A case of crush syndrome occurring during alcohol withdrawal: extended disturbance of consciousness with development of persistent Korsakoff's psychosis

Sir: Crush syndrome may be caused by compression of the extremities during transient unconsciousness induced by alcohol and other agents [1, 2]. However, rhabdomyolysis is also induced by alcohol withdrawal or alcoholic myopathy. We present a patient with crush syndrome occurring during alcohol withdrawal who remained unconscious for an extended period of time and developed persistent Korsakoff's psychosis. A 36-year-old man with a history of alcohol dependence was found lying on the floor at home with general convulsions. When he was transported to our intensive care unit, he was intubated, responsive only to painful stimuli, and horizontal nystagmus was noted. Convulsion was noted in his right arm and his left forearm was markedly swollen. Sinus tachycardia was noted by electrocardiogram, while no abnormalities were detected by echocardiogram. Urine color was brown and the laboratory data were remarkable for serum creatinine of 204 mmol/1, creatine kinase of 53009 IU/I and myoglobin of 61000 mg/l. Alcohol was not detected in the blood. No abnormal findings were noted on blood gas data, brain CT or cerebrospinal fluid examination. Administration of bicarbonate, total parenteral nutrition with thiamine 100 mg daily and hemodialysis were started, based on the diagnosis of crush syndrome induced during alcohol withdrawal. Fasciotomies of the right forearm compartments were performed for the marked swelling of the right hand and forearm on the day after admission. His level of consciousness gradually improved and the tracheal tube was removed on the 10th hospital day. No abnormal findings were detected on brain MRI. His renal function fully recovered and, approximately 5 weeks after admission, he became able to communicate with the medical staff, although disorientation persisted. A diagnosis of Korsakoff's psychosis was made by a psychiatrist, based on the presence of confabulation and anterograde and retrograde memory disorder. His mental state has not changed markedly since. The disturbance of consciousness associated with alcohol withdrawal usually lasts for only several days [3]. The duration of unconsciousness in our patient was remarkably long and the reason is unclear. Korsakoff's psychosis develops secondarily to Wernicke's encephalopathy in many patients and the horizontal nystagmus in our patient is commonly observed in Wernicke's encephalopathy [4]. However the absence of past history or classical signs of Wernicke's encephalopathy, such as hypothermia, hypotension and ataxia, prevents us from making the diagnosis of Wernicke's encephalopathy. Rhabdomyolysis in this patient may have been induced by alcohol withdrawal, as well as by compression of the arms during unconsciousness. Rhabdomyolysis may also be caused by alcoholic myopathy. However, the manifestations of alcoholic myopathy are typically more prominent in the legs, usually located in the proximal areas [5]. In this patient, the affected muscle was in the forearms and hand, which is common in rhabdomyolysis caused by compression [1, 2]. Alcohol withdrawal induces various conditions such as consciousness disturbance, convulsion and myopathy. In this patient, the prolonged unconsciousness might have been caused by alcohol withdrawal and subsequent Korsakoff's psychosis. Since crush syndrome may occur during unconsciousness, it is a rare, but important, complication during alcohol withdrawal.