Please answer all 4 questions. A 20-year-old male complained of red-brown urine

Question

Please answer all 4 questions.

A 20-year-old male complained of red-brown urine and muscle pain 3 hours after his early practice run for the Los Angeles Marathon. A physical exam done in the ER was unremarkable except for muscle tenderness. A routine physical performed two weeks earlier indicated he was in good health. Color Appearance Clear Specific Gravity 1.030 Brown 6.5 Protein Glucose Ketones Bilirubin Blood Urobilinogen 0.1 mg/dl Nitrite Leukocyte Esterase Neg Neg Large 3+ Neg 2+ diffuse Neg Microscopic Urinalysis WBC/hpf 0-1/hpf RBC/hpf0-1/hpf Casts Other 6-10 hyaline/lpf Occasional transitional cells Discuss the case and answer the questions. 1. What are the causes of red-brown urine? 2. In light of the patient's recent activities, how would you interpret the positive UA result? 3. Does this patient have renal disease? 4. What recommendation would you make to the health care provider about the UA results?

Explanation / Answer

1. The causes of red-brown urine for the given case scenario is attributed to RHABDOMYLOSIS.Red brown colour may also prompt the conditions of Haemolysis and Haematuria. But since it is clearly mentioned that previous examination of the subject revealed that he is healthy and fit. Since Haemolysis may be caused due to genetic conditions(Sickle cell anaemia) or long term microbial infections(Streptococcus, staphylococcus, plasmodium) or may be drug induced. Any of which could have been revealed during the examination which is done two weeks before. Hence Haemolysis is ruled out. Haematuria is also a similar condition with long term disposition to Urinary infection, kidney stones, nephritis, which if present would have been disclosed in the earlier examination, thus also ruling out the Haematuria.

So it can be confirmed that Rhabdomylosis would be the only the possible choice, given with the patient history. Let us see, how rhabdomylosis is caused, which can give further insight into this case and understand how it is caused to this particular subject.

Rhabdomylosis is a rare but sever condition which can lead to kidney failure. This condition arises when skeletal muscles breakdown and enters into blood which eventually pass through kidney. As these are unlikely substances handled by the kidney it may lead to kidney failure. The striated (skeletal) muscle breakdown may be due to very intense work out and exercises without gap, seizures, tetanus, accidents, physical strain etc

In the given case, it is clearly evident that a 20 year old(male subject) made 3 hours of practice before this condition which explains the reason for RHABDOMYLOSIS.

2. As we have seen earlier, presence of proteins, ketones, casts(normal 1-5) and blood(which should be negative in normal physiological urine) explains the extent of harm done to the skeletal muscles during the intense practice session of 3 hours, that led to rhabdomylosis.

Along with the positive Urine analysis report, muscle tenderness and brown color discoloration of urine(due to proteins, blood and tissue degradation products) clearly concludes that it is a condition of rhabdomylosis.

3. It is quite unlikely that this patient can have renal disease, as the prior examination of the subject turned out to be all normal. The problem arised only after the work out indicating that it is acute and no underlying renal disease.

Hence, we can conclude that the patient has no renal disease, but rhabdomylosis, can lead to kidney failure, if remedial measures are not implemented.

4. Recommendations to the health care provider include, rhabdomylosis should be confirmed by checking the Serum Creatinine Kinase levels which are distinctly high in rhabdomylosis(normal value 1500-1,00,000 IU/L). Also check for the presence of myoglobinuria for ascertaining the condition.

Management of the disease and further recommendation: Since the underlying cause is strenous physical exercise, further continuance of such work out should be prevented and avoided. Fluid and electrolyte replenishment should be done and most importantly complications like acute renal failure should be avoided by dialysis(if Creatinine Kinase and Myoglobin levels are very high), using urinary alkalisers, supportive metabolic acid-balance adjustment therapy.

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