Rhabdomyolysis associated with infection by Mycoplasma pneumoniae: a case report

Rhabdomyolysis and Neurological Manifestation With Progressive Weakness in a Young Adult: A Rare Extrapulmonary Presentation of Mycoplasma Pneumoniae

Mycoplasma pneumoniae (M. pneumoniae) is a common cause of community-acquired pneumonia. It has been associated with many extrapulmonary manifestations that can present even in the absence of pulmonary signs and symptoms. Rhabdomyolysis and central nervous system (CNS) manifestations are rare extrapulmonary manifestations. These are infrequently reported in adults. We present a case of a healthy 32-year-old male who initially presented with signs and symptoms of community-acquired pneumonia and was treated with antibiotics. However, he continued to have generalized malaise, night sweats, diffuse joint pain, and myalgias and was subsequently noted to have rhabdomyolysis with elevated creatine kinase (CK) and myoglobin levels. Rhabdomyolysis was attributed to M. pneumoniae based on the recent history of upper respiratory tract infection and M. pneumoniae immunoglobulin M (IgM) serology positivity along with high M. pneumoniae IgG titer. The other causes of rhabdomyolysis were diligently excluded based on patient history and laboratory and clinical data. This immune-mediated rhabdomyolysis improved with intravenous hydration, doxycycline, and prednisone therapy. However, the patient developed progressive weakness with neuropathy, which required treatment with intravenous immune globulin (IVIG). This case highlights the need to maintain a high index of suspicion for rare extrapulmonary manifestations of mycoplasma infection, which could be life-threatening or cause significant morbidity; and in cases of severe extrapulmonary manifestations, the appropriate use of immunosuppressive/immunomodulatory therapy may lead to a better outcome.

Rhabdomyolysis: A Case Report of an Extrapulmonary Presentation of Mycoplasma pneumoniae

Introduction

We present an unusual case of rhabdomyolysis secondary to Mycoplasma pneumoniae in a healthy 27-year-old female. M. pneumoniae is associated with numerous extrapulmonary manifestations, including acute hepatitis, Stevens-Johnson syndrome, and rhabdomyolysis. Most documented cases affect the pediatric population, with only five cases in adults reported in the literature.

Case Report

The patient presented with complaints of myalgia and intractable cough. In this case the initial presentation demonstrated hypoxia requiring supplemental oxygen, and a creatine kinase of 7,646 units per liter (U/L) (reference range 26–192 U/L) with a peak of 29,427. During her hospitalization, she also remained persistently hypoxic for several days but ultimately was successfully weaned off all supplemental oxygen. She was discharged home after a seven-day hospitalization.

Conclusion

This patient’s presentation of an insidious, upper respiratory infection along with the subsequent development of rhabdomyolysis with reactive antibodies to M. pneumoniae demonstrates a link between these two clinically important conditions.

Myositis and acute kidney injury in bacterial atypical pneumonia: Systematic literature review

BACKGROUND

Bacterial community-acquired atypical pneumonia is sometimes complicated by a myositis or by a renal parenchymal disease. Available reviews do not mention the concurrent occurrence of both myositis and acute kidney injury.

METHODS

In order to characterize the link between bacterial community-acquired atypical pneumonia and both myositis and a renal parenchymal disease, we reviewed the literature (United States National Library of Medicine and Excerpta Medica databases).

RESULTS

We identified 42 previously healthy subjects (35 males and 7 females aged from 2 to 76, median 42 years) with a bacterial atypical pneumonia associated both with myositis (muscle pain and creatine kinase ≥5 times the upper limit of normal) and acute kidney injury (increase in creatinine to ≥1.5 times baseline or increase by ≥27 μmol/L above the upper limit of normal). Thirty-six cases were caused by Legionella species (N = 27) and by Mycoplasma pneumoniae (N = 9). Further germs accounted for the remaining 6 cases. The vast majority of cases (N = 36) presented a diffuse myalgia. Only a minority of cases (N = 3) were affected by a calf myositis. The diagnosis of rhabdomyolysis-associated kidney injury was retained in 37 and that of acute interstitial nephritis in the remaining 5 cases.

CONCLUSION

Bacterial atypical pneumonia may occasionally induce myositis and secondary kidney damage.

Suspected Virus-Inducing Severe Acute Respiratory Distress Syndrome Treated by Multimodal Therapy Including Extracorporeal Membrane Oxygenation and Immune Modulation Therapy

A 44-year-old man who had been feeling general fatigue was found in an unconscious state on the same day. He had no remarkable medical history. On arrival at the hospital, his Glasgow Coma Scale was E1V2M3; he had tachycardia and hypertension, was afebrile, and in a severe hypoxic state. His PaO₂/FiO₂ (P/F) was under 100, even with tracheal intubation with 100% oxygen. Chest X-ray and CT revealed a bilateral ground-glass appearance with consolidation. Cardiac echo initially showed hyper-dynamic wall motion. The main results of a blood analysis suggested an acute inflammatory reaction, rhabdomyolysis, and pancreatitis. The microscopic findings of sputum and a rapid test for bacterial and viral infections were all negative. As he showed deterioration of P/F, venovenous extracorporeal membrane oxygenation (ECMO) was started. He also showed hypotension and therefore underwent vasopressor and steroid administration. Due to concerns of pneumonia, he received meropenem and azithromycin in addition to the infusion of γ-globulin and glycyrrhizin. The results of a COVID-19 test, culture of sputum, and collagen disease test were all negative. The serum virus neutralization assay as a serological test for Coxsackievirus B4 showed a four-fold increase in titer. The multimodal therapy mentioned above resulted in the improvement of his general condition, including acute respiratory distress syndrome (ARDS). In this report, we discuss the benefits of ECMO and immune modulation therapy in the treatment of severe ARDS.

Rhabdomyolysis associated with antimicrobial drug-resistant Mycoplasma pneumoniae

We describe a case of rhabdomyolysis in a patient infected with antimicrobial drug-resistant Mycoplasma pneumoniae The patient's acute-phase serum levels of interleukin-18 and tumor necrosis factor-α were high, which suggests a pathogenic role for M. pneumoniae. In an era of increasing antimicrobial drug resistance, a system for rapidly identifying resistant M. pneumoniae would be beneficial.

Mycoplasma pneumoniae with atypical stevens-johnson syndrome: a diagnostic challenge

The Stevens-Johnson syndrome (SJS) classically involves a targetoid skin rash and the association of the oral mucosa, genitals, and conjunctivae. Recently, there have been several documentations of an incomplete presentation of this syndrome, without the typical rash, usually associated with the mycoplasma pneumoniae infection. Our case illustrates that this important clinical diagnosis should not be missed due to its atypical presentation.

Ιnflammatory or septic arthritis associated with mycoplasma pneumonia in children: Two case reports and review of the literature

Inflammatory or septic arthritis due to Mp is an extremely unusual manifestation in children, and the functional outcome of the joints is difficult to be predicted. Two cases with Mp infection are presented. The first patient had positive PCR for Mp after hip aspiration and arthrotomy with thorough irrigation and debridement. A flattened femoral head was detected during the follow-up, which became quite spherical a year after. An arthrotomy with medial synovectomy of the knee was performed in the second patient. Lack of full knee extension was presented during the first 3 months, which gradually decreased to 7° in the final follow-up. The suspicion of Mp infection with extra-pulmonary involvement in children is mainly based on clinical, epidemiological and radiological data, but laboratory testing is required for confirmation. Rapid diagnosis of probability consists of serum tests, and their results are essential for early therapeutic planning. The direct diagnosis of Mp DNA through polymerase chain reaction (PCR) provides specificity and sensitivity. Very few cases of arthritis associated with Mp infection have been published but not with the severity of our cases. Clinical suspicion of Mp infection is of great importance, and the outcome depends on early diagnosis and specific treatment.

Fulminant type 1 diabetes mellitus with rhabdomyolysis: have we overlooked the situation?

Fulminant type 1 diabetes mellitus (FT1DM) is characterized as remarkably abrupt onset and severe metabolic disorder. Prominent derangement of serum electrolytes was frequently observed, which could be associated with rhabdomyolysis. But the issue was not touched upon in most of the articles concerning FT1DM. Herein, we reported 2 cases. Since the clinical features of rhabdomyolysis vary, and creatine kinase levels are not routinely tested in young patients, the situation of rhabdomyolysis associated with FT1DM may be overlooked.

Mycoplasma pneumoniae--associated transverse myelitis and rhabdomyolysis

Mycoplasma pneumoniae is a common cause of respiratory tract infection. Extrapulmonary manifestations of M. pneumoniae infection are also common. The present case is that of a previously healthy 4-year-old boy who displayed a novel simultaneous onset of both acute rhabdomyolysis and transverse myelitis associated with an infection of M. pneumoniae. He had no preceding symptoms or signs of respiratory tract infection. Intravenous immunoglobulin (1 g/kg per day) for 2 days was prescribed initially for the deterioration of neurologic condition. His rhabdomyolysis resolved without complication, but neurologic sequelae remained during 2 years of follow-up. Evaluation for M. pneumoniae infection is recommended in patients with idiopathic rhabdomyolysis and transverse myelitis, even if in the absence of antecedent respiratory symptoms.

Bacterial, fungal, parasitic, and viral myositis

Infectious myositis may be caused by a broad range of bacterial, fungal, parasitic, and viral agents. Infectious myositis is overall uncommon given the relative resistance of the musculature to infection. For example, inciting events, including trauma, surgery, or the presence of foreign bodies or devitalized tissue, are often present in cases of bacterial myositis. Bacterial causes are categorized by clinical presentation, anatomic location, and causative organisms into the categories of pyomyositis, psoas abscess, Staphylococcus aureus myositis, group A streptococcal necrotizing myositis, group B streptococcal myositis, clostridial gas gangrene, and nonclostridial myositis. Fungal myositis is rare and usually occurs among immunocompromised hosts. Parasitic myositis is most commonly a result of trichinosis or cystericercosis, but other protozoa or helminths may be involved. A parasitic cause of myositis is suggested by the travel history and presence of eosinophilia. Viruses may cause diffuse muscle involvement with clinical manifestations, such as benign acute myositis (most commonly due to influenza virus), pleurodynia (coxsackievirus B), acute rhabdomyolysis, or an immune-mediated polymyositis. The diagnosis of myositis is suggested by the clinical picture and radiologic imaging, and the etiologic agent is confirmed by microbiologic or serologic testing. Therapy is based on the clinical presentation and the underlying pathogen.

Mycoplasma pneumoniae and atypical Stevens-Johnson syndrome: a case series

Mycoplasma pneumoniae is a common cause of community-acquired respiratory illness in the adolescent population. Stevens-Johnson syndrome is an extrapulmonary manifestation that has been associated with M. pneumoniae infections. Three adolescent males presented within a 1-month period with M. pneumoniae respiratory illnesses and severe mucositis but without the classic rash typical of Stevens-Johnson. Diagnosis was facilitated by the use of a polymerase chain reaction-based assay. This case series highlights the potential for M. pneumoniae-associated Stevens-Johnson syndrome to occur without rash and supports the use of polymerase chain reaction for early diagnosis.

Acute rhabdomyolysis complicating status asthmaticus in children: case series and review

OBJECTIVES

To describe a case series of 4 children who developed acute rhabdomyolysis as a complication of acute respiratory failure secondary to status asthmaticus.

METHODS

A retrospective review of all children who were admitted to our pediatric intensive care unit (PICU) with status asthmaticus from November 1998 through July 2004 was performed and all children who developed acute rhabdomyolysis, defined as a 5-fold increase above the upper limit of normal in the serum creatine phosphokinase (CPK) concentration (CPK > or = 1250 IU/L), were identified. Demographic and clinical data were abstracted from the medical record.

RESULTS

During the study period, 108 children with status asthmaticus were admitted to our PICU (3.6% of all admissions). Four children (age 12-19 years) developed acute respiratory failure requiring mechanical ventilation, and all 4 of these children (3.7% of all children with status asthmaticus admitted to the PICU) developed acute rhabdomyolysis. The 4 children who developed acute rhabdomyolysis were older than the children with status asthmaticus, without rhabdomyolysis (median age 15 years vs. 5 years).

CONCLUSIONS

Acute rhabdomyolysis complicating status asthmaticus may be more common than previously ascertained. We therefore suggest that CPK levels should be followed closely in all children with status asthmaticus and acute respiratory failure. The early presentation of rhabdomyolysis in the current series suggests that factors other than corticosteroids and neuromuscular blockers are potentially involved. Mechanical ventilation and older age seem to be significant risk factors for rhabdomyolysis, perhaps implicating a mechanism similar to the pathogenesis of severe exercise-related rhabdomyolysis. Further clinical study of the incidence and causative factors of rhabdomyolysis in this population is warranted.

[Extrapulmonary infections due to Mycoplasma pneumoniae]

Pneumonia is the main site of infection with Mycoplasma pneumoniae in paediatric age. Nevertheless it can also give rise to other manifestations, with or without respiratory involvement. In the present review are described some unusual clinical features of M. pneumoniae in children. Encephalitis and meningoencephalitis is the most frequent neurological manifestation, but cases of meningitis, myelitis, and polyradiculitis, have been reported. Cardiac involvement is potentially severe, including pericarditis and myocarditis. Cold agglutinin haemolytic anaemia is the most frequent haematologic manifestation. Skin, renal, gastro-intestinal, osteoarticular, and other manifestations have also been reported in the literature. The pathogeny of these extrapulmonary infections is not fully elucidated and the treatment remains partly controversial. Extrapulmonary complications can occur as a result of direct invasion and/or autoimmune response.

Mycoplasma pneumoniae and its role as a human pathogen

Mycoplasma pneumoniae is a unique bacterium that does not always receive the attention it merits considering the number of illnesses it causes and the degree of morbidity associated with it in both children and adults. Serious infections requiring hospitalization, while rare, occur in both adults and children and may involve multiple organ systems. The severity of disease appears to be related to the degree to which the host immune response reacts to the infection. Extrapulmonary complications involving all of the major organ systems can occur in association with M. pneumoniae infection as a result of direct invasion and/or autoimmune response. The extrapulmonary manifestations are sometimes of greater severity and clinical importance than the primary respiratory infection. Evidence for this organism's contributory role in chronic lung conditions such as asthma is accumulating. Effective management of M. pneumoniae infections can usually be achieved with macrolides, tetracyclines, or fluoroquinolones. As more is learned about the pathogenesis and immune response elicited by M. pneumoniae, improvement in methods for diagnosis and prevention of disease due to this organism may occur.