Isolated left upper extremity myositis and severe rhabdomyolysis in an adult with H1N1 Influenza, a case report with literature review

Abstract

Acute viral myositis is a fairly rare condition and usually seen in recovery phase of illness, especially in pediatric or geriatric population. Influenza type A, specifically H1N1 may present with generalized myositis and mild elevation of creatinine kinase in addition to usual manifestations. We would like to discuss an atypical presentation of Type A Influenza (H1N1) in a middle aged male who was never immunized for influenza, presenting with fever, vomiting, anuria and acute severe left upper extremity pain. The most interesting presentation in our patient was that, it was limited to a single extremity, unlike generalized presentation, which was previously reported, acute renal failure warranting renal replacement therapy. This case serves as a reminder for clinicians about atypical manifestations of H1N1 and its threatening metabolic complications. Hence the practitioners should be aware of this rare but possible presentation of certain strains of influenza virus. It also accentuates the importance of being immunized, reminding us of the Old but Golden Adage “Prevention is better than Cure.”

A Rare Complication of Seasonal Influenza: Case Report and a Brief Review of the Literature

“…Interestingly, many muscle biopsies done for diagnostic purposes are either normal or inconclusive and, in most cases, a virus has not been detected. One study demonstrated the expression of alpha 2,3 and alpha 2,6-linked sialic acid receptors on muscle cells, which are the same as located on respiratory epithelial cells [10,30].…”

“…Acute viral myositis complicated by rhabdomyolysis is rare but can be a very serious and life-threatening complication of influenza infection which presents itself as a global burden every year [1][2][3][4][5][6][7][8][9][10][11]. It has been defined with the following virus: influenza [1][2][3][4][5][6][7][8][9][10][11][12]15], coxsackievirus [13], Epstein-Barr virus [16], adenovirus [17], echovirus [18], cytomegalovirus [19], measles virus [20], varicella-zoster virus [21], human immunodeficiency virus [22], dengue virus [23], parainfluenza [24], and herpes simplex virus [25]. According to one study, the most common viral agent responsible for viral-induced rhabdomyolysis is the influenza virus reported in 33% of cases [26].…”

“…Toxic cytokines that are released by the human body as a result of infection, one study of viral-induced rhabdomyolysis reported elevated levels of tumor necrosis factor in the serum. TNF has shown to cause muscle breakdown in some experimental studies done on animals [10,13].…”

“…Viral myositis occurs in the early recovery phase of influenza [4]. Cases have been defined with both influenza A and B [1][2][3][4][5][6][7][8][9][10]. In most cases, patients present with an isolated elevation of serum creatine kinase levels.…”

“…Most of the cases are in the pediatric population, however viral myositis is universally found in the adult population as well [1,3]. During the influenza pandemic of 2009, there are many reported cases in adults as well [5,6,7] Some rare cases of rhabdomyolysis and severe myositis associated with influenza infections are also defined in the literature [6][7][8][9][10][11][12]. Cases of rhabdomyolysis are more commonly associated with influenza A [1,5,6,7,8,9].…”