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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor&#58;</span></p><p class="elsevierStylePara">A 29-year-old male came to the Emergency department with abdominal pain with a 48 hour progression and diarrhoea without pathological characteristics&#46; He informed us that he had been energetically playing African drums &#40;<span class="elsevierStyleItalic">dyembe</span>&#44; Figure 1&#41; in the last 3 days&#44; in sessions lasting 9 hours each&#44; with little fluid intake&#44; hyporexia and subsequent reddish urine&#46; He always experiences these symptoms whenever he plays the drum&#46; Physical exam was unremarkable&#58; athletic body&#44; constants within normal range&#46; He had very positive dipstick results for blood&#44; with urine sediment negative for erythrocytes and proteinuria of 150mg&#47;dl&#44; creatinine of 4&#46;45mg&#47;dl&#44; urea 80mg&#47;dl&#44; creatine phosphokinase &#40;CPK&#41; of 255U&#47;l&#44; lactate dehydrogenase of 509U&#47;l&#44; compensated metabolic acidosis&#44; normal ions and no data for anaemia&#46; He was transferred to Nephrology where a radiograph and ultrasound &#40;Figure 2&#41; were performed with normal results&#46; The patient began fluid therapy&#46; He showed progressive worsening of renal function &#40;creatinine of 10&#46;49mg&#47;dl on the fifth day&#41; and oliguria&#59; he did not display acute haemodialysis criteria&#46; Renal function gradually improved until creatinine levels of 2&#46;23mg&#47;dl were recorded on the eighth day&#44; in the polyuric phase&#59; haemoglobin at admission was 14&#46;9g&#47;dl and at discharge it was 12g&#47;dl&#44; with creatinine of 1&#46;52mg&#47;dl&#46; The diagnosis was acute renal failure&#44; acute tubular necrosis in remission and haemoglobinuria&#46; After 10 days in the outpatient service&#44; he had normal renal function and sediment&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Haemoglobinuria secondary to extreme exercise was observed in 1881 as a result of microtrauma due to strenuous marching of soldiers&#44; and was known as &#34;march haemoglobinuria&#34;&#46; In 1964&#44; Davidson<span class="elsevierStyleSup">1</span> demonstrated that it involved transient extracorpuscular intravascular haemolysis due to erythrocyte microtraumas on their passage through the capillaries with the intravascular passage of haemoglobin following erythrocyte lysis&#59;<span class="elsevierStyleSup">2</span> this process saturates haptoglobin&#44; which causes free haemoglobin to be filtered by the glomeruli&#44; with subsequent haemoglobinuria&#59; filtered haemoglobin dimers are absorbed by tubular cells and broken down&#59; iron is stored as haemosiderin and it is excreted in chronic forms&#44; presenting haemosiderinuria&#46; This symptom occurs&#44; in most cases&#44; without anaemia expression&#46;<span class="elsevierStyleSup">3</span> Intravascular haemolysis is associated with the reduction of serum haptoglobin&#44; sometimes to undetectable levels&#46; However&#44; it is not a specific indicator of intravascular haemolysis&#44; as it may be low or absent with rapid onset extravascular haemolysis&#59; moreover&#44; it is an acute phase reactant&#46; Accordingly&#44; it may be normal in the presence of inflammation or infection&#46;<span class="elsevierStyleSup">4</span> When haemoglobin is broken down in tubules&#44; haem pigments are released&#46; These can cause renal damage due to tubular obstruction&#44; direct lesion or vasoconstriction at a spinal level&#44; with predisposing factors such as volume depletion&#44; acidosis and ischaemia&#46;<span class="elsevierStyleSup">5</span></p><p class="elsevierStylePara">The shear force required to produce the aforementioned erythrocyte lysis is 3000dyn&#47;cm&#59; <span class="elsevierStyleItalic">in vivo</span> it occurs with peak tangential forces<span class="elsevierStyleSup">6</span> of 6000dyn&#47;cm&#46;</p><p class="elsevierStylePara">Many cases have been published related to physical activity in the lower limbs&#44; and only 3 cases in the upper limbs&#58; in 1974 in the United States&#44; there was a case of a young man who had positive pigmenturia with myoglobin and haemoglobin after a percussion session&#59;<span class="elsevierStyleSup">7</span> in 2006&#44; in Uruguay&#44; a case was described of 26 individuals after playing drums on a national holiday&#44; and in 2011&#44; a Caucasian man had haemoglobinuria after playing drums&#44; which led to the term &#34;percussion haemoglobinuria&#34;&#46;<span class="elsevierStyleSup">8</span></p><p class="elsevierStylePara">We present our clinical experience of haemoglobinuria secondary to excessive percussion of African <span class="elsevierStyleItalic">dyembe</span> drums&#46; We rule out haematuria as the cause of the brownish-red urine&#44; because the urine sediment was negative despite it having a strongly positive dipstick test for blood&#44; since the dipstick used tested haem pigment concentration&#44; which is found in erythrocytes&#44; myoglobin and haemoglobin due to its pseudoperoxidase activity in catalysing a reaction between hydrogen peroxide and the chromogen tetramethylbenzidine&#44; which produces an oxidised dark blue product&#46;<span class="elsevierStyleSup">9</span> The combination of prolonged transit through the nephron and an acidic urine pH leads to methemoglobin formation of a red-chocolate or &#8220;Coke-colour&#8221;&#46;<span class="elsevierStyleSup">10</span> In acute renal failure due to myoglobin and rhabdomyolysis&#44; CPK values of around 1500-100&#44;000IU&#47;l<span class="elsevierStyleSup">11</span> are required&#59; our patient had a value of 255IU&#47;l&#46;</p><p class="elsevierStylePara">The presence of haematuric urine does not always imply a direct relationship with erythrocytes&#59; sediment without erythrocytes with a positive blood dipstick test provides us with another diagnostic possibility related to haem pigments&#46; In daily clinical practice&#44; we should not overlook the possible diagnosis of acute renal failure due to haem pigment toxicity and urine of haematuric appearance after exercise in upper limbs&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors declare that they have no conflicts of interest related to the contents of this article&#46;</p><p class="elsevierStylePara"><a href="grande&#47;11844&#95;16025&#95;49184&#95;en&#95;f111844&#46;jpg" class="elsevierStyleCrossRefs"><img src="11844_16025_49184_en_f111844.jpg" alt="African dyembe drum"></img></a></p><p class="elsevierStylePara">Figure 1&#46; African dyembe drum</p><p class="elsevierStylePara"><a href="grande&#47;11844&#95;16025&#95;49185&#95;en&#95;f211844&#46;jpg" class="elsevierStyleCrossRefs"><img src="11844_16025_49185_en_f211844.jpg" alt="Right kidney"></img></a></p><p class="elsevierStylePara">Figure 2&#46; Right kidney</p>"
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