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"documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2017;148:526-7" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Nutcracker syndrome associated with thin basement membrane nephropathy" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "526" "paginaFinal" => "527" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Síndrome del cascanueces asociado a la enfermedad de la membrana basal fina" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Marta Cano-Megías, Loreto Fernández-Rodríguez, Patricia Martínez-Miguel" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Marta" "apellidos" => "Cano-Megías" ] 1 => array:2 [ "nombre" => "Loreto" "apellidos" => "Fernández-Rodríguez" ] 2 => array:2 [ "nombre" => "Patricia" "apellidos" => "Martínez-Miguel" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775317301082" "doi" => "10.1016/j.medcli.2017.01.026" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775317301082?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020617303327?idApp=UINPBA00004N" "url" => "/23870206/0000014800000011/v1_201706250038/S2387020617303327/v1_201706250038/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Swollen arms due to acute rhabdomyolysis: An easily missed diagnosis" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "527" "paginaFinal" => "528" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Yale Tung-Chen, Gabriela González Alvárez, César Carballo-Cardona" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Yale" "apellidos" => "Tung-Chen" "email" => array:1 [ 0 => "yale.tung@salud.madrid.org" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Gabriela" "apellidos" => "González Alvárez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "César" "apellidos" => "Carballo-Cardona" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Urgencias, Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Reumatología, Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Edema de brazos tras rabdomiólisis aguda: un diagnóstico pasado por alto" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Rhabdomyolisis is a very common condition, characterized by an extensive, acute and rapid necrosis of the skeletal muscle, induced by inherited diseases, toxins, trauma or inflammatory processes.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> It is also regularly associated with exercise, especially in untrained subjects. The classical triad is myalgia, weakness and darkened urine, merely seen in 50% of the patients.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Diffuse muscle swelling has also been reported.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> If left untreated can lead to serious life threatening complications.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We herein report a case of a 32-year-old Caucasian man who presented in the emergency department with bilateral, symmetrical and painless upper extremity swelling over the course of 4 days. The patient did not report any relevant past medical history and denied any type of recreational drug abuse.</p><p id="par0015" class="elsevierStylePara elsevierViewall">He started a strength exercise routine in the gym 2 weeks earlier, which consisted in multiple repetitions of lifting weight with his upper body. The swelling started to appear gradually a week after the exercise started and was painless since the beginning. In the lapse of 4 days was clinically visible with evident subcutaneous edema. At that time, he consulted his general physician, and was diagnosed of tendonitis and treated with nonsteroidal anti-inflammatory drugs (ibuprofen 600<span class="elsevierStyleHsp" style=""></span>mg tid) without clinical improvement. He did not notice color changes, elbow joint stiffness or pain, tingling in her hands, cramping, weakness, redness or temperature increase. He denied fever, dark urine, previous trauma or injury, recent infectious diseases, changes in his daily routine or any recent travel abroad.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The physical examination revealed a visible bilateral pitting edema from his mid-upper arms to the distal forearms including the hand. There was no tenderness on palpation or increased local heat over the affected area. Skin coloration was normal with no visible wounds. He had painless passive and active range of motion of her wrists, elbows, and shoulders bilaterally. The neurologic exam was unremarkable, without muscle weakness or sensory deficit. Triceps, biceps, and brachioradialis deep tendon reflexes were equal bilaterally. Both radial and ulnar pulses were regular, strong, and symmetric. He was hemodynamically stable with normal blood pressure (134/63<span class="elsevierStyleHsp" style=""></span>mmHg), heart rate (52<span class="elsevierStyleHsp" style=""></span>bpm), and had no fever (36.5<span class="elsevierStyleHsp" style=""></span>°C).</p><p id="par0025" class="elsevierStylePara elsevierViewall">Laboratory results showed a creatine kinase (CK) of 8496<span class="elsevierStyleHsp" style=""></span>U/L [normal: 39–308], C-reactive protein (CRP)<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>2.9<span class="elsevierStyleHsp" style=""></span>mg/dL [0–3], <span class="elsevierStyleSmallCaps">d</span>-dimer of 934<span class="elsevierStyleHsp" style=""></span>ng/mL [0–500], lactate dehydrogenase (LDH) of 264<span class="elsevierStyleHsp" style=""></span>U/L [87–241]. B-type natriuretic peptide (BNP) 55<span class="elsevierStyleHsp" style=""></span>pg/mL [0–155]. Electrolytes (sodium, potassium, calcium, bicarbonate) and kidney function were normal with a creatinine level at 0.84<span class="elsevierStyleHsp" style=""></span>mg/dL [0.7–1.31] and urea level of 45<span class="elsevierStyleHsp" style=""></span>mg/dL [15–39]. WBC 4200/μL [3700–11600] (62.4% neutrophils; 27.4% lymphocytes), hemoglobin 14.9<span class="elsevierStyleHsp" style=""></span>g/dL [13.5–17.2], platelet 190,000/μL [150,000–370,000]. Complete coagulation and biochemistry tests results were normal.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Then, a point-of-care ultrasound was performed of the upper extremities using a GE LOGIQ-e ultrasound system fitted with a linear transducer (8.0–16.0<span class="elsevierStyleHsp" style=""></span>MHz) (General Electrics Healthcare, Madrid, Spain). This showed a cobblestone edema suggesting fluid surrounding the subcutaneous tissue, between the dermis and the muscular fascia. No signs of acute inflammation, distal or proximal venous thrombosis were detected. Acute exercise induced rhabdomyolysis was diagnosed on the basis of these results.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Because of the patient general appearance and hemodynamic stability, the clinical and blood test results, monitoring and observation were no necessary. The patient was discharged from the emergency room with proper advice to limit exercise and adequate oral hydration. There was a quick recovery in his clinical status, being asymptomatic 1 week later.</p><p id="par0040" class="elsevierStylePara elsevierViewall">We searched MEDLINE (1950 to week 1, December 2016) and EMBASE (1980 to week 49, 2016) using keyword searching related to “rhabdomyolysis” and “bilateral swelling”. Despite the popularity and increased expansion of hypertrophy-specific training methods,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> based on excessive exercising to allow muscle hypertrophy, exercise-induced rhabdomyolisis and muscle swelling has rarely been reported.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Edema due to rhabdomyolysis could be remarkably underdiagnosed, since it is usually self-limited in young patients, relays upon clinical suspicion and there are many other causes for subcutaneous edema (congestive heart failure, cellulitis, vein or arterial thrombosis, myositis, drug-induced myopathy), which makes the diagnosis even more challenging. Additionally, our case illustrates how powerful point-of-care ultrasound can be in the emergency setting, not only to rule out all other causes of limb edema, but also false positive <span class="elsevierStyleSmallCaps">d</span>-dimer elevation.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Awareness and prompt therapy are mandatory, essentially with fluid resuscitation and nephrotoxicity prevention measures, to reduce morbidity and mortality, usually due to rhabdomyolysis-related kidney injury and renal failure: avoiding ionizing radiation exams, harmful treatments (e.g. NSAIDs) and unnecessary hospitalization in patients without comorbidities.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,3</span></a> In the diagnostic evaluation, ultrasound can be of use; it is a cheap, sensitive, non-invasive and a reproducible test.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Tung-Chen Y, González Alvárez G, Carballo-Cardona C. Edema de brazos tras rabdomiólisis aguda: un diagnóstico pasado por alto. Med Clin (Barc). 2017;148:527–528.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Rhabdomyolysis: an evaluation of 475 hospitalized patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "G. Melli" 1 => "V. Chaudhry" 2 => "D.R. 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Cervellin" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ejim.2013.07.012" "Revista" => array:6 [ "tituloSerie" => "Eur J Intern Med" "fecha" => "2014" "volumen" => "25" "paginaInicial" => "45" "paginaFinal" => "48" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23948628" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000014800000011/v1_201706250038/S2387020617303315/v1_201706250038/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000014800000011/v1_201706250038/S2387020617303315/v1_201706250038/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020617303315?idApp=UINPBA00004N" ]
