M.l.expert's opinion on rhabdomyolysis to renal failure

MEDICO-LEAGAL EXPERT'S OPINION
sub: - Acute Renal Failure as a result of Rhabdomyolysis - Medico-Legal
Expert's Opinion - Regarding.
Ref: - Requisition dated 05.06.2019, from Mr. Shantanu Sanjiv Bhatt
*:F*
Mr. Shantanu Sanjiv Bhatt sent me through E-mail, a requisition dated
05.06.2019, along with the following documents, seeking certain clarifications, as
to whether the death of the deceased, Prabhudas Madhavji, aged about 40 years
was due to"Acute Renal Failure as a result of Rhabdomyolysis or not":
t. Report of Post-Mortem Examination in P.M.No.394/1990 of Forensic
Medicine Department, M.P. Shah Medical College, Jamnagar, dated
18.11.1990, on the body of the deceased, Prabhudas Madhavaji, aged
about 40 years, issued by the P.M. Doctors, Dr. H. M. Mangal, Associate
Professor and Dr. S.D. Kalele, Assistant Professor.
2. Final Opinion Report dated18.2.t99t, as to the Cause of Death of the
deceased, Prabhudas Madhavaji, in P.M.No.394/IggO dated 18.11.199,
opined by the P.M. Doctors, Dr. H. M. Mangal, Associate Professor and Dr.
S.D. Kalele, Assistant Professor, Dept. of Forensic Medicine, M.P. Shah
'
Medical College Jamnagar.
3. Histopathology Report dated 17.12.1990, in Pathology Serial Section
No.16/1990, of the Department of Pathology, M.P. Shah Medical College,
Jamnagar.
4. Reply dated 06.04.1991 from Dr. H. M. Mangal, Associate Professor and Dr.
S.D. Kalele, Assistant Professor to the questionnaire from Shri P.P. Pandey,
D.S.P., C.l.D.(Crime), Ahmedabad.
5. Reply dated 04.09.1991 from Dr. H. L. Trivedi, Director, Post-Graduate
Training Centre for Nephrology & Urology, B.J. Medical College & Civil

Hospital, Ahmedabad to shri P. P. Pandey, Police officer (E)' C'l'D' crime''
Govt. of Gujarat, Ahmedabad'
wound certificate: MLC/lP/OP No. t4T ltggo dated 09'11'1990', of the
diceased prabhudas Madhavaji, issued by the Medical officer, community
Health Centre, JamjodhPur'
XeroxcopyoftheHospitalCaseSheetoftheNavalbenManilalVirani
General Hospital, Rajkot, in relation to the patient, Prabhudas Madhavaji'
*:1.*
Through his application dated 05.05.2019, Mr. Shantanu Sanjiv Bhatt
requested for professional expert opinion, after examination of the above
mentioned documents, on the following issues:
i. what are the possible causes of Rhabdomylysis?
ii. ls there any raboratory/cfinicar evidence present for Rhabdomyolysis in this
case?
iii. ls this a case of Rhabdomyolysis?
iv. Can squats cause Rhabdomyolysis?
To know the answers for the above mentioned questions' one has to read
and understand the following documents:
L. what is Rhabdomyolysis, and how does it lead to Acute Renal Failure?; and
2.Whatarethecontentsofthemedicaldocuments,inthiscase?
RhabdomyolysisleadingtoRenal(Kidney)failure
Rhabdomyolysis is due to a direct or indirect injury/d amage to skeletal muscle' It
results from the-death of muscre fibers and release of their contents into the
bloodstreu-. wtt.n muscle it d;;;J, a protein called myoglobin is released
into the broodstream. It is then nit.ia oufof the body by the kidneys. Myoglobin
can damage kidney cells, f.uai.tg ;o-r.,iot" complicaiions such as renal (kidney)
failure. The kidneys cannot r.-tut waste due to scanty and concentrated urine
secretion. In rarest of rare cases,rhabdomyolysis can even cause death due acute
6.
7.
renal failure.
{et(

Direct compression of muscle for a prolonged periodo leading to a local crush
injury is the most common mdchanism of traumatic rhabdomyolysis resulting
in kidney failure. Compression causes muscle ischemia, as tissue pressure rises to
a level that exceeds capillayr pressure. When the compression is releaved, the
muscle tissue is reperfused. Muscle ischemia followed by reperfusion represents
the fundamental patho-physiologic mechanism of rhabdomyolysis.
Traumatic rhabdomyolysis is often due to a crush injury resulting from a
prolonged crushing force on skeletal muscle, for example, after being trapped
under a collapsed building or following a car accident. Symptoms may be caused
by an overabundance of intracellular substances (e.g., myoglobin, potassium,
phosphate) following their release from destroyed muscle cells.
Traumatic rhabdomyplysis is generally due to prolonged periods of pressure of
one or more limbs.
Presenting signs and symptoms of rhabdomyolysis are shock, swollen limbs, dark
urine, progressing to renal failure.
Histologic examination of kidneys reveals tubular necrosis and pigmented casts.
Rhabdomyolysis Causes: There are many traumatic and nontraumatic
causes of rhabdomyolysis.
Traumatic causes
. A crush injury such as from an auto accident, fall, or building collapse
. Long-lasting muscle compression such as that caused by prolonged
immobilization after a fall or lying unconscious on a hard surface during
illness or while under the influence of alcohol or medication
. Electrical shock injury, lightning strike, or third-degree burn
. Venom from a snake or insect bite
Nontraumatic causes:
. The use of alcohol or illegal drugs such as heroin, cocaine or amphetamines

. Extreme muscle Strain, especially in someone who is an untrained athlete;
this can happen in elite athletes, too, and it can be more dangerous if there
is more muscle mass to break down'
. The use of medications such as antipsychotics or statins' especially when
given in high doses
. A very high body temperature (hyperthermia) or heat stroke
. Seizures or delirium tremens
. A metabolic disorder such as diabetic ketoacidosis
.Diseasesofthemuscles(myopathy)suchascongenitalmuscleenzyme
deficiency or Duchenne's muscular dystrophy
. Viral infections such as the flu' HIV' or herpes simplex virus
. Bacterial infections leading to toxins in tissues or the bloodstream (sepsis)
Signs and Symptoms of Rhabdomyolysis:
Signs and symptoms of rhabdomyolysis lay be.hard to pinpoint' because the
course of rhabdomyolysis varies, Jtitlqi"g on its cause' Symptoms may occur 1n
;;;;;." of the b;iv or affect the whole bodv'
The "classic triad" of rhabdomyolysis symptoms are:
1. Muscle pain in the shoulders' thighs' or lower back;
2. Muscl. *;;k";" o' trouble -oui"g affns and legs; and
3. Dark red or brown urine or decreased urination'
other common signs of rhabdomyolysis include:
r $€fle rolized weakness'
. Abdominal Pain
. Nausea or vomiting
. Fever, raPid heart rate
. Confusion, Oeftydration' fever' or lack of consciousness
. Darkened urine (mYoglobinuria)
. HYPovolemia and shock
Diagnostic Tests:
o Blood tests for creatine kinase r

o Urine tests for myoglobin, released from damaged muscles
C ommon complications of rhabdomyolysis include :
. Very high levels of potassium in the blood, which can lead to an irregular
heartbeat or cardiac arrest and kidney damage
o About one in four also develop problems with their liver.
o A condition called compartment syndrome may also occur after fluid
resuscitation. This serious compression of nerves, blood vessels, and
muscles can cause tissue damage and problems with blood flow.
o Compartment syndrome of the affected extremity (usually the lower legs).
Report of Post-Mortem Examination in P.M.No.394/L990 of Forensic
Medicine Department, M.P. Shah Medical College, Jamnagar, dated
18.11.1990, on the body of the deceased, Prabhudas Madhavaji, aged
about 40 years, issued by the P.M. Doctors, Dr. H. M. Mangal,
Associate Professor and Dr. S.D. Kalele, Assistant Professor:
The postmortem examination was conducte on 18.11.1990 from 04:50 PM to
06:20 PM.
No evidence of any injury found over the body.
Brain was slightly edematous and congested. CSF was clear.
Both lungs were edematous and congested.
Peritoneal cavity contained about 200 cc of yellowish fluid.
Heart: Weight 330 gms. Pale pink coloured clotted blood present in the right
atrium and right ventricle which is extending upto pulmonary trunk. Clots
are adherent with wall. Left chambers contain small amount of fluid
blood.
ffia+

Stomach contained about,100 ml of"dark brown liquid. Mucosa uniformly
congested all over.
No gross abnormality except congestion was observed in Liver and Gall bladder'
Pancreas, Spleen, Kidneys and Suprarenals'
Organs of generation: Nothing particular was observed'
No evidence of any injury was found on internal examination of the
body, including the limbs.
Final opinion Report datedl8 .z.LggL, as to the cause of Death of the
deceased, Prabhudas Madhavaji, in P.M.No.3941L990 dated
1g.11.199, opined by the P.M. Doctors, Dr. H. M. Mangal' Associate
professor and Dr. S.D. Kalele, Assistant Professor, Dept. of Forensic
Medicine, M.P. Shah Medical College Jamnagar:
The cause of death of the deceased was "Acute renal failure as a
result of rhabdomYolYsis."
Histopathology Report dated t7.L2.t990, in Pathology Serial Section
No.15/1990, of the Department of PathologY, M.P. Shah Medical
College, Jamnagar:
Brain: Congested
Lungs: edematous and congested
Spleen: Congested
Liver: Mild congestion with fatty chnages'
Lungs: Marked congestion with mild Pulmornary oedema.
6
,f* ?rry
'' qwtutF

-
Kidneys: Marked congestion with many renal tubules showing hyaline casts and
haemoglobin casts. Focal patchy necrosis, interstitial haemorrhage and
Mononuclear infiltrates
Right thigh: Mild interstitial haemorrhage
Left thigh: No remarkable pathology could be detected.
Calf muscles: Mild interstitial haemorrhage
Reply dated 06.04.1991 from Dr. H. M. Mangal, Associate professor
and Dr. S.D. Kalele, Assistant Professor to the questionnaire from Shri
P.P. Pandey, D.S.P., C.l.D.(Crime), Ahmedabad:
The cause of death in layman English can be put as "Rapid failure of the
functioning of the kidneys as a result of disintegration of striated muscle fibres
of the body."
For furthur querries the case may please be referred to a
nephrologist.
Reply dated 04.09.1991 from Dr. H. L. Trivedi, Director, Post Graduate
Training Centre for Nephrology & Urology, B.J. Medical College & Civil
Hospital, Ahmedabad to shri p. p. pandey, potice officer (E), c.l.D.
Crime, Govt. of Gujarat, Ahmedabad:
There is no laboratory evidence for the presence of the
Rhabdomyolusis in this case.
There is no evidence of pre-existing renat disease in this patient as we do
not have any history available about the health of this person prior to this
episode.

Wound Certificate: MLC |lP|oPNo. 147 |tggodated 09.11.1990, of the
diseasedPrabhudasMadhavaii,issuedbytheMedicalofficer,
CommunityHealthCentre'Jamiodhpur:
l.Tendernesssoverbothbuttocks,Rt.Andsideofthigh.....andboth
calf regions'
2' Ascar over left chest'
3' A wart over nape of neck'
The injury nos' 2 and 3 are not injuries'
The injury no'l' is feeling of pain on touching the area'
Nomajorinjurywasnotedonclinicalexaminationofthepatient.
Hospitar case sheet of the Navarben Manilar virani General Hospital'
Raikot,inrelationtothepatient'PrabhudasMadhavaii:
HistorY of:
Reduced urine out Put
Haematuria
Excessive exertion
Beathlessness
The hospital case record is in scribbred itegibre handwriting, making it almost
impossibletoreadandunderstandtheentriesofthecasesheet.h
DEATH CERTIFICATE

Date of Admission: 12.11.1990"
Date of Death: 18.11.1990
Cause of Death: Acute Renal Failure secondary to Rhabdomyolysis with uremia
with Card iorespiratory a rrest.
M EDICO-LEGAL CLARI FICATIONS
L. What are the possible causes of Rhabdomylysis?
Ans. This is not a case of death due to Rhabdomyotysis.
There are many traumatic and nontraumatic causes of rhabdomyolysis, as
listed above. Non of those causes was noted in this case. Rhabdomyolysis
was a misdiagnosis in this case.
2. ls there any laboratory/Clinical evidence present for Rhabdomyolysis in this
case?
Ans. No laboratory/Clinical evidence is present to diagnose this as a case of
Rhabdomyolysis.
3. ls this a case of Rhabdomyolysis?
Ans. This is not a case of Rhabdomyolysis.
4, Can squats cause Rhabdomyolysis?
Ans. Squats cannot cause severe prolonged compression of muscles to the
extent of causing local ischemia of the muscres reading to ts
Rhabdomyolysis in such severity to release large quantities of myoglobin
that can bloch the renal tubules to cause kidney fairure.
ln'this case the clinical doctors, who treated the deceased as patient, did

not notice anY muscle damae.e'
ln the postmortem examination report it is clearly noted,
,,No evidence
ofanyiniurywasfoundoninternalexaminationofthebody,
including the limbs"'
lntheirreplytothelnvestigatingofficer,ShriP.P.Pande,D.S.P.,c.l.D.
(Crime),Ahmedabad,thepostmortemdoctorsadvisedhim,,,Forfurthur
querries the case may pr",," be referred to a nephrologist,,,
indicatingthattheirdiagnoseswasnotonthebasisofthe
Postmortem exami nation fi ndings'
Thepostmortemdoctorsweremisguidedbythemisdiagnosis
made bY the treating doctors'
OPINION:
Directcompressionofmuscleleadingtoalocalcrushinjuryisthemost
common mechanism of traumatic rhrbdomyolysis. compression causes muscle
ischemia, as the tissue pressure rir"s to a revel that exceeds capillary perfusion'
Evidenceofcompressionofmuscle,i.e.contusiom/bruisehasnotbeen
notedeitherinthehospital.,.,*.ntrecordsofthepatientorinthe
postmortem examination ,.port. ri.ru is no evidence of any damage to the
skeretal .'nur.ru, as per the histo-pathorogy report'
Tothebestofmyknowledgeandbelieflamofthefirmopinion
that it was not a case of death due to Rhabdomyolysis'
M.B.6.5-; M'D'(
lEPDY'
'rk"ntirMedici ne) I LL' B',
DR.
10
(

Medico-legal Consultant to the Truth-Labs.
Former Professor & Head of the Department of Forensic Medicine
&
vice Principal, osmania Medical college/ osmania General Hospitat,
HYDERABAD
DECLARATION
This is to solemnly affirm and declare that I worked in the department of Forensic
Medicine and Toxicology in various capacities from May, 1981 to November 1gB2 and again
from November, 1983 to September,2011 in the Medical Colleges and Teaching Hospitals
of the Government of Andhra Pradesh,
From November, 1991 to September,2011 (19 years 10 months), lworked in the
superior cadre as the Professor of Forensic Medicine in the Guntur Medical College,
Guntur, the Gandhi Medical College, Hyderabad, the Andhra Pradesh police Academy,
Hyderabad and the Osmania Medical College, Hyderabad.
From 1st January to 31st December,1997 (One full year) I worked as the in-house
faculty member in the cadre of Professor of Forensic Medicine in the Andhra Pradesh police
Academy.
I have been associated as the Guest Faculty Member of the A.P, Police Academy,
Hyderabad and the A.P. Judicial Academy, Hyderabad since their inception,
I am also associated as the Guest Faculty Member of the S.V.P. National police
Academy, Hyderabad.
I was the Head of the Department of Forensic Medicine, Osmania Medical College/
Osmania General Hospital, Hyderabad for 10 years 02 months, i.e., from July, 2000 to July,
2005 and from September, 2006 to September,2011. The faculty of the Department of
Forensic Medicine, Osmania Medical College/ Osmania General Hospital, Hyderabad was
(flMt71 r.

03 professors, 03 Associate professors, 05 Assistant
professors and 24 Resident Doctors'
The annual postmortem examination woik load I that depart was from 4'500 to 5'000'
t{, -"e rf
DR. M. NAR DDY,
M.D.(Forensic Medicine); LL'B'
Medico-legal Consultant, Truthe Labs, Hyderabad
&
Former professor & Head of the Department of Forensic Medicine & Toxicology
osmaniaMedicalCollege/osmaniaGeneralHospital,Hyderabad.
12

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