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Rhabdomyolysis-induced compartment syndrome secondary to atorvastatin and strenuous exercise

A 50-year-old male UK resident with a history of hypertension and hypercholesterolaemia presented to the emergency department with a 48-hour history of sudden onset bilateral thigh swelling and pain unrelieved by regular analgesia. 3 days prior to presentation, he performed a vigorous workout in the gym. His medications included ramipril 5 mg once daily and atorvastatin 20 mg at night time. He was a non-smoker and did not consume alcohol. He reported no known drug allergies. Physical examination confirmed bilateral swollen thighs, with no overlying skin changes, clinically suggestive of compartment syndrome. His creatine kinase was >50 000 IU with normal renal and liver function tests. Further investigation with MRI-identified prominent swelling of the vastus intermedius and medialis muscles, more marked on the left, with extensive diffuse short tau inversion recovery (STIR) signal hyperintensity and isointensity on T1 sequences, suggestive of rhabdomyolysis. He underwent bilateral fasciotomies of his thighs and aggressive intravenous fluid resuscitation with close monitoring of his electrolytes. Intraoperatively his muscle was healthy, with no evidence of haematoma or necrosis. His medication atorvastatin was stopped due to his rhabdomyolysis. 48 hours later, he returned to theatre and review of his fasciotomy wounds was unremarkable. 4 days later, he was discharged uneventfully. His postoperative recovery was complicated by a serous discharge from his left medial thigh wound. Further investigation with an ultrasound confirmed a 4×1×1cm multiloculated collection within the superficial tissue directly underlying the wound. An aspirate was performed and cultures revealed no growth. He remains under review in the department of plastic surgery. This case report discusses the aetiological spectrum, clinical presentation, pathophysiology, differential diagnosis, investigations, management and complications of rhabdomyolysis.