Open Forum Infectious Diseases BRIEF REPORT pressure of 210/130 mmHg, which rapidly deteriorated to a sys- Severe Rhabdomyolysis Associated tolic blood pressure of 90 mmHg, heart rate of 110, oxygen sat- With RSV uration of 88% breathing air, and respiratory rate of 30 breaths/ 1 2 2 3 James Bender, Rusheng Chew, Belinda Bin Lin, and Eugene Athan minute. He was mechanically ventilated on an inspired oxygen 1 2 Junior Medical Workforce, Barwon Health, Geelong, Australia; Department of Infectious fraction of 100% and required significant vasopressor support. Diseases, Barwon Health, Geelong, Australia; Department of Infectious Diseases, Barwon He became anuric within 24 hours and required hemofiltration. Health, Deakin University, Geelong, Australia His initial chest radiograph was suggestive of viral pneumonitis. Initial blood tests showed a significant leukocytosis with a Severe rhabdomyolysis is associated with morbidity and mor- 9 9 white cell count of 33.0 × 10 /L (4.0–11.0 × 10 /L) and predom- tality. We report on a previously well male who developed severe rhabdomyolysis, sepsis, and multi-organ failure. The pa- inant neutrophilia. He was also thrombocytopenic with a plate- 9 9 tient made a complete recovery. Extensive microbiological test- let count of 95 × 10 /L (150–500 10 /L). His C-reactive protein ing was only positive for RSV, making this the first reported case (CRP) was elevated to 55 mg/L (<2.9), lactate to 8.2 mmol/L of adult RSV-related rhabdomyolysis in the literature. (<2), and he had a severe metabolic acidosis with pH 7.11. His Keywords. acute kidney injury; respiratory syncytial virus; alanine aminotransferase (ALT) peaked at 4351 U/L, and aspar- rhabdomyolysis; RSV. tate aminotransferase (AST) at 9209 U/L on day 3 of admission. His creatine kinase (CK) levels were markedly raised, with ini- tial testing showing levels of 26 302 U/L (39–308 U/L). His CK CASE SUMMARY increased dramatically in the following days, peaking at 330 110 A 42-year-old male presented to the University Hospital Geelong, U/L on day 4. This CK level combined with the presence of Victoria, Australia, with a 2-day history of generalized myalgia, myoglobinuria in the ultrafiltrate bags indicated extreme rhab- dyspnoea, cough, headache, chills, and fever. He was a well and domyolysis. Blood and urine cultures, and urine antigen for active individual with no significant past medical history. He Legionella pneumophila type 1 and Streptococcus pneumoniae, was a smoker, consuming 20 cigarettes per day on a background were negative. of at least 10 years of variable smoking intensity, but consumed Initial management was supportive, with broad spectrum minimal alcohol. He had a BMI of 33 kg/m , putting him in the antibiotic coverage of azithromycin and ceftriaxone being obese range. Using BMI as a marker of adiposity in this patient commenced empirically on the day of presentation. The ini- was limited by his large muscle mass, and adiposity was not tial working diagnosis was severe community-acquired pneu- deemed to be a significant risk factor. His wife and children had monia, with viral pneumonitis considered a differential. This been unwell in the week prior to his presentation, with upper initial treatment was broadened when he failed to improve, respiratory tract symptoms, but they had all recovered. Further to include courses of ciprofloxacin, meropenem, vancomycin, questioning revealed significant exposure to animal excretions clindamycin, and oseltamivir. in the course of his work as a carpet layer. He was a keen fisher- An extensive workup was performed, including acute and man who ate his catch and regularly hunted rabbits and foxes. convalescent serology for Epstein-Barr virus (EBV), cyto- On admission, his respiratory status rapidly deteriorated, megalovirus (CMV), herpes simplex virus (HSV), human im- with increasing work of breathing and oxygen requirements. munodeficiency virus (HIV), hepatitis B and C, adenovirus, Within 24 hours, he was admitted to the intensive care unit Ross-River virus (RRV), influenza, Chlamydia pneumoniae , (ICU). In the ICU, his initial observations showed a blood Q-fever, Legionella, Brucella, Mycoplasma, and Leptospira spe- cies. These were all negative. Screening IgM for Leptospira spe - cies was positive; however, this was not confirmed in both acute Received 23 August 2017; editorial decision 13 December 2017; accepted 20 December and convalescent samples by microscopic agglutination for Correspondence: E. Athan, Department of Infectious Diseases, University Hospital Geelong, the 9 strains tested in Victoria, and therefore was regarded as Barwon Health, PO Box 281, Bellarine Street, Geelong, Victoria, Australia, 3220 (eugene@bar- a false-positive result. Serum polymerase chain reaction (PCR) wonhealth.org.au). for HSV and CMV were also negative. Cultures from blood, Open Forum Infectious Diseases © The Author(s) 2017. Published by Oxford University Press on behalf of Infectious Diseases bone marrow aspirate, sputum, and urine were negative for Society of America. This is an Open Access article distributed under the terms of the Creative pathogens. Sputum multiplex PCR was negative for Legionella Commons Attribution-NonCommercial-NoDerivs licence (http://creativecommons.org/licenses/ by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any spp, Mycoplasma spp, Chlamydiaeceae, Bordetella pertussis, and medium, provided the original work is not altered or transformed in any way, and that the work B. parapertussis. A naso-pharyngeal swab for respiratory viral is properly cited. For commercial re-use, please contact email@example.com DOI: 10.1093/ofid/ofx273 PCR detected RSV, but was negative for influenza. A computed BRIEF REPORT • OFID • 1 Downloaded from https://academic.oup.com/ofid/article-abstract/5/1/ofx273/4770304 by Ed 'DeepDyve' Gillespie user on 16 March 2018 tomography (CT) scan was completed on his abdomen and We hypothesized infection to be the most likely cause of our pelvis, which showed liver congestion and widespread muscle patient’s rhabdomyolysis, as his presentation was suggestive of edema (Figure 1). Due to the muscle edema and extensive CK a respiratory viral infection and his family had recently been rise, a muscle biopsy was completed, which showed no micro- unwell with upper respiratory tract symptoms. Toxins were con- scopic abnormality and was nondiagnostic. PCR for influenza, sidered a differential, with many toxins including snake, spider, parainfluenza, rhinovirus, adenovirus, metapneumovirus, RSV, and bee venom, as well as carbon monoxide, being associated enterovirus, parechovirus, EBV, CMV, varicella-zoster virus, with rhabdomyolysis [5, 6]. A rarer cause of rhabdomyolysis is and HSV done on the tissue biopsy specimen was negative. that induced by an unidentified toxin associated with fish diges- He required 15 days in the ICU, during 9 of which he was tion, known as Haff disease . While our patient regularly eats sedated and required mechanical ventilation. Due to shock, he his own catch, his family had not become ill despite eating the received high-dose inotropic support, and he required hemofil- same fish. The other causes of toxin-related rhabdomyolysis tration due to acute kidney injury, anuria, and a profound meta- were excluded aer t ft aking a thorough history, which failed to bolic acidosis. Antibiotics were ceased on day 16. identify exposure to other toxins. Aer di ft scharge from the ICU, he required extensive inpatient Infectious causes can be bacterial, viral, parasitic, or fungal rehabilitation with ongoing hemodialysis. He made a good re- in origin. The most common bacterial pathogens identified in covery and was discharged home aer 14 ft days of inpatient re- the literature are Legionella spp, followed by Francisella and habilitation, ceasing dialysis shortly aer di ft scharge. Streptococcal spp [8, 9]. Singh and Scheld documented creatine kinase levels associated with infection from different pathogens DISCUSSION . The only bacterial pathogens to cause levels greater than 300 000 U/L, similar to our patient, were Legionella, Francisella, Rhabdomyolysis is a clinical syndrome characterized by muscle Brucella, and Leptospira spp . Leptospirosis was a differential necrosis and the release of muscle constituents into circulation. diagnosis in our patient due to his recent exposure to animal The traditional characteristics of rhabdomyolysis include my- urine combined with an increase in leptospirosis notifications algia and weakness, and are often associated with dark urine in Victoria in 2016 . This diagnosis was excluded on sero- that results from myoglobin excretion . Rhabdomyolysis logical testing. ranges in severity from asymptomatic to life threatening, and Viral causes of rhabdomyolysis are more common than complications such as acute kidney injury are more likely to bacterial . Influenza is the most common viral pathogen, occur with higher CK levels and associated sepsis and acid- followed by HIV and coxsackie virus [8, 9]. Viral causes of rhab- osis [2, 3]. While the mortality of rhabdomyolysis is variably domyolysis also appear to correlate with higher creatine kinase reported in the literature, it is accepted that mortality is greater levels (>300 000 U/L) . Our patient received extensive viral if rhabdomyolysis is associated with acute kidney injury , and testing, and only returned a positive result for RSV. it has been reported as high as 59% in those with acute kidney er Th e have been only 2 documented cases of RSV-induced injury requiring ICU admission . rhabdomyolysis, both in pediatric patients. The first case was e et Th iology of rhabdomyolysis is variable and includes in a 2-year-old previously healthy boy who had RSV diagnosed infection, trauma, toxins, extreme exertion, prolonged immo- by enzyme-linked immunosorbent assay in a nasopharyngeal bilization, drugs and medications, and metabolic diseases . Figure 1. Increased psoas muscle size at time of raised creatinine suggestive of edema, and edematous lower limb muscle with inflammatory stranding. 2 • OFID • BRIEF REPORT Downloaded from https://academic.oup.com/ofid/article-abstract/5/1/ofx273/4770304 by Ed 'DeepDyve' Gillespie user on 16 March 2018 sample . The patient was referred to the hospital aer 10 ft days rhabdomyolysis, RSV should be considered a possible etio- of nonspecific symptoms including diarrhea, sore throat, fever, logical agent in a patient with rhabdomyolysis and symptoms of generalized myalgia, and weakness. Investigations showed sig- respiratory tract infection. nificant CK elevation (55 000 U/L) as well as liver dysfunction with ALT elevation to 1198 U/L (10–60 U/L) and AST to 4065 Acknowledgments U/L (10–55 U/L). While these are nonspecific findings, this case Financial support. No funding was required for this report. Potential conifl cts of interest. All authors: no reported conflicts of has a number of similarities to our patient, whose ALT peaked interest. All authors have submitted the ICMJE Form for Disclosure of at 4351 U/L and AST at 9209 U/L 3 days aer admi ft ssion, and Potential Conflicts of Interest. Conflicts that the editors consider relevant to who also presented with fever, myalgia, weakness, and respira- the content of the manuscript have been disclosed. tory symptoms. The second case is documented in a German report of RSV rhabdomyolysis in a 4-month-old child . This References 1. Nance JR, Mammen AL. Diagnostic evaluation of rhabdomyolysis. Muscle Nerve case also had similarities to ours, in that the child suffered acute 2015; 51:793–810. renal failure and hepatic dysfunction. 2. Bosch X, Poch E, Grau JM. Rhabdomyolysis and acute kidney injury. N Engl J Med 2009; 361:62–72. Our case is significant as it is the first documented case of 3. McMahon GM, Zeng X, Waikar SS. A risk prediction score for kidney failure or severe rhabdomyolysis associated with RSV infection in an mortality in rhabdomyolysis. JAMA Intern Med 2013; 173:1821–8. adult. RSV is oen a s ft elf-limiting disease in adults, and is more 4. Zutt R, van der Kooi AJ, Linthorst GE, et al. Rhabdomyolysis: review of the litera- ture. Neuromuscul Disord 2014; 24:651–9. commonly known for causing severe illness in infants. Despite 5. Vanholder R, Sever MS, Erek E, Lameire N. Rhabdomyolysis. J Am Soc Nephrol this, our patient’s history of respiratory symptoms, a recent 2000; 11:1553–61. 6. Luck RP, Verbin S. Rhabdomyolysis: a review of clinical presentation, etiology, viral respiratory infection in his family, a lack of any other clear diagnosis, and management. Pediatr Emerg Care 2008; 24:262–8. diagnosis, and only testing positive for RSV among a battery of 7. Buchholz U, Mouzin E, Dickey R, et al. Haff disease: from the Baltic Sea to the U.S. shore. Emerg Infect Dis 2000; 6:192–95. investigations suggest that this is the first documented case of 8. Singh U, Scheld WM. Infectious etiologies of rhabdomyolysis: three case reports RSV-associated rhabdomyolysis in an adult patient. and review. Clin Infect Dis 1996; 22:642–9. 9. Crum-Cianflone NF. Bacterial, fungal, parasitic, and viral myositis. Clin Microbiol Rev 2008; 21:473–94. CONCLUSION 10. Department of Health & Human Services, Victorian Government. Surveillance of notifiable conditions in Victoria. Available at: https://www2.health.vic.gov.au/ We have reported on a severe case of RSV-associated rhab- public-health/infectious-diseases/infectious-diseases-surveillance/search-infec- domyolysis in a previously healthy 42-year-old male. It is the tious-diseases-data/victorian-summary. Accessed 16 March 2017. 11. Ertuğrul S, Yolbaş İ, Aktar F, et al. Recurrent rhabdomyolysis in a child. Case first documented case of severe rhabdomyolysis related to RSV presentation. Arch Argent Pediatr 2016; 114:e192–4. in an adult patient, and only the third case in a patient of any 12. Trück J. More than muscle stiffness [German]. Praxis (Bern 1994) 2006; age that can be found in the literature. While a rare cause of 95:501–4. BRIEF REPORT • OFID • 3 Downloaded from https://academic.oup.com/ofid/article-abstract/5/1/ofx273/4770304 by Ed 'DeepDyve' Gillespie user on 16 March 2018
Open Forum Infectious Diseases – Oxford University Press
Published: Jan 1, 2018
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