I am a 29 year old cyclist and triathlete. I have had two bouts of rhabdo this year, all associated with traveling (without any type of abnormal strenuous exercise). The first time it occurred after a 4 hour flight from WA to TN, and it was only my left quad that was in excruciating pain. The second time occurred in both quads after traveling in the car for 10 hours (with stops every 30-60 minutes, walks, and plenty of fluids). Does anyone else have knowledge or experience with these random episodes of rhabdo? Doctors are at a loss for why this is happening to my body.
sent PM, best wishes
.
lots of other causes for rhabdo other than exertion. drugs, metabolic processes, genetics
here’s an interesting case, were you sick in the month before?
https://journals.lww.com/em-news/blog/TheCaseFiles/Lists/Posts/Post.aspx?List=b36793fc-09b9-4746-8cc5-0aa90f6188ef&ID=135&Web=51bd4619-bc72-45d8-a970-801a8c90877c
Rhabdo was confirmed with lab work? Are you taking in enough fluids? Kidney issues?
That really sucks.
Meghan! Glad you decided to post this.
For all reading:
I hope you’ll consider pinging any MD or athlete friends who might have answers in this case. Seems peculiar to me, and so far, her med team have been unable to help in any way.
She’s following through with all present MD requests.
Can for sure rule out that it’s related to exertion, trauma, drug, viral, bacterial. Her Hx = remarkable only in it’s complete lack of remarkableness. (Read: 1 glass of wine a month but stopped months ago.)
CK of course has been sky high when rhabdo diagnosed and symptoms present.
Liver enzymes slightly elevated, in all testing. Peculiar to me, but very outside my expertise.
Rhabdo was confirmed with lab work? Are you taking in enough fluids? Kidney issues?
That really sucks.
Yes Rhabdo confirmed with lab work. Hydration practices are good. No know kidney issues.
More FYI to all interested:
Liver enzymes have been routinely elevated, as has MCV, slightly, but no MD has mentioned liver concern… which seems odd. Of course, she has no reason to be expected to have liver disease. Certainly not via obesity or alcohol intake as a lean and competitive endurance athlete circa age 30.
AST has ranged from 128-192unit/L. (Normal = 5-32unit/L)
ALT has ranged from 55-101unit/L. (Normal = 5-41unit/L)
MCV has ranged from 95-99fL. (Normal = 81-93fl to 80-99fL depending on source don’t quote me here)
I believe liver enzymes have been elevated chronically, away from any recurrent rhabdo diagnosis but maybe Meghan can confirm here.
More related info: This study points to potential interaction between liver disease and rhabdo.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4087657/#:~:text=Muscular%20symptoms%20such%20as%20muscle,established%20as%20a%20disease%20entity.
There’s quite a few studies on Rhabdo and migrants/refugees who undergo hard travel…but I couldn’t see anything on the google about getting rhabdo from a plan flight.
Is sickle cell trait a possibility?
Or other hemoglobinopathy…
edit:
has the elevated liver enzymes been worked up-check for hepatitis, unusual liver diseases etc?
She’s out practicing transitions with my wife right now but I’ll make sure she jumps on and answers these Q’s this evening. She’s new to ST.
Rhabdo was confirmed with lab work? Are you taking in enough fluids? Kidney issues?
That really sucks.
Yes Rhabdo confirmed with lab work. Hydration practices are good. No know kidney issues.
More FYI to all interested:
Liver enzymes have been routinely elevated, as has MCV, slightly, but no MD has mentioned liver concern… which seems odd. Of course, she has no reason to be expected to have liver disease. Certainly not via obesity or alcohol intake as a lean and competitive endurance athlete circa age 30.
AST has ranged from 128-192unit/L. (Normal = 5-32unit/L)
ALT has ranged from 55-101unit/L. (Normal = 5-41unit/L)
MCV has ranged from 95-99fL. (Normal = 81-93fl to 80-99fL depending on source don’t quote me here)
I believe liver enzymes have been elevated chronically, away from any recurrent rhabdo diagnosis but maybe Meghan can confirm here.
More related info: This study points to potential interaction between liver disease and rhabdo.
https://www.ncbi.nlm.nih.gov/...%20disease%20entity.
In all honesty, I think that we need to unpack the liver enzymes first. She’s borderline with the AST values as typically clinicians look for values <5x upper limit while asymptomatic. It’s likely nothing (e.g. byproduct of strenuous training, elevated CK potentially supports this), or it could be something. If it’s something, it’s worth knowing about.
- Do you have the rest of the liver panel values? ALP / GGT / Bili / Albumin / Total Protein?
- Markers of inflammation (Ferritin, CRP, ESR / Sed Rate, etc.)
- Thyroid Values?
- Digestive issues? e.g. Frequent diarrhea, modified diets, etc.
- Any physical symptoms (peripheral edema / Itching / abdominal pain or tenderness?)
- What supplements / Natural Remedies / etc. have been consumed in the past?
- Medications (including antibiotics such as Tetracycline for acne, SSRIs, Heart Burn meds, etc.)?
- Are NSAIDS used regularly?
- Hx of Autoimmunity in relatives (e.g. Lupus / Crohns or Colitis / etc.) ?
- Ashkenazi Jewish Descent?
- Negative for Viral Hepatitis?
Feel free to PM me if you want to take this offline.
Disclaimer: I’m not a doctor, just a physiologist with Auto-immune induced liver issues.
I am a 29 year old cyclist and triathlete. I have had two bouts of rhabdo this year, all associated with traveling (without any type of abnormal strenuous exercise). The first time it occurred after a 4 hour flight from WA to TN, and it was only my left quad that was in excruciating pain. The second time occurred in both quads after traveling in the car for 10 hours (with stops every 30-60 minutes, walks, and plenty of fluids). Does anyone else have knowledge or experience with these random episodes of rhabdo? Doctors are at a loss for why this is happening to my body.
Hi Meagan,
I am a doctor, without much experience in rhabdo overall, but more in my particular area (anaesthesia) where there is a specific genetic mutation which can cause something similar in response to some of our commonly used anaesthetic medications. This is definitely not the case in your situation.
Do you know what your CK was/peaked at with these two episodes?
What other signs/symptoms of rhabdo did you get?
Did you have any compartment pressures measured when you presented with this pain?
This is unusual, in that you go through strenuous training and have no issues yet you run into issues with travel where I presume you are seated in probably a similar position each time, and it has been isolated to your quads. What were you wearing when travelling? Anything that would constrict blood flow to your legs, particularly when seated??
I will do some investigation at this end, but looking at what is similar between the episodes then it would primarily be travel and the position you are in, which potentially points to more of a vascular issue as such. There are some vascular issues that are more common in endurance athletes, namely arterial endofibrosis. I am not sure if this is linked with rhabdo, will do some research now.
Abnormal LFTs is to be expected after some rhabdo.
Rhabdo was confirmed with lab work? Are you taking in enough fluids? Kidney issues?
That really sucks.
Yes Rhabdo confirmed with lab work. Hydration practices are good. No know kidney issues.
More FYI to all interested:
Liver enzymes have been routinely elevated, as has MCV, slightly, but no MD has mentioned liver concern… which seems odd. Of course, she has no reason to be expected to have liver disease. Certainly not via obesity or alcohol intake as a lean and competitive endurance athlete circa age 30.
AST has ranged from 128-192unit/L. (Normal = 5-32unit/L)
ALT has ranged from 55-101unit/L. (Normal = 5-41unit/L)
MCV has ranged from 95-99fL. (Normal = 81-93fl to 80-99fL depending on source don’t quote me here)
I believe liver enzymes have been elevated chronically, away from any recurrent rhabdo diagnosis but maybe Meghan can confirm here.
More related info: This study points to potential interaction between liver disease and rhabdo.
https://www.ncbi.nlm.nih.gov/...%20disease%20entity.
That isolated increase in AST is quite different to the article you quote Alex, which is a subset of relatively severe liver disease (cirrhosis). So I would not be chasing a liver related link to these two episodes.
There are many reasons for the mildly deranged LFTs and viral studies and things such as a liver ultrasound should be performed as a matter of course. Again, it would be most unlikely that these are related to the two episodes of rhabdo, the link to travel is important as if there was a link to underlying liver issues etc then you would expect to see it with hard racing and training etc.
Its always fun being a bit of a medical mystery!
Its always fun being a bit of a medical mystery!
Just as long as you are the mystery detective…Be it fun or not for the “victim in crime” its very important to have good mystery detectives around
.
I had a hematologist on my case about two years ago. No abnormal genetic blood disorders were found. I believe that the elevated liver enzymes may be looked into, but this may be correlated with the slightly elevated CK levels? When my CK is within NL (baseline is usually around 105), my ALT/AST levels also go back within normal limits.
Is sickle cell trait a possibility?
Or other hemoglobinopathy…
edit:
has the elevated liver enzymes been worked up-check for hepatitis, unusual liver diseases etc?
Here’s the list-you can decide who to see next-very puzzling, and not in my field of expertise. Consider myopathy?
Seems this is a ‘nontraumatic/nonexertional’ case unless the events are related to recent exertion…good luck to you.
Causes of muscle injury (rhabdomyolysis)
**Traumatic or compression **
Multiple trauma
Crush injuries
Vascular or orthopedic surgery
Coma
Immobilization
**Nontraumatic **
Exertional
Normal muscle
Extreme exertion
Environmental heat illness
Sickle cell trait
Seizures
Hyperkinetic states
Abnormal muscle
Metabolic myopathies
Mitochondrial myopathies
Malignant hyperthermia
Neuroleptic malignant syndrome
**Nonexertional **
Alcoholism
Drugs and toxins
Infections (including HIV)
Electrolyte abnormalities
Endocrinopathies
Inflammatory myopathies
Miscellaneous
All below labs were pulled on 11/4 - Asymptomatic, no more muscle pain. Bilateral quad pain and muscle cramping again with travel about 1.5 weeks prior to labs being pulled
- ALB 4.6 / Protein 7.8 / Bili 0.5 / *AST 41 (slightly high) / ALT 34
- ESR = 2. Creatinine = 0.8. Sed rate normal.
- **Tested positive for antibody Thyroid Peroxidase (77.1). T4 = 5.8. TSH 2.520. T3 Uptake = 33. T3 Total = 74. NOTE: Thyroid ultrasound will be completed. I have tested positive for this antibody before, and do have the diagnosis of Hashimotos. However, I have not been on any treatment or medications. **
- No digestive issues
- No physical symptoms
- No supplements taken or natural remedies
- No medications taken (occasional Tylenol, but nothing taken on a daily basis)
- No NSAID use chronically. Maybe once a month for a headache
- No family history of autoimmune diseases
- No Jewish descent
- Never tested positive for viral hepatitis
Rhabdo was confirmed with lab work? Are you taking in enough fluids? Kidney issues?
That really sucks.
Yes Rhabdo confirmed with lab work. Hydration practices are good. No know kidney issues.
More FYI to all interested:
Liver enzymes have been routinely elevated, as has MCV, slightly, but no MD has mentioned liver concern… which seems odd. Of course, she has no reason to be expected to have liver disease. Certainly not via obesity or alcohol intake as a lean and competitive endurance athlete circa age 30.
AST has ranged from 128-192unit/L. (Normal = 5-32unit/L)
ALT has ranged from 55-101unit/L. (Normal = 5-41unit/L)
MCV has ranged from 95-99fL. (Normal = 81-93fl to 80-99fL depending on source don’t quote me here)
I believe liver enzymes have been elevated chronically, away from any recurrent rhabdo diagnosis but maybe Meghan can confirm here.
More related info: This study points to potential interaction between liver disease and rhabdo.
https://www.ncbi.nlm.nih.gov/...%20disease%20entity.
In all honesty, I think that we need to unpack the liver enzymes first. She’s borderline with the AST values as typically clinicians look for values <5x upper limit while asymptomatic. It’s likely nothing (e.g. byproduct of strenuous training, elevated CK potentially supports this), or it could be something. If it’s something, it’s worth knowing about.
- Do you have the rest of the liver panel values? ALP / GGT / Bili / Albumin / Total Protein?
- Markers of inflammation (Ferritin, CRP, ESR / Sed Rate, etc.)
- Thyroid Values?
- Digestive issues? e.g. Frequent diarrhea, modified diets, etc.
- Any physical symptoms (peripheral edema / Itching / abdominal pain or tenderness?)
- What supplements / Natural Remedies / etc. have been consumed in the past?
- Medications (including antibiotics such as Tetracycline for acne, SSRIs, Heart Burn meds, etc.)?
- Are NSAIDS used regularly?
- Hx of Autoimmunity in relatives (e.g. Lupus / Crohns or Colitis / etc.) ?
- Ashkenazi Jewish Descent?
- Negative for Viral Hepatitis?
Feel free to PM me if you want to take this offline.
Disclaimer: I’m not a doctor, just a physiologist with Auto-immune induced liver issues.
If I remember correctly, my CK peaked at 12,000. Please note that I do have a hx of DVT, PEs, and saddle PE (this occurred back in May 2019 - cause is believed to be birth control. I had several specialists on the case, with no further findings on why blood clots occurred). The first rhabdo episode occurred back in June 2021.I believe something occurred when I was flying. This was my first long flight since blood clot event. I remember falling asleep for several hours on the plane. I woke up and was in a pool of sweat. My clothes were completely drenched and I was extremely lightheaded. I thought that maybe the plane had some type of air conditioning dysfunction, but everyone else on the plane was still bundled up. I don’t really know why I was sweating profusely. The plane landed, and I continued to drink my normal amount of fluids.
The following day, that is when the left quad pain started. The pain was immobilizing and started when I tried to ride my bike. When the first episode occurred, I thought it was another DVT. Pain was isolated left quad. I could no longer contract the muscle. I could barely walk. My first ER visit when this occurred, DVT workup was done, with no findings. No CK was pulled during this ER visit. I was sent home. I went back to the ER three days later, because I was still struggling to perform daily activities and could no longer ride my bike, as I was in TN for nationals. I would say the left quad pain at the time was severe, it would bring me to tears just walking around the grocery store. CK was finally ordered, with levels at about 12,000. I had no other symptoms. No urinary symptoms. The pain would actually move, from one quad muscle to another, i.e., rectus femoris, vastus lateralis, and even vastus medialis.
When I travel, I typically just wear loose athletic shorts. No compression socks.
Vascular Aortic Iliac ultrasound was ordered a couple weeks later (6/29/2021), to see if I had any scarring from previous blood clots. No abnormal stenosis was noted in the aorta. Right and left iliac arteries showed no evidence of arterial occlusive diseases.
I am a 29 year old cyclist and triathlete. I have had two bouts of rhabdo this year, all associated with traveling (without any type of abnormal strenuous exercise). The first time it occurred after a 4 hour flight from WA to TN, and it was only my left quad that was in excruciating pain. The second time occurred in both quads after traveling in the car for 10 hours (with stops every 30-60 minutes, walks, and plenty of fluids). Does anyone else have knowledge or experience with these random episodes of rhabdo? Doctors are at a loss for why this is happening to my body.
Hi Meagan,
I am a doctor, without much experience in rhabdo overall, but more in my particular area (anaesthesia) where there is a specific genetic mutation which can cause something similar in response to some of our commonly used anaesthetic medications. This is definitely not the case in your situation.
Do you know what your CK was/peaked at with these two episodes?
What other signs/symptoms of rhabdo did you get?
Did you have any compartment pressures measured when you presented with this pain?
This is unusual, in that you go through strenuous training and have no issues yet you run into issues with travel where I presume you are seated in probably a similar position each time, and it has been isolated to your quads. What were you wearing when travelling? Anything that would constrict blood flow to your legs, particularly when seated??
I will do some investigation at this end, but looking at what is similar between the episodes then it would primarily be travel and the position you are in, which potentially points to more of a vascular issue as such. There are some vascular issues that are more common in endurance athletes, namely arterial endofibrosis. I am not sure if this is linked with rhabdo, will do some research now.
Abnormal LFTs is to be expected after some rhabdo.
All below labs were pulled on 11/4 - Asymptomatic, no more muscle pain. Bilateral quad pain and muscle cramping again with travel about 1.5 weeks prior to labs being pulled
- ALB 4.6 / Protein 7.8 / Bili 0.5 / *AST 41 (slightly high) / ALT 34
- ESR = 2. Creatinine = 0.8. Sed rate normal.
- **Tested positive for antibody Thyroid Peroxidase (77.1). T4 = 5.8. TSH 2.520. T3 Uptake = 33. T3 Total = 74. NOTE: Thyroid ultrasound will be completed. I have tested positive for this antibody before, and do have the diagnosis of Hashimotos. However, I have not been on any treatment or medications. **
- No digestive issues
- No physical symptoms
- No supplements taken or natural remedies
- No medications taken (occasional Tylenol, but nothing taken on a daily basis)
- No NSAID use chronically. Maybe once a month for a headache
- No family history of autoimmune diseases
- No Jewish descent
- Never tested positive for viral hepatitis
Terrific, with those numbers, I agree that liver issues driving this are unlikely. I was under the impression that they were running 3-5x the reference range consistently which does not appear to be the case.