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横纹肌溶解的临床表现与诊断

Author
Marc L Miller, MD
Section Editors
Ira N Targoff, MD
Jeremy M Shefner, MD, PhD
Deputy Editor
Monica Ramirez Curtis, MD, MPH
Translators
刘艺, 主治医师

引言

横纹肌溶解是一种综合征，特征是肌肉坏死和肌细胞内容物释放进入血液循环。肌酸激酶(creatine kinase, CK)水平通常显著升高，并可能存在肌肉疼痛及肌红蛋白尿。病情严重程度不一，从无症状的血清肌酶升高，到出现伴有酶极度升高、电解质紊乱和急性肾损伤(acute kidney injury, AKI)的危及生命的疾病。

横纹肌溶解的临床表现及诊断将总结在此。横纹肌溶解的病因，横纹肌溶解所致AKI的临床特征及诊断，横纹肌溶解患者的处理(包括AKI及相关代谢性并发症的预防方法)，以及急性骨筋膜室综合征的预防和处理，将会单独详细讨论。 (参见“血红素所致急性肾损伤(急性肾衰竭)的临床特征及诊断”和“血红素诱导性急性肾损伤(急性肾衰竭)的预防和治疗”和“挤压相关急性肾损伤(急性肾衰竭)”和“肢体的急性骨筋膜室综合征”)

临床表现

横纹肌溶解的临床特征为肌痛、肌红蛋白尿所致的红色至棕色尿，以及血清肌酶(包括CK)水平升高[1]。患者肌肉疼痛及其他症状的程度差异很大。病毒感染相关的横纹肌溶解将会进一步做更详细的讨论。 (参见“病毒性肌炎”，关于‘病毒性肌炎伴横纹肌溶解’一节)

症状 — 横纹肌溶解患者主诉的典型三联征为肌肉疼痛、乏力和深色尿[2-5]。然而，1/2以上的患者可能不会报告有肌肉症状[3]；而偶有患者可能经历非常严重的疼痛。如果存在肌肉疼痛，则通常在近端肌群(如大腿和肩部)及在腰部和小腿最为显著[2,5]。其他肌肉症状包括僵硬和痛性痉挛。

更常见于严重受累患者的其他症状包括不适、发热、心动过速、恶心和呕吐，以及腹痛[2]。因存在基础病因(如毒素、药物、创伤或电解质异常)，可能出现神志改变。

                  

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Literature review current through: 2017-06 . | This topic last updated: 2016-10-13.
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References
Top
  1. Knochel JP. Rhabdomyolysis and myoglobinuria. Annu Rev Med 1982; 33:435.
  2. Giannoglou GD, Chatzizisis YS, Misirli G. The syndrome of rhabdomyolysis: Pathophysiology and diagnosis. Eur J Intern Med 2007; 18:90.
  3. Gabow PA, Kaehny WD, Kelleher SP. The spectrum of rhabdomyolysis. Medicine (Baltimore) 1982; 61:141.
  4. Warren JD, Blumbergs PC, Thompson PD. Rhabdomyolysis: a review. Muscle Nerve 2002; 25:332.
  5. Huerta-Alardín AL, Varon J, Marik PE. Bench-to-bedside review: Rhabdomyolysis -- an overview for clinicians. Crit Care 2005; 9:158.
  6. Khan FY. Rhabdomyolysis: a review of the literature. Neth J Med 2009; 67:272.
  7. Melli G, Chaudhry V, Cornblath DR. Rhabdomyolysis: an evaluation of 475 hospitalized patients. Medicine (Baltimore) 2005; 84:377.
  8. Mikkelsen TS, Toft P. Prognostic value, kinetics and effect of CVVHDF on serum of the myoglobin and creatine kinase in critically ill patients with rhabdomyolysis. Acta Anaesthesiol Scand 2005; 49:859.
  9. Akmal M, Massry SG. Reversible hepatic dysfunction associated with rhabdomyolysis. Am J Nephrol 1990; 10:49.
  10. Grossman RA, Hamilton RW, Morse BM, et al. Nontraumatic rhabdomyolysis and acute renal failure. N Engl J Med 1974; 291:807.
  11. Koffler A, Friedler RM, Massry SG. Acute renal failure due to nontraumatic rhabdomyolysis. Ann Intern Med 1976; 85:23.
  12. Bosch X, Poch E, Grau JM. Rhabdomyolysis and acute kidney injury. N Engl J Med 2009; 361:62.
  13. Llach F, Felsenfeld AJ, Haussler MR. The pathophysiology of altered calcium metabolism in rhabdomyolysis-induced acute renal failure. Interactions of parathyroid hormone, 25-hydroxycholecalciferol, and 1,25-dihydroxycholecalciferol. N Engl J Med 1981; 305:117.
  14. Akmal M, Bishop JE, Telfer N, et al. Hypocalcemia and hypercalcemia in patients with rhabdomyolysis with and without acute renal failure. J Clin Endocrinol Metab 1986; 63:137.
  15. Veenstra J, Smit WM, Krediet RT, Arisz L. Relationship between elevated creatine phosphokinase and the clinical spectrum of rhabdomyolysis. Nephrol Dial Transplant 1994; 9:637.
  16. Olson SA, Glasgow RR. Acute compartment syndrome in lower extremity musculoskeletal trauma. J Am Acad Orthop Surg 2005; 13:436.
  17. Paletta CE, Lynch R, Knutsen AP. Rhabdomyolysis and lower extremity compartment syndrome due to influenza B virus. Ann Plast Surg 1993; 30:272.
  18. Criddle LM. Rhabdomyolysis. Pathophysiology, recognition, and management. Crit Care Nurse 2003; 23:14.
  19. Chatzizisis YS, Misirli G, Hatzitolios AI, Giannoglou GD. The syndrome of rhabdomyolysis: complications and treatment. Eur J Intern Med 2008; 19:568.
  20. Wakabayashi Y, Kikuno T, Ohwada T, Kikawada R. Rapid fall in blood myoglobin in massive rhabdomyolysis and acute renal failure. Intensive Care Med 1994; 20:109.
  21. Wakabayashi Y, Nakano T, Kikuno T, et al. Massive rhabdomyolysis associated with influenza A infection. Intern Med 1994; 33:450.
  22. Hino I, Akama H, Furuya T, et al. Pravastatin-induced rhabdomyolysis in a patient with mixed connective tissue disease. Arthritis Rheum 1996; 39:1259.
  23. Al-Shekhlee A, Hachwi R, Jaberi MM, Katirji B. The electromyographic features of acute rhabdomyolysis. J Clin Neuromuscul Dis 2005; 6:114.
  24. Moratalla MB, Braun P, Fornas GM. Importance of MRI in the diagnosis and treatment of rhabdomyolysis. Eur J Radiol 2008; 65:311.
  25. Korff S, Katus HA, Giannitsis E. Differential diagnosis of elevated troponins. Heart 2006; 92:987.
  26. Jaffe AS, Vasile VC, Milone M, et al. Diseased skeletal muscle: a noncardiac source of increased circulating concentrations of cardiac troponin T. J Am Coll Cardiol 2011; 58:1819.
  27. Rider LG, Miller FW. Laboratory evaluation of the inflammatory myopathies. Clin Diagn Lab Immunol 1995; 2:1.
  28. Caccamo DV, Keene CY, Durham J, Peven D. Fulminant rhabdomyolysis in a patient with dermatomyositis. Neurology 1993; 43:844.
  29. Pirovino M, Neff MS, Sharon E. Myoglobinuria and acute renal failure with acute polymyositis. N Y State J Med 1979; 79:764.
  30. Kim HW, Choi JR, Jang SJ, et al. Recurrent rhabdomyolysis and myoglobinuric acute renal failure in a patient with polymyositis. Nephrol Dial Transplant 2005; 20:2255.
  31. Gupta S, Blaivas M, Ike RW, Crofford LJ. Polymyositis evolving after rhabdomyolysis associated with HMG-CoA reductase inhibitors: a report of two cases. J Clin Rheumatol 2001; 7:332.
  32. Christopher-Stine L, Casciola-Rosen LA, Hong G, et al. A novel autoantibody recognizing 200-kd and 100-kd proteins is associated with an immune-mediated necrotizing myopathy. Arthritis Rheum 2010; 62:2757.
  33. Mammen AL, Chung T, Christopher-Stine L, et al. Autoantibodies against 3-hydroxy-3-methylglutaryl-coenzyme A reductase in patients with statin-associated autoimmune myopathy. Arthritis Rheum 2011; 63:713.
  34. Needham M, Fabian V, Knezevic W, et al. Progressive myopathy with up-regulation of MHC-I associated with statin therapy. Neuromuscul Disord 2007; 17:194.
  35. Grable-Esposito P, Katzberg HD, Greenberg SA, et al. Immune-mediated necrotizing myopathy associated with statins. Muscle Nerve 2010; 41:185.