Introduction

If you ever hear of relatively fit and healthy young people dropping dead during strenuous activity you normally think of heart related causes like cardiomyopathy or a straightforward myocardial infarction (heart attack).

There is a another potential cause which I would like to discuss and is not as rare as people might think. It is called Rhabdomyolysis and it affects about 26000 people a year annually in the US.

I will first cover my own personal experience followed by a brief overview of what this disorder is.

N.B. This is intended for regular non-medical people to read and is not a guide for clinicians.

If you are a heath professional I would reccomend this article on Medscape (note login/registration maybe required) for a more clinically focussed approach.

My Experience

Idiot at the Gym

In 2012 I decided to go back to the Gym to work on my shrinking musculature. (Note the photos is not me!)

Being a textbook idiot I decide to lift weights with my ego rather than using my actual muscles or utilising my brain at all.

It had been a good few years since I had gotten out of the habit of going to the gym, but despite this I was trying (very badly) to lift the same kind of weights and do the same kind of intensity I used to.

Bad idea.

When I got home I felt pretty sore - but not the worst I had ever felt after a workout. I also didn't seem to have an injury like a muscle tear or anything that would restrict my movement.

(The photo below is not me either sadly.)

My urine looks like Coca Cola

I went to pass urine and there was an unpleasant suprise.

It came out a very dark brown colour with a red tinge. This was not like concentrated urine when you are dehydrated. (Note the photo is not a serving suggestion for your urine.)

This was not just dark but like pure undiluted Coca-Cola or Dr Pepper and this was despite being well hydrated and having drunk more than 500ml of water about half an hour earlier.

I felt no pain or other symptoms on passing water as I would if I had a UTI (urinary tract infection). There was also no smell that I was able to detect.

Had I not known about these things I might have ignored it because I felt fine. I'm sure a lot of people do. Some of those people probably end up dead or seriously injured as a result of ignoring this and other signs.

I knew what it was immediately. Rhabdomyolysis (scroll down for explanation) - exercise induced in this case.

Fun at the Hospital

So I took myself straight to hospital and explained the situation.

Unfortunately I had some blank stares when explaining the situation as many people, even health professionals, don't really think about this very often.

Some of the first nurses I saw were telling me "You should have been drinking plenty of water to prevent this".

Whilst it is important to stay hydrated to protect your kidneys this is not the cause of rhabdomyolysis and I explained I had been drinking plenty of water. I think some of them thought I just had very concentrated urine due to dehydration.

So I found myself explaining what was actually going on to quite a few people who hadn't actually come across it before or had forgotten about it.

Thankfully I ended up under the care of the very nephrologist who taught me as a student. It would have looked bad if I hadn't spotted this!

I was on a drip in hospital being monitored for the next 3-4 days and being given plenty of fluids. It was incredibly boring but I was very lucky to not have had any complications.

Had I not known about this serious condition and ignored it I could well be dead now or with very serious damage to my kidneys.

What is Rhabdomyolysis?

Rhabdo - referring to striped (striated), myo to muscle, lysis means destruction of cells. (Image shows muscle cells.)

- It is a disorder where the breakdown of excessive quantities of striated (skeletal) muscle cells releases potentially toxic breakdown products into the bloodstream.

These can cause damage to the renal (kidney) tubules resulting in acute renal failure which is very serious and a potential cause of sudden death often due to potassium abnormalities.

Early treatment can prevent any damage to the kidneys occuring, hence preventing renal failure and further complications.

As I said in the introduction when you hear of people suddenly dropping dead after or even during a marathon or athletic event - this can be a common contributing cause.

- If you slip into acute renal failure it can disrupt levels of blood electrolytes particularly potassium which can lead to fatal abnormalities of heart rhythm.

Even if it does not reach that point there can be long lasting damage to your kindeys causing chronic renal failure.

What causes it?

Basically anything that can damage muscle cells (a comprehensive list would be too long to post here) but some common causes are:

extreme muscle strain or injury e.g. marathons, athletic events, being an idiot at the gym
drugs e.g. alcohol, cocaine or certain medications (e.g.statins) which can cause damage to muscle cells
crush injuries or immobilisation which exerts continuous pressure on large muscles

Rarer:

electric shocks/burns
hyperthermia (raised body temperature) or heat stroke
metabolic disorders like ketocidosis
muscular diseases e.g. muscular dystrophy
viral or bacterial infections
cancers either directly or indirectly due to metasteses

Signs/Symptoms

Mainly muscular pain or weakness but can be asymptomatic. The classic clinical triad for presentation (source Medscape) is:

myalgias (muscle pain)
generalised weakness
dark urine

However this is only seen in about 50% of patients.

In more severe cases or latter stages can cause abdominal pain, nausea, raised pulse, reduced urine output and fever. Alteration of consciousness can also occur.

What to do - VERY IMPORTANT

-Go to hospital ER/Casualty immediately and inform them of your symptoms.

Even if you are wrong it is not worth waiting around to see.

(Also maintain your hydration by drinking water - don't force it down though, that can cause problems in itself.)

Diagnosis/Tests (basic there are many more see link)

History and examination (injury, muscle soreness, pre-existing condition etc), including visualisation of urine.
Urinalysis for myoglobin (an oxgen carrying protein similar to haemoglobin that is found in muscle cells, it has a red/brown colour and gives the urine it's characteristic appearance).
Blood tests for muscle enzymes such as CK (Creatine Kinase).
Routine bloods can help to elucidate the cause and U&Es (Urea and Electrolytes) are used to monitor renal function.
It is also standard practise to keep an eye on liver function too, liver enzyme disruption may occur which can confuse the issue.
Specific tests to narrow down causes depending on the situation and clinical history.

Treatment

This mainly involves flushing the kidneys with IV fluids and monitoring for signs of renal failure.

In severe cases dialysis may be required and any metabolic or secondary complications as a result of renal failure will need to be treated.

If it is a secondary complication of a pre-existing disease or illness then that will need to be appropriately managed or brought under control too.

Most people who get to hospital in time suffer no long term consequences.

TLDR- If your urine looks like Coca-Cola go straight to hospital - even if you feel fine - your life could depend on it.

Conclusions

I have kept this as simple as possible for people to read. I hope I have struck the right balance.

If you want more detailed information I would recommend reading the Wikipedia article which actually contains a lot of useful information. For detailed clinical information I would reccomend the Medscape update.

This post has not been sponsored by Coca-Cola or Dr Pepper!

The Obligatory Kitten Photo

Thank you for reading. I hope you found it useful.

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Some of my Previous Posts and Tutorials:

Does your urine look like COCA COLA? - GO STRAIGHT TO HOSPITAL - Rhabdomyolysis