Collapse In A First-time Marathoner

HISTORY: 22 yo Naval Academy Midshipman collapsed at mile 22 of his first attempted marathon. He was not observed to lose consciousness and had clear recall of all events during the race and after his collapse. He was unable to ambulate without assistance and was taken via EMS to a local Emergency Room. His chief complaint was pain to his thighs bilaterally and profound lower extremity fatigue. Conditions were sunny and cool, with max temp during the race of 67 degrees. He had trained for the marathon over the previous 4 months without significant complcation. His longest training run had been approximately 20 miles, which he had completed 3 weeks prior to the race without difficulty and had continued his training in the next few days. PHYSICAL EXAMINATION: First documented vitals signs showed Temp 97.9 F, Pulse 113, BP 120/52, RR 22. Pt was alert and oriented X 3. Pt displayed significant tenderness to palpation over his quadriceps bilaterally. The quadriceps muscles felt tense and tight. Distal pulses and sensation were intact. Hip extension and knee flexion were limited by discomfort. DIFFERENTIAL DIAGNOSIS: Exertional Rhabdomyolysis Exercise Associated Collapse Exertional Cramping TEST AND RESULTS: Day of Admission: CK 7807, Serum Cr 1.9, WBC 25,000, AST/ALT 182/48, Ca+ 8.0. FINAL WORKING DIAGNOSIS: Exertional Rhabdomyolysis TREATMENT AND OUTCOMES: 1.Pt was admitted and treated initially with IV fluids (normal saline) overnight. Labs the following day were as follows: CK 101,000, Serum Cr 1.7, WBC 16,000, AST/ALT 1964/344. 2.Fluids switched to 1/2 NS with 1.5 ampule of sodium bicarb per liter at 150 cc/hr. 3.Pt discharged on HD #3 with CK 55,748, Serum Cr 1.4. 4.Pt presented for follow-up at Academy clinic 2 days thereafter seeking advice on how this experience might affect his future in regards to his Navy service, particularly the highly competitive field of aviation, and further athletic endeavors. (Case is currently ongoing. Expect disposition by 1 Jan 2009)