Polysubstance abuse and rhabdomyolysis

A 23-year-old man with 1-day history of agitation, passage of tea colored urine and progressively decreased urine volume presented to the emergency room in the company of law enforcement officers. He had been an inmate in the county jail for the past 2 days and was brought in restraints owing to his agitated state. He reported usage of marijuana, methamphetamine, and Xanax (alprazolam) “bars” 2 days prior to presentation and stated that methamphetamine is his preferred drug. According to his drug use history, he uses methamphetamine “all day, every day.” While in jail, his urine became dark and the volume gradually decreased, prompting presentation. On physical examination, he was severely dehydrated, anxious, agitated and hallucinating. His vital signs on presentation include: BP 137/88, pulse 104beats per minute, temperature 37.9°C (100.3°F), respiratory rate 18breaths per minute and SpO2 97% on room air. Initial laboratory results include potassium 4.8mmol/L [reference interval (RI) 3.5-5.0mmol/L], sodium 153mmol/L (RI 135-145mmol/L), chloride 120mmol/L (RI 98-108mmol/L), bicarbonate 15mmol/L (RI 23-31mmol/L), total protein 8.6g/dL (RI 6.3-8.2g/dL), albumin 5.5g/dL (RI 3.5-5.0g/dL), creatinine 2.60mg/dL (RI 0.60-1.25), BUN 50mg/dL (RI 7-23mg/dL), total bilirubin 2.1 (RI 0.1-1.1mg/dL), AST 119U/L (RI 13-40U/L), ALT 80U/L (RI 9-51U/L), anion gap 18 (RI 2-16), and estimated glomerular filtration rate (eGFR) 30.7mL/min/1.73m2. He had no prior history of kidney disease. Past medical/psychiatric history was significant for depression, bipolar disorder, posttraumatic stress disorder since age 12 years and polysubstance abuse (methamphetamine, cocaine, heroin, alcohol, marijuana, and benzodiazepines) since age 15 years, with documented alcohol withdrawal seizures in the past. A diagnosis of acute renal failure and severe dehydration was made. He was started on intravenous fluids and worked up for the etiology of renal failure.