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A woman with a history of chronic idiopathic constipation and remote eating disorders presented to our hospital with generalised weakness and confusion due to severe hypokalaemic rhabdomyolysis. Her initial ECG showed down-sloping ST segment elevations consistent with the 'shark fin' sign, and initial echocardiography was consistent with Takotsubo cardiomyopathy (TCM). She later developed hypotension, hypoxaemia and low central venous oxygen saturation consistent with cardiogenic shock. A repeat ECG demonstrated the 'spiked helmet' sign, and repeat echocardiography showed new global hypokinesis. She was successfully supported with dobutamine on recognition of her worsening cardiomyopathy. This case highlights how the combination of recognised triggers of TCM such as hypokalaemia and rhabdomyolysis may predispose patients to a more morbid cardiac course and how the severity of such triggers may also influence cardiac morbidity. We additionally highlight the prognostic significance of two ECG patterns associated with TCM., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

SummaryRhabdomyolysis is characterised by muscle breakdown which causes myoglobin light chain release and can result in renal injury. While some of the most common causes of rhabdomyolysis are trauma related, others include toxins, autoimmune processes or viral aetiologies. We present the case of a 20s-year-old man, with no significant medical history, who presented to the emergency department with a 1-week history of weakness, myalgias, nausea, vomiting and subjective fevers. A review of systems and physical exam were otherwise unremarkable, including being negative for sore throat, dysphagia and lymphadenopathy. On presentation, the patient was noted to have dark urine with a creatine kinase value of 452 458 U/L and an elevated creatinine at 7.23 mg/dL. The patient denied any trauma or increased physical activity. His toxin screen and autoimmune workup were negative. The patient's serological workup was significant for acute Epstein-Barr virus (EBV) infection, without additional viral coinfection or mononucleosis. During his hospitalisation course, the patient was managed with supportive care including haemodialysis. The patient made a full renal recovery and was discharged with scheduled outpatient follow-up. This case highlights the recognition of an acute EBV infection causing rhabdomyolysis in the absence of mononucleosis or concomitant infection., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

McArdle disease is a glycogen storage disease that results in rhabdomyolysis during intense exercise. A number of different triggers have been described. We evaluated a patient with McArdle disease who presented with rhabdomyolysis after recreational scuba diving. There was no concern for barotrauma or decompression sickness. His symptoms resolved with standard-of-care management for non-diving-related rhabdomyolysis. Features of his experience provoked questions about the diving-related factors contributing to his presentation. We present the case and explore possible mechanisms of diving-related injury in patients with McArdle disease, including the possible effects of hyperoxia, hyperbaria, hypothermia and strenuous activity., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

A man, in his early 30s, with no significant medical history presented with a 2-week history of fatigue, chest and abdominal pain, associated with anorexia and vomiting. Initial laboratory testing was suggestive of rhabdomyolysis with acute renal failure and transaminitis. The aetiology of his rhabdomyolysis initially remained unexplained as there were no clear risk factors or inciting events. An extensive workup revealed acute HIV as the precipitant of rhabdomyolysis., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Olanzapine is a commonly used and effective second-generation antipsychotic agent used for the control of paranoia and agitation in schizophrenia and bipolar disorder as well as in the behavioural and psychological symptoms of dementia. Serious side effects of treatment are uncommon but spontaneous rhabdomyolysis represents a rare complication. We describe here a patient treated with a stable dose of olanzapine for more than 8 years who developed acute severe rhabdomyolysis without an identifiable trigger and without features suggestive of neuroleptic malignant syndrome. The rhabdomyolysis was atypical in its delayed onset and severity with a creatine kinase level of 345 125 U/L, the highest level reported in the available literature. We also describe the clinical manifestations of delayed-onset olanzapine-induced rhabdomyolysis and its differentiation from neuroleptic malignancy syndrome, and we highlight key aspects of management to prevent or minimise further complications such as acute kidney injury., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

This case describes the first report of Haff disease in Australia, where a family of three all presented with myalgia, after ingesting recently thawed, baked queen snapper fish, caught off the coast of Western Australia. All three members (mother, father and son) developed rhabdomyolysis; however, the son, who had a higher creatine kinase level, also developed an acute kidney injury, likely linked to his double fish consumption. All members were admitted for intravenous hydration and clinically improved. This case highlights the importance of dietary and environmental history in cases of rhabdomyolysis without an obvious aetiology in an otherwise self-limiting disease., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

We present the case of a 12-year-old African girl infected with SARS-CoV-2 who was admitted to a tertiary academic hospital in Johannesburg with severe acute inflammatory myositis complicated by rhabdomyolysis and acute kidney injury requiring renal replacement therapy and intensive care. She also fulfilled the diagnostic criteria for multisystem inflammatory syndrome in children., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Tourette syndrome (TS) is a condition wherein motor and vocal tics occur, provoked by an urge, but often not able to be completely voluntarily controlled. Tics are known to cause physical and emotional risks to quality of life, and in rare extreme cases, may have permanent consequences. We report the first cases, to our knowledge, of rhabdomyolysis due to extreme tic fits in two distinct patients with TS. Both patients presented with severe tics, leading to elevated creatine kinase and a diagnosis of rhabdomyolysis requiring hospitalisation and intravenous fluids. Neither had neuroleptic malignant syndrome. One patient was on concurrent neuroleptic therapy, but his laboratory parameters improved when tics subsided despite continued neuroleptic use. Our cases highlight the potential complication of rhabdomyolysis secondary to severe tic fits independent of neuroleptic use., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Influenza A and B commonly cause benign respiratory disease in humans, but can cause more severe illness in high-risk populations. We report an unusual case of a previously healthy adult patient who presented with myositis and severe rhabdomyolysis secondary to influenza A infection that resulted in atraumatic compartment syndrome of all four extremities, each requiring emergent fasciotomy. The patient was subsequently managed with delayed primary closure and skin grafting in the operating room. Prompt recognition of this rare complication by the team resulted in no limb amputations. On his first follow-up appointment, 1 month after discharge, he had regained full functionality in both his hands and his feet were both close to 50% of baseline and improving with physical therapy., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

A 73-year-old woman presented with an acute exacerbation of her long-standing psoriasis. Ciclosporin was commenced due to the severity of her symptoms resulting in remission within 2 weeks. Full blood count, urea and electrolytes following initiation of treatment were unremarkable, although she complained of muscle aches, which was attributed to her known multiple sclerosis. Three weeks later she was admitted to the hospital with diarrhoea and vomiting. Repeat blood tests revealed raised creatinine (528 μmol/L (normal range (NR) n=45-84 μmol/L)), urea (32.6 mmol/L (NR 2.5-7.8 mmol/L)) and creatine kinase (6792 IU/L (NR 25-200 IU/L)) levels and reduced estimated glomerular filtration rate of 7. A diagnosis of acute kidney injury secondary to rhabdomyolysis was made due to an interaction between ciclosporin and simvastatin, precipitated by the dehydration from gastroenteritis. Haemofiltration was required to stabilise her renal function and she made a complete recovery., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

We describe the case of a 76-year-old man who presented with bilateral lower limb weakness associated with decreased urine output. His initial blood results showed acute kidney injury (AKI) stage 3 with substantially raised serum creatine kinase concentration of 37 950 IU/L (normal range <171 U/L). He had been on high-dose rosuvastatin for 4 years with a recent brand change occurring 1 week prior to onset of symptoms. There was no history of pre-existing neuromuscular disease. Statin-related rhabdomyolysis was suspected and rosuvastatin was withheld. His muscle strength gradually improved. He required haemodialysis for 10 weeks. He was discharged home after a complicated course of hospitalisation. His renal function improved and he became dialysis-independent; however, he was left with residual chronic kidney disease., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Neuropsychiatric and muscular symptoms can develop as part of hypothyroidism. However, frank psychosis or rhabdomyolysis due to hypothyroidism are uncommon and have been reported rarely as the first presenting features of hypothyroidism. We report a case of a 44-year-old man who presented with a 2-week history of delusions, hallucinations and mild bilateral leg pain, without apparent signs of myxedema. Investigations revealed raised thyroid stimulation hormone >100 mIU / L and high creatine kinase >21 000 U/L. Diagnosis of hypothyroidism-induced psychosis and rhabdomyolysis was made. He received thyroxine, olanzapine and a short course of steroids. His symptoms improved after 2 weeks of treatment and he remained free of symptoms at 6 months of follow-up. To the best of our knowledge, this is the first case of concomitant psychosis and rhabdomyolysis leading to hypothyroidism diagnosis. This case highlights the importance of hypothyroidism screening when faced with unexplained psychosis or rhabdomyolysis, especially if combined., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

A 43-year-old man presented with acute onset rapidly progressive weakness in all four limbs (proximal greater than distal), following an episode of binge alcohol ingestion, and was admitted for evaluation and management. There was a history of decreased urine output since 2 days with dark-coloured urine. He was found to have severe hypokalemia and renal dysfunction. Serum creatine kinase was significantly high, and further investigation revealed significantly elevated serum and urine myoglobin levels suggestive of rhabdomyolysis, which was secondary to severe hypokalemia. Following supplementation with intravenous and oral potassium and supportive care, the weakness improved significantly, and he was subsequently discharged. This case describes severe hypokalemia, resulting in rhabdomyolysis and generalised lower motor neuron weakness, in a setting of binge alcohol ingestion, which is an entity rarely described in literature., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Rhabdomyolysis is a serious and life-threatening condition which has many established causes including endocrine disturbances. Of those, thyroid, adrenal and pituitary deficiencies are the most commonly seen. Most cases of rhabdomyolysis with adrenal insufficiency that have been reported have been primary. Here, we report an encounter with a patient who presented with her second case of severe rhabdomyolysis in the setting of secondary adrenal insufficiency. The cause for corticotropic suppression was most likely autoimmune hypophysitis given the presence of other autoimmune comorbidities including a new diagnosis of autoimmune hepatitis. In addition to her case, we present a brief review of the literature pertaining to cases of rhabdomyolysis attributed to adrenal insufficiency., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Rhabdomyolysis is characterised by muscle breakdown with release of damaging proteins that can have devastating consequences. Acute influenza infection is being increasingly recognised as an underlying aetiology. We report an unusual case of severe rhabdomyolysis with acute renal failure due to influenza A infection that improved with high-dose oseltamivir and intravenous fluids. In our case, we also noticed a temporal relation between fever spikes and subsequent increase in serum creatine kinase. The precise mechanism between the rise in temperature and creatine kinase is unclear but it could be due to direct viral invasion of myocytes or due to release of new viral progeny following replication in the myocyte., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

A 14-year-old young adult took an overdose of 1.2 g of fluoxetine, a selective serotonin reuptake inhibitor (SSRI) that he had been prescribed for depression. He had a generalised tonic/clonic seizure at 6 hours postingestion.After the seizure, he developed signs consistent with serotonin syndrome: fine tremor, agitation, sweating and hyperreflexia. This was followed by severe muscle pain and rhabdomyolysis with peak creatine kinase (CK) of 33 941 at 74 hours. He was managed with intravenous fluids and analgesia and discharged after 4 days, having avoided renal injury. The use of SSRI's such as fluoxetine in teenagers has increased in recent years. While it is generally considered benign in overdose, this report illustrates the severe consequences of overdose at high quantities and discusses appropriate management in these cases. We note that in this case, there was a delayed onset of rhabdomyolysis with peak CK at 74 hours postingestion., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2018. No commercial re-use. See rights and permissions. Published by BMJ.)

H3N2 was first detected in July 2011 in the USA. It is responsible for sporadic cases of influenza and localised outbreaks and has not yet taken over on an epidemic or pandemic scale. An 84-year-old man presented with a dry cough, fever and myalgia for 3 days. On examination, he had a pulse of 98 bpm and blood pressure of 124/88 mm Hg. The patient was tachypnoeic, SpO 2 was 90%. Auscultation revealed bilateral diffuse wheeze and crackles. He had generalised muscle tenderness on examination. On admission, creatinine was 1.9 mg/dL and CK(creatine kinase) was 44 000 U/L. Chest X-ray was suggestive of ARDS (acute respiratory distress syndrome). Throat swab was positive for H3N2. The patient was given intravenous fluids, oral sodium bicarbonate, oxygen and oseltamivir tablet. In view of ARDS, he was given intravenous methylprednisolone and bronchodilators for bronchospasm. The patient improved symptomatically; vitals and lab reports were normal at the time of discharge., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

A 6-month-old male infant with Stuve-Wiedemann syndrome (SWS) presented with an acute respiratory arrest secondary to a rhinovirus respiratory infection from which he was rapidly resuscitated. He developed an acute kidney injury requiring supportive treatment and on day 3 of his illness was noted to have developed severe rhabdomyolysis (creatine kinase level 132 040 U/L (normal <320 U/L)). He was born from consanguineous parents with homozygous mutations in the leukaemia inhibitory factor receptor. He had skeletal dysplasia with metabolic bone disease and episodes of hyperthermia with lactic acidosis. He also had paroxysmal ventricular tachycardia treated with prophylactic propranolol. This is a case report of a child with SWS who had a febrile illness and epileptic seizures which led to severe rhabdomyolysis outside the context of anaesthesia, and we would like to draw the attention of clinicians to this potential complication., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) . All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Hyponatraemia-induced rhabdomyolysis is a rare, but reported phenomenon, particularly in patients with chronic schizophrenia on depot antipsychotics prone to psychogenic polydipsia. To the best of our knowledge, there are no reported cases of hyponatraemia-induced rhabdomyolysis complicated by oligo-anuric acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT). The initiation of CRRT is complicated in severe hyponatraemia, predominantly due to the need to avoid rapid changes in tonicity associated with rapid changes in sodium. We report a case of severe hyponatraemia (104 mmol/L) complicated by oligo-anuric rhabdomyolysis-induced AKI and our management of the renal prescription., Competing Interests: Conflicts of Interest: None declared., (2016 BMJ Publishing Group Ltd.)

We report a case of bilateral anterolateral crural compartment syndrome elicited by hyponatraemia and psychogenic polydipsia. The unusual constellation of clinical findings and diminished pain expression made initial diagnostic procedures challenging. The possible pathogenesis and treatment options are discussed. Impairment of lower extremity function at follow-up was serious and permanent., (2015 BMJ Publishing Group Ltd.)

Hypokalaemic rhabdomyolysis represents a medical emergency requiring rapid diagnosis and appropriate aetiological treatment. Renal tubular acidosis is a common cause of hypokalemia which can be idiopathic or secondary to systemic disorders such as Sjogren's syndrome. It can remain asymptomatic or manifest with metabolic abnormalities including hypokalemia paralysis, hypocalcaemia and hyperchloremic metabolic acidosis. Rhabdomyolysis presenting with severe hypokalemia as the first manifestation of Sjogren's syndrome is rare. We report a case of a 59-year-old woman who presented to our department with severe weakness of all limbs. Laboratory examination demonstrated hypokalemic rhabdomyolysis caused by distal renal tubular acidosis. Investigations revealed Sjogren's syndrome as the underlying cause of the metabolic disorders.

Gluteal compartment syndrome is a rare entity but a recognised complication of prolonged immobilisation. It can present as renal failure as a result of severe rhabdomyolysis and can lead to sepsis and death. We report a case of gluteal compartment syndrome in a 25-year-old man who was found unconscious following intoxication with alcohol and cocaine of an unknown duration. He presented with tense tight left buttock swelling, right thigh swelling, cold immobile extremeties and acute renal failure. Immediate left gluteal, thigh and calf fasciotomy resulting in an improvement of lower limb and renal function.

Rhabdomyolysis is a potentially life-threatening condition to be considered when muscular damage is suspected. We present a case of a 39-year-old woman who developed rhabdomyolysis after prolonged circulatory insufficiency to the legs, leading to life-threatening complications including bilateral tibial compartment syndrome, acute kidney failure, hyperkalaemia with cardiac arrhythmia and finally lifesaving bilateral transfemoral amputation. This case emphasises that early diagnosis, removal of triggering factor, early and aggressive fluid therapy and treatment and prevention of complications are essential for the patient's morbidity and mortality.

A young man with bipolar disorder was admitted in a coma. Cerebral oedema secondary to severe hyponatraemia was implicated. This was due to self-induced water intoxication. He developed rhabdomyolysis, a massive creatine kinase (out of proportion to longstanding antipsychotic medication) and acute renal failure. In the intensive care unit, hyponatraemia was corrected, and following appropriate fluid resuscitation, with forced alkaline diuresis, the rhabdomyolysis and renal function normalised, averting renal support. While a full recovery ensued, the persisting risk factors for hyponatraemia, that is polydipsia, and its association with rhabdomyolysis, increased the chances of a recurrence. Closely supervised regulation of his water intake, and monitoring of antipsychotic efficacy (for biochemical homeostatsis) are essential for secondary prevention. Rhabdomyolysis is a rare complication of hyponatraemia. When associated with psychogenic polydipsia, the acute and chronic management are challenging. Vaptans, which are aquaretics, that preferentially prevent renal tubular water reabsorption, may be beneficial in this situation.