ABC | Volume 113, Nº2, August 2019

Case Report Pereira et al. Exertional rhabdomyolysis microvascular reactivity Arq Bras Cardiol. 2019; 113(2):294-298 Table 1 – Laboratory testing of the patient before military training, during hospitalization (D, days) and one day after hospital discharge Parameters BEFORE D1 D2 D3 D4 D5 AFTER Reference ranges Red blood cells (10 6 /µL) 5.3 5.8 5.0 4.6 4.4 4.9 5.3 4.5 – 6.2 Hemoglobin (g/dL) 15.8 16.9 14.5 13.5 13.0 15.1 15.4 13.5 – 18.0 Hematocrit (%) 47.5 51.5 43.3 40.5 38.1 43.2 47.0 40 – 54 White Blood Cell Count (µL) 9,000 18,600 9,580 7,120 6,470 8,920 9,200 5,000 – 10,000 Platelet counts (x1000/µL) 278 313 233 201 195 267 269 150 – 450 Urea (mg/dL) 39 67 47 31 25 27 40 15 – 40 Creatinine (mg/dL) 1.05 2.1 1.3 1.6 1.4 1.2 1.03 0.6 – 1.2 Creatinine Clearance (mL/min) 121 60 98 80 106 123 120 97 – 137 Calcium (mmol/L) 2.34 10.9 9.8 8.7 8.2 9.6 2.72 2.23 – 2.55 Magnesium (mg/dL) 1.9 2.3 2.1 1.8 2.5 2.4 2.1 1.6 – 2.6 Sodium (mmol/L) 138 140 136 142 155 141 138 137 – 145 Potassium (mmol/L) 3.6 4.2 3.6 3.7 3.3 4.2 4.1 3.6 – 5.0 Creatine kinase (U/L) 370 1,100 2,116 1,496 306 211 158 30 – 170 TSH (µIU/mL) 2.10 - - - - - 2.60 0.35 – 4.94 T3 (ng/ml) 1.13 - - - - - 1.49 0.59 – 1.49 T4 (ng/dl) 1.19 - - - - - 1.16 0.70 – 1.48 T3: triiodothyronine; T4: thyroxine; TSH: Thyroid-Stimulating Hormone. Table 2 – Cytokine plasma levels (in pg/mL) of the patient before military training and one day after hospital discharge Cytokines BEFORE AFTER IL-1β 0.29 29.44 IL-6 0.41 0.74 IL-10 0.038 6.089 IL-1Ra 5.86 156.57 TNF-α 19.28 3.75 INF-γ 0.88 0.69 IL-1β: Interleukin-1 beta; IL-6: Interleukin-6; IL-10: Interleukin-10; IL-1Ra: IL-1 receptor antagonist; TNFα: tumour necrosis factor alpha; INF-γ: Interferon gamma. Conclusion ER may be accompanied by systemic microvascular dysfunction even after the resolution of symptoms and normalization of conventional laboratory tests. The microcirculatory disturbance is concurrent with alterations of plasma levels of both pro- and anti-inflammatory cytokines. Accordingly, ER should always be considered in the clinical scenario of muscle pain and disability, fever and dark urine after heavy exercise, including that performed for professional reasons. Besides that, the case report shows that ER may be associated with other complex and potentially severe conditions, which are microvascular dysfunction and systemic inflammation. These are novel findings which we would like to add to the clinicians´ reasoning. If the evaluation of microvascular function is made available clinically, it may be another potentially interesting evaluation to be performed in patients with ER. Nevertheless, more studies are needed to clarify the association between microvascular dysfunction and ER, as well as its clinical implications. Author contributions Conception and design of the research, Analysis and interpretation of the data and Critical revision of the manuscript for intellectual content: Pereira F, Moraes R, Bavel D, Lorenzo AR, Tibirica E; Acquisition of data: Pereira F, Bavel D; Statistical analysis and Obtaining financing: Tibirica E; Writing of the manuscript: Pereira F, Moraes R, Lorenzo AR, Tibirica E. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported. Sources of Funding This study was funded by FAPERJ and CNPq. Study Association This study is not associatedwith any thesis or dissertationwork. 296