hyperreninemia, hyperaldosteronism, renal hypomagnesemia, hypocalciuria and hyperplasia of the juxtaglomerular apparatus which are a diagnostic set of disorders in Gitelman's syndrome, a variant of Bartter's syndrome. This is the first reported case of ARF due to hypokalemic rhabdomyolysis associated with Gitelman's syndrome.     

Disturbance of consciousness associated with hypophosphatemia in a chronically alcoholic patient

A 69-year-old man with chronic alcoholism was admitted to our hospital due to disturbance of consciousness and oliguria. Emergency laboratory examination revealed metabolic acidosis, hypoglycemia, hyponatremia, mild liver dysfunction, acute renal failure and rhabdomyolysis. After administration of fluids and nutrients and continuous hemodiafiltration, he recovered from all signs and symptoms except for disturbance of consciousness after 7 days. Since severe hypophosphatemia persisted, we administered adequate phosphates, and then his level of consciousness normalized. We discuss the relationships among alcohol abuse, hypophosphatemia and disturbance of consciousness, and recommend that hypophosphatemia be considered a potential cause of disturbance of consciousness in alcoholic patients.     

Schizophreniform psychosis with polydipsia and electrolyte imbalance in multiple sclerosis

We present the case report of a young woman who suffered from schizophrenia-like psychosis leading to polydipsia and consequent water intoxication. Because of progressive somnolence and epileptic seizures therapy on the intensive care unit became necessary. Findings of MRI and cerebrospinal fluid were consistent with the diagnosis of chronic inflammatory disease of the central nervous system. As other possible causes could be excluded, multiple sclerosis seemed to be most probable. Simultaneous incidence of schizophrenia and multiple sclerosis and the differential diagnosis of central pontine myelinolysis following hyponatremia are discussed.     

Lead and the kidney: nephropathy, hypertension, and gout

Lead intoxication in human beings has been documented since the second century B.C. Renal disease, hypertension, and gout have all been linked to lead by strong circumstantial evidence. Both acute and chronic nephropathy can occur as a result of lead poisoning. Acute renal failure develops following acute lead intoxication and is often associated with gastrointestinal, neurologic, and hematologic disorders. Both blood and urinary laboratory abnormalities are associated with acute intoxication and are often diagnostic. Chronic lead nephropathy, a chronic tubulointerstitial nephritis on biopsy, occurs in the setting of long-term lead exposure and is often associated with hypertension and gout. Diagnosis of chronic lead nephropathy is more difficult since the laboratory abnormalities seen with acute lead intoxication are not present with chronic lead exposure. The typical clinical picture and the exclusion of other causes of renal disease allow the diagnosis of chronic lead nephropathy to be made. Evaluation of lead stores by either the calcium disodium edetate (EDTA) mobilization test or K-x-ray fluorescence are helpful in clinching the diagnosis. Treatment with EDTA lead mobilization is effective for acute lead poisoning while avoidance of further lead exposure prevents recurrence of lead intoxication. Treatment of chronic lead nephropathy with EDTA lead mobilization is useful if renal failure is modest; however, EDTA mobilization is of no benefit in patients with more severe renal insufficiency.     

Effect of manual segmental vibration on neuromuscular excitability

The prevalence of amphetamine abuse and the frequency of emergency department visits for amphetamine intoxication have increased dramatically worldwide. In this study, we retrospectively investigated the relationship between the prognostic features and clinical manifestations among patients admitted to the emergency department of a university hospital for acute methamphetamine intoxication during a 6-year period. Data collected included gender, age, route of abuse, time between drug exposure and arrival at the emergency department, estimated dose, signs and symptoms, laboratory values, and complications. Emergency therapy and cooling procedures were also recorded. After excluding 26 patients with multiple-drug intoxication, 18 patients (male-to-female ratio, 11:7) were include in the analysis. The mean age was 25.6 years. Thirteen patients survived and five died. Patients who died often presented with coma (80% vs 0%, p = 0.002), shock (60% vs 8%, p = 0.044), convulsions (100% vs 23%, p = 0.007), oliguria (80% vs 0%, p = 0.002), and high body temperature (41.4 +/- 0.5 degrees C vs 39.4 +/- 2.1 degrees C, p = 0.005). Furthermore, patients who died had significantly higher concentrations of blood urea nitrogen (8.7 +/- 2.1 vs 5.6 +/- 2.0 mmol/L, p = 0.01) and serum creatinine (212 +/- 71 vs 115 +/- 27 mumol/L, p = 0.033), and lower values of arterial pH (7.12 +/- 0.12 vs 7.34 +/- 0.10, p = 0.03), than those who survived. In the fatality group, the most common complication was rhabdomyolysis with acute renal failure (5 of 5); multiple organ failure resembling that from heatstroke was the leading cause of death from acute methamphetamine intoxication. In conclusion, the adverse prognostic features in patients with acute methamphetamine intoxication include coma, shock, convulsion, oliguria, and high core temperature. Acidosis, volume depletion, and ischemic renal damage were potential risk factors for development of acute renal failure in these patients.     

Hemostatic evaluation of a patient with haloperidol-induced neuroleptic malignant syndrome associated with disseminated intravascular coagulation

A 94-year-old man who had been admitted to our hospital for the treatment of senile dementia and restless behavior exhibited consciousness disturbances, acute respiratory failure, high fever, and thrombocytopenia the day after receiving haloperidol as prescribed by a psychiatrist. On the fourth day following administration of haloperidol, acute renal failure with rhabdomyolysis and disseminated intravascular coagulation (DIC) developed in the patient, who was accordingly given a diagnosis of haloperidol-induced neuroleptic malignant syndrome (NMS) associated with DIC. He was then given heparin and antithrombin III, and his DIC symptoms improved soon thereafter. Elevated plasma levels of tissue factor and tumor necrosis factor-alpha (TNF-alpha) were sustained during this therapy course. Other cytokines, including interleukin IL-1 beta, IL-2 and IL-6, were not elevated. There are activation of extrinsic coagulation and an elevated level of TNF-alpha during acute renal failure and rhabdomyolysis associated with NMS, which is thought to trigger the onset of DIC.     

Rhabdomyolysis in European viper bite

The case of a child who presented with severe rhabdomyolysis associated with renal failure after a viper bite is reported. Rhabdomyolysis is a serious complication resulting from systemic envenomation and is uncommon after viper bites in Europe. It may be due to oedema, myotoxic agents and haemorrhagic factors and may be responsible for two types of potentially fatal complications, i.e. acute renal failure and hyperkalaemia. The present case highlights the need to investigate routinely for rhabdomyolysis after viper bites. Antivenom therapy is recommended as soon as signs of envenomation are present, without waiting for the onset of complications.     

Hemodialysis of acute arsenic intoxication with transient renal failure

A striking reduction in serum arsenic level was achieved after four hours of hemodialysis in a patient with acute arsenic intoxication and transient renal failure. Quantitative dialysance of arsenic and a comparison of daily urinary excretion of arsenic with amount removed by dialysis suggested that hemodialysis is indicated in the treatment of acute arsenic intoxication if there is concomitant renal failure. In the presence of normal renal function, supportive measures, including dimercaprol (BAL in Oil) therapy, constitute the best available treatment.     

Ecstasy

"Ecstasy" (3,4-methylenedioxymethamphetamine, MDMA) is a prototype of a class of amphetamine derivatives that selectively destroy serotonergic neurons in several brain regions of various species, including, most probably, humans. Due to its psychostimulant and psychodelic effects, "Ecstasy" has been increasingly abused, especially in association with the "Rave" (sub)culture. However, it is not an innocent stimulant. At least 30 cases of severe psychiatric disturbances (chronic psychoses, panic disorders, suicides) induced by recreational doses of "Ecstasy" have been reported during the past 10 years in periodicals included in MEDLINE data base. Moreover, about 70 cases of severe systemic intoxication in young, otherwise healthy individuals, characterized by hyperthermia, arrhythmias and blood pressure disturbances, disseminated intravascular coagulation, rhabdomyolysis and acute renal failure, have also been reported. Despite the fact that the patients were treated at the intensive care units, the mortality exceeded 40%. Furthermore, about 20 cases of acute or recurrent non-infective hepatitis, some of which with lethal outcome, have been described as well.     

Drug induced rhabdomyolysis: case report

Rhabdomyolysis results from skeletal muscle injury leading to the release of intracellular contents into blood and urine. Its diverse aetiology includes severe exercise, muscle trauma or ischaemia, metabolic disorders, infections and exposure to drugs and toxins. Known risk factors include heredity disorders of glycogen and lipid metabolism as well as a history of substance abuse. A case of rhabdomyolysis associated with exposure to opiates and benzodiazepines is described and the pathogenesis and treatment are reviewed. The rhabdomyolysis was complicated by acute renal failure; the patient fully recovered. It is suggested that rhabdomyolysis should be borne in mind in patients presenting with altered mental status, or fluid and electrolyte abnormalities, in particular, if they also give a history of substance abuse.     

Grand rounds: Acute changes in mental status secondary to selective serotonin reuptake inhibitor-induced hyponatremia.

Hyponatremia represents the most common electrolyte abnormality in hospitalized patients and is of particular concern in hospitalized elderly patients. Multiple studies have identified an association between hyponatremia and selective serotonin reuptake inhibitor (SSRI) therapy. The present report provides as illustration 2 elderly patients identified to develop hyponatremia following initiation of SSRI therapy, which subsequently resolved following discontinuation of the medications. These cases demonstrate the unique position of the rehabilitation psychologist in identifying SSRI-induced hyponatremia as one potential mechanism underlying acute changes in mental status. Diagnostic factors and differential causes of hyponatremia are discussed, and alternative medications for addressing depressive symptomatology in cases of SSRI-induced hyponatremia are provided. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Behr''s syndrome. A report of 2 siblings studied by MR

Neuroleptic malignant syndrome is an idiosyncratic reaction associated with the use of neuroleptic drugs. We report a case of this rare syndrome in a head injury patient associated with some unusual features: rhabdomyolysis with a high level of creatine kinase, the development of acute renal failure, the early use of continuous venovenous haemofiltration in treatment and rigidity that was refractory to conventional treatment with dantrolene and bromocriptine. The diagnosis in patients with multiple injuries must be based on a high index of suspicion.     

Rhabdomyolysis and acute renal failure caused by haloperidol-decanoate (neuroleptic malignant syndrome)

A case of rhabomyolysis with attendant severe acute renal failure, arisen in a 59-year-old male treated with haloperidol-decanoate, is presented. The patient has been affected by paranoia schizophrenia since childhood, and he was treated with electroshock and successively with neuroleptics p.o. Four years before our observation, a therapy with haloperidol decanoate (50 mg i.m. monthly) was started. After some time, catatonic like episodes appeared, which got more and more frequent, until they appeared weekly. In occasion of the last of them, he was admitted to our hospital. At the objective examination he presented psychomotory arrest, perspiration, mytacism, severe muscle rigidity, moderate oedems to lower limbs. Laboratory findings showed a pattern consistent with rabdomyolysis and severe renal failure. After that haloperidol decanoate was stopped and rehydration and intensive diuretic therapy was started, the clinical and laboratory pattern went normal, persisting however a light creatinine increase. Probably the rhabdomyolysis was induced by the haloperidol decanoate, and renal failure by secondary severe hyvolemia. This case comes into the so-called neuroleptic malignant syndrome which can rarely arise in patients treated with antipsycotic agents and which causes high mortality, particularly when there are rhabdomyolysis and acute renal failure.     

A causative role for redox cycling of myoglobin and its inhibition by alkalinization in the pathogenesis and treatment of rhabdomyolysis-induced renal failure

Muscle injury (rhabdomyolysis) and subsequent deposition of myoglobin in the kidney causes renal vasoconstriction and renal failure. We tested the hypothesis that myoglobin induces oxidant injury to the kidney and the formation of F2-isoprostanes, potent renal vasoconstrictors formed during lipid peroxidation. In low density lipoprotein (LDL), myoglobin induced a 30-fold increase in the formation of F2-isoprostanes by a mechanism involving redox cycling between ferric and ferryl forms of myoglobin. In an animal model of rhabdomyolysis, urinary excretion of F2-isoprostanes increased by 7.3-fold compared with controls. Administration of alkali, a treatment for rhabdomyolysis, improved renal function and significantly reduced the urinary excretion of F2-isoprostanes by approximately 80%. EPR and UV spectroscopy demonstrated that myoglobin was deposited in the kidneys as the redox competent ferric myoglobin and that it's concentration was not decreased by alkalinization. Kinetic studies demonstrated that the reactivity of ferryl myoglobin, which is responsible for inducing lipid peroxidation, is markedly attenuated at alkaline pH. This was further supported by demonstrating that myoglobin-induced oxidation of LDL was inhibited at alkaline pH. These data strongly support a causative role for oxidative injury in the renal failure of rhabdomyolysis and suggest that the protective effect of alkalinization may be attributed to inhibition of myoglobin-induced lipid peroxidation.     

Syndrome of inappropriate secretion of antidiuretic hormone in nasopharynx carcinoma

The syndrome of inappropriate secretion of antidiuretic hormone (ADH) or SIADH has been reported in various disorders. We report a pediatric patient with nasopharynx carcinoma who may have developed a clinical SIADH with severe hyponatremia and generalized seizure during the administration of intravenous hydration. We propose that the inappropriately high plasma level of ADH led to the inability to excrete sufficient amounts of free water during a hyperhydration protocol with a relatively hypotonic fluid, which resulted in acute hyponatremia and central nervous system involvement. To avoid this complication, intravenous hydration before chemotherapy in children with nasopharynx carcinoma should be performed at a slower infusion rate and with a sodium chloride concentration of more than half isotonic.     

Dilutional hyponatremia in pre-eclampsia

OBJECTIVE: The objective of this report is to describe a defect in water metabolism, characterized by hyponatremia, in patients with pre-eclampsia-induced nephrotic syndrom. STUDY DESIGN: This was an observational study of 3 women. RESULTS: Hyponatremia was observed in 3 women with pre-eclampsia characterized by various extrarenal manifestations, as well as by nephrotic syndrome with normal or nearly normal renal function. Restriction in water intake partially corrected hyponatremia before delivery in each case, and no complications were observed in the neonates. The mechanism of impaired excretion of water in these patients is proposed to involve persistent and inappropriate production of vasopressin through stimulation of the nonosmotic mechanism for vasopressin secretion in response to a reduction in effective plasma volume. CONCLUSIONS: These results indicate for the first time that women with pre-eclampsia are, at least when nephrotic, at risk for development of dilutional hyponatremia, which can cause neurologic complications that simulate those of eclampsia.     

Acute kidney failure in hypothermia

Two cases with acute renal failure after prolonged hypothermia are presented. Both patients were found in come, became rapidly uremic and required hemodilaysis treatment. Although the laboratory findings were typical of severe muscle damage, e.g. elevated levels of serum creatinine phosphokinase, serum lactic dehydrogenase and serum aldolase activities, visible "crush-injuries" were not found. Acute renal failure was characterized by extreme catabolism and severe metabolic acidosis. After 4 and 10 hemodialyses respectively, the patients became polyuric and finally were discharges with normal renal and muscle function. Hypotension with diminished renal perfusion and nontraumatic rhabdomyolysis due to prolonged hypothermia are regarded as the dominant pathogenetic factors in the acute renal failure.