Rhabdomyolysis in a patient with Kawasaki disease

Abstract

A previously healthy, 8-month-old boy suffered from Kawasaki disease with rhabdomyolysis.Although Kawasaki disease (KD) is a systemic vasculitis affecting multiple organ systems, muscle involvement has rarely been reported [1,2,3,4,5,6]. This report describes rhabdomyolysis in a patient with KD.A previously healthy, 8-month-old boy was referred to another hospital because of a 5-day history of highgrade fever, cervical lymph node swelling, and exanthema. The patient was transferred to our hospital because of elevated creatine kinase (CK) levels. The patient did not take any anti-inflammatory drugs including ibuprofen before admission. Upon admission, physical examination revealed bilateral conjunctivitis, a strawberry-like tongue, enlarged cervical lymph nodes, polymorphic truncal rash and oedema of the peripheral extremities. His vital signs were as follows: body temperature 40.3°C; blood pressure 102/ 48 mmHg; and pulse rate 140 beats/min. The body weight was 9.6 kg (-0.4 kg before present illness). The patient did not suffer from apparent muscle pain, tenderness or weakness. Neurological examinations showed no remarkable findings. Laboratory studies revealed anaemia (red blood cell count 364·10 4 /ll, haemoglobin 9.3 g/dl, and haematocrit 28.9%), elevated C-reactive protein (CRP) (5.34 mg/dl, reference range 0.01-0.31 mg/dl), increased levels of aspartate aminotransferase (AST, 528 IU/l, reference range 11-31 IU/l), alanine aminotransferase (ALT, 225 IU/l, reference range 7-42 IU/l) and lactate dehydrogenase (LDH, 1,716 IU/l, reference range 232-427 IU/l), and an elevated CK level (10,356 IU/l, reference range 48-280 IU/l) with 98.6% MM isozyme. Serum concentrations of aldolase (25.0 IU/l, reference range 2.5-5.8 IU/l) and myoglobin (380 ng/ml, normal <60 ng/ml) were also elevated. Serum sodium (138 mEq/l), potassium (4.7 mEq/l), chloride (102 mEq/l) and creatinine (0.2 mg/dl) and blood urea nitrogen (4.9 mg/dl) were normal. Urinalysis showed 1+ protein and 1+ occult blood without red blood cells. Urinary concentration of myoglobin (111 ng/mL, normal <10 ng/ml) was elevated. Urinary electrolytes were as follows: sodium 10 mEq/l, potassium 9.1 mEq/l and chloride 17 mEq/l. Urinary creatinine concentration was 15.3 mg/dl. Antinuclear antibody, hepatitis B virus surface antigen, and anti-hepatitis C virus antibody were negative. Bacterial and viral culture of throat swabs grew no pathogens. Echocardiograms and electrocardiograms revealed no abnormalities. The patient was diagnosed as having KD with rhabdomyolysis. Intravenous infusion of 1 g/kg c-globulin for 2 days and oral administration of flurbiprofen (2 mg/kg per day) promptly improved his condition. His body temperature normalised 4 days after the start of treatment and his serum CK and CRP levels normalised 7 and 10 days after treatment, respectively. He was discharged with elevated AST, ALT and LDH levels 13 days after he was admitted to the hospital. The levels of these enzymes returned to normal 4 weeks later. A follow-up examination 4 months later showe...

Hyponatremia in Kawasaki disease

“…Two of three patients with CNS involvement had hyponatremia. One patient suffered from rhabdomyolysis [6]. Pyuria and hematuria were present in 43 (37.7%) and ten (8.8%) patients, respectively.…”

“…Because KD is systemic vasculitis, multiple organ involvement can develop, including coronary artery lesions (CALs), carditis, arthritis, hepatitis, central nervous system (CNS) disease [3], kidney and urinary tract abnormalities [4,5], muscle involvement [6] and hyponatremia [7,8]. Although hyponatremia frequently occurs in KD [7,8], the clinical characteristics of KD patients with hyponatremia and the pathogenesis of hyponatremia in KD remain incompletely understood.…”

Sterile pyuria in patients with Kawasaki disease originates from both the urethra and the kidney

“…Although renal disease in KD is relatively rare [9][10][11][12][13][14][15][16][17][18], an abnormal urinalysis result is a well-known finding and includes proteinuria [4,9,22,23], hematuria [4], urinary excretion of casts and renal tubular epithelial cells [4], myoglobinuria [21] and pyuria [2,[4][5][6][7][8]. Although Shiono et al [24] described a KD patient with pyuria and pyelonephritis due to Escherichia coli, all other KD patients with pyuria exhibited sterile pyuria, and this is the most common finding in KD patients with abnormal urinalysis results.…”

“…KD is a systemic vasculitis, and, therefore, multiple organs and tissues may be involved in the disease process, including the coronary arteries, heart, joints, liver, central nervous system [1][2][3]20], muscle [21] and kidneys [4]. Although renal disease in KD is relatively rare [9][10][11][12][13][14][15][16][17][18], an abnormal urinalysis result is a well-known finding and includes proteinuria [4,9,22,23], hematuria [4], urinary excretion of casts and renal tubular epithelial cells [4], myoglobinuria [21] and pyuria [2,[4][5][6][7][8].…”

Rhabdomyolysis with Kawasaki disease and a family history of rhabdomyolysis

“…There have been only two reports about rhabdomyolysis in patients with KD, but they did not clarify the pathogenetic mechanism for rhabdomyolysis in the KD patients. 2,3 With regard to the incidence of KD, not the KD on its own but the persistent high fever might have been the trigger for rhabdomyolysis in this case, because when the prolonged fever resolved, serum CK rapidly decreased; also, the cause of the father's rhabdomyolysis had been high fever due to virus infection. Moreover, the most important point is that the father has a medical history of rhabdomyolysis twice.…”