RHABDOMYOLYSIS

Scenario: A case of RTA with fracture tibia, fibula and compartment syndrome
with marked raised S. creatinine level. Urine RME shows plenty RBC, High K+
level!

1. What is your diagnosis?

ARF due to rhabdomyolysis with compartment syndrome
following RTA.
2. What are Causes of this clinical scenario?
Crush injury, Compartment syndrome, hyperkalemia, acute
reperfusion injury.
3. What is the pathophysiology of Renal failure?
Impairment of sarcoplasmic Na-K pump resulting in decreased Na
extrusion, reduce Ca and water efflux and myofibril disruption with
muscle damage specially Type-2 Muscle. That causes release of
myoglobin, Purine, K+ and Phosphate.
4. Why DIC?
Pathological activation of coagulation cascade by release of muscle
component.
5. What might be the Complications:
Hypovolemia: Sequestration of fluid within injured muscle and
hemorrhage in necrosed muscle.
ARF: Due to myoglobinuria as because iron is toxic to renal tubule and
forms mechanical blockage. Also ARF develops from hypovolemia.
Metabolic complications:
i. Metabolic acidosis
ii. Hyperkalemia: Release of intracellular K + , Rena failure, and
acidosis.
iii. Hyperuricemia: Due to increased hepatic conversion of
purine.
iv. Hyperphosphatemia: Increased release of phosphate from
injured muscle.

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6. Investigation:
a. Urine R/M/E: Myoglobinuria (positive dipstick test for blood in
absence of hematuria).
b. Serum enzyme:
CK, CK-MM, CPK (creatinine phosphokinase)
LDH
Carbonic anhydrase 3 (more specific marker).
7. What is reperfusion injury?
Revascularization of non-viable acutely injured muscle causes acidosis,
hyperkalemia, rhabdomyolysis and myoglobinuria due to release of toxic
anaerobic metabolites from infarcted muscle.
8. Management:
a. Assessment and maintenance of ABC.
b. Transfer patient to ITU.
c. Iv fluids, O2 inhalation, Analgesics
d. Inform consultant, involve Critical care team.
e. Maintenance of adequate fluid balance-
Adequate hydration
Maintain Urine output >300ml/hour (To clear
myoglobin).
Start Glucose Insulin infusion and IV CaCl2
Diuretics- Mannitol (30ml/hour)
IV NaHCO3
9. How will you be monitoring patient?
CVP Line
ABG, S electrolyte
ECG, Pulse oximetry
Pulmonary artery occlusive pressure
Vital chart
10. When will you consider renal replacement therapy?
a. Established oliguric renal failure
b. Uncontrolled hyperkalemia
c. Fluid overload.

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 UTI AND CARCINOMA PROSTATE

Case scenario: A case of urinary tract infection (URE report positive) with
PSA level high with H/O Radical prostatectomy for Prostate cancer.

1. What is your diagnosis?

Urinary tract infection/ Sepsis due to UTI.
2. How much colony count positive for UTI?
105 colony/ml or 1lac colony/ml
3. Most common organism for UTI?
E Coli
4. Suggest 3 blood investigations for this patient?
FBS with ESR, CRP, Culture sensitivity.
5. What's main component in white cell count?
Neutrophil
6. What causes of increase WCC post operation?
UTI, infection, sepsis.
7. PSA normal value is <4ng/ml. 6 months after prostatectomy, PSA level is
3ng/ml. what might be the cause?
Recurrence of carcinoma of prostate.
8. Biopsy done and histopathology shows presence rectal tissue. What
might be the cause?
Metastatic involvement of rectum.
9. Why multiple biopsy taken?
Due to multiple lobe of prostate and cancer may involve one lobe.
10. In Bone metastasis, which blood component will raise?
Lymphocyte
11. Normally in prostate cancer, one of the treatments is bilateral
orchidectomy. What is your rationale? Is there any role of orchidectomy?
Yes, it reduces or stop testosterone production, so decrease
chance of recurrence. It also reduces bone pain due to metastasis.
12. Which primary cell in testes produce testosterone?
Leydig cell and also sertoli cell.

13. What scoring system used in Carcinoma prostate?

Gleasons score.

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 Hypercalcemia and MEN syndrome

Scenario: Patient with parathyroid hyperplasia.

1. What are the causes of secondary hypercalcemia?
Renal failure, Bony metastasis, Vit-D toxicities, TB, Sarcoidosis,
Thiazide diuretics, Para-neoplastic syndrome in multiple
myeloma, Ca lung.
2. What are the position of parathyroid gland?
2 Superior glands-
2 inferior glands-
3. What is hyperplasia?
Increased volume of organ by increased number of cell.
4. Hyperplasia occurs in which parathyroid gland?
Hyperplasia occurs in all 4 glands but adenoma developed only in
one gland.
5. Parathyroid hyperplasia belongs to which syndrome?
MEN-2a Syndrome.
6. In Insulinoma- what is the insulin level?
Raised
7. How do you diagnose?
FBS, CT scan of Abdomen, PTH hormone, S Ca++, MRI of brain.
8. What are the Pancreatic tumor causing hypoglycemia?
Insulinoma, Nesidioblastoma, Addisons disease.
9. Given that this is having parathyroid and pancreatic involvement, what is
the other pathology? What does it is called?
Pituitary gland. MEN-1 syndrome and MEN-2a Syndrome.
10. What is Knudson two hit hypothesis?
Hypothesis that explain cancer is the result of accumulation of
mutation to a cell DNA. In MEN-1, mutation of menin gene either
negatively regulate cell growth or participate in maintenance of
genomic integrity.
11. Apart from tumor suppressor gene, what are the other groups of gene
mutation?
TNF, Oncogene, Proto-oncogene.

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12. What's apoptosis? Is it energy driven?
Its a pathway of cell death that is induced by a tightly regulated
intracellular programme in which cell destinate to die.
13. What is telomere?
Telomere is the distinctive structures of DNA found at the end of
our chromosome and consist of the same sequence of bases
repeated over and over.