A Rare Pediatric Case of Severe Rhabdomyolysis Owing to Dual Infection

Abstract

Aim We aimed to report a severe and rare pediatric rhabdomyolysis case associated with a dual viral infection.

Case A 13 year-old, healthy girl presented with the complaints of fever, abdominal pain, weakness and dark-colored urine. She was diagnosed with rhabdomyolysis based on clinical signs and laboratory findings. The diagnosis was confirmed by serological tests and real-time polymerase chain reaction for Epstein-Barr virus (EBV) and cytomegalovirus (CMV), respectively. Other potential genetic, metabolic and infectious causes were evaluated meticulously but no evidence was found. This case is also important as it is the first reported case to our knowledge on rhabdomyolysis associated with EBV and CMV co-infection in children.

Conclusion The presented case experienced tetraplegia due to the severe muscular damage and muscle power returned to normal range after 3 months. This suggests that EBV and CMV may have exert synergistic effects leading to more severe inflammation and degeneration.

Zusammenfassung

Ziel Unser Ziel war es, einen schweren und seltenen Fall von Rhabdomyolyse im Kindesalter zu berichten, der im Zusammenhang mit einer Koinfektion mit zwei Viren auftrat.

Fall Ein 13-jähiges gesundes Mädchen kam mit Fieber, Bauchschmerzen, Schwäche und dunklem Urin zur Aufnahme. Anhand der klinischen Symptomatik und Laborergebnisse wurde die Diagnose Rhabdomyolyse gestellt. Mittels serologischer Tests und Real-Time-Polymerase-Kettenreaktion erfolgte der Nachweis von EpsteinBarr-Virus (EBV) und Zytomegalievirus (CMV) und die Bestätigung der Diagnose. Andere mögliche genetische, metabolische und infektiöse Ursachen wurden genauestens untersucht, ließen sich jedoch nicht nachweisen. Der Fall ist auch deshalb wertvoll, weil es sich um den ersten Fall von Rhabdomyolyse im Rahmen einer EBV- und CMV-Koinfektion in Kindsalter handelt.

Schlussfolgerung Im vorgestellten Fall kam es durch die schwere Muskelschädigung zu einer Tetraplegie. Bis zur Normalisierung der Muskelkraft vergingen drei Monate. Dies weist darauf hin, dass das EBV und CMV einen synergistischen Effekt ausgeübt haben könnten, der dann zu schwereren entzündlichen und degenerativen Reaktionen führte.

Key words

Rhabdomyolysis - Childhood - Epstein-Barr virus (EBV) - Cytomegalovirus (CMV) - Dual Infection

Schlüsselwörter

Rhabdomyolyse - Kindesalter - Epstein-Barr-Virus (EBV) - Zytomegalievirus (CMV) - Koinfektion

Publication History

Article published online:
16 July 2021

• References

• 1 Agyeman P, Duppenthaler A, Heininger U. et al. Influenza-associated myositis in children. Infection 2004; 32: 199-203
• 2 Attanasi M, Petrosino MI, Guidone PI. et al. A pediatric case of rhabdomyolysis with acute renal failure due to co-infection with Epstein-Barr virus and Human herpesvirus 6. Arch Med Sci 2018; 14: 254-256
• 3 Chen SC, Liu KS, Chang HR. et al. Rhabdomyolysis following pandemic influenza A (H1N1) infection. Neth J Med 2010; 68: 317-319
• 4 Crum-Cianflone NF. Bacterial, fungal, parasitic and viral myositis. Clin Microbiol Rev 2008; 21: 473-494
• 5 Dalakas MC. Virus-related muscle diseases. In Engel A, Franzini- Armstrong C. Myology. 2nd ed.. Vol 2. New York: McGraw-Hill; 2004: 1389-1417
• 6 Elsayed EF, Reilly RF. Rhabdomyolysis: a review, with emphasis on the pediatric population. Pediatr Nephrol 2010; 25: 7-18
• 7 Friedman BI, Libby R. Epstein-Barr virus infection associated with rhabdomyolysis and acute renal failure. Clin Pediatr (Phila) 1986; 25: 228-229
• 8 Hamel Y, Mamoune A, Mauvais F-X. et al. Acute rhabdomyolysis and inflammation. J Inherit Metab Dis 2015; 38: 621-628
• 9 Gindre Héloïse, Féasson Léonard, Auboyer Christian. et al. Severe rhabdomyolysis associated with a primary cytomegalovirus infection in an immunocompetent patient. BMJ Case Rep 2013; e2012008140
• 10 Konrad RJ, Goodman DB, Davis WL. Tumor necrosis factor and coxsackie B4 rhabdomyolysis. Ann Intern Med 1993; 119: 861
• 11 Mannix R, Tan ML, Wright R. et al. Acute pediatric rhabdomyolysis: causes and rates of renal failure. Pediatrics 2006; 118: 2119-2125
• 12 Michot C, Hubert L, Brivet M. et al. LPIN1 gene mutations: a major cause of severe rhabdomyolysis in early childhood. Hum Mutat 2010; 31: E1564-E1573
• 13 Nauss MD, Schmidt EL, Pancioli AM. Viral myositis leading to rhabdomyolysis: a case report and literature review. Am J Emerg Med 2009; 27 372 e5-e6
• 14 Osamah H, Finkelstein R, Brook JG. Rhabdomyolysis complicating acute Epstein-Barr virus infection. Infection 1995; 23: 119-120
• 15 Poels PJ, Ewals JA, Joosten EM. et al. Rhabdomyolysis associated with simultaneous Epstein-Barr virus infection and isolation of echovirus 6 from muscle: a dual infecti. J Neurol Neurosurg Psychiatry 1989; 52: 412-414
• 16 Rizzi D, Basile C, Di Maggio A. et al. Clinical spectrum of accidental hemlock poisoning: neurotoxic manifestations, rhabdomyolysis and acute tubular necrosis. Nephrol Dial Transplant 1991; 6: 939-943
• 17 You J, Lee J, Park YS, Lee JH. Virus-associated Rhabdomyolysis in Children. Child Kidney Dis 2017; 21: 89-93