AR Meijer de

Gerhard A. Mueller

Gerrit Hagenah

JM Sarjeant

K Reynes

KC Goswami

L Pinede

Michael Klinger

Miriam Puls

Sabine Blaschke

Stefan Schweyer

Ulf Nagorsnik

English

PubMed

Springer - Publisher Connector

Gerrit Hagenah
Michael Klinger
Ulf Nagorsnik
Miriam Puls
Stefan Schweyer
Gerhard A. Mueller
Sabine Blaschke
Acute renal failure due to severe
rhabdomyolysis: a rare clinical
manifestation of atrial myxoma
Accepted: 12 November 2008
Published online: 24 January 2009
 The Author(s) 2009. This article is
published with open access at
Springerlink.com
Rhabdomyolysis is usually caused by
physical, infectious or toxic factors
and may be complicated by acute
renal failure (ARF) associated with a
high mortality rate of more than 20%
[1]. We report about a very unusual,
but emergent cause of severe
rhabdomyolysis due to peripheral
embolism of a left atrial myxoma.
A 36-year-old male patient was
admitted to hospital due to lumbalgia.
Patient’s history revealed neither
traumatic injury nor intake of drugs.
Clinical examination only showed
right-sided weakness in ankle dorsi-
flexion, hip flexion and adduction.
Vital parameters, ECG findings,
X-ray and MRI of the lumbar spine
were normal. Laboratory tests
revealed highly elevated serum crea-
tine phosphokinase (286,580 U/l, n:
B270 U/l), myoglobin (56,000 lg/l,
n: B75 lg/l), lactate dehydrogenase
(4,926 U/l, n: B232 U/l), aspartate
aminotransferase (4,263 U/l,
n: B35 U/l), alanine aminotransferase
(701 U/l, n: B45 U/l) levels and
inflammation parameters (CRP
145 mg/l, n: B8 mg/l). Renal func-
tion was impaired (creatinine
173 lmol/l, n: 61–104 lmol/l; urea-
Fig. 1 Embolism of a left atrial cardiac myxoma a Echocardiography. Four-chamber
image from ECG-gated line-balanced fast field echo pulse sequence showed an intra-atrial
mass (arrow) with attachment to the inter-atrial septum. LA left atrial cavity, LV left
ventricular cavity, RA right atrial cavity, RV right ventricular cavity b MRI angiography of
the aortic and large lower extremity vessels. MRI perfusion image shows a circumscribed
perfusion defect at the aortic bifurcation with subocclusive stenosis of the right-sided A.
iliaca communis. This area revealed a bright signal enhancement on T1-weighted inversion
recovery images obtained after intravenous injection of gadobutrol. c Histopathology. At
thoracic surgery the left atrial mass was 6 9 4 9 3 cm in diameter. Histopathological
examination of the resected tumor revealed a benign myxoma with characteristic myxoid
stromal tissue containing a low number of tumor cells with uniform small nuclei and focal
accumulation of siderophages. Tumor cells did not exhibit any signs of atypia (H&E,
9100)
Intensive Care Med (2009) 35:1312–1313
DOI 10.1007/s00134-009-1398-3 CORRESPONDENCE
N 5 mmol/l, n: 1.3–3.5 mmol/l; uric
acid 655 lmol/l, n: 208–440 lmol/l;
glomerular filtration rate 31 ml/min,
n: 80–170 ml/min/1.73 m2). Kidney
ultrasonography revealed no signs of
hydronephrosis or perfusion defects.
MRI of pelvis and thighs due to the
development of acute myalgias in the
right leg demonstrated compartment
syndrome of the M. iliopsoas and
femoral muscles. After emergent
fasciotomy, transthoracic echocardi-
ography performed due to
hemodynamic instability demon-
strated a left atrial inhomogenous
mass (Fig. 1a). Furthermore, MRI
angiography initiated due to signs of
lower extremity vascular occlusion
revealed a circumscribed perfusion
defect at the aortic bifurcation
(Fig. 1b). Surgical removal of the
atrial mass and its aortic embolus was
immediately performed and histopa-
thology revealed a typical cardiac
myxoma (Fig. 1c). Patient’s postop-
erative course was complicated by
ARF, arrhythmias and serious infec-
tions. However, multiple organ
dysfunction could completely be
restored after 6 weeks of intensive
care management.
Discussion
Atrial myxomas represent 50% of all
primary benign cardiac tumors in
adults aged 30–60 years and occur
more often in women [2]. Clinical
manifestations include one or more of
the classical triad of cardiovascular
symptoms, constitutional symptoms
and peripheral or visceral signs of
embolization which is detected in up
to 30–50% of cases [3]. Peripheral
embolism leads to clinical signs of
ischemia including purple discolor-
ation of the skin not present on
admission of our case. Furthermore,
renal embolism as a potential cause of
ARF could be ruled out in this case
by Doppler sonography. Thus,
although embolism of cardiac myxo-
mas represents a common feature,
ARF due to severe rhabdomyolysis as
primary manifestation of myxoma is
rare and has not been published so
far. To prevent ARF in rhabdomyol-
ysis fluid resuscitation, urine
alkalinization and administration of
loop diuretics are recommended. In
severe cases precipitation of myo-
globin and uric acid crystals within
renal tubules may lead to ARF.
Due to a low specificity of clinical
symptoms as demonstrated in this
case, diagnosis of cardiac myxomas
represents a challenge. Two-dimen-
sional echocardiography was shown
to be the most useful screening
method [4]. Despite adequate treat-
ment options by open thoracic heart
surgery [5], serial echocardiography
at regular intervals is recommended
during long-term follow-up due to
recurrence in up to 5% of cases.
Open Access This article is distributed
under the terms of the Creative Commons
Attribution Noncommercial License which
permits any noncommercial use, distribu-
tion, and reproduction in any medium,
provided the original author(s) and source
are credited.
References
1. de Meijer AR, Fikkers BG, de Keijzer
MH, van Engelen BG, Drenth JP (2003)
Serum creatine kinase as predictor of
clinical course in rhabdomyolysis: a
5-year intensive care survey. Intensive
Care Med 29:1121–1125
2. Reynes K (1995) Cardiac myxomas. N
Engl J Med 333:1610–1617
3. Pinede L, Pierre D, Loire R (2001)
Clinical presentation of left atrial cardiac
myxoma: a series of 112 consecutive
cases. Medicine 80:159–172
4. Goswami KC, Shrivastava S, Bahl VK,
Saxena A, Manchanda SC, Wasir HS
(1998) Cardiac myxomas: clinical and
echocardiographic profile. Int J Cardiol
63:251–259
5. Sarjeant JM, Butany J, Cusimano RJ
(2003) Cancer of the heart: epidemiology
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G. Hagenah  U. Nagorsnik  G. A. Mueller
S. Blaschke
Department of Nephrology and
Rheumatology, University Medicine of
Goettingen, Go¨ttingen, Germany
M. Klinger
Department of Orthopaedics,
University Medicine of Goettingen,
Go¨ttingen, Germany
M. Puls
Department of Cardiology and
Pulmonology, University Medicine
of Goettingen, Go¨ttingen, Germany
S. Schweyer
Department of Pathology,
University Medicine of Goettingen,
Go¨ttingen, Germany
S. Blaschke ())
Department of Nephrology and
Rheumatology, Georg-August-University of
Go¨ttingen, Robert-Koch Str.40,
37075 Go¨ttingen, Germany
e-mail: sblasch@gwdg.de
Tel.: ?49-551-396331
Fax: ?49-551-398906
1313


Acute renal failure due to severe rhabdomyolysis: a rare clinical manifestation of atrial myxoma

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Serum creatine kinase as predictor of clinical course in rhabdomyolysis: a 5-year intensive care survey. Intensive Care Med 29:1121–1125 2. Reynes K

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Acute renal failure due to severe rhabdomyolysis: a rare clinical manifestation of atrial myxoma

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