Mind On The Run: “Case Report: Weightlifters Beware!”
By Anthony Kovatch, M.D., Pediatric Alliance — Arcadia Division
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(Musical Accompaniment: “Vertigo” by Bernard Herrmann, from the original motion picture soundtrack.)
Case Report: Weightlifters Beware
Abstract: When two excessive-compulsive adolescent athletes engage in a friendly weight-lifting competition in the off-season, the outcome can be threatening — to the muscles of the most valuable player on the golf team, as well as to his life. We report a case of rhabdomyolysis that progressed so rapidly that all involved were confounded and therapy was delayed.
Introduction: The patient (BH) was a 17-year-old high school senior envied in the school district for his trim, muscular build and athletic and intellectual prowess; he lettered in golf and baseball. Due to his popularity and stage presence, BH anchored the morning news report at his school — joined by his lifelong friend and sidekick Norman, who was even more muscular and a star on the football team.
The two were inseparable, so engaging in head-to-head competitions merely ratified the close friendship. Conditioning for baseball started upon completion of the golf and football seasons and the trainer urged the boys to progress slowly. Ignoring this judicious input, the two entered into a fierce one-upmanship marathon of upper body weight lifting, alternating ten curls each until their biceps was so sore that they could no longer bend their arms (and then some). Continuing in the spirit of abject excess, BH continued his “conditioning” by working out his quads with squats the following day. He ignored the fact that he could not move his arms without pain. “No pain, no gain!”
Results: The following day the mother of BH (a triage nurse) realized that in spite of his lack of complaints his upper arms were swollen and that his behavior was stranger than that of a normal teenager; she made the mistake of making an appointment with an excessive-compulsive physician who runs long distance as a “weekend warrior” under the premise “no pain, no gain.” In the couple of hours before the appointment, the patient developed dizziness, blurring of vision to the point where he could hardly drive, and nausea. BH continued to wear his perennial smile during examination by the physician (let’s call him “Quack”) and the diagnosis of severe biceps muscle strain with toxins in body was made. Quack was correct about one thing: BH was dehydrated and required extra fluids; inability to do so mandated IV fluids. The patient reassured everybody that he could manage self-hydration at home. Quack should have realized at that time that the patient was delirious!
BH never made it home. He vomited repeatedly and was taken by his mother to the local ER, where his delirium worsened to the point where he could not remember what month it was. With IV fluids he was able to produce a urine specimen resembling dark tea.
Bloodwork showed an elevated potassium level, abnormal liver functions tests, and a creatine phosphokinase (CPK) of 58,000 (normal less than 300). The diagnosis which had escaped Quack — severe, life-threatening rhabdomyolysis — prompted transfer to an esteemed tertiary care center.
Flushing the muscle breakdown products out of the body to prevent obstruction in the kidneys and shutdown of function was crucial. The intoxicating body fluids had to be removed promptly at the expense of cosmesis. Infusion of 3-4 times the patient’s blood volume per day resulted in swelling of his arms to look like sausages and bloating of his face. His nurse mother cried so many tears over the three days of his hospitalization that she also became dehydrated and dizzy. Norman visited to provide comic relief as all realized that “laughter is the best medicine.” Slowly but surely, BH’s CPK diminished and his delirium faded. The swelling of his arms never reached the point where his muscles had to be flayed open to release the pressure.
As his mental status improved, BH remembered that he had taken a dose of oral creatine powder on the day of his weight lifting to increase the bulk of his muscles; this likely added to his egregiously elevated CPK levels. With no more secrets to uncover, the patient, mother, and doctors became very bored and BH was discharged to the care of a sports medicine clinic. Quack insisted on follow-up with Doctor Freddie Fu, but no one took him seriously at that point.
(Musical Accompaniment: “Happy” by Pharrell Williams.)
Because of his overall athleticism, BH’s outpatient rehabilitation was brief, lasting only 2 weeks. His psychological rehabilitation was complete after a two-week vacation to Australia to visit his godfather over the holidays. He recently was awarded a dean’s scholarship to an advanced 5-year Physician’s Assistant program at a college where he can play Division III baseball. Surpassing all these honors was the ability to rejoin his life-long friend Norman and anchor the morning news.
Discussion: The goal of weight training is to break down muscle fibers gradually with compensatory hypertrophy increasing muscle bulk and consequently overall strength. In our case, youthful enthusiasm essentially made this go awry. Norman was a regular weightlifter with football and his muscles were accustomed to constant breakdown and recovery. Although also muscular, BH was required to tone his muscles for the finesse of perfecting his golf swing. He sought avidly to catch-up to his sidekick in off-season conditioning for baseball by “blitzkrieg” lifting which caused rapid muscle breakdown and release of the products of this process — myoglobin (shed in urine), creatine, and other toxins into the bloodstream where they produced an encephalitis-like clinical presentation. Deposition of these toxins in the kidneys can lead to kidney shutdown (requiring dialysis) or even death. Correcting the metabolic derangements (high potassium can cause cardiac arrest) is life-saving. Managing flush-out of the toxins requires “oceans” of IV fluids which must be administered with extreme caution and monitoring in a medical center. This must never be attempted at home as Quack initially thought might be possible.
Rhabdomyolysis is not a usual player on the pediatric stage outside of prolonged seizures, crush injuries, and electrocutions. CPK can be mildly elevated with the muscle aches commonly accompanying influenza and moderately elevated after prolonged athletic endeavors, like marathons and triathlons, especially when maintaining hydration is a challenge. Prolonged pressure on muscles with enforced bedrest is common in adults. The intoxicated individual who falls asleep on the toilet for hours is at risk, as are those on statins for high cholesterol.
(This citation from WebMD provides a reader-friendly overview.)
Conclusion: Rhabdomyolysis is a rare but serious complication of overzealous weightlifting, especially when the individual has a good amount of muscle to break down, ignores the caveat to progress gradually, has excessive-compulsive tendencies, and has a close lifelong athletic friend who can tempt him into irrational undertakings. The prognosis is excellent for those with vigilant mothers (especially if they are nurses), symptoms so dramatic that they seek prompt medical attention (in spite of opposition by the patient), and those who have a close lifelong athletic friend who can incite enough laughter to reverse the consequences of irrational undertakings.
Key words: Rhabdomyolysis, excessive-compulsive, Quack