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Acute rhabdomyolysis caused by Spirulina (Arthrospira platensis).


Rhabdomyolysis is a potentially life-threatening disorder that occurs as a primary disease or as a complication of a broad spectrum of other diseases. We report the first case of acute rhabdomyolysis after ingestion of Spirulina (Arthrospira platensis), a plantonic blue-green alga, as a dietary supplement. [c] 2008 Elsevier GmbH. All rights reserved.

Keywords: Rhabdomyolysis; Spirulina; Arthrospira platensis

The term "rhabdomyolysis" literally means "striped muscle dissolution", but is usually thought to encompass the clinical and laboratory phenomena associated with skeletal muscle injury and subsequent release of muscle cell contents into the systemic circulation (Mazokopakis in press). Physical symptoms of syndrome include muscular weakness, swelling, pain, cramping and darkened or tea-colored urine. One of the most reliable methods of assessing muscular damage is to check for increases in blood serum levels of creatine kinase (CK), which is located in the sarcolemma and mitochondrial intermembrane space of healthy muscle cells. Other laboratory indicators of rhabdomyolysis include elevated serum myoglobin, aldolase, aminotransferases (ALT/SGPT, AST/SGOT) and lactate dehydrogenase (LDH) levels and the presence of myoblobinuria. Rhabdomyolysis can be caused by a number of factors divided into several fundamental catagories, namely, an imbalance between muscle energy consumption and production (the latter of which can be genetically based or acquired), primary muscle injury, decreased muscle oxygenation, infections, drugs, foods and toxins (Giannoglou et al. 2007; Mazokopakis in press). This syndrome can result in electrolyte abnormalities, acidosis, clotting disorders, hypovolemia, and acute renal failure. In this letter, we describe the first case of acute rhabdomyolysis after ingestion of Spirulina (Arthrospira platensis), a plantonic blue-green alga, as a dietary supplement.


A 28-year-old man was admitted to the hospital because of weakness and myalgias localized at his chest and loin. He was taking 100% Hawaiian Spirulina (A. platensis) tablets manufactured in the USA by Solgar Vitamin and Herb, as a dietary supplement (3 g per day) during the previous 1-month period. He was not taking other medications, had no allergies to food or medications, and did not use alcohol, cigarettes or illicit drugs. His clinical examination revealed normal cardiopulmonary findings and a temperature of 36.7 [degrees]C. The hematological tests were indicative of rhabdomyolysis, showing elevated CK levels (9000 U/l, normal range: 40-226 U/l), and elevated levels of other muscle enzymes such as myoglobin (2243 [micro]g/1, normal range: 0-70 [micro]g/1), ALT (180 U/l, normal range: 0-45 U/l), AST (288 U/l, normal range: 0-45 U/l), LDH (1265 U/l, normal range: 120-450U/1, normal range: 0-8 U/l). His urine was dark brown and urinalysis revealed myoglobinuria. Chest X-ray and electrocardiogram (ECG) were normal. Results of troponin and direct Coombs' test were negative. Thyroid function tests, glucose-6-phosphate dehydrogenase (G-6PD) in the erythrocytes, and serum lactic acid were normal. Serological and immunologic tests, such as tests for hepatotropic viruses were negative. The patient did not report consumption of Spirulina in the past or relevant family history. He was hydrated for 4 days and then discharged. One week later, he remained free of symptoms and laboratory findings were normal. The forearm ischemic exercise test which performed to differentiate possible genetic causes of rhabdomyolysis (Sinkeler et al. 1986) was normal. Consumption of Spirulina was the cause of acute rhabdomyolysis, as other known causes of rhabdomyolysis were excluded.

Spirulina is the common name for human and animal food supplements produced primarily from two species of free-floating filamentous cyanobacteria classified into the Genus Arthrospira: A. platensis (Fig. 1), and Arthrospira maxima (Vonshak 1997). Spirulina is distinguished from other cyanobacteria by its spiral morphology; however, this cyanobacterium has frequently been observed with a linear morphology in laboratory and industrial conditions (Hongsthong et al. 2007). This blue-green algae is cultivated around the world, and is used as a human dietary supplement, available in tablet, flake, and powder form. Spirulina has been proposed as one of the primary foods to be cultivated during long-term space missions (Cornet and Dubertret 1990). It is also used as a feed supplement in the aquaculture, aquarium, and poultry industries (Vonshak 1997). Spirulina contains up to 70% protein of dry weight (Khan et al. 2005). It is a complete protein containing all essential amino acids, though with reduced amounts of methionine, cysteine, and lysine, as compared to standard proteins such as that from meat, eggs, or milk (Ciferri 1983; Khan et al. 2005). Spirulina is rich in essential fatty acids (mainly gamma-linolenic acid), vitamins, minerals, photosynthetic pigments, polysaccharides, glycolipids and sulpholipids (Khan et al. 2005; Tokusoglu and Unal 2003; Vonshak 1997). Beyond nutritional value, Spirulina species possess specific therapeutic properties. Certain species of Spirulina have shown metabolic effects (hypocholesterolemic, hypoglycemic), anti-viral effects, anti-cancer, anti-inflammatory and anti-oxidant properties, liver-protecting and blood-vessel relaxing effects, and positive effects on both innate and specific immunity (Ayehunie et al. 1998; Khan et al. 2005; Lu et al. 2006; Torres-Duran et al. 2007, 1998). In clinical trials Spirulina is also effective for the clinical improvement of melamosis and keratosis due to chronic arsenic poisoning (Misbahuddin et al. 2006), improves weight-gain and corrects anaemia in both HIV-infected and HIV-negative undernourished children (Simpore et al. 2005), and protects against hay fever (grass pollen allergy) (Mao et al. 2005).

Few side effects have been reported from spirulina including headache, muscle pain, flushing of the face, sweating, and difficulty concentrating. These have been described in people taking 1 g of Spirulina per os daily. Skin reactions and liver damage have also been reported (Iwasa et al. 2002). It is remarkable that the appropriate dosing of Spirulina has not been standardized for the various health problems; doses used in the few human studies that have been conducted varied from about 1 g per day to more than 5 g per day (Torres-Duran et al. 2007). Under certain conditions, blue-green algae, as Spirulina, seems to be able to produce a neurotoxin called BMAA ([beta]-N-methylamino-L-alanine), which can cause a neurodegenerative disease (amyotrophic lateral sclerosis-parkinsonism-dementia complex) (Papapetro-poulos 2007). The amino acid phenylalanine in blue-green algae may cause an adverse reaction in people with the genetic condition phenylketonuria, and should be used cautiously. Moreover, Spirulina as blue-green algae can accumulate heavy metals from contaminated water, consuming blue-green algae could increase the body's load of lead, mercury, and cadmium (Johnson and Shubert 1986), though non-contaminated blue-green algae have been identified (Slotton et al. 1989). Samples of Spirulina have also been found to be contaminated with animal hairs and insect fragments (Nakashima et al. 1989). Although a recent study has shown preventive effects of Spirulina platensis on skeletal muscle damage under exercise-induced oxidative stress (Lu et al. 2006), to the best of our knowledge, Spirulina as a cause of acute rhabdomyolysis in a person without known predisposing factors has not been reported elsewhere. Our patient started the ingestion of Spirulina without medical advision but according to the typical manufacturer's recommended intake (2-3 g per day divided throughout the day); the recorded instructions for storing and consumption of tablets had also been kept. In addition, according to the manufacturer, 100% Hawaiian Spirulina is carefully cultivated in an environment that is free from pesticides and pollutants, and tablets are free of corn, yeast, wheat, soy and dairy products. Because of nutritional and therapeutic potential of Spirulina, more research is needed to determine its usefulness and effectiveness, such as the safe appropriate dosing for the treatment of any medical condition or as diet supplement.


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Elias E. Mazokopakis (a), (b), *, Christos M. Karefilakis (b), Athanasios N. Tsartsalis (b), Anastataios N. Milkas (b), Emmanuel S. Ganotakis (a)

(a.) Department of Internal Medicine, University Hospital of Heraklion, Crete. Greece

(b.) Department of Internal Medicine, Naval Hospital of Crete, Chania, Greece

* Corresponding author at: Iroon Polytechniu 38A, Chania 73 132, Crete, Greece. Tel.: +30 2821 082754; fax: +302821089307.

E-mail address: erru (E.E. Mazokopakis).

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Author:Mazokopakis, Elias E.; Karefilakis, Christos M.; Tsartsalis, Athanasios N.; Milkas, Anastataios N.;
Publication:Phytomedicine: International Journal of Phytotherapy & Phytopharmacology
Geographic Code:4EUGR
Date:Jun 1, 2008
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