Cocaine-induced rhabdomyolysis with secondary acute renal failure

A 50-year-old male patient with a history of prostate cancer treated with iodine-125 seed implants and previously documented degenerative lumbar spinal stenosis with chronic low back pain presented to the emergency room with severe low back and right flank pain. The patient denied any history of trauma or recreational drug use. The patient was treated with valium and pain medications; however, he experienced no improvement of symptoms. The patient also noted on the following day that his urine had darkened. The patient had earlier denied any history of abdominal pain, jaundice, rectal bleeding, or melena. On laboratory evaluation at the time of admission, the white cell count was 18000 per mcl (18000 μL), creatinine was 1.0 mg/dl and BUN 12 mg/dl. Upon subsequent testing, the patient's creatine kinase (CK) level was greatly elevated to 21613 units/L (U/L). The patient's erythrocyte sedimentation rate was also elevated and the urine returned positive for cocaine. The patient's creatinine level rose over the following days to 4.7 mg/dl. As his back pain worsened, a magnetic resonance image (MRI) of the lumbar spine was obtained. A diagnosis of cocaine-induced rhabdomyolysis with secondary acute renal failure was made. With treatment, the patient's creatine kinase levels decreased and pain improved in the muscle, representing hemorrhage with loss of muscle architecture and more prominent areas of confluent necrosis. Enhancement was again seen and was only slightly decreased in prominence compared to the preceding study and the areas of confluent necrosis were clearly delineated (Figure 2). The abnormal signal in the left muscle complex had slightly improved in the interval.