Correspondence

Challenge, 110 Deep Knee Bends; Reward, Rhabdomyolysis

N Engl J Med 1994; 330:1620-1621June 2, 1994

Article

To the Editor:

A 21-year-old man presented to our hospital with a one-day history of brown urine, nocturia, urinary frequency, and mild suprapubic pain. Three days earlier, while participating in a prison hazing ritual, he was challenged to maneuver 10 chess pieces, a task requiring 110 deep knee bends in rapid sequence. The chess pieces were lined up on the floor, and the prisoner had to squat to pick up the first piece and then squat to set it down next to the second piece. He then had to retrieve the first two pieces by squatting twice to pick them up and twice to set them down. Then three pieces were to be picked up one at a time and placed down next to the fourth, requiring six more squats. This process was to continue until all 10 pieces were picked up and set down, requiring 110 squats; however, the patient tired after 100.

Within 12 hours he was unable to leave his bed because of anterior thigh pain. He had not done any exercise since 1989, when he underwent surgery of both knees after a bicycle accident. He was taking no medications and had no history of similar episodes. He denied using alcohol or other drugs; at admission his blood alcohol level was zero and his urine was negative on toxicologic screening.

On physical examination the patient had mildly swollen, warm, erythematous, soft, and exquisitely tender quadriceps muscles and was unable to flex his knees. His urine was 2+ positive for protein and 3+ positive for occult blood, as well as positive on orthotolidine testing; the urinary sediment contained one to five red and white cells and occasional pigmented granular casts per high-power field. The serum creatinine concentration was 1.3 mg per deciliter, the creatine kinase concentration more than 160,000 U per liter, and the potassium concentration 4 mmol per liter. The patient was given a diagnosis of exertion-induced rhabdomyolysis and treated with intravenous fluids, furosemide, analgesic drugs, and rest. The creatine kinase concentration was 12,130 U per liter on day 5, 994 U per liter on day 10, and 6 U per liter on day 12. On day 12 urinalysis was negative, the serum creatinine concentration 1.0 mg per deciliter, and the serum potassium concentration 4 mmol per liter.

Rhabdomyolysis with myoglobinuria has been associated with conga drumming,1 karate kicking,2 and mechanical-bull riding3. We report the chess-piece challenge of deep knee bends resulting in rhabdomyolysis. This might also be called checkmate rhabdomyolysis.

Madeline Frucht, M.D.
University of Connecticut, Farmington, CT 06030

3 References

1. 1

   Furie B, Penn AS. Pigmenturia from conga drumming: hemoglobinuria and myoglobinuria. Ann Intern Med 1974;80:727-729
   Web of Science | Medline

2. 2

   Russell SM, Lewis A. Karate myoglobinuria. N Engl J Med 1975;293:941-941
   Web of Science

3. 3

   Powers RD, Lamb GC, Matyasz RC, Spilane MT, van Iyn RA. Urban-cowboy rhabdomyolysis. N Engl J Med 1981;304:427-427
   Web of Science | Medline