Myopericarditis and exertional rhabdomyolysis following an influenza A (H3N2) infection
© Tseng et al.; licensee BioMed Central Ltd. 2013
Received: 13 February 2013
Accepted: 19 June 2013
Published: 21 June 2013
Acute myopericarditis and exertional rhabdomyolysis, two uncommon but well-described diseases with potentially life-threatening effects, are generally considered as independent clinical entities. However, they may in fact be pathophysiologically related under certain circumstances. This is the first ever report of influenza myopericarditis provoked by exertional rhabdomyolysis to the best of our knowledge.
A 25-year-old immunocompetent Chinese man presented with bilateral leg pain, dizziness, and shortness of breath on admission soon after completing vigorous training comprising running drills. Exertional rhabdomyolysis was diagnosed with 44 fold high serum creatine phosphokinase. Then he developed chest pain, pericardial effusion, changes of electrocardiography and positive troponin I suggestive of myopericarditis. Influenza A (H3N2) virus infection was confirmed by polymerase chain reaction analysis of nasopharyngeal wash samples. Other possible infective and autoimmune causes were excluded. Patient recovered completely with anti-inflammatory therapy and the supportive care.
This case suggests that clinicians who treat patients with exertional rhabdomyolysis should be aware of the potential vulnerability to acute myopericarditis, especially in the presence of recent influenza A infection.
KeywordsMyopericarditis Exertional rhabdomyolysis Influenza A Inflammation
Acute myopericarditis and exertional rhabdomyolysis, two uncommon but well-described diseases with potentially life-threatening effects, are generally considered as independent clinical entities. However, they may in fact be pathophysiologically related under certain circumstances. Here, we report an unusual case of an immunocompetent man who presented to the emergency department after a resolving upper respiratory infection with an unusual presentation of exertional rhabdomyolysis accompanied by acute myopericarditis caused by influenza A. The relationship among these three pathologies and their clinical implications are discussed.
A previously healthy 25-year-old male conscript presented to our emergency department. He complained of bilateral leg pain, dizziness, and shortness of breath soon after completing vigorous training comprising running drills. Ten days before admission, he attended his family clinic complaining of cough and a sore throat. The rapid test for influenza A was positive and he was treated with a 5-day course of oseltamivir. Five days after completing the course, his symptoms had resolved completely and he recommenced regular military training. There was no history of trauma or illicit drug use. He also denied having fatigue, weakness, or weight loss, and the rest of his verbal review of systems was unremarkable.
In the 3 days after admission, the CPK peaked at 34,308, and the cTnI and creatinine peaked at 1.17 and 2.46, respectively. He also developed new-onset left-sided and central chest pain. The pain was pleuritic in nature, and a pericardial friction rub was noted on auscultation. A second echocardiography demonstrated moderate circumferential pericardial effusion without any other abnormalities (Figure 1B), consistent with myopericarditis with a predominant pericarditic component. Based on these findings, he was treated with aspirin for acute myopericarditis and aggressive hydration and urinary alkalinization as per the local rhabdomyolysis protocol. After a total of 20 days of hospitalization, the patient’s leg pain resolved, chest pain relieved, and CPK level declined to 656 U/L. His serum cTnI and creatinine levels normalized after anti-inflammatory therapy and supportive management. Preserved ejection fraction without deterioration of the pericardial effusion was noted in subsequent serial follow-up echocardiographic assessments. The patient was discharged with a normal electrocardiogram and no further sequelae.
Etiologies of viral myopericarditis
Human immunodeficiency virus
Vaccinia (smallpox vaccine)
Influenza is an acute febrile illness caused by influenza viruses. Most infections are uncomplicated and the illness is usually limited to symptoms of upper respiratory infection in combination with several constitutional symptoms, including headache, lethargy, and myalgia. However, some patients are at risk of severe illness and fatal complications affecting multiple organ systems . Various complications of influenza A infection have been reported in the pulmonary, neurological, renal, cardiac and muscular systems [10–12]. Our patient presented with exertional rhabdomyolysis and concurrent myopericarditis, a rare combination. Reports in the literature have indicated that, in adults, exercise during or after a viral illness increases the risk of rhabdomyolysis . As muscle damage occurs, release of constituents of necrotic muscle results in the accumulation of free radicals and tumor necrosis factor-α (TNF-α) in the serum, which are responsible for a systemic inflammatory reaction during rhabdomyolysis. Experimental and necropsy studies have shown convincingly that free radicals produced in any organ of the body can induce myocardial damage . Proinflammatory cytokines including TNF-α are also considered important in the initiation and development of the pathophysiology of inflammatory cardiomyopathies . Moreover, human studies have shown that infection of the myocardium by influenza A is associated with increased expression of TNF-α and its receptors in the myocardium . These findings suggest that exertional rhabdomyolysis may be an important underlying condition for the development of cardiac involvement in influenza A infection.
Exertional rhabdomyolysis with acute kidney injury and acute myopericarditis are uncommon yet potentially life-threatening complications of influenza A infection. To the best of our knowledge, this is the first case of influenza myopericarditis spurred by exertional rhabdomyolysis. It suggests that clinicians who treat patients with exertional rhabdomyolysis should be aware of the potential vulnerability to acute myopericarditis, especially in the presence of recent influenza A infection. Early diagnosis and the intensive care with supportive treatment of such cases can reduce the risk of further cardiac events. As influenza A affects millions of people worldwide, clinicians should also advise patients to avoid strenuous physical activities during and after the infection.
Written informed consent was obtained from the patient for the publication of this case report. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
White blood cell
Cardiac troponin I
Tumor necrosis factor-α.
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