American Journal of Medical Case Reports
ISSN (Print): 2374-2151 ISSN (Online): 2374-216X Website: http://www.sciepub.com/journal/ajmcr Editor-in-chief: Samy, I. McFarlane
Open Access
Journal Browser
Go
American Journal of Medical Case Reports. 2014, 2(11), 232-236
DOI: 10.12691/ajmcr-2-11-2
Open AccessArticle

Rhabdomyolysis Complicating Acute CO Poisoning: A Case Study and a Review

Shimaa M. Motawei1, , Salwa M. El-Wasify2, Sahar A. Eldakroury1 and Adel M. Elmansoury1

1Forensic Medicine & Clinical Toxicology, Mansoura University Emergency Hospital, Mansoura, Egypt

2Nephrology Department, Urology & Nephrology Center, Mansoura University, Egypt

Pub. Date: October 28, 2014

Cite this paper:
Shimaa M. Motawei, Salwa M. El-Wasify, Sahar A. Eldakroury and Adel M. Elmansoury. Rhabdomyolysis Complicating Acute CO Poisoning: A Case Study and a Review. American Journal of Medical Case Reports. 2014; 2(11):232-236. doi: 10.12691/ajmcr-2-11-2

Abstract

Introduction: Carbon Monoxide (CO) is a colourless, odourless, tasteless gas. Mild poisoning by CO can be Mistaken for a non-specific headache or a viral illness headache or viral illness. Moderate to severe CO poisoning produces significant morbidity and mortality that provokes treatment controversy. Rhabdomyolysis, compartment syndrome, renal failure and peripheral neuropathy are unusual complications of CO That can be faced during practice and should be considered by physicians. Case presentation: A 34-years old Egyptian male was referred to the Toxicology Unit from the ED for evaluation of his lower limb weakness. Initial examination revealed a fully conscious patient with stable vital signs and arterial blood gases. However, the patient cannot stand steadily or walk. Neurologic examination revealed hypotonia and diminished reflexes in both lower limbs. No history of toxin exposure but a condition of sudden acute illness affecting him and his parents and upon which his old-age parents, were transferred to ICUin coma. Investigations revealed increased serum alanine transaminase and serum creatinine. A work-up that involved appropriate imaging and serum creatinekinase (CK) measurement revealed extremely elevated serum CK, normal appearance of liver and increased echogenicity of both kidneys with preserved cortico-medullary differentiation. Based on the above-mentioned data, a diagnosis of rhabdomyolysis complicating acute CO exposure with secondary renal insult was made. The patient begins haemodialysis with follow up of his serum K+, creatinine and CK. After one month, levels of serum creatinine and alanine transaminase became normal. The patient underwent rehabilitation therapy to improve his neuromuscular state. Conclusion: Carbon monoxide poisoning should be suspected in patients presented with acute illness without prior medical or surgical cause, and rare complications of CO poisoning like rhabdomyolysis should be suspected particularly in patients with delayed seek of medical care. Timely prompt medical care involving team therapy is necessary to prevent further complications like RF and muscle wasting.

Keywords:
acute CO poisoning complications rhabdomyolysis acute renal failure

Creative CommonsThis work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

References:

[1]  Lavonas E. J.: Carbon Monoxide Poisoning. In: Haddad and Winchester’s Clinical Management of Poisoning and Drug Overdose, 4th ed., 2007, Shannon, M. W., Borron, S. W. and Burns, M. J., Eds., Elsevier, publisher. Ch. (87). P. p. 1297-1307.
 
[2]  Tomaszewski C. "Carbon Monoxide". In: Goldfrank’s Toxicologic Emergencies, 8th ed., Flomenbaum, Neal E.; Goldfrank, Lewis R.; Hoffman, Robert S.; Howland, Mary Ann; Lewin, Neal A.; Nelson, Lewis S. Eds., 2006, McGraw-Hill publisher. Ch. (120). P.p. 1689-1703.
 
[3]  White DB, Curtis JR, Wolf LE, Prendergast TJ, Taichman DB, Kuniyoshi G, Acerra F, Lo B, Luce JM. Life support for patients without a surrogate decision maker: who decides?. Ann Intern Med. 2007; 147(1): 34-40.
 
[4]  Centres for Disease Control and Prevention. Non-fatal, unintentional, non-fire related carbon monoxide exposures-United States, 2004-2006. MMWR Morbid. Mortal. Wkly Rep. 2008; 57: 896-899.
 
[5]  Weaver LK, Hopkins RO, Chan KJ,Churchill S, Elliott CG, Clemmer TP, Orme JF Jr, Thomas FO, Morris AH.Hyperbaric oxygen for acute carbon monoxide poisoning. N Engl J Med. 2002; 117: 801-808.
 
[6]  Sefer S, Degoricija V, Bilić B, Trotić R, Milanović-Stipković B, Ratkovi-Gusić I, Kes P. Acute carbon monoxide poisoning as the cause of rhabdomyolysis and acute renal failure. Acta Med Croatica. 1999; 53(4-5): 199-202.
 
[7]  Janković SR, Stosić JJ, Vucinić S, Vukcević NP, Ercegović GV. Causes of rhabdomyolysis in acute poisonings. Vojnosanit Pregl. 2013. 70 (11): 1039-45.
 
[8]  Huang, L. E.; Willmore, W. G.; Gu, J.; Goldberg, M. A. andBunn, H. F., Inhibition of hypoxia-inducible factor 1 activation by carbon monoxide and nitric oxide. Implications for oxygen sensing and signalling". J. Biol. Chem. 1999; 274 (13): 9038-9044.
 
[9]  Huzar, T. F.; George, T. andCross, J. M., Carbon monoxide and cyanide toxicity: etiology, pathophysiology and treatment in inhalation injury. Expert Rev Respir Med., 2013; 7 (2): 159-170.
 
[10]  Szponar, J.; Kołodziej, M.; Majewska, M.; Zaleski, K. andLewandowska-Stanek, H., Myocardial injury in the course of carbon monoxide poisoning. PrzeglLek., 2012; 69 (8): 528-534.
 
[11]  Bild, W.; Ciobica, A.; Padurariu, M. andBild, V., The interdependence of the reactive species of oxygen, nitrogen, and carbon. J PhysiolBiochem. 2013; 69 (1): 147-154.
 
[12]  Aksu, N. M.; Akkaş, M.; Çoşkun, F.; Karakiliç, E.; Günalp, M.; Akküçük, H.; Ataman, D. K.; Özcan, H.; Özmen, M. M., Could vital signs predict carbon monoxide intoxication?. J Int Med Res. 2012; 40 (1): 366-370.
 
[13]  Ruth-Sahd, L. A.; Zulkosky, K.and Fetter, M. E., Carbon monoxide poisoning: case studies and review. DimensCrit Care Nurs. 2011; 30 (6): 303-314.
 
[14]  Kao, L. W. and Nañagas, K. A., Carbon monoxide poisoning. Med Clin North Am. 2005, 89 (6): 1161-1194.
 
[15]  Zorbalar, N.; Yesilaras, M. and Aksay, E., Carbon monoxide poisoning in patients presenting to the emergency department with a headache in winter months. Emerg Med J. 2013, Epub ahead of print.
 
[16]  Kamisawa, T.; Ikawa, M.; Hamano, T.; Nagata, M.; Kimura, H. andYoneda, M., A case of interval form of carbon monoxide poisoning without increased carboxyhemoglobin level diagnosed by characteristic MR spectroscopy findings. RinshoShinkeigaku. 2014, 54 (3): 234-237.
 
[17]  Kudo K, Otsuka K, Yagi J, Sanjo K, Koizumi N, Koeda A, Umetsu MY, Yoshioka Y, Mizugai A, Mita T, Shiga Y, Koizumi F, Nakamura H, Sakai A. Predictors for delayed encephalopathy following acute carbon monoxide poisoning. BMC Emerg Med., 2014, 14: 3.
 
[18]  Ilano AL, Raffin TA. Management of carbon monoxide poisoning. Chest. 1990, 97 (1): 165-169. Cited from: Tomaszewski C. "Carbon Monoxide". In: Goldfrank’s Toxicologic Emergencies, 8th ed., Flomenbaum, Neal E.; Goldfrank, Lewis R.; Hoffman, Robert S.; Howland, Mary Ann; Lewin, Neal A.; Nelson, Lewis S. Eds., 2006, McGraw-Hill publisher. Ch. (120). P. 1694.
 
[19]  Buckley NA, Isbister GK, Stokes B, Juurlink DN. Hyperbaric oxygen for carbon monoxide poisoning: a systematic review and critical analysis of the evidence. Toxicol. Rev., 2005; 24 (2): 75-92.
 
[20]  Boehmer TK, Foster SL, Henry JR, Woghiren-Akinnifesi EL, Yip FY; Centers for Disease Control and Prevention (CDC). Residential proximity to major highways - United States, 2010. MMWR SurveillSumm. 2013, 62 Suppl. 3: 46-50.