Exercise induced macroscopic haematuria: run for a diagnosis?

Blood Case report Hb (mmol/l, 7.5–9.9) 8.1 8.5 Potassium (mmol/l, 3.6–4.8) 4.4 4.5 A 42-year-old Caucasian female consulted our outpaLDH (u/l, 114–235) 187 207 CPK total (u/l, 0–50) 37 45 tient clinic because of exercise-related macroscopic Haptoglobin (g/l, 1.0–3.0) 1.8 1.9 haematuria. She has always been in excellent health, Myoglobin (mg/l, 10–100) <25 <25 with different examinations during several years of her Urine sporting career. A few months before, after return Urinalysis no RBC many normal RBC from a training camp in Denmark, she developed no casts myalgia in the upper legs and frequently yellowish thin no protein trace protein stool. After treatment with metronidazole, given pH 6.0 7.0 Free Hb (ml/l ) 1 109 because intestinal amebiasis was diagnosed in two Myoglobin (mg/l ) 9 7 participants of the same training camp, these comProteinuria (g/l ) 0.0 0.0 plaints disappeared. A few weeks later, reddish-coloured urine was anormal ranges between brackets: Hb, haemoglobin; LDH, lactic observed after running, which she thought to be the dehydrogenase; CPK, creatine fosfokinase; RBC, red blood cells. result of menstruation, but tampons remained clean. Since that time, she consequently produced bright redDiscussion coloured urine after running, regardless of running distance or intensity. Every time, the urine returned to appear normal two or three voidings later. There was This patient had running-related, asymptomatic macno dysuria or abdominal pain. The urine was bright, roscopic haematuria within the urinalysis normal erythwithout grit or smell. There were no other complaints rocytes without casts with full recovery within 24 h and she had never had this before. Our patient was after running. Red or russet discolouration of the urine working as a physiotherapist and usually ran 40–50 after running cannot only be due to haematuria, but kilometres a week. She had already run a marathon also to myoglobinuria or (march)haemoglobinuria. three times. At physical examination, we found a Prevalence of running-related haematuria is about healthy, slim woman with a blood pressure of 20–25% for a running distance of 21–90 km [1–3], 126/80 mmHg, heart rate of 60 beats per minute withwith even higher urinary erythrocyte counts in 69% of out abnormalities. Laboratory examination 30 min athletes after a 9–14 km distance run [4]. Macroscopic before and immediately after a 1.5 h run, are mentioned haematuria was found mainly in long-distance runners in Table 1. After, but not before exercise, many normal (>10 km) and appears usually to be asymptomatic. It red blood cells without casts with only a trace protein is usually most pronounced in the first urine voiding and free haemoglobin was seen in the urine. after exercise, normalizes often within 72 h after runWe concluded it was postrenal, exercise-related macning and seems to be independent of the exercise roscopic haematuria and found no reason for further intensity [1,3,5]. The pathogenesis of running-related urological examinations. We advised her to not comhaematuria is complex [5–7]. If at urinalysis erythropletely empty the bladder prior to exercise. She cytes are normal without dysmorphic features and restarted running and haematuria did not reappear. without cellular casts, and the urine becomes normal within 72 h after exercise, no further diagnostic procedures are indicated. However, further analysis is Correspondence and offprint requests to: Froukje L. Ubels, MD, necessary in the presence of persisting or repeated Department of Internal Medicine, University Hospital, PO Box 30.001, 9700 RB Groningen, The Netherlands. haematuria with abnormalities in the urinalysis. There