1. 2013. 2. 1 핵의학과 PK18 조 22 번 류원선

2.  이름 : 송 O O  나이 : 15  성별 : Male  Case No. 2633198

3.  Gross Hematuria

4.  내원 2 일전 학교에서 체벌 ( 앉았다 일어서기, 오리걸음 ) 받 은 후 both leg pain develop  내원 당일 gross hematuria( 갈색 ) develop 되어 본원 내원.

5.  HTN/DM/Tb (-/-/-)  Previous Illness/Op (-/-)  Smoking (-)  Alcohol (-)

6.  pulmonary tuberculosis (-)  type 2 DM (-)  hypertension (-)

7.  Vital sign : Stable  General appearance : ALERT  Extremities : pitting edema (-/-) cyanosis (-/-) Tenderness(Lt, +)

8.  WBC 12180 BUN/Cr 9/0.6 Na/K 143/4.3 CK/CKMB 125027/56.8 AST/ALT 1539/373 LDH 4795.3 myoglobin positive (40000 이상 )  U/A albumin(500mg), RBC 2-4, WBC 0-1, cast(-)

9.  # Rhabdomyolysis

11.  Massive hydration & medication

12. Rhabdomyolysis ( 횡문근융해증 )  Classification : muscle necrosis and the release of intracellular muscle constituents into the circulation

13.  Result from muscle cell death, which may be triggered by any of a variety of initiating events.  The final common pathway for injury is an increase in intracellular free ionized cytoplasmic and mitochondrial calcium.  The increased intracellular calcium leads to activation of proteases, increased skeletal muscle cell contractility, mitochondrial dysfunction, and the production of reactive oxygen species, resulting in skeletal muscle cell death

15.  Traumatic or muscle compression (Crush syndrome or Prolonged immobilization)  Nontraumatic exertional (Marked exertion in untrained individuals, Hyperthermia, or Metabolic myopathies)  Nontraumatic nonexertional (Drugs or Toxins, Infections, or Electrolyte disorders)

16.  Triad >  Stiffness, Cramping  Malaise, Fever, Tachycardia, Nausea and Vomiting, and Abdominal pain

17.  Muscle tenderness and swelling  Elevation in creatine kinase(CK) and other serum muscle enzymes  Reddish-brown urine of myoglobinuria(50%)  Fluid and electrolyte abnormalities (Hypovolemia, Hyperkalemia, Hypocalcemia, hyperuricemia, metabolic acidosis)

18.  Acute kidney injury (m/c)  Compartment syndrome  Disseminated intravascular coagulation

19.  Creatine kinase (1500~100000 이상 )  Urinalysis  Complete blood count, including differential and platelet count  Blood urea nitrogen, creatinine, and routine electrolytes including potassium  Calcium, phosphate, albumin, and uric acid  Electrocardiography  MRI  Bone scan

20. Extraosseous Uptake  99mTc- 인산염 제제가 연조직에 섭취됨.  세포 손상 후 세포막의 투과성이 비정상으로 증가되어 Ca 유입을 증가 시키며 유입된 Ca 은 세포내 미토콘드리아와 다른 세포내 소기관에 축적됨.  특히 횡문근 융해증에서 광범위한 연조직 섭취가 보고되어 있다.  Ex. Tissue infarction, Rhabdomyolysis, myositis ossificans, dermatomyositis, Renal failure 등

21. 99m Tc-MDP whole body bone scan

22.  Myocardial infarction  Hematuria and hemoglobinuria  Inflammatory myopathy  Immune-mediated necrotizing myopathy  Deep vein thrombosis  Renal colic

23. 1. Recognition and management of fluid and electrolyte abnormalities. 2. Identification of the specific causes. 3. Prompt recognition, evaluation, and treatment of compartment syndrome.

24. Acute Rhabdomyolysis : Importance of MRI and Bone Scintigraphy J M Park, H J Shin, Y C Choi. 대한소아신장학회지 제 13 권 제 1 호 2009

25.  The etiology of rhabdomyolysis is roughly classified into two categories: physical causes and non- physical causes. If undiagnosed, rhabdomyolysis may be fatal; the major complications are hyperkalemia and acute renal failure  In rhabdomyolysis case, magnetic resonance imaging (MRI) and bone scintigraphy were very valuable for demonstrating its site and extent.

26.  A 13-year-old boy presented with dark urine and myalgia on both thighs one day after a strenuous muscular exertion  Laboratory findings showed a positive serum and urinary myoglobin and very high levels of creatine kinase and LDH. Renal function was normal.  He complained of severe pain at both thighs, and both buttock areas

27.  The MRI showed a diffuse, increased signal intensity at both quadriceps and adductor magnus muscles and a thickening of fasciae on T2 weighted images  A Tc-99m MDP bone scintigraphy also showed abnormal uptakes in both thighs.  Two weeks later, follow up bone scintigraphy showed no abnormal uptake and his laboratory findings were also normalized.

28. Fig. 1. A magnetic resonance imaging(MRI) showed diffuse, increased signal intensity at both quadriceps and adductor magnus muscles and a thickening of fasciae on T2 weighted images. (VL : vastus lateralis, VM : vastus medialis, RF : rectus femoralis, QC : quadriceps) VL RF VM VL RF VM QC

29. Fig. 2. A whole-body bone scintigraphy also showed abnormal uptakes in both thighs.

30.  MRI is more sensitive than ultrasonography or computed tomography in evaluation of muscle injuries. These measurements enable determination of the actual site and extent of damaged muscles, especially when fasciotomy is considered for treatment.  Tc-99m MDP scintigraphy is also clearly valuable for visualizing the site and extent of damaged muscles.  Although scintigraphy is inferior to MRI with regard to spatial resolution, it is a valuable tool for screening actual muscle damage within the whole body. In addition, bone scintigraphy is also a good method for systemic survey and follows up  In summary, both MRI and Tc-99m MDP scintigraphy greatly supported an estimate of the severity and significance of acute rhabdomyolysis

31. REFERENCE  정준기 외. 고창순 핵의학 제 3 판  Acute Rhabdomyolysis : Importanceof MRI and BoneScintigraphy. JM Park 외. 대한소아신장학회지 2009  Bone and Gallium Scintigraphies in Rhabdomyolysis:A Case Report, CJ Chen 외, Ann Nucl Med Sci 2008;21:231-235  Arend et al. Cecil medicine 23 rd. Ch.114 Rhabdomyolysis  Up to date

32.  15 세 남자가 소변색이 변하였다고 내원하였다. 환자는 일주일전 가벼운 감기증상을 앓았고, 이틀 전 다이어트를 위해 심하게 윗몸일으키기를 했다고 한다. 소변색은 진한 갈색이었고, 배뇨통은 없다고 한다. 또한 환 자는 심한 복부근육통이 있었으며, 힘이 없다고 한다. 검사실 검사 결과 는 다음과 같다. 이 환자의 진단에 도움이 되는 검사는 ? 1. 복부 CT 2. 복부 초음파 3. Bone scan whole body 4. 신장 생검 5. 복부 KUB 키 : 145cm, 몸무게 65kg, WBC 12843 (NEUT 60% LYMP 35%), HGB 15.1, BUN/Cr 12/0.7, AST/ALT 658/321, Na/K/Cl 141/3.8/98, CK 128049, Myoglobulin : positive Urine analysis : albumin(500mg), RBC 2-4, WBC 0-1

33.  답 : 3 번  운동이후 증상이 발생한 환자로 콜라색의 소변과 복부 근육통, 무력감 등의 소견과 CK, AST/ALT, Myoglobulin 등의 증가 소견으로 봤을 때 Rhabdomyolysis 를 의심해 볼 수 있으며 이 때 bone scan whole body, MRI 등이 도움이 될 수 있다.