Rhabdomyolyse bei Hashimoto-Thyreoiditis – Fallbericht und Literaturübersicht

Zusammenfassung

Bei klinisch vorhandenen Muskelschmerzen, einer massiven Erhöhung der CK im Serum und Myoglobulinurie liegt eine Rhabdomyolyse vor. Ursachen können neben Trauma, myotoxischen Medikamenten, Alkohol-, Drogenkonsum und Infektionen auch endokrine Stoffwechselstörungen oder Autoimmunerkrankungen sein. Auftretende Komplikationen sind beispielsweise akutes Nierenversagen und Kompartmentsyndrom. Das frühzeitige Erkennen der Ursache und deren Behebung und eine adäquate symptomatische Therapie verhindern schwerwiegende Komplikationen.

Wir präsentieren den klinischen Fall einer 44-jährigen Patientin, die sich mit dem Leitsymptom Myalgie vorstellte. Bei CK-Werten bis 8 830 IU/l. Begleitend zeigte sich ein Perikarderguss, ein Myxödem der Stimmlippen und im Verlauf trat eine Verschlechterung der Nierenfunk­tion auf. Unter L-Thyroxin Substitution und Volumensubstitution waren die Beschwerden rückläufig. Als Ursache diagnostizierten wir eine Hashimoto-Thyreoiditis.

Eine isolierte Hypothyreose als Ursache einer Rhabdomyolyse ist selten. In der Literatur finden sich häufig auslösende Kofaktoren in der Anamnese, vor allem eine Therapie mit HMG-CoA-Reduktase-Hemmern.

Bei Myalgien und CK-Erhöhung als Leitsymptom muss als Ursache neben anderen Auslösern an eine Hashimoto-Thyreoiditis gedacht werden. Durch Hormonsubstitution und adäquate symptomatische Therapie können Komplikationen vermieden werden.

Abstract

Clinical signs of rhabdomyolysis consist in myalgia, strong elevation of CK in the serum and myoglobinuria. Besides being caused by physical trauma, myotoxic drugs, infections, alcohol and drug abuse, rhabdomyolysis may also occur due to endocrinological disorders and autoimmune disease. Potential complications include acute renal failure and compartment syndrome. Early recognition of the cause underlying rhabdomyolysis allows adequate treatment and is important for the prevention of such complications.

Here we present the clinical case of a 44-year-old female patient presenting with severe myalgia and CK serum concentration of 8 830 IU/l. In addition the patient exhibited pericardial effusion, vocal cord myxedema and developed acute renal failure in the clinical course. Under treatment with L-Thyroxin and intravenous volume replacement therapy the patient’s symptoms improved rapidly. As underlying cause for rhabdomyolysis we diagnosed Hashimoto’s thyroiditis.

An isolated hypothyroidism as single cause of rhabdomyolysis is rare. In literature, published cases of rhabdomyolysis frequently exhibit cofactors in the patients’ medical history, mostly treatment with HMG-CoA reductase inhibitors.

When patients present with myalgia and elevated CK serum concentration as cardinal symptoms, apart from other causes, Hashimoto’s thyroiditis should be considered. In these cases, hormone substitution therapy as well as an adequate symptomatic treatment helps to prevent severe complications.

Schlüsselwörter

Rhabdomyolyse - Hypothyreose - Myxödem

Key words

rhabdomyolysis - hypothyreoidism - myxoedema

• Literatur

• 1 Khan FY. Rhabdomyolysis: a review of the literature. Neth J Med 2009; 67: 272-283
• 2 Melli G, Chaudhry V, Cornblath DR. Rhabdomyolysis: an evaluation of 475 hospitalized patients. Medicine (Baltimore) 2005; 84: 377-385
• 3 Karre PR, Gujral J, Rodriguez E. Rhabdomyolysis with erratic serum creatinin phosphokinase levels: intramuscular injection of haloperidol decanoate. BMJ Case Rep, 2009 2009;
• 4 Hohenegger M. Drug induced rhabdomyolysis. Curr Opin Pharmacol 2012; 12: 335-339
• 5 Ruggeri EM, Cecere FL, Moscetti L et al. Severe rhabdomyolysis during sunitinib treatment of metastatic renal cell carcinoma. A report of two cases. Ann Oncol 2010; 21: 1926-1927
• 6 Papadopoulos S, Ball AM, Liewer SE et al. Rhabdomyolysis during therapy with daptomycin. Clin Infect Dis 2006; 42: e108-e110
• 7 Sauermann R, Rothenburger M, Graninger W et al. Daptomycin: a review 4 years after first approval. Pharmacology 2008; 81: 79-91
• 8 Watanabe T. Renal complications of seasonal and pandemic influenza A virus infections. Eur J Pediatr 2013; 172: 15-22
• 9 Ishiwada N, Takada N, Okunushi T et al. Rhabdomyolysis associated with influenza A/H1N1 2009 infection in a pediatric patient. Pediatr Int 2012; 54: 703-705
• 10 Guedj R, Desguerre I, Brassier A et al. Unusual muscular injury in an infant with severe H1N1 infection. Pediatr Neurol 2012; 47: 51-54
• 11 Espiritu RP, Stan MN. Rhabdomyolysis after withdrawal of thyroid hormone in a patient with papillary thyroid cancer. Endocr Pract 2008; 14: 1023-1026
• 12 Madariaga MG. Polymyositis-like syndrome in hypothyroidism: review of cases reported over the past twenty-five years. Thyroid 2002; 12: 331-336
• 13 Kisakol G, Tunc R, Kaya A. Rhabdomyolysis in a patient with hypothyroidism. Endocr J 2003; 50: 221-223
• 14 Qari FA. Severe rhabdomyolysis and acute renal failure secondary to use of simvastatin in undiagnosed hypothyroidism. Saudi J Kidney Dis Transpl 2009; 20: 127-129
• 15 Farias Moeller R, Zecavati N, Sherafat-Kazemzadeh R et al. Adolescent with Rhabdomyolysis due to Undiagnosed Hypothyroidism. Case Rep Pediatr 2011; 2011: 670673
• 16 Sousa AA, Stauber Kronit H, Assis Rocha Neves F et al. Fenofibrate-induced rhabdomyolysis in a patient with chronic kidney disease: an unusual presenting feature of hypothyroidism. Arq Bras Endocrinol Metabol 2009; 53: 383-386
• 17 Muir P, Choe MS, Croxson MS. Rapid development of anterotibial compartment syndrome and rhabdomyolysis in a patient with primary hypothyroidism and adrenal insufficiency. Thyroid 2012; 22: 651-653
• 18 Sahoo J, Veerappan I, Abraham A et al. Hypothyroidism complicating nephropathy in a diabetes patient. Case Rep Endocrinol 2012; 2012: 237563
• 19 Kuo HT, Jeng CY. Overt hypothyroidism with rhabdomyolysis and myopathy: a case report. Chin Med J (Engl) 2010; 123: 633-637
• 20 Nikolaidou C, Gouridou E, Ilonidis G et al. Acute renal dysfunction in a patient presenting with rhabdomyolysis due to Hypothyroidism attributed to Hashimoto’s Disease. Hippokratia 2010; 14: 281-283
• 21 Delgado Hurtado JJ, Guevara W, Ramos E et al. Hypothyroidism in a five-year-old boy with rhabdomyolysis and recent history of cardiac tamponade: a case report. J Med Case Rep 2011; 5: 515
• 22 Mazokopakis EE. Unusual causes of rhabdomyolysis. Intern Med J 2008; 38: 364-367
• 23 Cai Y, Tang L. Rare acute kidney injury secondary to hypothyroidism-induced rhabdomyolysis. Yonsei Med J 2013; 54: 172-176