Rhabdomyolysis is a clinical syndrome caused by the necrosis of skeletal muscle fibers due to various etiologies and the release of components from the muscle cells into the plasma. Evidence includes the detection of myoglobin via urinalysis and the macroscopic detection of a red-brown color in the urine. The causes include traumatic factors, such as direct physical damage and long-term muscle pressure, and nontraumatic factors, such as excessive exercise, alcohol abuse, drugs, metabolic diseases, and infections [1-4].

In patients with rhabdomyolysis, acute renal failure, oliguria, muscle weakness, systemic or topical muscle pain, edema, and dark brown urine are common, and compartment syndrome may rarely occur. For symptoms such as urinary dysfunction in patients with renal failure or oliguria, Western medical treatments such as hemodialysis are implemented, and for muscle symptoms caused by compartment syndrome, fasciotomy is performed [3].

Studies on rhabdomyolysis have shown improvement through Western treatment; however, no studies have focused on patients treated for rhabdomyolysis with a comparison to other reports in the existing literature [5-8]. As clinically meaningful results were obtained using traditional Korean medicine (TKM) treatment including acupuncture, pharmacopuncture, and herbal medicine treatment in patients treated at the hospital for rhabdomyolysis complicated by compartment syndrome, a comparative review of other studies in the existing literature was conducted.

1. Patient

A 55 years old female.

1) Chief complaint

Both leg pain, weakness, and hypoesthesia.

2) Past history

On medication for hyperlipidemia (suspended on patient’s accord). On medication for insomnia (etizolam 1 mg 1 T 1–2 times/week).

3) Family history

None.

4) Present illness

The patient took nearly 20 sleeping pills at midnight on December 11, 2021. She was subsequently hospitalized at the Soonchunhyang University Hospital from December 11 to December 27 for symptoms of hypoesthesia in her leg as well as lower extremity edema and hypotonia. During hospitalization, the patient was also diagnosed with pulmonary thromboembolism, sciatic neuralgia, and rhabdomyolysis on abdominal and pelvic computed tomography (CT), brain CT, and brain magnetic resonance imaging phases. To treat acute renal failure, central venous catheter insertion and hemodialysis were implemented for 4 days. During hospitalization, in cooperation with the Soonchunhyang University Hospital Neurosurgery, an additional electromyography test showed right (Rt.) lumbosacral plexopathy at the branch level (partial axonotmesis in the lateral femoral cutaneous, obturator, and superior gluteal nerves and severe partial axonotmesis in the sciatic nerve). After discharge, she received follow-up treatment including acupuncture, pharmacopuncture, and moxibustion treatment at the Cheonan Korean Medicine Hospital of Daejeon University.

5) Treatment duration

December 27, 2021, to March 2, 2022 (66 days of hospitalization).

6) Patient protection policy on patient information use

To protect the patient’s personal information, the use of medical records was approved by the Cheonan Korean Medicine Hospital of Daejeon University Institutional Review Board (No. DJUMC-2022-BM-08-1).

2. Treatment

1) Acupuncture

The acupuncture needles used were standardized disposable 0.25 × 30 mm and 30 × 40 mm stainless steel (Eastern Acupuncture Equipment Manufacturer). Acupuncture was performed at BL36, BL37, BL38, BL39, BL40, BL55, BL56, BL57, BL58, BL59, BL60, GB35, GB36, GB37, and tender points on tissues, including the hamstrings and gastrocnemius muscle for 15 minutes twice daily.

2) Pharmacopuncture

Pharmacopuncture was performed once a day for hospitalization. Acupoints BL55, BL56, BL57, or trigger points around the calf were used. Jungsongouhyul pharmacopuncture (Korean Pharmacopuncture Institute) was administered just before acupuncture (Table 1). Doses of 0.1–0.2 mL were introduced at each acupoint to a depth of 1.0–1.2 cm. The maximum total dose per treatment was 1.0 mL. This was administered using a 1.0-mL disposable syringe and needle (30 G × 1/2”, 12.7 mm needle; Jungrim Medical).

Table 1 . Jungsongouhyul phamacopuncture details.

Component	Injection site (method)	Volume (cc)
Root of Corydalis turtschaninovii Besser	Gluteus (IM)	1
Dakura of Boswellia carterii Birdwood	Gluteus (IM)	1
Dakura of Commiphora molmol Engler	Gluteus (IM)	1
Seed of Prunus persica (Line) Batsch	Gluteus (IM)	1
Root of Paeonia obovata Maxim	Gluteus (IM)	1
Root of Salvia miltiorrhiza Bunge	Gluteus (IM)	1
Heartwood of Caesalpinia sappan L	Gluteus (IM)	1

IM, intramuscular..

3) Bee venom

Given the potential risks of a delayed hypersensitivity reaction or anaphylaxis associated with the use of bee venom (BV), informed consent was obtained from the patient prior to treatment. First, a hypersensitivity skin test to BV (1:20,000, 0.1 mL; Korean Pharmacopuncture Institute) was performed, and the result was negative. The concentration of BV administered was increased in the order of 1:20,000, 1:10,000, 1:5,000, 1:2,000, 1:1,000, 1:500, and sweet BV 10% was also used for intramuscular (IM) injection. The volume injected was also increased with each treatment if no hypersensitivity reaction occurred (Table 2). BV was substituted by Jungsongouhyul pharmacopucture, for the patient felt pain and itching from IM injection of BV on the calf area. BV was injected using 30 G, 1-mL syringes (30 G × 1/2”, 12.7-mm needle; Jungrim Medical).

Table 2 . Bee venom injection table.

Date	Day	Injection site (method)	Bee venom concentration	Volume (cc)
January 9, 2022	14	Gluteus (IM)	SBV 10%	1.0
January 10, 2022	15	Gluteus (IM)	20,000:1	1.0
January 11, 2022	16	Gluteus (IM)	20,000:1	1.0
January 12, 2022	17	Gluteus (IM)	10,000:1	1.0
January 17, 2022	22	Gluteus (IM)	5,000:1	1.0
January 18, 2022	23	Gluteus (IM)	2,000:1	0.6
January 22, 2022	27	Gluteus (IM)	2,000:1	0.8
February 12, 2022, reuse of bee venom	48	Gluteus (IM)	20,000:1	1.0
February 13, 2022	49	Gluteus (IM)	10,000:1	1.0
February 14, 2022	50	Gluteus (IM)	5,000:1	2.0
February 16, 2022	52	Gluteus (IM)	2,000:1	0.5
February 17, 2022	53	Gluteus (IM)	2,000:1	0.6
February 19, 2022	55	Gluteus (IM)	2,000:1	0.7
February 21, 2022	57	Gluteus (IM)	1,000:1	0.4
February 22, 2022	58	Gluteus (IM)	1,000:1	0.5
February 23, 2022	59	Gluteus (IM)	1,000:1	0.6
March 1, 2022	65	Gluteus (IM)	500:1	0.3

IM, intramuscular; SBV, sweet bee venom..

4) Herbal medicine

The patient took herbal medication three times daily. Binchang-san, Danguijakyak-tang, Hwalak-tang, Oyak Sungi-san, Paljung-san, and Sayuktang-gagambang were prescribed (Table 3).

Table 3 . Herbal composition of six herbal medications for daily dosage.

Binchang-san Day 8 to 10	Dosage (g)	Danguijakyak-tang Day 11 to 12	Dosage (g)	Hwalak-tang Day 13 to 52	Dosage (g)	Oyaksungi-san Day 53 to 54	Dosage (g)	Paljung-sanDay 55 to 59	Dosage (g)	Sayuktang-gagambangDay 60 to 66	Dosage (g)
Atractyodis rhizoma	24	Paeoniae radix	12	Chaenomelis fructus	20	Ephedrae herba	12	Dianthi herba	8	Rehmanniae radix preparata	32
Cyperi rhizma	16	Atractylodis rhizoma alba	12	Chelidonii herba	20	Aurantii nobilis pericarpium	12	Rhei rhizoma	8	Dioscoreae radix	16
Achyranthis radix	8	Angelicae gigantis radix	8	Corydalis tuber	16	Linderae radix	12	Akebiae caulis	4	Corni fructus	16
Aurantii nobilis pericarpium	8	Hoelen	8	Osterici radix	16	Ligusticum officinale	8	Polygoni avicularis herba	8	Moutan radicis cortex	12
Angelicae koreanae radix	8	Alimatis rhizoma	8	Clematidis radix	12	Angelicae dahuricae radix	8	Talcum	8	Hoelen	12
Chaenomelis frutus	8	Scutellariae radix	8	Angelicae pubescentis radix	12	Bombycis corpus	8	Gardeniae fructus	8	Alimatis rhizoma	12
Preilae herba	8	Coptidis rhizoma	6	Angelicae gigantis radix	12	Aurantii fructus	8	Plantaginis semen	8	Angelicae gigantis radix	12
Gltcyrrhizae radix	4	Saussureae radix	6	Rehmanniae radix siccus	12	Platycodi radix	8	Glycyrrhizae radix	8	Ligusticum officinale	12
Zingiberis rhizoma	24	Glycyrrhizae radix	6	Paeoniae radix rubra	12	Zingiberis rhizoma	4	Junci herba	8	Paeoniae radix	12
Allii fistulosi bulbus	16	Plantaginis semen	8	Atractylodis rhizoma	8	Glycyrrhizae radix	2			Eucommiae cortex	12
Angelicae gigantis radix	8			Citri pericarpium	8					Phlomidis radix	8
Plantaginis semen	8			Olibanum	8					Psoraleae semen	8
				Myrrha	6					Persicae semen	8
				Carthami novella	6					Carthami flos	8
				Amomi fuctus	4
				Glycyrrhizae radix	8
				Crataegii fructus	8
				Galli stomachichum corium	8
				Massa medicata fermentata	8
				Hordei fructus germiniatus	8

5) Physiotherapy

Interferential current therapy and hot pack treatment were applied once a day for 20 minutes on the lower limbs to reduce pain.

6) Moxibustion treatment

Indirect electric moxibustion (Technoscience) therapy was applied once daily at BL36, BL37, and GB35 of the Rt. lower limb for 15 minutes at 42℃.

3. Evaluation

1) Digital infrared thermal imaging

The digital infrared thermal imaging (DITI; OsongLife) test was conducted in an environment where light and heat were blocked from the outside. Two photos of the anterior and posterior surfaces of the lower extremities were recorded using DITI. DITI was employed to assess both legs weekly during hospitalization. Among the DITI data, three photos in which the degree of improvement was easy to spot were selected (Fig. 1).

Figure 1. Digital infrared thermal imaging of the improvement in the temperature of the right foot over the treatment period (January 11, 2022 [day 16]; January 18, 2022 [day 23]; February 9, 2022 [day 45]).

2) Numerical rating scale

The patient’s pain was assessed daily using the numerical rating scale (NRS). A score of 0 indicated no pain, whereas 10 indicated the most severe pain the patient had ever felt.

3) Subjective state of the patient

The patient’s electronic medical record was reviewed to evaluate the changes in her symptoms. The patient’s subjective hypoesthesia in her Rt. foot was evaluated using a 0–10 scoring system. A score of 10 indicated no sensation, whereas a score of 0 indicated the presence of normal sensation.

4. Treatment progress

1) Numerical rating scale

On admission, the patient complained of pain with an NRS of 10 in the inguinal region, calf, and foot of the Rt. lower limb. A decrease in the inguinal pain was noticed on day 12 (January 7, 2022) of treatment (Fig. 2). In addition, the patient noticed decreased pain in the foot and calf on days 16 (January 11, 2022) and 25 (January 20, 2022) of admission, respectively.

Figure 2. Changes in the NRS score of the right lower limb. From the day 12 (January 7, 2022) of treatment, the pain in the inguinal region declined from 10 to 5. On day 16 (January 11, 2022), the NRS decreased in the foot from 10 to 8 and in the inguinalis from 5 to 3. On day 25 (January 20, 2022), the score decreased in the calf from 10 to 9 and on day 30 (January 25, 2022) from 9 to 8. On day 55 (February 19, 2022), the NRS in the foot decreased from 8 to 7. NRS, numerical rating scale; Rt, right; Adm, admission; D/C, discharge.

2) Subjective state of the patient

On admission, the patient used a wheelchair and experienced swelling and hypoesthesia on the Rt. foot. From day 12 (January 7, 2022) of treatment, the hypoesthesia started to improve, and the patient could walk 20 m using an auxiliary device (Fig. 3).

Figure 3. Changes in hypoesthesia score of the right foot. On the hospitalization day 12 (January 7, 2022), the hypoesthesia improved from 10 to 5. On the day 16 (January 11, 2022), the senses improved from 5 to 2 and the degree decreased by 1 until the discharge date (March 2, 2022). Rt, right; Adm, admission; D/C, discharge.

Rhabdomyolysis complicated by compartment syndrome is caused by damage to the muscles from an increase in compartment pressure. When pressure within a specific muscle area increases due to a fixed posture for an extended period, the pressure in that compartment increases. Increased pressure causes muscle ischemia, resulting in muscle cell necrosis over time if not corrected, and additional fluid accumulates in the muscle tissue surrounded by a hard fascia. Pressure increases due to the limited expansion of the muscle fascia, resulting in compartment syndrome, which causes extreme pain, ischemia, temperature reduction, paralysis, and swelling in the damaged area [3,9-12].

Upon literature review, four case studies have documented the treatment of rhabdomyolysis, whereas no cases induced by compartment syndrome have been reported [6-8,13].

In the present case, the patient was using a wheelchair upon admission for complaints of swelling and weakness of the lower limbs. With treatment, the patient was able to assume an upright position. On day 4 of hospitalization, the patient could walk 20 m using an auxiliary device. By day 61, the walking time had increased, and the patient was able to walk 10 m without assistance.

Improvement in the patient’s condition was confirmed by DITI performed at the same time on a weekly basis. This imaging detects temperature changes caused by microvascular changes in the affected area. The temperature increased in the Rt. lower extremity with the progression of hospitalization (Fig. 1). This result showed that an increase in temperature was associated with improved blood flow to the Rt. lower extremity.

BV therapy, a type of nephropathy therapy with anti-inflammatory effects, is used for the treatment of various pain conditions [14]. The patient received BV injections (IM) in her Rt. lower extremity. She was also managed with Jungsongouhyul pharmacopuncture as an auxiliary treatment in her Rt. lower extremity.

Initially, Jungsongouhyul pharmacopuncture was performed; however, symptom improvement was slow, so BV therapy was additionally started on day 14. The pain decreased on the initiation of BV therapy. In consideration of the degree of pruritus in BV therapy, it was delayed and applied again from day 48. Thereafter, the pain reduction effect was also confirmed in the Rt. Foot (Fig. 2). In the early stages of hospitalization (days 12–19), DITI also showed an improvement in temperature drop, consistent with the improvement in symptoms caused by BV therapy (Fig. 1).

In the early stage of hospitalization, the patient took Binchang-san to treat lower limb edema. Based on the improvement of the edema, she was prescribed Danguijakyak-tang, Hwalak-tang, and Oyak Sungi-san, to relieve pain [15-17]. Paljung-san was prescribed to treat urinary pain during hospitalization [18]. Following the relief of the urination pain, Sayuktang-gagambang was prescribed for pain management [15].

This case study demonstrated the improvement in patients with rhabdomyolysis caused by compartment syndrome through TKM. To confirm the patient’s improvement through objective indicators, DITI was conducted, demonstrating improvement in the temperature of the lower extremity, which resulted in the improvement of muscle pain and muscle strength. Accordingly, BV therapy was found to contribute to the patient’s pain reduction. Through other case reports on the effects of Korean medicine treatments on patients with rhabdomyolysis, we found it meaningful to report this case as it relates to compartment syndrome. However, the current case is limited to one patient; therefore, accurately determining the efficacy of each treatment alone and in combination with each other is challenging. In addition, no improvement in muscle weakness was observed. To improve the results, more clinical studies involving a large number of patients with compartment syndrome are needed.

Conceptualization: YK, JK. Data curation: YK. Formal analysis: YK. Investigation: YK. Methodology: All authors. Project administration: HR, HL, JK. Resources: YK. Supervision: HR, HL, JK. Visualization: YK. Writing – original draft: YK. Writing – review & editing: HR, HL, JK.

The authors have no conflicts of interest to declare.

None.

The use of medical records was approved by the Cheonan Korean Medicine Hospital of Daejeon University Institutional Review Board (No. DJUMC-2022-BM-08-1). The potential side effects of bee venom therapy were disclosed in advance, and informed consent was obtained.