|
|
|
Indian Pediatr 2013;50: 595-596 |
 |
Influenza-B Associated Rhabdomyolysis and
Acute Renal Failure
|
|
Pi-Lien Hung, Pei-Chin Lin and Pi-Lai Tseng
From the Department of Pharmacy, Taiwan, Republic of
China.
Correspondence to: Dr Pi-Lien Hung, Department of
Pharmacy, Taiwan, Republic of China.
Email: [email protected]
Received: October 16, 2012;
Initial review: November 26, 2012;
Accepted: January 01, 2013.
|
|
We present a 15-year-old boy who developed severe rhabdomyolysis and
acute renal failure following influenza B infection. His renal function
was restored after appropriate therapy for rhabdomyolysis. Although
rapidly progressive pneumonia, respiratory failure, and acute
respiratory distress syndrome are the most common severe complications
of influenza B infection, clinicians should be aware that influenza B
may be complicated with rhabdomyolysis and acute renal failure in
children.
Key words: Rhabdomyolysis, Renal failure,
Influenza B.
|
Influenza B often present with myalgia,
rhabdomyolysis is rarely seen. The clinical presentation of
rhabdomyolysis varies from an asymptomatic increase in
creatine kinase (CK) to severe ARF and hypovolaemic shock.
Few reports are available on association of rhabdomyolysis
and acute renal failure (ARF) with influenza virus type B
infection in children [1-5]. We present the case of a child
with cerebral palsy whose renal dysfunction, caused by
influenza-associated rhabdomyolysis, was restored after
adequate treatment.
Case Report
A 15-year-old boy, diagnosed with
cerebral palsy, was in bedridden status. He had been
admitted to the hospital many times for airway infection.
Four days prior to presentation, he developed sudden onset
of fever, decreased activity, productive cough and yellow
sputum. On examination, his weight was 31 kg. The vital
signs were stable. Coarse crackles were heard over bilateral
lower lung fields. Laboratory investigations revealed TLC
7,600/mm 3 (P61L31
M6E2);
serum urea nitrogen (BUN), 16 mg/dL, serum creatinine, 0.9
mg/dL; asparatate aminotransferase (AST), 33 U/L; (normal,
5-35 U/L); and alanine transaminase (ALT) 16 IU/L (normal,
<40 U/L). The rapid screen test for acute influenza
infection was positive for influenza B, but negative for
influenza A. Chest radiography showed no active lung lesion.
The electrocardiogram was normal, and blood cultures, sputum
cultures, urine cultures and viral throat cultures were all
negative for microbial growth. After admission, oseltamivir
60 mg bid and ampicillin and sulbactam 1.5g every 6 hours
were prescribed. On day 3, chest radiography revealed an
increased pneumonitis patch on right upper lung.
Shortness of breath, and dark urine with
oliguria were noted on the 5 th
day. Laboratory test results revealed serum CK 407,421 IU/L
(normal, 27-168 U/L), CK-MB 827 IU/L (normal, <16 U/L);
creatinine:1.47 mg/dL; AST/ALT 3060/744 IU/L, LDH 23,880
IU/L (normal, 135-147 U/L); sodium 157 meq/L, potassium 5.1
meq/L, calcium 6.6 meq/L; uric acid 13.8 mg/dL (normal,
2.5-7.2 mg/dL). Clinical presentation and laboratory
findings were suggestive of rhabdomyolysis with acute renal
failure, most probably caused by influenza B infection. The
patient was transferred to intensive care unit. Due to
altered consciousnes, he received endotracheal intubation
and mechanical ventilation. The systolic blood pressure
decreased to 50-60 mmHg and poor cardiac contractility was
detected. Standard management was instituted for shock
including inotropic agents. Metabolic acidosis was treated
by administration of sodium bicarbonate.
On hospital day 6, the blood pressure and
cardiac contractility recovered to normal. However, the
child developed disseminated intravascular coagulation, and
had hematuria and bleeding from the gastrointestinal tract.
Renal functions deteriorated and the child was started on
hemodialysis. The oseltamivir treatment was shifted to
peramivir because of poor GI absorption. Peramivir was
discontinued 2 days later due to increasing liver enzymes,
and subsequently fever subsided. After hemodialysis therapy,
his renal function was improved gradually. The serum levels
of the muscle enzymes CK and AST decreased rapidly to 2711
IU/L and 168 IU/L, respectively, at discharge 27 days after
admission.
One week after discharge, the patient
visited our outpatient department for follow-up; the serum
CK level, renal and liver function had returned to normal.
Discussion
Rhabdomyolysis is defined as a clinical
and laboratory syndrome resulting from skeletal muscle
breakdown with leakage of muscle cell contents into the
systemic circulation. It is characterized by an elevated
serum creatine kinase level and myoglobinuria, and may lead
to renal dysfunction [2]. Rhabdomyolysis can cause
life-threatening complications, including hypovolemia,
hyperkalemia, metabolic acidosis, acute renal failure (ARF)
and DIC [3]. ARF
often results from the nephrotoxic effects of lytic myocyte
components and usually presents as oligouric pigment-induced
intrinsic renal failure [4]. The early and aggressive fluid
repletion and bicarbonate therapy are the standard treatment
to prevent ARF in such cases.
Influenza B-associated rhabdomyolysis is
an infrequent and little-known complication of influenza B
virus infection in children. In 2010, Wu, et al. [5]
reviewed hospitalized children with influenza B virus
infection at a university children’s hospital in North
Taiwan during 2000–2007 and found that 24 had presented with
rhabdomyolysis; none had renal involvement. A recent review
suggests that the risk of acute kidney injury in
rhabdomyolysis is usually low when CK level at admission is
<15, 000 to 20,000 IU/L [3]. Our patient had high level CK
407,421 IU/L. Because limited data indicate that
administering oseltamivir via a gastric tube can provide
systemic absorption in critically ill patients [6], our
patient was treated with intravenous peramivir. It is, a
neuraminidase inhibitor, authorized for emergency use for
the treatment of hospitalized patients with known or
suspected 2009 H1N1 influenza. Clinicians should be alert to
patients with flu-like symptoms with severe muscle pain and
dark brown urine (to rule out rhabdomyolysis). The high
level of CK could be an indicator for the fatal complication
of ARF. The early diagnosis and appropriate therapy should
decrease mortality and restore renal function.
References
1. Naderi AS, Palmer BF. Rhabdomyolysis and acute renal
failure associated with influenza virus type B infection. Am
J Med Sci. 2006;332:88-9.
2. Bosch X, Poch E, Grau JM.
Rhabdomyolysis and acute kidney injury. N Engl J Med.
2009;361:62-72.
3. Chen HP, Lin WT, Tsai MF, Chen CY,
Tsai TC. Influenza A (H1N1) infection with rhabdomyolysis
and acute renal failure-a case report. J Intern Med Taiwan.
2011;22: 138-41.
4. Lin CC, Chian CF, Perng WC. Influenza
A infection with rhabdomyolysis and acute renal failure.
Thorac Med. 2010;25:131-6.
5. Wu CT, Hsia SH, Huang JL. Influenza
B-associated rhabdomyolysis in Taiwanese children. Acta
Paediatr. 2010;99:1701-4.
6. Kohno S, Yen MY, Cheong HJ, Hirotsu N, Ishida T,
Kadota JI, et al. Phase III randomized, double-blind
study comparing single-dose intravenous peramivir with oral
oseltamivir in patients with seasonal influenza virus
infection. Antimicrob Agents Chemother. 2011;55: 5267-76.
|
|
|
 |
|
