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13 September 2022 : Case report  USA

[In Press] Physiologic Response to Exercise or Rhabdomyolysis? Creatine Phosphokinase Elevation in 16 Asymptomatic Firefighters

Unusual clinical course, Challenging differential diagnosis

Rajia Arbab12ABCDEF, Carla Erb12BCDE, Justin Joy2E, Hanady Zainah2EG, Majed Mark Samarneh3BEG

DOI: 10.12659/AJCR.937084

Am J Case Rep In Press; DOI: 10.12659/AJCR.937084  

Available online: 2022-09-13, In Press, Corrected Proof

Publication in the "In-Press" formula aims at speeding up the public availability of the pending manuscript while waiting for the final publication. The assigned DOI number is active and citable. The availability of the article in the Medline, PubMed and PMC databases as well as Web of Science will be obtained after the final publication according to the journal schedule


We present a case series of 16 trainee firefighters who presented to the Emergency Department with elevated creatine phosphokinase levels of greater than 14 000 units per liter 3 days after the initiation of intense aerobic exercise. All 16 patients were diagnosed with exercise-induced rhabdomyolysis and were mostly asymptomatic. While exercise-induced rhabdomyolysis often affects untrained individuals who abruptly initiate strenuous exercises, our patients were all physically well-trained and maintained an active training regimen. In review of this unusual case series, we assess the patients’ risk factors for exercise-induced rhabdomyolysis and the complications of their elevated creatine phosphokinase levels despite their asymptomatic presentations.
We focus on the exercise routine, hospital admission, and course of treatment for 4 of the 16 patients who gave written consent to participate in the study. Therapy was targeted towards intravenous fluids and the lowering of creatine phosphokinase levels. Patients 1, 2, 3, and 4 were discharged when creatine phosphokinase levels decreased by 17%, 40%, 39%, and 40%, respectively.
Given the differing guidelines for diagnosis, treatment, and discharge for asymptomatic exercise-induced rhabdomyolysis, it was unclear if this was a physiologic or pathologic response to exercise, if hospital admission was indicated, and the extent to which creatine phosphokinase had to decrease for discharge. Our aim is to: 1) determine recommendations to prevent muscle injury following exercise, 2) distinguish between physiologic response to exercise and clinically significant muscle damage, and 3) and recommend a course of treatment given asymptomatic presentation.

Keywords: Acute Kidney Injury; Rhabdomyolysis; Sports Medicine


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American Journal of Case Reports eISSN: 1941-5923
American Journal of Case Reports eISSN: 1941-5923