Case Presentation: 34-year-old lady with IgG deficiency, pseudotumor cerebri post VP shunt, malnutrition, recently started on jejunostomy nutrition presented with fever and chills for 1 week. Associated symptoms were frontal headache and generalized muscle pain. Labs were significant for leukocytosis of 7,900 and CPK of 12,920, and a positive blood culture for Eneterobacter Aerogenes and Pseudomonas Aeruginosa. She was admitted for severe sepsis from presumed intra-abdominal wound infection and severe rhabdomyolysis. VP shunt infection was ruled out by negative CSF analysis and cultures. She was treated with Aztreonam over the next week and was eventually afebrile with improving CPK levels and negative blood cultures and was discharged with plan to continue antibiotics. She was readmitted within few hours of discharge with high grade fever and worsened muscle pain. She was now neutropenic with ANC of 0.7 K/uL; bandemia of 19 and CPK again trending up.  Bacterial blood cultures remained negative but additional fungal cultures obtained this time returned positive for Candida Glabrata. She was treated with intravenous fluids and Caspofungin over the next two weeks with clinical improvement, normal CPK level  and  negative cultures by the time of discharge.

Discussion: Rhabdomyolysis is a syndrome characterized by swollen, tender and stiff muscles with elevated levels of Creatine Phosphokinase (CPK) and myoglobinuria often leading to acute kidney injury and severe electrolyte disorders. It has high morbidity (57% developing AKI) and mortality (38% cases), especially in the setting of sepsis. It can result from traumatic, nontraumatic exertional and non-traumatic non-exertional (electrolyte abnormalities, drugs and toxins or infections) causes. Bacterial sepsis accounts for 1-31% of causes, with Legionella species being most common, followed by Streptococcus, Francisella Tularensis and Salmonella Species.  CPK levels usually range from 606 to >400,000, but in most cases remain less than 10,000 U/L.

While rhabdomyolysis is well known to be induced by various viruses and bacteria, mycosis has only rarely been identified as a cause, with only three such cases previously reported in the English literature per our search. Of these, one case involved fungemia by Candida sp. and Aspergillus hyphae, while the other involved a C. krusei infection. All patients had acute leukemia and suffered from severe sepsis while immunocompromised. The peak CK levels in all three cases ranged from 16,000 to >100,000.

Conclusions: Rhabdomyolysis is a treatable condition with significantly high morbidity and mortality in the setting of sepsis. In immunocompromised patients with sepsis and persistent severe rhabdomyolysis (CPK levels- >5,000 U/L), it may be worthwhile to evaluate for underlying fungemia at presentation, so as not to delay treatment.