Rhabdomyolysis Associated with Opiate Abuse: A Case Report/Opioid Kötüye Kullanimina Bagli Rabdomiyoliz: Olgu Sunumu

Headnote

ABSTRACT

Introduction: There are several complications associated with opiate abuse, including respiratory suppression, disturbance of consciousness, aspiration pneumonia, pulmonary edema, myocarditis, rhabdomyolysis, and compartment syndrome. Some of these complications may be life-threatening.

Case Report: Herein, we present a case of rhabdomyolysis due to opiate abuse in a young man. Rhabdomyolysis is a known but rare complication of intravenous opiate abuse.

Conclusion: Because rhabdomyolysis may be life-threatening, and prompt diagnosis and treatment are essential, physicians should be aware of this complication among opioid addicts.

Keywords: Rhabdomyolysis, opioid abuse, case

Received: 06.11.2014 Accepted: 07.01.2015

Available Online Date: 27.02.2015

ÖZET

Giris: Opioid kötüye kullanimi ile iliskili pek çok komplikasyon bildirilmistir. Bunlarin arasinda solunum depresyonu, bilinç bulanikligi, aspirasyon gnömonisi, pulmoner ödem, miyokardit, rabdomiyoliz ve kompartman sendromu sayilabilir. Bu komplikasyonlarin bazilari hayati tehdit eder.

Olgu Sunumu: Burada genç bir erkek hastada opioid kötüye kullanimina bagli gelisen rabdomiyoliz vakasi sunacagiz.

Sonuç: Rabdomiyoliz intravenöz opioid kötüye kullanimina bagli nadir görülen bir komplikasyondur. Rabdomiyoliz hayati tehdit edebilecek sonuçlar dogurabilecegi için erken tani ve tedavisi çok önemlidir. Bu nedenle klinisyenler opioid kullanicilarinda bu komplikasyona karsi uyanik olmalilardir.

Anahtar Kelimeler: Rabdomiyoliz, opioid kötüye kullanimi, olgu

Gelis Tarihi: 06.11.2014 Kabul Tarihi: 07.01.2015

Çevrimiçi Yayin Tarihi: 27.02.2015

Introduction

There are several complications associated with opioid abuse, including respiratory suppression, disturbance of consciousness, aspiration pneumonia, pulmonary edema, myocarditis, rhabdomyolysis, and compartment syndrome (1). Some of these complications may be life-threatening.

Rhabdomyolysis is a disorder caused by toxic substances such as creatine kinase (CK) and myoglobin released from damaged muscle tissue. Drug use or overdosage of some drugs such as cocaine, amphetamines, statins, and heroin has been associated with rhabdomyolysis (2). Herein, we present a case of rhabdomyolysis due to opioid abuse in a young man.

Case Report

A 21-year-old man who was found unconsciousness was admitted to the emergency department (ED). He was a night watchman and was found by his friends in the morning at work lying on the ground. Clinical examination revealed tachycardia of 124 bpm and blood pressure of 90/60 mmHg. His body temperature was 38.5°C. Initially, his complete blood count white blood cell count was 24.9 x 109/L, hemoglobin level was 14.3 g/dL, and arterial blood gas analysis revealed mixed metabolic and respiratory acidosis (pH = 7.23, PCO2 = 50 mmHg, HCO3 = 20.1 mm). His biochemical data are summarized in Table 1. The multidrug test performed for toxicology was positive for opioid. A few hours after treatment in ED, he awoke, and his physical examination revealed no abnormal findings, except for a slight power loss in the leftleg. He was not known to have any history of systemic diseases. He was asked regarding opioid usage, and he replied that he was using opioids for 2 years. After stabilizing his hemodynamic status, he was transferred to the intensive care unit (ICU). His urinary test and posteroanterior lung graph were normal. Brain computed tomography (CT) (Somatom Sensation 16 software version A50, Siemens, Forchheim, Germany) and diffusion magnetic resonance imaging (MRI) (Avanto, Siemens Medical Systems, Erlangen, Germany) performed to determine the cause of unconsciousness were all normal. The neurology department evaluated the patient and did not identify any sign of central nervous system infection. Due to fever and increased white blood cell count, ceftriaxone 2 × 1 gr intravenously was started as prophylaxis. Owing to the power loss noted in his leftleg in neurological examination, vertebral CT and pelvic and leftfemur direct graphs were performed, which were also normal. In softtissue ultrasound (Antares, Siemens AG, Medical Solutions Henkestr, Erlangen, Germany) examination of the leftfemur, minimal fluid accumulation compatible with a hematoma was observed, and this was followed-up by orthopedists without any treatment. Although his electrocardiography was normal, his cardiac markers [Troponin I, creatinine kinase (CK), CK-MB] were high at admission and followup. The cardiology department determined that this increase was a result of opioid abuse, but this department could not exclude acute coronary syndrome, and acetylsalicylic acid 1 × 100 mg, clopidogrel 1 × 1, carvedilol 2 × 6.25 mg per oral, and enoxaparin sodium 2 × 0.6 cc sc were started. On the 2nd day of his hospitalization, his urinary output decreased, and he developed hematuria. He was diagnosed with rhabdomyolysis, and 'crush fluid' treatment was started to him. On the 6th day of his follow-up, he was transferred to the nephrology ward and diagnosed with rhabdomyolysis and accompanying focal segmental glomerulosclerosis. With fluid resuscitation, his condition improved; his renal functions improved, and hemodialysis was not required. He was discharged from the hospital on the 15th day of his hospitalization. The patient's informed consent was obtained before the preparation of this report.

Discussion

Opioid abuse is a problem commonly encountered in ED. In a recent retrospective, population-based study, middle age, male sex, public insurance, lower household income, and comorbidities (such as chronic pulmonary and neurological diseases) were determined to be associated with frequent (2 or more) ED visits. Moreover, in this cohort, frequent ED visits for opioid overdose were reported to be associated with a higher likelihood of future hospitalizations and near-fatal events (3). Opioid use may result in mental depression, depressed cardiac and respiratory function, skin flushing, dry mouth and nausea, peripheral nervous system injury, rhabdomyolysis, and compartment syndrome (4). Rhabdomyolysis is a known but rare complication of intravenous opioid abuse (5). It may be caused by muscle injury including postural muscle compression when comatose or an allergic or toxic reaction to opioid or its adulterants (6). Dehydration, vascular insufficiency, vasoconstriction, shock, trauma, seizure, acidosis, and a direct toxic effect may also be the causes contributing to the establishment of opioid associated rhabdomyolysis (7).

Rhabdomyolysis is a potentially life-threatening syndrome because it can result in electrolyte disturbances, arrhythmia, acute renal failure, and compartment syndrome. Boulanger-Gobeil et al reported a 22-year-old woman who was brought to ED following several episodes of tonic-clonic seizures a few hours after ingesting "legal ecstasy" and who developed prolonged rhabdomyolysis requiring 6 days of hospitalization (8).The diagnosis of rhabdomyolysis relies on the clinical and laboratory findings. In laboratory investigations, serum total creatinine kinase levels and myoglobin in urine are important to determine the presence of rhabdomyolysis in case of occurrence of its signs (9). Hypovolemia, aciduria, and increased urinary myoglobin excretion may contribute to the nephrotoxic effects of rhabdomyolysis (10). Kosmadakis et al prospectively evaluated the severity of rhabdomyolysis and acute renal failure in narcotic drug users and reported that rhabdomyolysis and acute renal failure were more severe in heroin users compared with the nonheroin users (2). In the presence of acute renal failure, the keystone of treatment is aggressive volume resuscitation and expansion of the extracellular fluid compartment to diminish the effects of myoglobin and prevent progression to acute renal failure. Other treatment modalities include the use of bicarbonate in an attempt to alkalinize the urine and mannitol. Electrolyte disturbances should be evaluated carefully and treated on time. Acute hemodialysis may also be required in some cases.

Conclusion

Because rhabdomyolysis may be life-threatening, and prompt diagnosis and treatment is essential, physicians should be aware of this complication among opioid addicts.

Informed Consent: Written informed consent was obtained from patient's relative who participated in this case.

Peer-review: Externally peer-reviewed.

Author Contributions: Concept - M.G., D.A.; Design - M.G., D.A., N.B.A., S.G.Ç., Y.K.G., R.K., C.B.; Supervision - M.G., D.A., N.B.A., S.G.Ç., Y.K.G., R.K., C.B.; Materials - M.G., D.A., N.B.A., S.G.Ç., Y.K.G., R.K., C.B.; Data Collection and/or Processing - M.G., D.A., N.B.A., S.G.Ç., Y.K.G., R.K., C.B.; Analysis and/or Interpretation - M.G., D.A., N.B.A., S.G.Ç., Y.K.G., R.K., C.B.; Literature Review - M.G., D.A., N.B.A., S.G.Ç., Y.K.G., R.K., C.B.; Writer - M.G., D.A.; Critical Review - M.G., D.A. ,N.B.A., S.G.Ç., Y.K.G., R.K., C.B.

Conflict of Interest: The authors declared no conflict of interest.

Financial Disclosure: The authors declared that this study has received no financial support.

Hasta Onami: Yazili hasta onami bu olguya katilan hastanin yakinindan alinmistir.

Hakem degerlendirmesi: Dis bagimsiz.

Yazar Katkilari: Fikir - M.G., D.A.; Tasarim - M.G., D.A., N.B.A., S.G.Ç., Y.K.G., R.K., C.B.; Denetleme - M.G., D.A., N.B.A., S.G.Ç., Y.K.G., R.K., C.B.; Malzemeler M.G., D.A., N.B.A., S.G.Ç., Y.K.G., R.K., C.B.; Veri toplanmasi ve/veya islemesi - M.G., D.A., N.B.A., S.G.Ç., Y.K.G., R.K., C.B.; Analiz ve/veya yorum - M.G., D.A., N.B.A., S.G.Ç., Y.K.G., R.K., C.B.; Literatür taramasi - M.G., D.A., N.B.A., S.G.Ç., Y.K.G., R.K., C.B.; Yaziyi yazan - M.G., D.A.; Elestirel Inceleme - M.G., D.A., N.B.A., S.G.Ç., Y.K.G., R.K., C.B.

Çikar Çatismasi: Yazarlar arasinda herhangi bir çikar çatismasi yoktur.

Finansal Destek: Bu çalisma için herhangi bir finansal destek alinmamistir.

References

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