According to a legend, about 2500 years ago, Pheidippides, a legendary Greek hemerodrome, or courier, died shortly after running from Marathon to Athens to bring the news about the Greek victory over the Persians. The very cause of his death remains undetermined [1].
We want to propose yet another explanation for Pheidippides’ death based on the case of a 35-year-old man — an amateur ultramarathon runner who was admitted to the emergency department with severe fatigue and skeletal muscle pain lasting over two days after a 210 km 24-hour run. His history was negative for anabolic steroids or other medication.
His Glasgow coma scale score on admission was 13 points. His electrocardiography (ECG) on admission (Figure 1) showed bradycardia with junctional rhythm 25/min. After administration of atropine 0.5 mg i.v., the rhythm accelerated to 45 BPM with no visible P waves.
Elevations of J-point in the anterior leads and broad peaked T waves were observed. Echocardiography showed hypokinesis of the apical segments of the left ventricle with ejection fraction of 40%, with no significant valvular disease. After bladder catheterization, dark-colored brown urine was obtained.
Blood tests showed severe hyperkalemia (8.4 mmol/l) with a high creatinine level (6.18 mg/dl) and low estimated glomerular filtrated rate (eGFR, 11.05 ml/min/1.73 m2), along with extreme serum myoglobin concentration (>30 000 ng/ml), CK-MB mass (>300 ng/ml), and elevated troponin T (0.109 ng/ml), white blood cell count, and C-reactive protein. The patient was diagnosed with exercise-related rhabdomyolysis, which led to acute kidney injury with consecutive hyperkalemia, and hemodialysis in the intensive care unit was introduced. He recovered after 4 weeks, with normal electrocardiography and normal left ventricular function (ejection fraction [EF], 58%, global longitudinal strain [GLS], 19.7%) restored.
Rhabdomyolysis with renal failure may represent a possible explanation for Pheidipiddes’ death [2] — especially while taking into account that the distances he covered were similar to those made by our patient. The Athenian runner had run from Athens to Sparta (212 km) in 4 days, and on the next day — again ran from Athens to the battlefield near Marathon (40 km) and back to Athens to bring the news of victory. Both he and our patient were properly trained with previous experience in running similar distances.
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