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A 24 y/o athlete presents to your office with complaints of reddish discoloration of urine. He A 46 year old man claims that he has been exercising and running vigorously for the past two days. He is very determined to lose the extra weight that he has put up in the recent months and has been fasting in the nights for the past one week. His past medical history is significant for two abdominal surgeries which included laparotomy and appendicectomy in the past for intermittent severe abdominal pain. The patient does not smoke but does occassional consumes alcohol in binges. He did involve in one such alcohol binge last night. Physical examination is benign except for decreased power and reflexes in bilateral lower extremities. There is no rash. His urine specimen was grossly red in color. Urine dipstick was negative for protein, blood, leucoesterase and nitrite. Urine microscopy did not reveal any RBCs, WBCs or Casts. Serum creatinine and complete blood count are with in normal limits. A Creatinine Phosphokinase ( CPK) level has been ordered but is not yet available. The most likely cause of this patient’s grossly red urine is :
A) Rhabdomyolysis
B) Paroxysmal Nocturnal Hemoglobinuria
C) Acute Intermittent Porphyria
D) Await CPK level for correct diagnosis
E) Glomerulonephritis
Which of the following would be typically found
in rhabdomyolysis?
A) Elevated calcium, decreased phosphate.
B) Decreased potassium, elevated phosphate.
C) Elevated phosphate, decreased calcium.
D) Any of the above combinations may be seen
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1,red urine no RBC cast suggests rhabdomyolysis,but he had intermittent abd pain and could not reveal the cause,went for unwanted surgeries suggests AIP which get worsens after vigorously exercising,i think it would be better to wait for CPK ...?
2)C
hyperkalemia,hypocalcemia,hyperphosphatemia seen in rhabdomyolysis...hypocalemeia because calcium gets deposited in the muscles after the breakdown and decreases in serum.
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episodic abd pain C
and C
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first q ..i'll go with C..:-(
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1) Ans.C
Reddish discolration of urine with a negative dipstick for blood suggests that this red color is not from either a pigment globin ( hemoglobin or myoglobin) or a Red blood cell ( Hematuria). Such red colored urine with negative dipstick can be seen with drugs such as Rifampin, foods such as beets and substances like porpyrins in urine.
This patient also has sensory as well as motor neuropathy in his lower extremities, a typical manifestation of Acute intermittent porpyria attacks. The presence of peripheral neuropathy in patients with history of recurrent abdominal pains should raise the suspicion of Acute Intermittent Porphyria ( AIP). This patient had several severe abdominal pain episodes which were misdiagnosed as appendicitis and he even underwent a futile laparotomy. Patients are pain free between the attacks. Fasting and drugs like phenobarbital, alcohol can precipitate AIP attacks. Unlike other porphyrias, rash is not typically seen in AIP.
A. is not the answer because dipstick would be positive for blood in rhabdomyolyisis
B. is not the answer because dipstick would be positive in hemoglobinuria
D. is not the answer since the diagnosis of reddish urine here is not in favor of myoglobinuria.
E. a negative dipstick and negative microscopic urinalysis rules out gross hematuria as a cause of this red urine
F. Negative dipstick for blood, negative urine microscopy and absence of RBC casts rule out glomerulonephritis as a cause of this patient’s red urine
2---CCCCCCCC
Crush syndrome (CS) is a reperfusion injury as a result of traumatic rhabdomyolysis.
Crush syndrome appears to be common in earthquakes of disastrous proportions.
A crush injury is a direct injury resulting from crush.
Crush syndrome is the systemic manifestation of rhabdomyolysis caused by prolonged continuous pressure on muscle tissue
DX
The diagnose criterias for crush syndrome are:
Crushing injury to a large mass of skeletal muscle.
The sensory and motor disturbances in the compressed limps, which subsequently become tense and swollen.
Myoglobinuria and/or hematuria.
Peak creatine kinase (CK) > 1000 U/L.
Patients with nephrological problems are defined as crush injury and one of the following characteristics; oliguria (urine output 40 mg/dl), serum creatinine (2 mg/dl), uric acid (8 mg/dl),
****** potassium (>6 mg/dl), phosphorus (> 8 mg/dl),
****** or decreased serum calcium (< 8 mg/dl)12.
PATHOGENESIS AND CLINICAL FEATURES
The mechanism behind the crush syndrome is the leakiness of the sarcolemmal membrane caused by pressure or stretching. As the sarcolemmal membrane is stretched, sodium, calcium and water leak into the sarcoplasm, trapping extracellular fluid inside the muscle cells (COMPARTMENT SYNDROME). In addition to the influx of these elements into the cell, the cell releases potassium and other toxic substances such as myoglobin, phosphate and urate into the circulation
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