Eats Beef From the Vietnam War Era and Amphetamine From 1940s
Clin Kidney J. 2021 Apr; 14(4): 1088–1096.
From quail to earthquakes and human conflict: a historical perspective of rhabdomyolysis
Mirna Aleckovic-Halilovic
1 Department of Nephrology, Dialysis and Transplantation, Academy Hospital Tuzla, Tuzla, Bosnia and Herzegovina
Mirha Pjanic
1 Department of Nephrology, Dialysis and Transplantation, Academy Hospital Tuzla, Tuzla, Bosnia and herzegovina
Enisa Mesic
1 Department of Nephrology, Dialysis and Transplantation, University Infirmary Tuzla, Tuzla, Bosnia and Herzegovina
Joshua Storrar
ii Department of Renal Medicine, Lancashire Education Hospitals NHS Foundation Trust, Preston, UK
Alexander Woywodt
2 Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
Received 2020 Mar 23; Accustomed 2020 Apr 13.
Abstract
Rhabdomyolysis is a mutual cause of acute kidney injury, featuring muscle pain, weakness and nighttime urine and concurrent laboratory evidence of elevated musculus enzymes and myoglobinuria. Rhabdomyolysis is ofttimes seen in elderly and frail patients following prolonged immobilization, for example subsequently a fall, simply a variety of other causes are likewise well-described. What is unknown to near physicians dealing with such patients is the fascinating history of rhabdomyolysis. Cases of likely rhabdomyolysis accept been reported since biblical times and during antiquity, often in the context of poisoning. Every bit interesting is the link between rhabdomyolysis and armed conflict during the 20th century. Salient discoveries regarding the pathophysiology, diagnosis and treatment were fabricated during the two globe wars and in their backwash. 'Haff disease', a form of rhabdomyolysis offset described in 1920, has fascinated scientists and physicians alike, but the marine toxin causing it remains enigmatic fifty-fifty today. As a specialty, we have also learned a lot virtually the disease from 20th-century earthquakes, and networks of international help and cooperation take emerged. Finally, rhabdomyolysis has been described every bit a sequel to torture and similar forms of violence. Clinicians should be aware that rhabdomyolysis and the development of renal medicine are deeply intertwined with human history.
Keywords: AKI, beat injury, history, rhabdomyolysis
INTRODUCTION
The term rhabdomyolysis derives from the Greek words ῥάβδος (rhabdos, rod), μῦς (mus, musculus) and λύσις (lusis, loosening), and describes a syndrome with disintegration of striated muscle and release of muscular cell constituents into the circulation [i]. Most cases are caused by trauma, prolonged immobilization or extreme concrete exertion [2]. Recreational drugs, medication and genetic myopathies are less normally implicated [iii] (Table 1). Astute kidney injury (AKI) is one of the almost astringent complications of rhabdomyolysis. AKI in rhabdomyolysis oft leads to rapid release of potassium and phosphate from muscle, leading to a need for higher doses of renal replacement therapy (RRT) than is required for other forms of AKI. The diagnosis is often straightforward, usually when there is an obvious cause such as prolonged immobilization or trauma. However, belatedly diagnosis occurs even in contemporary clinical exercise often in conjunction with ane of the rarer causes (Table 1). Common and unusual causes of rhabdomyolysis are well known to nephrologists and to renal faculty, and are also regularly taught during ward rounds and in case presentations. What is much less known even among seasoned renal educators is the fascinating and thought-provoking history of rhabdomyolysis from biblical times to the late 20th century. This is likewise underscored by the fact that a PubMed search for 'Rhabdomyolysis' in the title and 'historical article' as publication type currently yields only 4 articles. None of them is published in a periodical within our own specialty. Here, nosotros provide a brief review of the history of rhabdomyolysis for the clinical nephrologist and for use during teaching. Nosotros draw interesting causes of rhabdomyolysis throughout human history, highlight upstanding dilemmas and describe how historical events helped our specialty diagnose, understand and treat AKI acquired by rhabdomyolysis.
Table ane.
Causes of rhabdomyolysis
| Category | Examples |
|---|---|
| Abnormal body temperature and related syndromes | Heatstroke |
| Hypothermia | |
| Malignant hyperthermia | |
| Neuroleptic cancerous syndrome [four] | |
| Drugs [5] | Antimalarials |
| Baclofen withdrawal (abrupt) [6] | |
| Colchicine | |
| Corticosteroids | |
| Cyclosporine | |
| Fluconazole | |
| Neuromuscular blocking agents | |
| Statins and fibrates | |
| Electrolyte abnormalities | Hypophosphatemia (particularly in conjunction with alcohol) [7], hypokalaemia, hypocalcaemia, hyponatraemia, hypernatraemia |
| Diabetic ketoacidosis [8] | |
| Endocrine disorders [9] | Hypothyroidism |
| Non-ketotic hyperosmolar syndrome | |
| Thyrotoxicosis | |
| Exertion [x] | Long-altitude running |
| Physical overexertion in sickle cell disease | |
| Genetic syndromes (metabolic myopathies) [11, 12] | Carnitine deficiency |
| Creatinine palmitoyltransferase deficiency | |
| McArdle illness (myophosphorylase deficiency), mitochondrial respiratory chain deficiencies, phosphofructokinase deficiency | |
| Immune-mediated myopathies [13, 14] | Dermatomyositis |
| Polymyositis | |
| Infections | Bacteria [15]: Streptococcus, Salmonella, Legionella, Staphylococcus, Listeria, Tetanus |
| Viruses: Influenza, Adenovirus, Coxsackie, Herpes Cytomegalovirus, Epstein-Barr virus, Human Immunodeficiency Virus | |
| Malaria [16] | |
| Miscellaneous | Alcoholism |
| Cardioversion | |
| Sepsis | |
| Unexplained rhabdomyolysis in migrants [17, 18] | |
| Physical violence | Beating, torture, child corruption |
| Recreational drugs [nineteen, twenty] | Amphetamine, Cocaine, Ecstasy, LSD |
| Toxins [3, 21] | Snake and insect bite |
| Mushrooms | |
| Haff disease | |
| Hemlock (coturnism) | |
| Carbon monoxide | |
| Trauma and pinch | Burns |
| Crush injuries and Immobilization | |
| Ischaemic limb injury and vascular surgery [22] | |
| High-voltage electric injury |
CAUSES OF RHABDOMYOLYSIS SINCE ANTIQUITY: QUAIL AND HEMLOCK
The beginning (admitting vague) mention of possible rhabdomyolysis is often credited to the Bible. In numbers 11:31, the Israelites are hungry and god sends quail (Coturnix coturnix; Figure 1), which the people collect and eat with considerable greed:
A wind sent by the Lord came up and blew quail in from the body of water; it dropped them all around the camp … The people were upwards all that twenty-four hour period and nighttime and all the side by side day gathering the quail … and they spread them out all around the camp. While the meat was nonetheless betwixt their teeth, before it was chewed, the Lord's anger burned against the people, and the Lord struck them with a very severe plague. [23]
Quail poisoning (coturnism) is a well-described cause of rhabdomyolysis [24], although peradventure most nephrologists volition be unaware of the link. Toxins ingested with contaminated quail meat are believed to be the cause [25]. Whether the toxins are from hemlock or other plants such as henbane (Hyoscyamus niger) or cherry-red hemp nettle (Galeopsis ladanum) [26] is non entirely articulate [27]. Coturnism is well described in artifact [27] and has been reported from effectually the Mediterranean throughout the 20th century, usually in autumn when the bird migrates in big numbers [24]. Rhabdomyolysis is a key feature of coturnism [24] and some authors accept suggested a genetic background that confers vulnerability to the toxin [28]. Much of our knowledge stems from the detailed clarification of the condition by Edmond Sergent in the 1940s [29, thirty]. Sergent, who at the time worked as director of the Morocco Institut Pasteur in Casablanca, described the instance of an Algerian hunter who had previously eaten quail without incident just and so developed astringent symptoms after some other repast involving quail [30]. Others accept suggested that Sergent viewed the biblical quail incident every bit one of transcendent mystery and they note that some questions around coturnism remain unresolved to the present day [30].
A like condition has been reported from Italy following consumption of skylarks, chaffinches and robins that have ingested plants from the hemlock family in jump [31]. Of note, the birds themselves are not susceptible to the agile alkaloids and they are heat stable. Other biblical accounts of poisoning have been linked to hemlock besides. Davies and Davies speculated whether the sudden and otherwise unexpected death of ii salubrious immature priests could be explained past their having inhaled incense contaminated with hemlock [32]. The use of plants from the hemlock family unit as a poison goes far dorsum in time. As a medicine, hemlock has multiple backdrop and was used since artifact well into the 18th century for a variety of weather including cancer [33] and whooping coughing [34]. The idea that 'hemlock' (Greek 'koneion') was the toxicant used in the suicide of Socrates is well known, although it has been attacked on linguistic likewise as on medical grounds [35]. In Plato's account of events, Socrates' muscles are described as cold and stiff but clear evidence of rhabdomyolysis is lacking [35].
In trying to link muscular toxicity to hemlock, it is important to appreciate that hemlock species are a member of the order Umbelliferae, which also includes many edible plants such equally carrot, fennel and parsnip. In that location is ofttimes confusion between water hemlock species (Cicuta and Oenanthe) and toxicant hemlock (Conium maculatum) [36]. Many contemporary incidents of accidental poisoning relate to the sometime, whereas the latter is implicated in intentional poisoning and Socrates' suicide. Many symptoms overlap simply differentiation between the two is important. Cicuta spp. (Effigy two) feature as their master toxins cicutoxin and oenanthotoxin, which human activity as (non-competitive) γ-aminobutyric acid antagonists in the central nervous arrangement, resulting in seizures [36]. In contrast, C. maculatum results in respiratory paralysis, secondary to muscle weakness [36] and rhabdomyolysis attributed to its main alkaloid coniine. Accidental hemlock poisoning is all the same seen today [38], often as a result of 'foraging' [39]. Rhabdomyolysis is described in conjunction with both water [36] and poison [xl] hemlock and occurs due to seizure-induced muscle injury or as a result of directly myotoxicity. Roots of water hemlock are ingested past mistake for their sweet taste, which has been described every bit pleasant and similar to wild parsnip or wild carrot.
Spotted water hemlock (Cicuta maculata), from Clark and Fletcher [37] (epitome in the public domain).
NINETEENTH TO Early on 20TH CENTURY: RHABDOMYOLYSIS DURING Armed services Conflict
To the best of our cognition, the outset description of rhabdomyolysis in state of war dates back to 1812 when Larrey, the smashing military surgeon of the Napoleonic ground forces, described muscle necrosis in carbon monoxide poisoning during the occupation of Berlin [41]. Carbon monoxide remains a well-described cause of rhabdomyolysis to the present day [42]. It is often High german surgeon Ludwig Frankenthal (1885–1944) who is credited with the kickoff report of traumatic rhabdomyolysis and AKI caused by war injuries, just this occurred almost a century later than Lerry'due south account, in 1916 [43]. A few years later on, Minami, a Japanese dermatologist who studied in Deutschland, under the supervision of the High german pathologist, Professor Ludwig Choice, described the kidneys of three German soldiers who died of traumatic injuries during Globe War I and suspected muscle harm as a likely culprit of the ensuing renal failure [44]. Minami's study is notable not only for its cute illustrations of the histopathology just as well for the clarity of its way and language. In his conclusion Minami states
… This is caused by the acute breakdown of muscular protein where multiple necrosis has occurred, which is seen in all cases of this group. [44] (Authors' translation).
Despite such detailed reports of beat syndrome and its complications and a well-developed concept of pathogenesis in the German literature, the Allies entered World State of war II more or less oblivious of its beingness. It was Eric Bywaters (1910–2003), a Hammersmith hospital rheumatologist [45], who in 1940 rediscovered the syndrome in victims of the London Blitz [46]. L years later on Bywaters commented:
History … teaches usa that human being does non learn from history. … the medical machine in 1939 was not as fully prepared … as it might take been had it consulted its opponent's publications. [47]
In retrospect, it is quite remarkable that until Bywaters' 1941 publication this potentially lethal entity was largely unknown to the British and American medical literature, including textbooks of military medicine [48]. It is noteworthy that the official German language military medical account of World War I described as many as 126 cases with this syndrome [49, 50].
Following their feel at Hammersmith, Bywaters and Beall described 4 victims of trauma-related beat out syndrome (Figure 3) with limb oedema, shock and oliguria with chocolate-brown urine. All four patients died in about a week with nitrogen retention and necropsy revealing pigment casts, polymorphonuclear invasion and acute tubular necrosis [46]. Blood transfusion was initially considered as a contributing factor. However, Mayon-White and Solandt, describing a similar patient who had never received blood, refuted this assumption [51]. In 1943, using animal models, Bywaters and Stead identified myoglobin as the offending agent and formulated a treatment programme. Their arroyo involved vigorous rehydration preferably starting at the site of blow and alkalization of urine with the purpose of decreasing myoglobin precipitation in the renal tubules [52].
Musculus of patient buried for vi h and surviving seven one/2 days showing oedema and necrotic lateral muscles of the leg. From Bywaters [47], with permission.
Rhabdomyolysis has remained an important topic in military medicine during more recent armed disharmonize. In their seminal 1966 newspaper, Fitts et al. reported a case of a young soldier who was buried under rubble for 20 h during the Vietnam War and sustained shell injury, extensive muscle necrosis and rhabdomyolysis [53]. The case illustrates the advances made since Bywaters' reports and the patient survived following extensive debridement of necrotic muscle and haemodialysis in several military facilities [53]. The authors emphasize that due to the advent of dialysis more patients with rhabdomyolysis may survive, and also recommend intravenous fluids even earlier the crushed limbs are released [53]. A lot of experience was as well gathered during the Lebanese republic war in the 1980s [54]. Contemporary guidelines on the management of crush injury on the battlefield emphasize the early utilize of intravenous fluids [55]. However, fifty-fifty on 20th-century battlefields, rhabdomyolysis is associated with mortality as described in recent studies of the Iraq and Afghanistan wars [56].
UNUSUAL CAUSES OF RHABDOMYOLYSIS IN THE 20TH CENTURY: HAFF-KRANKHEIT, MUSHROOMS AND GENETIC DISORDERS
Some other fascinating crusade of rhabdomyolysis was first described in the summer and fall of 1924 when physicians near the Prussian city of Königsberg (at present Kaliningrad in Russia) described an outbreak of an disease characterized by sudden, severe muscular rigidity and coffee-coloured urine [57]. A witness described the scenery in i of the coastal villages as follows:
It was an unbelievably saddening matter to watch: Strong men being carried from their fishing boats to their homes – completely strong and utterly helpless. (Authors' translation) [58]
Later chosen the Haff disease (from the High german word 'Haff'—shallow lagoon) the syndrome featured rhabdomyolysis in a person who had ingested freshwater fish, such equally burbot, crayfish or Atlantic salmon, inside 24 h earlier onset of illness. The fact that the victims were unremarkably fishermen immediately intrigued both public wellness officials and researchers, and a toxin in the aquatic nutrient chain was suspected more or less immediately. The affliction was observed simply in summer and fall and only on the declension of this particular part of the Baltic Sea, where it occurred in epidemics, small-scale clusters or sporadically [59, lx]. Several toxins were proposed as possible causes [61]. 1 hypothesis assumed that arsenic-containing waste matter derived from the nearby chemical manufacture led to the germination of arsenic gas just above the water surface, which was then inhaled by the victims during early morning line-fishing trips [58]. At some stage 600 gas masks were issued to fishermen. Former later the 'gas theory' was replaced by the 'eel theory' but this, too, remained controversial, not least because eel was the master source of income for these line-fishing communities. Eventually, no further cases were observed although the reasons for its disappearance remained as enigmatic as its actual cause [55]. Haff disease withal occurs [61–63], often associated with crayfish, only the exact nature of the toxin in the aquatic food concatenation remains unknown to the present solar day [64].
Mushroom poisoning is another cause of rhabdomyolysis that has emerged in the 20th century. A recent classification of mushroom poisoning proposed by White et al. [65] includes ii subgroups with muscular toxicity, namely 3A with a rapid onset (caused by Russula spp.) and 3B with a delayed onset (Tricholoma spp.). There are reports of Russula subnigricans causing delayed-onset rhabdomyolysis with AKI in the severely poisoned patient [66]. Tricholoma equestre is known nether diverse names and is consumed throughout the earth. Since there are controversial opinions on its edibility and ability to cause rhabdomyolysis [67], a group of French authors investigated the rhabdomyolysis apparently induced in 12 humans past several consecutive meals of T. equestre by administering equivalent doses of extracts of this mushroom to mice. They concluded that a genetic muscular susceptibility was a likely key gene for sometimes severe rhabdomyolysis to develop in individuals after repeated consumption of T. equestre and/or when the corporeality of mushrooms ingested exceeds a sure threshold and unmasks it [68].
Another interesting cause of rhabdomyolysis besides became evident in the late 20th century: genetic disorders. A typical patient develops rhabdomyolysis after moderate exercise in a scenario that ane would not usually associate with rhabdomyolysis [69]. A whole host of genetic conditions that predispose to rhabdomyolysis have at present been identified, many of which are mitochondrial [seventy]. A more recent discovery is that mutations in the ryanodine receptor i gene predispose to rhabdomyolysis and too, interestingly, to malignant hyperthermia [71]. The diagnosis of an inherited myopathy in a patient with rhabdomyolysis requires a loftier degree of suspicion and often involves musculus biopsies and tests in specialized centres. Even other forms of rhabdomyolysis may have a more subtle genetic groundwork [70].
SEISMO-NEPHROLOGY: EARTHQUAKES AND OTHER NATURAL DISASTERS
The history of rhabdomyolysis is not limited to state of war and homo conflict; crush injury also takes its cost in peacetime. Natural disasters such as earthquakes, hurricanes, tsunamis and cyclones are now well appreciated equally a cause of rhabdomyolysis, and the term 'disaster nephrology' [72] has been coined. In improver, seismo-nephrology [72] relates specifically to earthquake-associated renal injury. Antonino D'Antona [73] and Von Colmers [74] get-go described musculus destruction in victims of the 1909 Messina earthquake. Much of our current cognition about crush injury and rhabdomyolysis in this context stems from feel gained during of one of the greatest earthquakes of all time, which occurred in Tangshan, Communist china in 1976 with 242 769 dead and 164 851 injured [75], and a high per centum of victims suffering from some class of crush injury [76]. It has been reported that in the instance suddenly plummet of an eight-story building, 80% of the entrapped victims dice instantly from the straight effects of trauma, 10% survive with minor trauma, while 10% are desperately injured; of those, seven/10 develop crush syndrome [77]. But it was not before the Armenian earthquake in 1988 (Figure 4)—and an additional 150 000 deaths—that this entity received attention through the establishment of the International Society of Nephrology's 'Renal Disaster Relief Task Forcefulness' [79] and recommendations for the management of crush victims in mass disasters.
(A) Makeshift dialysis facility in the All Marriage Surgical Scientific Centre in Yerevan, Soviet Commonwealth of Armenia, 1988. From Tattersall et al. [78] with permission. (B) Improvised dialysis facility using the NxStage device following the Haiti earthquake. With permission from NxStage, Lawrence, MA, USA.
As a renal community, we have learned a considerable amount about the pathogenesis of AKI and crush syndrome in earthquake victims. Rhabdomyolysis can occur either as a sequel to crush injury from direct trauma or due to the ischaemia reperfusion injury that occurs when at that place is restoration of blood flow one time victims are extracted from the rubble. Both mechanisms can coexist. The crush syndrome is the second most common cause of expiry in earthquake victims later asphyxia [72]. While rhabdomyolysis is the primary cause of AKI in these patients, there are other possible pre- and mail service-renal causes such every bit hypovolaemia from blood loss or aridity, too equally direct trauma to the kidneys and urinary tract.
Various studies, for example, involving victims of the Bam and Bingöl earthquakes (both in 2003) accept noted the benign effect of early handling at the disaster scene with intravenous fluids [80–83]. This helps to reduce the incidence of AKI and ultimately requirement for RRT. This concept had been proposed starting time in the 1940s and later reiterated following the Vietnam State of war [55], but the government for fluid assistants has evolved considerably and in parallel to growing experience with rhabdomyolysis overall. A detailed discussion of this topic is beyond the scope of our trivial article. Suffice to say that some studies advocate a fairly conservative approach (3 L over the first 24 h), whereas others suggest being more than aggressive (with upwards of 12 L in the same time catamenia) [81, 82].
Factors that increase the adventure of developing AKI and requirement for RRT include increased time under rubble, decreased book of fluid received and increased value of serum creatinine kinase [83]. However, it is still not easy to predict which patients are more probable to progress to a worse outcome. 1 small study assessed patients treated with crush syndrome in the Hanshin convulsion in Kobe, January 1996 [82]. It evaluated various laboratory markers such equally serum amylase, LDH and AST in these patients. There was a statistically pregnant divergence in the level of amylase between those who survived (lower level) and those who died. The cause for this was not established [82].
Compared with war injuries, earthquakes affect a vast number of victims—often in rural areas—without prepared and efficient pre-hospital and hospital services. As such, optimal managements for these patients are difficult if not impossible to attain. A key challenge for dialysis units but also for renal teams coming to help from away in the aftermath of an earthquake is the disrupted water supply. The fact that it is oft impossible for outside teams to appreciate the calibration of the disaster, permit lone to arrive in time to be of any use, has been highlighted elsewhere [78]. Branch work co-ordinated by the international renal societies has been extremely beneficial in several contempo earthquakes [79, 84].
RHABDOMYOLYSIS DUE TO TORTURE AND Like FORMS OF VIOLENCE
I of the saddest aspects of this condition is when it occurs as a sequel to torture [85] or to other forms of violence [86]. The World Medical Clan's Tokyo Declaration of 1975 defines torture as:
The deliberate, systematic or wanton infliction of physical or mental suffering past one or more than persons acting lone or on the orders of any authorisation, to force another person to yield data, to make a confession, or for any other reason. [87]
As of today there is no uniformly accepted definition of torture, and different opinions be [88]. In full general, our noesis of the medical aspects of torture is rather express. There are several reasons for this, including the lack of autopsy data following such deaths in captivity, especially in times of socio-political instability [89]. Secondly, medical practitioners oft accept an understandable feeling of unease and discomfort regarding publishing information derived from treating the victims of man cruelty [85]. It is also important to bear in mind that medical practitioners take had diverse roles in torture, ranging from complicit witness, to bystander and facilitator, to perpetrator [ninety]. There is considerable dilemma in publishing reports of torture, although in many cases one has to admire the courage and dedication of the authors [85]. Lameire and Vermeersch have highlighted a number of ethical dilemmas for doctors who await afterwards victims of torture [85]: what if medical practitioners provide care to prisoners, knowing that subsequently treatment they would merely be exposed to new abuse? Similarly, what if whatsoever attempt at publication would alert government and thereby deny futurity victims medical care?
Viewed against this background, the gruesome bear witness linking rhabdomyolysis and torture is quite considerable. Not surprisingly, victims of rhabdomyolysis due to torture and violence are predominantly immature males, well active and with good muscular fitness at the time they were detained [89, 91–93]. Some authors have speculated that muscular individuals are more prone to rhabdomyolysis due to the larger quantities of muscle breakdown products released into the bloodstream [94]. According to the cases described in bachelor literature, the most prevalent types of physical torture and violence that victims underwent were fell beating of the whole body with sticks, rods made of metallic and guns, for several days, countless hours of 'sit-and-stand' exercise, electric shocks and hanging upside-downwardly with tied legs [89, 92, 93]. Another particular form of torture that causes rhabdomyolysis is reverse hanging in which victim's wrists are spring behind the back, and the victim is suspended for several hours with overstretching of the muscles and ischaemic necrosis [89].
AKI is common in rhabdomyolysis every bit a sequel to torture and many patients are oliguric [86, 89, 91, 93, 95]. The presenting clinical, biochemical and radiological features practice non differ much from other aetiologies and some patients ofttimes lack obvious external bear witness of torture and violence [86, 89, 92, 93]. Aridity [92, 93], hunger strike [96] and the use of straightjackets [97] may also contribute to AKI and rhabdomyolysis. In some cases a combination of rhabdomyolysis and haemolysis could have caused AKI [92]. Haemoglobinuria can occur as a result of mechanical trauma to the red claret cells due to the repetitive physical trauma of microcirculation of the soles during beating in a way that is similar to that seen in March haemoglobinuria [92]. The majority of reported patients required dialysis [91–93] and fatalities are not uncommon with mortality rates ∼xv% [86, 91–93]. Some authors have emphasized the importance of early recognition and timely management of potentially reversible condition [92].
Rhabdomyolysis can also occur in victims of domestic or other violence, ofttimes children, elderly or individuals with cognitive disabilities [95]. A detail form of violence observed in Southern Africa is chirapsia with the sjambok, a heavy whip made of rhinoceros hibernate (Effigy 5) [86, 91]. The soft tissue injury that ensues is ofttimes invisible and the extent of damage is underestimated [86, 91]. Lazarus et al. described rhabdomyolysis due to child abuse [98], and other similar reports do exist [99]. A high degree of suspicion is required in cases of rhabdomyolysis where the cause is not entirely obvious afterwards the initial assessment. Finally, when assessing patients with rhabdomyolysis in conjunction with violent behaviour information technology is important to comport in mind that drugs may also be involved [100].
A young patient who presented with AKI from rhabdomyolysis post-obit astringent traumatic ('sjambok') injuries. He recovered fully after receiving dialysis in our ICU. Courtesy of Prof Ikechi Okpechi, Division of Nephrology and Hypertension, University of Cape Town, South Africa.
CONCLUSION
Rhabdomyolysis has been described since antiquity and our understanding of the illness is closely linked to the history of the concluding 100 years (Figure 6). Nephrologists have learned a swell deal about rhabdomyolysis from studying victims of human conflict, peculiarly since Bywaters described the syndrome during the London Blitz in the 1940s [46]. It is sobering to larn that lessons already learned were ofttimes ignored, only to be relearned by a subsequent generation of physicians. Another interesting attribute of this topic is that the cause of one of the most enigmatic causes of rhabdomyolysis, the Haff affliction, remains unclear despite the fact that researchers have tried their hardest, with generations of theories existence proposed and afterward discarded. We can, yet, accept some alleviation from the fact that afterward on in the 20th century we accept fabricated peachy progress in elucidating the genetic basis of some cases of rhabdomyolysis. Another pitiful and oftentimes tragic aspect of the history of rhabdomyolysis is its link to earthquakes. Only a multinational effort supported past international organizations can bargain with large numbers of rhabdomyolysis victims requiring RRT in a disaster setting such as the earthquakes in Turkey or Haiti [84]. Much of this knowledge has been acquired the hard manner, but we are conspicuously much better prepared for our encounter with such patients in the setting of catastrophe or conflict. Some of the history of rhabdomyolysis makes for grim and uncomfortable reading, particularly when the disease occurs as a upshot of torture and violence. In this sense, the history of our specialty is very much intertwined with some of the darkest chapters of 20th-century history and with human conflict. Yet, it is equally linked to great examples of coordinated help and support for victims of natural disasters. Nosotros can only promise that future generations will exist more aware of the history of rhabdomyolysis, preserve and aggrandize the knowledge gained past their predecessors, and encounter cases more as an intellectual challenge during clinical exercise than as a sequel to human being violence and conflict.
Time line: history and rhabdomyolysis intertwined from 1900 to present day. Bottom half: events relating to armed conflict and violence. Top half: events non associated with human conflict.
Conflict OF INTEREST STATEMENT
None declared.
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