106 Rabdomiolisis

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Text of 106 Rabdomiolisis

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RabdomiolisisDr Ricardo FadiUnidad NeuromuscularDepartamento de NeurologaFacultad de MedicinaPontificia Universidad Catlica de Chile

Lancet 2009;373:154Tc99-labelled diphosphonate bone scan1Rabdomiolisis historia

NUMEROS 11:31-34

31Y vino un viento de Jehov, y trajo codornices del mar, y las dej sobre el campamento, un da de camino a un lado, y un da de camino al otro, alrededor del campamento, y casi dos codos sobre la faz de la tierra.

32Entonces el pueblo estuvo levantado todo aquel da y toda la noche, y todo el da siguiente, y recogieron codornices; el que menos, recogi diez montones; y las tendieron para s a lo largo alrededor del campamento.

33An estaba la carne entre los dientes de ellos, antes que fuese masticada, cuando la ira de Jehov se encendi en el pueblo, e hiri Jehov al pueblo con una plaga muy grande.

34Y llam el nombre de aquel lugar Kibrot-hataava, por cuanto all sepultaron al pueblo codicioso.

Billis AG. Acute renal failure after a meal of quail. Lancet 1971; 298:7021500 AC appRabdomiolisis historia

Intoxication due to quail consumption is rarely seen. Such a toxicological syndrome (also called coturnism) occurs during the migration of quails from north to south, when they consume hemlock seeds.

Coturnix coturnixEarly writers used quail as the standard example of an animal that could eat something poisonous to man without ill effects for themselves.

Aristotle (On Plants 820:6-7),

Philo (Geoponics: 14: 24),

Lucretius (On the Nature of Things: 4: 639-640),

Galen (De Temperamentis: 3:4) Rabdomiolisis historia

Conium maculatum: Cicutina o coniinaNeurotoxina que bloquea receptorescolinrgicos nicotnicos

399 ACCicuta acutica (Cicuta maculata) vs cicuta venenosa (Conium maculatum)Rabdomiolisis historia

History of the crush syndrome: from the earthquakes of Messina, Sicily 1909 to Spitak, Armenia 1988. Am J Nephrol 1997;17:392Primera descripcin del sndrome de aplastamiento. Terremoto en Messina, Sicilia 1909

Captain Scott's expedition to the South Pole. Standing, left to right - Capt Lawrence Oates, Capt Robert Falcon Scott, PO Edgar Evans. Seated, left to right - Lt Henry Bowers, Dr Edward Adrian Wilson

Freedman BJ. Dr. Edward Wilson of the Antarctic. Proc R Soc Med 1954;47:183Rabdomiolisis historiaPrimera descripcin del sndrome del compartimiento. Wilson en su msculo tibial anterior durante la expedicin de Scott (30 Enero 1912)Rabdomiolisis

Rabdomiolisis: ruptura rpida de clulas musculares con entrada masiva de componentes intracelulares potencialmente txicos a la circulacin

Tra clsica: paresia, mialgia, pigmenturia

Menos del 10% presenta trada clsica.

Mas del 50% no tiene paresia o mialgias, presentandose solo con mioglobinuria

26.000 casos reportados anualmente en EEUU.22.2 casos /100.000 reclutas por ao (1)

1. Natural history of exertional rhabdomyolysis: a population-based analysis. Muscle Nerve 2010;42:48791Rabdomiolisis

American Heart Association: CK mayor 10x valor normal. Proposiciones entre 5x a 50x valor normal

Rabdomiolisis: clinica

Msculos sensibles y edematosos

Debilidad muscular

Orinas color t mioglobinuria

Considerar debilidad por otras causas: miopata del paciente crtico, parlisis peridica, sGB, miopata aguda no necrotizante

Considerar que debilidades focales pueden ser neuropatas por compresin secundarias a aplastamiento

Rabdomiolisis: clinica

CK sobre 16.000 aumenta riesgo de falla renal

75% causa adquirida

AdultosAbuso drogas (34%)Farmacos (11%)Trauma (9%)Crisis convulsiva (7%)

60% pacientes: dos o mas causas

Rhabdomyolysis: Review of the literature Neuromuscular Disorders 2014;24:651659phosphatidate phosphataseThis enzyme participates in 4metabolic pathways:glycerolipid,glycerophospholipid,ether lipid, andsphingolipidmetabolism.10Rabdomiolisis: clinica

Rhabdomyolysis: Review of the literature Neuromuscular Disorders 2014;24:651659Nios

Miositis virales (38%)Trauma (26%)Dermatomiositis (5%)Intoxicacin farmacolgica (4%)Ejercicio (4%)Alt. Metablicas (4%)

phosphatidate phosphataseThis enzyme participates in 4metabolic pathways:glycerolipid,glycerophospholipid,ether lipid, andsphingolipidmetabolism.11Rabdomiolisis: clinica

Causas comunes

No recurrente en adultos:

alcohol y drogas, convulsiones, compresin muscular (aplastamiento e inmobilidad)

No recurrente en nios:

trauma, coma hiperosmolar, infecciones (influenza, CMV, EBV, estrepto hemoltico, VIH, Salmonella, Legionella), distona

Rhabdomyolysis: an evaluation of 475 hospitalized patients. Medicine 2005;84:377

Miopata subyacente o defecto metablico muscular 10%Rabdomiolisis

Dia entrenamiento03714CK Promedio/mediana223/157734/4781226/567667/486499 reclutas. Ninguno hizo rabdomiolisis (paresia, CK elevada, mioglobinemia y/omioglobinuria. Rango de CK: 34-35056Serum creatine kinase after exercise: drawing the line between physiological response and exertional rhabdomyolisis. Muscle Nerve 2012;45:356-362Rabdomiolisis: clinica

Rhabdomyolysis: Review of the literature Neuromuscular Disorders 2014;24:651659Complicaciones:

Insuficiencia renal agudaHipercalemiaHipocalcemiaInflamacin hepticaArritmias y paro cardacoCIDSndrome del compartimiento10%- 40% de pacientes desarrollan IRA, y 15% de los casos de IRA pueden ser atribudos a rabdomiolisisphosphatidate phosphataseThis enzyme participates in 4metabolic pathways:glycerolipid,glycerophospholipid,ether lipid, andsphingolipidmetabolism.14Rabdomiolisis

Irrespective of the initial insult, the final stepsleading to rhabdomyolysis involve either direct myocyteinjury or a failure of the energy supply within themuscle cells.15Rabdomiolisis: causas adquiridas

Exertion (1, 2, 4)Exercise; march myoglobinuria; status epilepticus; delirium; psychosis; electric shock, electroconvulsive therapy; prolonged cardiopulmonary resuscitation and cardioversion; status asthmaticus; tetanus; prolonged myoclonus, dystonia or chorea;neuromyotonia; conga drumming; keyboard operation; ravers hematuriaCrush (2)External weight; prolonged immobility (including coma, Parkinsons disease); exaggerated lithotomy position and other surgical positions; pseudo-crush syndrome (torture victims, child abuse); pneumatic antishock garmentIschemia (4)Arterial occlusion; compartment syndrome; cardiopulmonary bypass; vena cava ligation; disseminated intravascular coagulation; sickle cell disease; air embolism; atrial myxoma; diabetes mellitus; increased capillary permeability syndromeMetabolic (1, 3, 4)Hypokalemia; diabetic ketoacidosis; nonketotic hyperglycemic/hyperosmolar states; hyper/hyponatremia; hypophosphatemia; hypothyroidism; near drowning; renal tubular acidosis; pancreatitis; Crohns disease with elemental dietExtremes of body temperature (1, 2, 4)Fever; burns; hypothermia (exposure, hypothyroidism)Rabdomiolisis: causas adquiridas

Drugs and toxinsMetabolic (1, 3, 4)Anticholinergics; antidepressants (all classes); antihistamines (diphenhydramine, doxylamine); arsenic; azathioprine; barbiturates; benzodiazepines; bezafibrate; carbon monoxide; clofibrate; cytotoxics; ethanol; ethylene glycol; fenfluramine; gemfibrozil;glutethamide; interferon; methanol; naltrexone; opiates; propofol; oxprenolol; labetolol; paracetamol; podophyllin; statins; zidovudine; isolated limb perfusion (multiple agents); streptokinase; alteplaseHypokalemia (1, 4)Amphotericin; carbenoxolone; glycirrhizate (licorice); itraconazole; laxative abuse; methylxanthines (caffeine, theophylline);thiazides and other kaliureticsIschemia (4)Aminocaproic acid; cocaine; vasopressinAutoimmune (2, 4)Cyclosporin; famotidine; levodopa; nonsteroidals; penicillamine; phenylbutazone; phenytoin; trimethoprimsulfamethoxazoleMembrane effect (1, 2)Carbon tetrachloride; cimetidine; colchicine; didanosine; dyes; gasoline; hydrocarbons; herbicides; iron dextran; metal fumes;quinidine; solvents; detergents; succinylcholine; toluene; vecuronium, pancuronium (especially combined with high-dose steroids);snake/spider/hornet/bee/fugu/parrotfish venomsRabdomiolisis: causas adquiridas

Drugs and toxins (2)

Agitation (2, 4)Hemlock (quail eaters); ketamine; lithium; loxapine; LSD; mercuric chloride; phencyclidine; salicylates; strychnine; terbutaline

Neuroleptic malignant syndrome (1, 2, 4)Butyrophenones; levodopa and dopamine agonist withdrawal; lithium; phenothiazines; pimozide; promethazine; thioxanthenes

Serotonergic syndrome (1, 2, 4)Amphetamines; Ecstasy; lithium; monoamine oxidase inhibitors; nefazodone; pethidine; selective serotonin reuptake inhibitors;tricyclic antidepressants; tryptophan; venlafaxine

Mechanism uncertainAmiodarone; blowpipe dart poisoning; chromium picolinate; Haff disease; isoniazid; kidney beans; lamotrigine; nicotinic acid;peanut oil; pentamidine; valproateRabdomiolisis: causas hereditarias

Glycolytic/glycogenolytic (4)Myophosphorylase deficiency (McArdles disease)Phosphofructokinase deficiencyPhosphoglycerate kinase deficiencyPhosphoglycerate mutase deficiencyLactate dehydrogenase (LDH)-A deficiencyPhosphorylase b kinase deficiencyDebrancher enzyme

Fatty acid oxidation (4)Carnitine palmitoyl transferase (CPT) II deficiencyCarnitine deficiencyShort/medium/long/very long-chain and multipleacyl-coenzyme A dehydrogenase deficienciesElectron transfer flavoprotein (ETF) deficiencyETF dehydrogenase deficiencyKetoacyl CoA thiolase deficiencyTrifunctional enzyme deficiencyLong-chain fatty acid -oxidation defects (incompletely characterized)Rabdomiolisis: causas hereditarias

Krebs cycle (4)Aconitase deficiencyLipoamide dehydrogenase deficiency

Pentose ph