Case Presentation: 18-year-old female college student with a past medical history of polycystic kidney disease, febrile seizures and treated Kawasaki’s disease presented with bilateral lower extremity muscle weakness, which was acute and uniform without any patterns such as ascending or descending quality. The severity of the symptoms lead to patient’s inability to ambulate without support over the past week.The patient also complained of nausea and vomiting and cough with yellow sputum and dyspnea. In the ED, physical exam was positive for bilateral decreased motor strength of 3/5 of proximal lower extremities, however sensation was intact and 2+ pulses palpable. Mild wheezing was noted on auscultation of bilateral lung fields, more prominent on the right side. Patient also had diffuse tenderness to palpation of the abdomen. Patient’s vitals were HR of 130 bpm, BP of 100/52 mmHg, T of 98F, RR of 18 breaths/min and SaO2 of 99% on RA. The patient was found to have creatine kinase (CK) greater than 200,000 IU/L with ALT of 533 IU/L and AST of 1825 IU/L, and elevated troponin of 0.047 ng/mL. Other significant lab values was a creatinine of 1.54 mg/dL and D-dimer of 7,691 ng/mL FEU. Patient was started on aggressive crystalloid therapy with frequent monitoring of CK and CMP. After extensive rheumatological work up for autoimmune sources of myositis was ruled out, patient muscle biopsy confirmed myositis given the tissue showed inflammation and necrosis. Infectious evaluation eventually showed that the patient was serologically positive for Epstein Barr Virus, Parainfluenza Type 2, and Coxsackie B virus. The patient was discharged with great clinical improvement and improvement of lab values.

Discussion: This case highlights the atypical presentation and evaluation of rhabdomyolysis. In a study of 3,501 hospitalizations, the clinical conditions most frequently associated with rhabdomyolysis were trauma (26.3%), immobilization (18.1%), sepsis (9.9%), and vascular and cardiac operations (8.1%, 5.9%, respectively). Another study of 475 hospitalized patients demonstrated illicit drugs, alcohol, and prescribed drugs responsible for 46% of rhabdomyolysis cases. While rhabdomyolysis is commonly seen in the setting of trauma, sepsis, and toxins, it has also been linked less commonly to viral infections. Influenza is the most commonly reported viral cause of rhabdomyolysis, but there are 10 reported cases of parainfluenza-related rhabdomyolysis documented on PubMed. While the exact underlying mechanism behind the development of rhabdomyolysis in the setting in parainfluenza is not known, it has been suggested that parainfluenza-mediated induction of Type 1 Interferon production may be responsible. More research is needed in order to elucidate the mechanism of parainfluenza infection and rhabdomyolysis.

Conclusions: Rhabdomyolysis is defined as the rapid breakdown of striated skeletal muscle with hallmark features of elevated creatinine kinase, myopathy, and myoglobinuria. We have presented the case of an atypical presentation of rhabdomyolysis in the setting of viral illness. It is difficult to assess the true prevalence or severity of rhabdomyolysis in the setting of viral infection as viral myositis has been mostly associated with benign myalgias and many of the acute cases likely go undocumented. In the absence of a more common etiology, the workup of rhabdomyolysis should include viral infection.

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