# Rhabdomyolysis Associated With Excess Pine Bark Extract: A Case Report

## TL;DR

A man developed severe muscle breakdown after taking too much pine bark extract, even with minor physical activity, highlighting the need to consider supplements in such cases.

## Contribution

This case report highlights a novel association between excessive pine bark extract intake and rhabdomyolysis.

## Key findings

- A 35-year-old man experienced rhabdomyolysis with CK levels of 154,000 U/L after overusing pine bark extract.
- The patient's muscle enzymes decreased with IV hydration and no kidney injury occurred.
- A Naranjo score of 3 supports a potential causal link between pine bark extract and rhabdomyolysis.

## Abstract

Rhabdomyolysis can cause complications such as acute kidney injury (AKI), with common etiologies including strenuous exercise, trauma, medications, and toxins. Given that creatine kinase (CK) levels of about 100,000 U/L are rare, this level of elevation may indicate the presence of an underlying contributor, such as excessive pine bark extract intake, emphasizing the importance of taking a thorough patient history to identify factors that may otherwise be overlooked. We present a case of a 35‑year‑old previously healthy male who presented with diffuse myalgia, soreness, and tea‑colored urine two days after lifting furniture for a friend. The physical examination revealed mild tenderness and edema in his upper extremity muscles. Laboratory studies showed an initial CK of 154,000 U/L, aspartate aminotransferase (AST) of 2,400 U/L, alanine aminotransferase (ALT) of 700 U/L, and normal renal function (creatinine: 0.7-0.8 mg/dL throughout admission). Urine toxicology, viral serologies, and antinuclear antibody (ANA) were negative. During a subsequent interview, the patient disclosed consuming over-the-counter French pine bark extract in excess of the labeled recommendations. On day six of the patient’s admission, the CK level declined to 7,874 U/L; transaminase levels decreased to AST of 252 U/L and ALT of 468 U/L with aggressive IV hydration. There was no evidence of kidney injury during the hospital course. This case suggests a potential association between excessive pine bark extract consumption and severe rhabdomyolysis triggered by minimal physical activity, supported by a Naranjo score of 3. Clinicians should inquire about dietary supplement use when CK levels are disproportionately elevated relative to the inciting event.