Rhabdomyolysis: A Rare Extrapulmonary Manifestation of Mycoplasma Pneumoniae Infection in Adults - A Case Report

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

¹Internal Medicine, St. John Episcopal Hospital, Far Rockaway, NY USA

²Internal Medicine, St. John Episcopal Hospital & Ross, University School of Medicine, Miramar, FL USA

³Infectious Disease, St. John Episcopal Hospital, Far Rockaway, NY USA

Cite this paper:
Dr. Negin Hatami, Brandon P. Coats and Dr. Rita Jammal. Rhabdomyolysis: A Rare Extrapulmonary Manifestation of Mycoplasma Pneumoniae Infection in Adults - A Case Report. American Journal of Medical Case Reports. 2023; 11(4):77-80. doi: 10.12691/ajmcr-11-4-4

Abstract

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.

Keywords:
Rhabdomyolysis Mycoplasma Pneumoniae infectious disease antibodies Creatine Kinase

This work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

References:

[1]	Atkinson TP, Balish MF, Waites KB. Epidemiology, clinical manifestations, pathogenesis and laboratory detection of Mycoplasma pneumoniae infections. FEMS Microbiol Rev 2008; 32: 956-73.
[2]	Miyashita N. Atypical pneumonia: Pathophysiology, diagnosis, and treatment. Respir Investig. 2022 Jan; 60(1): 56-67.
[3]	Kashyap S, Sarkar M. Mycoplasma pneumonia: Clinical features and management. Lung India. 2010 Apr; 27(2): 75-85.
[4]	Foy HM. Infections caused by Mycoplasma pneumoniae and possible carrier state in different populations of patients. Clin Infect Dis 1993;17 Suppl 1: S37-46.
[5]	Khan FY, A Yassin M. Mycoplasma pneumoniae associated with severe autoimmune hemolytic anemia: case report and literature review. Braz J Infect Dis 2009; 13: 77-9.
[6]	Narita M. Classification of Extrapulmonary Manifestations Due to Mycoplasma pneumoniae Infection on the Basis of Possible Pathogenesis. Front Microbiol. 2016 Jan 28; 7: 23.
[7]	Torres PA, Helmstetter JA, Kaye AM, Kaye AD. Rhabdomyolysis: pathogenesis, diagnosis, and treatment. Ochsner J. 2015 Spring; 15(1): 58-69.
[8]	Melli G, Chaudhry V, Cornblath DR. Rhabdomyolysis: an evaluation of 475 hospitalized patients. Medicine (Baltimore) 2005 Nov; 84(6): 377-385.
[9]	Rothstein TL, Kenney GE. Cranial neuropathy, myeloradiculopathy, and myositis: complications of Mycoplasma pneumoniae infection. Arch Neurol 1979; 36: 476-7.
[10]	G. Decaux, M. Szyper, M. Ectors, A. Cornil, and L. Franken, Central nervous system complications of Mycoplasma pneumoniae, Journal of Neurology, Neurosurgery and Psychiatry, vol. 43, no. 10, pp. 883-887, 1980.
[11]	F. Daxbock, G. Brunner, H. Popper et al. A case of lung transplantation following Mycoplasma pneumoniae infection, European Journal of Clinical Microbiology and Infectious Diseases, vol. 21, no. 4, pp. 318-322, 2002.
[12]	R. Gupta, A. Gupta, V. Goyal, R. Guleria, and A. Kumar. Mycoplasma pneumonia associated with rhabdomyolysis and the Guillain-Barre syndrome, Indian Journal of Chest Diseases and Allied Sciences, vol. 47, no. 4, pp. 305-308, 2005.
[13]	F. Y. Khan and H. Sayed. Rhabdomyolysis associated with Mycoplasma pneumoniae pneumonia,” Hong Kong Medical Journal, vol. 18, no. 3, pp. 247-249, 2012.
[14]	A. Gosselt, J. Olijhoek, and T. Wierema. Severe asymptomatic rhabdomyolysis complicating Mycoplasma pneumonia. BMJ Case Reports, vol. 2017, 2017.
[15]	Kaler J, Mukhtar O, Khan B, Shrestha B, Kaler R, Ting B, Khalid M. Rhabdomyolysis: An Unusual Presentation of Mycoplasma pneumoniae Infection in an Adult-A Case Report and Literature Review. Case Rep Med. 2018 Jun 21; 2018: 6897975.
[16]	Gulenay M, Sasson VA, Taylor K. Rhabdomyolysis: A Case Report of an Extrapulmonary Presentation of Mycoplasma pneumoniae. Clin Pract Cases Emerg Med. 2021 May; 5(2): 194-197.
[17]	Kc O, Dahal PH, Koirala M, NtemMensah AD. Rhabdomyolysis and Neurological Manifestation With Progressive Weakness in a Young Adult: A Rare Extrapulmonary Presentation of Mycoplasma Pneumoniae. Cureus. 2021 Dec 20; 13(12): e20552.
[18]	Bébéar C, Pereyre S, Peuchant O. Mycoplasma pneumoniae: susceptibility and resistance to antibiotics. Future Microbiol. 2011 Apr; 6(4): 423-31.