Rhabdomyolysis Caused by a Behavioral Manifestation of Acute Mania

Abstract

Introduction

While seen in patients with bipolar disorder due to NMS, antipsychotic side effects, or substance use, rhabdomyolysis resulting from behaviors seen in mania has not been reported in recent literature. We present a case of a patient with rhabdomyolysis due to exertion during a manic episode.

Case

A 29-year-old male with a history of bipolar disorder type 1 was brought to the ED in June 2022 after he was found on the roof of a local theater sharing excerpts from a book he had written. Temperatures outside were 100–102 Fahrenheit. On presentation, the patient had rapid, pressured speech and demonstrated flight of ideas. He was religiously preoccupied. He had been previously admitted to Psychiatric Emergency Services in April 2022 for mania and was discharged with lithium and lamotrigine. He had been titrating these medications with his outpatient psychiatrist.

The patient’s labs showed an elevated creatinine of 1.49, up from his baseline of 1.09. Further workup revealed an elevated CK of 3,538. Additional abnormalities included an AST of 70, calcium of 10.6, total bilirubin of 1.6, and WBC of 15.5. He was afebrile, oriented, and had no obvious signs of infection. The patient received 2 liters of Lactated Ringers (LR) and was admitted to Internal Medicine. Later, he was agitated overnight and received 10mg olanzapine and 2mg lorazepam. Lithium level following fluid resuscitation was 0.6.

On interview the next day, the patient described working on a creative religious piece that he wanted to share with others, leading to him climbing on the roof. He had been hyper-focused on this work, with 1–4 hours of sleep nightly. He also had been frequently doing gymnastics, walking long distances, and climbing other buildings. He endorsed diffuse muscle pain, but this was not reproducible on exam.

150mL/hr of LR was started, and PO fluid intake was encouraged. He agreed to resume his medications and was started on lithium 900mg and lamotrigine 50mg. His CK continued to downtrend. WBC count decreased and was 12.9 at discharge. Lamotrigine was titrated up to home dose of 100mg. His mania improved, and he was ultimately discharged home with outpatient follow-up.

Conclusion

Rhabdomyolysis results from the release of toxic cellular compounds from muscle fibers. Complications include acute renal failure, hyperkalemia, and compartment syndrome. Causes include substance use, medications, trauma, seizures, ischemia, overexertion, and dehydration. Recently reported cases of mania-associated rhabdomyolysis involve iatrogenic causes, such as neuromuscular malignant syndrome (NMS) and non-NMS antipsychotic side effects.Other causes include high-risk drug use during mania. Rhabdomyolysis due to behavioral manifestations of mania have been documented more rarely in older reports, similarly, addressing excessive exercise and dehydration. Therefore, our case represents a reminder of the medical sequalae resulting from actions undertaken during acute mania. This highlights the importance of implementing effective treatment to prevent such episodes.

Funding

No Funding