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Rhabdomyolysis Induced Renal Failure Secondary to Dual Infection With Influenza A and Legionella pneumophilia FREE TO VIEW

Amith George Jacob, MD; Amrutha Mary George, MD; Teny John, MD
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Stroger Hospital, Chicago, IL

Chest. 2014;146(4_MeetingAbstracts):281A. doi:10.1378/chest.1995077
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SESSION TITLE: Critical Care Global Case Reports

SESSION TYPE: Global Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Rhabdomyolysis is characterized by elevated creatine phosphokinase levels and can cause renal failure if not recognized promptly. Numerous precipatiting factors have been identified for this condition including injury, drug toxicity and infections. Here we report a case of severe rhabdomyolysis caused by dual infection with Influenza and Legionella. This case novel in the fact that both infectious agents are known to cause rhabdomylosis independantly however co-infection with both leading to rhabdomyolysis has not been reported earlier.

CASE PRESENTATION: 47 year-old male presented with fever, sore throat, cough, myalgias and dark urine ongoing for the past 4 days. He denied any nausea, vomiting, diarrhea or recent trauma. Past medical history was unremarkable and he denied any medication use. On examination he was febrile(100.8F) and tachypneic. Air entry was decreased in the left lower lung zones along with crepitations. Lower extremity muscle groups were tender to palpation. Remainder of the examination was normal. Laboratory investigation showed leukocytosis with neutrophil predominance, elevated serum creatine(3.2mg/dl), increased blood urea nitrogen(60mg/dl) and markedly high levels of creatine phosphokinase(140,000IU/L). Urinanalysis showed presence of large amount of blood however red blood cell count was normal on microscopic examination. Urine myoglobin test was positive. Chest radiography demonstrated left lower lobe consolidation with mild effusion. Given clinical picture of rhabdomyolysis secondary to pneumonia an intensive infectious workup was initiated. Influenza viral swab and urine antigen for legionella both returned positive. Appropriate antibiotic therapy and aggressive fluid therapy was initiated. His respiratory status worsened the following day necessitating transfer to the intensive care unit for closer monitoring. Serum urea nitrogen and creatine levels continued to rise with declining urine output necessitating renal replacement therapy. Following two weeks of intensive theraepy his condition improved with near complete recovery of kidney function.

DISCUSSION: Infections account for around 5% of rhabdomyolysis cases1. Though Legionnaire's disease is more common among the elderly population, rhabdomyolysis complicating pneumonia has been more commonly reported among younger males. It is usually from infection with serogroup 1. Bacterial endotoxin mediated muscle injury is thought to be responsible in such cases. Presence of severe uremia is recognized as a marker for increased morbidity and mortality in such patients. Among viral etiologies, influenza A is the most common agent associated with rhabdomyolysis2. Invitro studies have demonstrated viral invasion of muscle fibers as possible mechanism for muscle injury. Renal failure is more common among patients with influenza as compared to other infectious etiologies and is found to occur in around 50% of cases. Other possible bacterial, viral etiologies of rhabdomyolysis include streptococcus, shigella, salmonella, coxsackie virus and human immunodeficiency virus3. Though uncommon fungal and atypical parasitic infections can also cause elevated creatine phosphokinase levels, though not to the degree found with viral or bacterial infections. Management usually involves aggressive fluid therapy along with use of appropriate antimicrobial agents. Prognosis is usually good for lower levels of uremia and complete recovery of renal function is generally the norm. Our case is novel in the fact that it is the first one to demonstrate presence of both legionella and influenza infection in a patient with atraumatic rhabdomyolysis.

CONCLUSIONS: Rhabdomyolysis in the setting of infection needs to be recognised early. Legionella and Influenza are the most common infectious agents associated with rhabdomyolysis and as demonstrated can occur concomitantly. Treatment consists of intravenous hydration and control of infection. Early recognition allows for prompt institution of appropriate therapy and helps to minimize renal complications associated with this disorder

Reference #1: Gabow PA et al. The spectrum of rhabdomyolysis.Medicine 1982; 61:141

Reference #2: Foulkes W etal. Influenza A and rhabdomyolysis. J Infect 1990; 21:303

Reference #3: Upinder S et al. Infectious etiologies of rhabdomyolysis: Three case reports and review. Clin Infect Dis 1996; 642: 9

DISCLOSURE: The following authors have nothing to disclose: Amith George Jacob, Amrutha Mary George, Teny John

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