Wei Wang, MD
Pediatric Critical Care Medicine Fellow
University of Florida
Gainesville, Florida
Disclosure information not submitted.
Desiree Machado, MD
Pediatric Critical Care Medicine
University of Florida, United States
Disclosure information not submitted.
Lawrence Shoemaker, MD
Clinical Associate Professor And Chief of Pediatric Nephrology
University of Florida, United States
Disclosure information not submitted.
Larry Patterson, MD
Clinical Associate Professor of Pediatric Nephrology
University of Florida, United States
Disclosure information not submitted.
Shruthi Mahadevaiah, MD
Pediatric Critical Care Medicine
University of Florida, United States
Disclosure information not submitted.
Title: Therapeutic Plasma Exchange for Refractory Rhabdomyolysis in a Child
Case Report Body:
Introduction: Rhabdomyolysis (RM) is a common disease in critically ill patients, characterized by the release of intracellular contents due to myocyte death. Triggers are diverse and complications include hepatic dysfunction, kidney injury and disseminated intravascular coagulation. There is a paucity of pediatric reports on the use of therapeutic plasma exchange (TPE) for refractory RM treatment.
Description: A 13-year-old previously healthy boy was admitted post craniotomy for subdural empyema. He underwent decompressive hemicraniectomy for refractory intracranial hypertension on postoperative day (POD) 3. He subsequently developed pulseless ventricular tachycardia requiring extracorporeal membrane oxygenation (ECMO) on POD4. Due to fluid overload, oliguria and electrolyte derangements unresponsive to therapies, continuous veno-venous hemofiltration (CVVH) was initiated. At this time creatine kinase (CK) level was measured at 12,458 U/L due to the presence of dark urine. Despite ECMO de-cannulation on POD8, CVVH, and optimizing nutrition and fluid balance, CK levels peaked to 78,600 U/L by POD13 with worsening Cr 1.4 mg/dL and signs of multi-organ dysfunction. The differential for RM etiology included electrolyte disturbances, drug-induced RM, myositis, vasculitis, steroids, and sepsis, all of which were addressed or ruled out. There was no family history of myopathy. TPE was then initiated for refractory RM, improving CK to 29,182 U/L after two days with normalization of all laboratory tests after 12 days. The patient received five days of TPE with 5% albumin on days 1-2 and fresh frozen plasma (FFP) on days 3-5. Renal replacement therapies were discontinued 13 days after TPE. He was discharged to a rehabilitation center after 55 hospital days with normal cognition and renal function.
Discussion: TPE may be effective in treating refractory RM in patients without obvious signs of muscle injury or history of myopathy and after correction of identified RM causes. The mechanism of action for this patient most likely involved unidentified toxic humoral substances responsible for myocyte injury that were cleared by TPE. This case is the first to demonstrate the potential for TPE as a rescue therapy for the critically ill child with RM refractory to conventional therapies.