横纹肌溶解综合征误诊为糖尿病酮症酸中毒1例报告及文献复习

doi:10.13481/j.1671-587x.20200127

摘要/Abstract

摘要： 目的：分析横纹肌溶解综合征（RM）误诊为糖尿病酮症酸中毒（DKA）的原因，阐明二者引起代谢性酸中毒的机制，提高临床医生对RM和代谢性酸中毒的认识。方法：收集1例以DKA转入本科室后诊断为RM患者的一般情况、临床表现和实验室检查结果，结合国内外文献，分析RM的病因、临床表现、并发急性肾损害（AKI）的治疗方案及预后和本例患者出现RM的病因，探讨RM所致AKI引起的代谢性酸中毒及DKA所致的代谢性酸中毒发生机制和治疗等方面的异同。结果：患者，女性，56岁，因血糖升高15年，乏力、恶心和呕吐4 d入院。查体见患者颜面部水肿，舌质干，皮肤弹性差，心率110 min^-1，四肢重度凹陷性水肿，肌力Ⅳ级。辅助检查提示血清肌酸激酶、肌红蛋白、尿素氮和肌酐水平明显升高，血气分析提示代谢性酸中毒，还存在电解质紊乱及血常规异常。结合病史、症状、体征和各项辅助检查，明确诊断为RM、急性肾衰竭、酸碱平衡失调-代谢性酸中毒并发呼吸性碱中毒及电解质紊乱等，给予大量补液、碱化和保护重要脏器等治疗后，患者临床症状改善，血肌酸激酶、肌红蛋白和肾功能等各项指标较入院时明显好转，预后良好。结论：糖尿病患者可出现多种原因所致的代谢性酸中毒，应注意鉴别。由AKI和DKA所致的代谢性酸中毒在发病机制及治疗上存在差异，临床医生在救治由RM并发AKI所致的代谢性酸中毒时，应尽早给予充足的补液、碱化等有效治疗，以改善患者预后。

关键词: 代谢性酸中毒, 横纹肌溶解综合征, 糖尿病酮症酸中毒, 糖尿病

Abstract: Objective: To analyze the reasons of rhabdomyolysis (RM) misdiagnosed with diabetetic ketoacidosis (DKA), to clarify the mechanisms of metabolic acidosis caused by RM and DKA,and to enhance the clinical understanding of RM and metabolic acidosis. Methods: The general situation, clinical manifestation, laboratory examination results of the patient who was admitted with DKA and was diagnosed as RM in our department, were collected. Based on the literatures, the causes and manifestations of RM, as well as the treatments and prognosis of the acute kidney injure (AKI) induced by RM, and the reasons of RM of the presented patient were analyzed; the similiarities and differences of the mechanisms and treatments of metabolic acidosis caused by AKI induced by RM and DKA were discussed. Results: The patient who was a 56 year-old female with hyperlycemia for 15 years, and fatigue, nausea and vomiting for 4 d was admitted. The physical examination results showed facial edema, dry tongue, poor skin elasticity, heart rate 110 min^-1, severe depressed edema of extremities, muscle strength Ⅳ level. The anxiliary examination results demonstrated that the levels of blood muscle enzymes, myoglobin, urea nitrogen and creatinine were increased; the blood gas analysis indicated metabolic acidosis, accompanying with electrolyte disturbance and abnormal blood routine. According to the history, symptoms and signs, as well as the laboratory test results, the patient was diagnosed as RM, AKI, metabolic acidosis combined with respriatory alkalosis, electrolyte disturbance, and so on.The clinical symptoms and signs of the patient were recovered, and the blood creatine kinase, myoglobin and renal fuction were significantly improved after the treatment of adequate volume replacement, alkalization and protection of vital organs; the patient had a good prognosis. Conclusion: The diabetic patients may suffer from metabolic acidosis due to various causes which should be paid attention to differential diagnosis. There are some differences of the mechanisms and treatments of metabolic acidosis caused by AKI and DKA. If given the treatment of adequate volume replacement, alkalization early and aggressively, the metabolic acidosis caused by RM combined with AKI can have an excellent prognosis.

Key words: metabolic acidosis, rhabdomyolysis, diabetic ketoacidosis, diabetes mellitus

中图分类号:

R578.1

赫广玉, 刘玉佳, 高影, 韩丹, 王桂侠. 横纹肌溶解综合征误诊为糖尿病酮症酸中毒1例报告及文献复习[J]. 吉林大学学报(医学版), 2020, 46(01): 154-158.

HE Guangyu, LIU Yujia, GAO Ying, HAN Dan, WANG Guixia. Rhabdomyolysis misdiagnosed as diabetic ketoacidosis: A case report and literature review[J]. Journal of Jilin University(Medicine Edition), 2020, 46(01): 154-158.

参考文献

[1] ZUTT R, VAN DER KOOI A J, LINTHORST G E, et al. Rhabdomyolysis:review of the literature[J]. Neuromuscul Disord, 2014, 24(8):651-659.
[2] KELTZ E, KHAN F Y, MANN G. Rhabdomyolysis:The role of diagnostic and prognostic factors[J]. Muscles Ligaments Tendons J, 2013, 3(4):303-312.
[3] CERVELLIN G, COMELLI I, LIPPI G. Rhabdomyolysis:historical background, clinical, diagnostic and therapeutic features[J]. Clin Chem Lab Med, 2010, 48(6):749-756.
[4] BLANCO J R, ZABALZA M, SALCEDO J, et al. Rhabdomyolysis of infectious and noninfectious causes[J]. South Med J, 2002, 95:542-544.
[5] LANDAU M E, KENNEY K, DEUSTER P, et al. Exertional rhabdomyolysis:A clinical review with a focus on genetic influences[J]. J Clin Neuromuscul Dis, 2012, 13(3):122-136.
[6] SCHIFMAN R B, LUEVANO D R. Value and use of urinalysis for myoglobinuria[J]. Arch Pathol Lab Med, 2019,143(11):1378-1381.
[7] BIALO S R, AGRAWAL S, BONEY C M, et al. Rare complications of pediatric diabetic ketoacidosis[J]. World J Diabetes, 2015, 6(1):167-174.
[8] 王慧媛,赵志刚,陈晓红. 药源性横纹肌溶解综合征回顾性分析[J]. 中国医院用药评价与分析,2010, 10(4):373-376.
[9] TOYOHARA T, TANEMOTO M, URUNO A, et al. Case of rhabdomyolysis induced by the approved daily dose of a traditional Chinese medicine[J]. Nihon Jinzo Gakkai Shi, 2008, 50(2):135-139.
[10] MANSI I A, HUANG J. Rhabdomyolysis in response to weight-loss herbal medicine[J]. Am J Med Sci, 2004, 327(6):356-357.
[11] Rhabdomyolysis linked to Chinese red yeast rice[J]. Prescrire Int, 2008, 17(94):64.
[12] 陈亚红, 刘梅林, 刘滕飞. 服用安宫牛黄丸后横纹肌溶解一例[J]. 中华心血管病杂志, 2015, 43(10):913-914.
[13] BEBARTA V S, KING J A, MCDONOUGH M. Proton pump inhibitor-induced rhabdomyolysis and hyponatremic delirium[J]. Am J Emerg Med, 2008, 26(4):519.e1-519.e2.
[14] CERVELLIN G, COMELLI I, BENATTI M, et al. Non-traumatic rhabdomyolysis:Background, laboratory features, and acute clinical management[J]. Clin Biochem, 2017, 50(12):656-662.
[15] MICHELSEN J, CORDTZ J, LIBORIUSSEN L, et al. Prevention of rhabdomyolysis-induced acute kidney injury-A DASAIM/DSIT Clinical Practice Guideline[J]. Acta Anaesthesiol Scand, 2019, 63(5):576-586.
[16] GU H X, YANG M, ZHAO X M, et al. Pretreatment with hydrogen-rich saline reduces the damage caused by glycerol-induced rhabdomyolysis and acute kidney injury in rats[J].J Surg Res, 2014, 188(1):243-249.
[17] REIS N G, FRANCESCATO H D C, DE ALMEIDA L F, et al. Protective effect of calcitriol on rhabdomyolysis-induced acute kidney injury in rats[J]. Sci Rep, 2019, 9(1):7090.
[18] PETEJOVA N, MARTINEK A. Acute kidney injury due to rhabdomyolysis and renal replacement therapy:A critical review[J]. Crit Care, 2014, 18(3):224.
[19] VAN NESS-OTUNNU R, HACK JASON B. Hyperglycemic crisis[J]. J Emerg Med, 2013, 45(5):797-805.
[20] KASPER D L. 哈里森内科学-泌尿系统疾病分册[M]. 19版. 北京:北京大学出版社, 2017:17-31.
[21] CHAVEZ L O, LEON M, EINAV S,et al. Beyond muscle destruction:A systematic review of rhabdomyolysis for clinical practice[J]. Crit Care, 2016, 20(1):135.