Rhabdomyolysis Occurring After Use of Cocaine Contaminated With Fentanyl Causing Bilateral Brachial Plexopathy
Background: Rhabdomyolysis is caused by muscle overuse, trauma, prolonged immobilization, drugs, or toxins. As rhabdomyolysis progresses, swelling and edema can compress surrounding structures. Few cases of the phenomenon occurring as a sequela of substance use have been described.
Case Presentation: We present a 68-year-old male patient with rhabdomyolysis following use of crack cocaine contaminated with fentanyl. The patient had 0/5 strength bilaterally and bilateral absent reflexes in the upper extremities. Sensation was markedly decreased, as he was unable to feel temperature, pinprick sensation, or general touch. Creatine phosphokinase level was elevated at 21,292 IU/L. On magnetic resonance imaging, there was abnormal signal in the lower neck bilaterally. It is presumed that muscular edema resulted in partial narrowing of the thoracic outlet bilaterally with corresponding mass effect on the traversing brachial plexus.
Conclusions: This is the seventh case of brachial plexopathy secondary to rhabdomyolysis precipitated by opioid use that has been reported in the literature. Prospective studies should examine treatment for this condition.
Aside from physical rehabilitation programs, cases of plexopathy secondary to rhabdomyolysis similar to our patient have largely been treated with supportive therapy and symptom management. Pain management was the primary goal in this patient, which was achieved with moderate success using a combination of muscle relaxants, antiepileptics, tramadol, and serotonin-norepinephrine reuptake inhibitors. Some surgical approaches have been reported in the literature. One case of rhabdomyolysis of the shoulder girdle causing a similar process benefitted from fasciotomy and surgical decompression.7 This patient had a complete recovery of all motor functions aside from shoulder abduction at 8 weeks postoperation, but neuropathic pain persisted in both arms. It is possible our patient may have benefitted from a similar treatment. Further research is necessary to determine the utility of this type of procedure when treating such cases.
Conclusions
This case report adds to the literature describing focal rhabdomyolysis causing secondary bilateral brachial plexopathy after substance use. Further research is needed to establish a definitive pathophysiology as well as treatment guidelines. Evidence-based treatment could mean better outcomes and quicker recoveries for future patients with this condition.
