SESSION TITLE: Atypical Presentations in the ICU
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Wednesday, October 30, 2013 at 11:30 AM - 12:30 PM
INTRODUCTION: Influenza is known to induce rhabdomyolysis. This is a case of a young man with influenza A complicated with severe rhabdomyolysis with the highest associated creatine kinase reported in the literature of over 4 million.
CASE PRESENTATION: 30 year old male with a past medical history of asthma presented with 5 day history of progressively worsening myalgias particularly of his bilateral lower extremities, subjective fevers, productive cough, and 1 day of dark colored urine. His creatine kinase (CK) on admission was 67,997, urine toxicology screen was negative, influenza A positive for which he completed a course of ostelamivir. Over the next 48 hours he had progressive acute kidney injury (AKI) with his creatine increasing from 1.6 to 2.99 despite some initial improvement with aggressive intravenous fluids (IVF) and intravenous sodium bicarbonate. His CK peaked to 4,312,211 U/L on the second day of admission with a subsequent CK of over 1 million on day three with a myoglobin of 35,964 ng/ml. MRI of his lower extremities at this time showed diffuse muscle edema of bilateral thigh musculature without of muscle atrophy Hemodialysis (HD) was initiated for up trending CK, worsening AKI (his creatine peaking at 8.09), and progression to anuria. His 31 day hospital course was further complicated with a superimposed Streptococcus pneumoniae pneumonia, hypoxic respiratory failure requiring mechanical ventilation, and subsequent acute respiratory distress syndrome (ARDS) necessitating airway pressure release ventilation (APRV) and nitric oxide. With worsening hypoxia, his hospital course ended with a (pulseless electrical activity) PEA arrest. His CK had declined to 734 and creatine 1.98.
DISCUSSION: Our patient had a complicated course of influenza A with rhabdomyolysis resulting in CKs above 4 million, which is the highest level documented in the literature to date. A CK of over 1 million was reported in an exercise induced rhabdomyolysis for which the patient was treated with IVF with resolution of his AKI without requiring HD. Review of the literature of influenza induced rhabdomyolysis revealed varying CK levels (200-500k) that did not correlate with AKI progression requiring HD. The 2009 H1N1 strain was associated with increased rates of rhabdomyolysis, and those requiring HD had higher mortality.
CONCLUSIONS: Rhabdomyolysis is a relatively uncommon complication of Influenza A. The CK level itself does not predict need HD. Rhabdomyolysis induced by influenza A requiring HD itself is a poor prognostic indicator associated with an increased mortality.
Reference #1: Ayala E, Kangawa F, Wener J. Rhabdomyolysis associated with 2009 influenza A (H1N1). JAMA 2009; 302(17):1863-1864.
Reference #2: Berry L, Braude S. Influenza A infection with rhabdomyolysis and acute renal failure a potentially fatal complication. Postgrad Med J 1991;67:389-390.
Reference #3: Casares P, Marull J. Over a million Creatine Kinase due to a heavy work-out: A case report. Cases J 2008; 1(1):173-176.
DISCLOSURE: The following authors have nothing to disclose: Rupinder Kullar, Daniel Fitelson, Sharon O'Brien
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