Question 4.2

A 22-year-old male is brought into the Emergency Department with a decreased conscious state with a history of having been missing for over twenty-four hours. Results of his investigations are given below:


Patient Value

Adult Normal Range


149 mmol/L*

135 – 145


6.0 mmol/L*

3.5 – 5.0


114 mmol/L*

95 – 105


19.0 mmol/L*

22.0 – 26.0


210 μmol/L*

45 – 90


10.1 mmol/L*

3.0 – 8.0


1.75 mmol/L*

2.10 – 2.60


2.29 mmol/L*

0.80 – 1.50


1.42 mmol/L*

0.70 – 1.30


21 g/L*

35 – 50

Alkaline phosphatase (ALP)

62 IU/L

< 120

Gamma-glutamyl transferase (GGT)

22 IU/L

< 50

Alanine aminotransferase (ALT)

424 IU/L*

< 55

Aspartate aminotransferase (AST)

1679 IU/L*

< 50

Total bilirubin

12 μmol/L

< 19

T Protein

38 g/L*

60 – 82

Creatinine Kinase

10315 IU/L*

< 175

a) Give the likely diagnosis and list five possible underlying causes.    (30% marks)

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College answer

Not available.


What happened to this random dude?

  • Hypernatremia suggests dehydration
  • Raised creatinine and urea suggest the same
  • Raised CK, high phosphate and low calcium  suggest rhabdomyolysis
  • The LFTs are not particularly exciting, nor is the bilirubin, but the wildly elevated AST also suggests muscle injury (as AST can also leak from injured muscle)

So, everything looks like rhabdomyolysis, with a bit of kidney injury perhaps from the myoglobin-related damage or perhaps from the dehydration related to being collapsed on the kitchen floor for a day. Now we have to come up with five reasons why. There are literally a million possible causes of rhabdomyolysis, and the successful candidate would need to identify five which are associated with a decreased level of consciousness. Drugs trauma and environmental exposure would have to be on that list, because young people do be like that.

  • Intoxication with a CNS depressant
  • Necrotising fasciitis and septic shock
  • Seizures (status epilepticus)
  • Heat stroke
  • Head injury (?drug-related)
  • Subarachnoid haemorrhage (could be related to drugs)
  • Serotonin syndrome (also drugs)
  • Accidental intrararterial injection of cocaine 


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Bosch, Xavier, Esteban Poch, and Josep M. Grau. "Rhabdomyolysis and acute kidney injury." New England Journal of Medicine 361.1 (2009): 62-72.

Shapiro, Mark L., Anthony Baldea, and Fred A. Luchette. "Rhabdomyolysis in the intensive care unit." Journal of intensive care medicine 27.6 (2012): 335-342.

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Vanholder, Raymond, et al. "Rhabdomyolysis." Journal of the American Society of Nephrology 11.8 (2000): 1553-1561.

Bosch, Xavier, Esteban Poch, and Josep M. Grau. "Rhabdomyolysis and acute kidney injury." New England Journal of Medicine 361.1 (2009): 62-72.

Allison, Ronald C., and D. Lawrence Bedsole. "The other medical causes of rhabdomyolysis." The American journal of the medical sciences 326.2 (2003): 79-88.

Brown, Carlos VR, et al. "Preventing renal failure in patients with rhabdomyolysis: do bicarbonate and mannitol make a difference?." Journal of Trauma-Injury, Infection, and Critical Care 56.6 (2004): 1191-1196.

Scharman, Elizabeth J., and William G. Troutman. "Prevention of kidney injury following rhabdomyolysis: a systematic review." Annals of Pharmacotherapy47.1 (2013): 90-105.

Sorrentino, Sajoscha A., et al. "High permeability dialysis membrane allows effective removal of myoglobin in acute kidney injury resulting from rhabdomyolysis." Critical care medicine 39.1 (2011): 184-186.

Tang, Wanxin, et al. "Renal protective effects of early continuous venovenous hemofiltration in rhabdomyolysis: improved renal mitochondrial dysfunction and inhibited apoptosis." Artificial organs 37.4 (2013): 390-400.

Ioannidis, Konstantinos, et al. "Safety and effectiveness of the combination acetazolamide and bicarbonates to induce alkaline diuresis in patients with rhabdomyolysis." European Journal of Hospital Pharmacy 22.6 (2015): 328-332.

Hohenegger, Martin. "Drug induced rhabdomyolysis." Current opinion in pharmacology 12.3 (2012): 335-339.

Chavez, Luis O., et al. "Beyond muscle destruction: a systematic review of rhabdomyolysis for clinical practice." Critical care 20.1 (2016): 135.

Chatzizisis, Yiannis S., et al. "The syndrome of rhabdomyolysis: complications and treatment." European journal of internal medicine 19.8 (2008): 568-574.