Dr. Negin Hatami^1,, Brandon P. Coats², Dr. Rita Jammal³

Mycoplasma pneumoniae can be responsible for up to 40% of cases of Community-Acquired Pneumonia (CAP). The M. pneumoniae infection causes a variety of pulmonary and extrapulmonary manifestations. Rhabdomyolysis is a rare and life-threatening extrapulmonary complication of the M. pneumoniae infection, requiring early recognition, prompt supportive management, and treatment with appropriate antibiotics. We describe this case in 60-year-old male who present to the Accident and Emergency (A&E) with a 4-day history of dyspnea and generalized weakness. Further, investigations showed positive mycoplasma IgG and IgM serology. He was admitted to the ICU to undergo emergency dialysis for rhabdomyolysis-driven anuric acute kidney injury. Case Summary: Here, we present a case of a 60-year-old male with a 4-day history of dyspnea and generalized weakness. His past medical history was positive for high blood pressure and dyslipidemia, for which he was taking amlodipine, hydralazine, metoprolol, clonidine, and statin, however, was not compliant with his medication. He denied any recreational drug use. His lab work showed BUN 44, Cr 5.4, AST 1500, ALT 473, K 6.9, anion gap 23, and unrecordable CK levels (>160,000). His CXR and CT scan showed right-middle zone consolidation. Investigations showed positive mycoplasma IgG and IgM serology. He was admitted to the ICU to undergo emergency dialysis for rhabdomyolysis-driven anuric acute kidney injury and was started on azithromycin for Mycoplasma pneumoniae. Further probing of his past medical history revealed that he had a similar episode a few years ago where he developed rhabdomyolysis requiring dialysis for a total of 3 months, at which point he was likewise positive for mycoplasma. Given the new information, other causes of rhabdomyolysis such as inflammatory myositis and statin-induced myositis were ruled out based on diligent history-checking, examination, and opinions from rheumatologists. We were thus left with mycoplasma-induced rhabdomyolysis as the most likely cause. The patient clinically improved but remained dialysis-dependent and was discharged with outpatient dialysis. Discussion: Rhabdomyolysis is a pathological condition causing necrosis of the skeletal muscles and release of intracellular toxins into the bloodstream. The clinical sequelae of rhabdomyolysis can vary from asymptomatic disease to myalgia, electrolyte derangement, and life-threatening renal failure requiring dialysis. Rhabdomyolysis commonly results from ischemia, trauma, high temperature, exertion, drugs, and infections. Among infections, M. pneumoniae is a rare yet important cause of rhabdomyolysis. In our case, the clinical history, imaging findings, positive serology, and clinical response to the appropriate antibiotic regimen support meant that Pneumoniae was the cause of the rhabdomyolysis. Only a handful of cases report rhabdomyolysis as an extrapulmonary manifestation of M. pneumoniae infection. The severity of Rhabdomyolysis in these cases was variable, with the highest CK levels reported by Kaler et al. (49,578) responding to hydration. Our case is unique, as the CK levels were higher than the reference lab values (>160,000) and led to anuric renal failure requiring immediate dialysis. Antibiotics should be started promptly, considering the increasing incidences of macrolide resistance in M. pneumoniae.

Rhabdomyolysis, Mycoplasma Pneumoniae, infectious disease, antibodies, Creatine Kinase