Rhabdomyolysis from spinning exercise and ephedra-contained herbal medicine

Hoyoung Ryu，Hong Sup Kim，Heejung Choi，Jooyoung Kim，Dong Jun Sung，*

aDivision of Sport Science，College of Science and Technology，Konkuk University，Chungju-si 380-701，Republic of KoreabDepartment of Urology，Konkuk University Hospital，Chungju-si 380-704，Republic of KoreacDepartment of Nephrology，Konkuk University Hospital，Chungju-si 380-704，Republic of KoreadHealth and Rehabilitation Major，Kookmin University，Seoul 136-702，Republic of Korea Received 25 June 2015；accepted 30 June 2015 Available online 4 September 2015



Rhabdomyolysis from spinning exercise and ephedra-contained herbal medicine

Hoyoung Ryua，Hong Sup Kimb，Heejung Choic，Jooyoung Kimd，Dong Jun Sunga，*

aDivision of Sport Science，College of Science and Technology，Konkuk University，Chungju-si 380-701，Republic of KoreabDepartment of Urology，Konkuk University Hospital，Chungju-si 380-704，Republic of KoreacDepartment of Nephrology，Konkuk University Hospital，Chungju-si 380-704，Republic of KoreadHealth and Rehabilitation Major，Kookmin University，Seoul 136-702，Republic of Korea Received 25 June 2015；accepted 30 June 2015 Available online 4 September 2015

Dear editor，

Frequent participation in physical activity has a positive impact on individual physical and psychological well-being，and the effect of physical activity and exercise varies according to individual physical fitness level，the environment，and drug intake.Particularly，severe exercise that exceeds the individual physical fitness level may result in musculoskeletal injury or damage，1and rhabdomyolysis is a pathological condition of the musculoskeletal system that can be complicated by acute renal failure，compartment syndrome，and hepatitis.2People who fail to receive proper management for rhabdomyolysis may face life-threatening conditions，even death.3

Recent studies4have reported on a number of cases that developed myopathy associated with herbal medicines containingMahuang（ephedrasinica），suggestingthepossibilitythatthe increased activity of the sympathetic nervous system triggered bytheephedrinecontainedinephedraanditsderivativeephedra alkaloids may cause rhabdomyolysis as well as myopathy.5

The maximum dose for ephedra is usually recommended to be32 mg/day.6Althoughtheexactdoseofephedrausedinherbal drugs is unknown，we postulate that rhabdomyolysis may be inducedbytheherbalmedicine.In2004，theU.S.FoodandDrug Administration banned ephedra-containing products due to numerous reports of adverse events.7Nevertheless，the use of ephedra-containing products is still allowed in Asian countries，including China and Korea，so the adverse events of its use should be taken into consideration.To this end，this letter presentsacaseofapreviouslyhealthyfemalesubjectwhodeveloped rhabdomyolysis while exercising and using an herbal medicine containing ephedra that was marketed to accelerate fat loss.

The 29-year-old female subject （height=165 cm，weight=68 kg）did not have a remarkable history of disease or a family history of cardiovascular disease.The patient was performing a regular spinning exercise（Borg’s scale 15:hard intensity）for weight loss after having taken an herbal medicine containing ephedra.The woman experienced an unusually severe pain in her thighs and produced dark urine 48 h after the exercise.

The first physical examination after being admitted to the emergency room revealed swelling in her thighs.A neurological examination and an electrocardiograph presented normal results.However，some test items in the blood（including electrolytes），biochemical examinations，and urinalysis revealed abnormal findings associated with rhabdomyolysis（Table 1）. An examination of the blood chemistry revealed liver function test results consisting of 1728 IU/L in aspartate transaminase （AST）and 364 IU/L in alanine transaminase（ALT），indicating the presence of hepatitis.

The patient’s c-reactive protein（CRP），a blood inflammatory marker，was high（1.94 mg/dL）.The laboratory findings of creatinine and K+were normal，but high levels of creatinine kinase（CK；25，010 U/L），myoglobin（MB；15，510.40 ng/mL），and CK-MB（206.9 ng/mL）indicated rhabdomyolysis.Thepatient had a lactate dehydrogenase（LDH）level of 7370 IU/L，which was 10 times higher than normal.The LDH level is an indicator of muscular injury.Re-test results 4 days after admission revealed a normal CRP level but abnormal results in terms ofliverfunction and blood （AST=1193 IU/L，ALT=468 IU/L，CK=14，615 U/L，MB=231.60 ng/mL；and CK-MB=27.30 ng/mL）.

This case highlights the risk of developing rhabdomyolysis，even during regular exercise，if herbal drugs containing ephedra are consumed.In order to exercise more safely，special attention should be taken in people consuming ephedra during physical activity.We plan to further investigate the mechanism of ephedra-induced rhabdomyolysis.

Acknowledgment

This paper was supported by Konkuk University in 2016.

Authors’contributions

HR and DJS conceived of and designed the study；DJS and JK contributed to the writing of the manuscript；HSK and HC evaluated the patient.All authors have read and approved the final version of the manuscript，and agree with the order of presentation of the authors.

Competing interests

None of the authors declare competing financial interests.

References

1.Kinler WB，Chandler TJ，Stracener ES.Musculoskeletal adaptations and injuries due to overtraining.Exerc Sport Sci Rev 1992；20:99-126.

2.Clarkson PM，Hubal MJ.Exercise-induced muscle damage in humans.Am J Phys Med Rehabil 2002；81:52-69.

3.Patel DR，Gyamfi R，Torres A.Exertional rhabdomyolysis and acute kidney injury.Phys Sportsmed 2009；37:71-9.

4.Baek JH，Suh BC，Kim YB，Chung PW，Moon HS，Jin DK，et al.Myopathy following ingestion of Ma-Huang（ephedra）-based herbal remedy.Korean J Neurosci 2009；27:424-7.

5.StahlCE，Borlongan CV，Szerlip M，Szerlip H.No pain，no gain—exercise-induced rhabdomyolysis associated with the performance enhancer herbal supplement ephedra.Med Sci Monit 2006；12:CS81-4.

6.Abourashed EA，El-Alfy AT，Khan IA，Walker L.Ephedra in perspective:a current review.Phytother Res 2003；17:703-12.

7.Burke J，Seda G，Allen D，Knee TA.A case of sever exercise-induced rhabdomyolysis associated with a weight-loss dietary supplement.Mil Med 2007；172:656-8.

Peer review under responsibility of Shanghai University of Sport. *Corresponding author.

E-mail address:sls98@kku.ac.kr（D.J.Sung）.

http://dx.doi.org/10.1016/j.jshs.2015.09.002

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