Yezan Abderrahman, MD
Pediatric Critical Care Fellow
University of Iowa Hospital and Clinics
Iowa City, IA, United States
Disclosure information not submitted.
Ramya Deepthi Billa, MBBS
University of Iowa Stead Family Children's Hospital
Iowa City, IA
Disclosure information not submitted.
Lukasz Weiner, MD
Clinical Assistant Professor, Pediatric Infectious Diseases
University of Iowa Hospitals and Clinics
Iowa City, Iowa, United States
Disclosure information not submitted.
Rabia Khan, MD
Clinical Assistant Professor, Pediatric Cardiology
University of Iowa Hospitals and Clinics
Iowa City, Iowa, United States
Disclosure information not submitted.
Kathy Lee-son, MD
Clinical Associate Professor, Pediatric Nephrology
University of Iowa Hospitals and Clinics
Iowa City, Iowa, United States
Disclosure information not submitted.
Aditya Badheka, MD, MS
Clinical Associate Professor, Pediatric Critical Care
University of Iowa Hospital and Clinics
Iowa City, Iowa, United States
Disclosure information not submitted.
Title: A Case of Severe Rhabdomyolysis and Acute Myocarditis in an Adolescent Female
Case Report Body:
Introduction: Rhabdomyolysis describes a condition where muscle tissue destruction occurs. Mortality and morbidity can be significant especially when multi-organ injury ensues. In very few instances, myocarditis has been described in association with this condition.
Description: An 11-year-old previously healthy female presents with vomiting, diarrhea, tactile fever, worsening severe bilateral leg pain and gross hematuria for four days. At the Emergency Department, her ECG showed ST depression in lateral leads and abnormal Q waves. Laboratory studies were notable for significantly elevated CK >330,000 U/L. Elevated Troponin T and Troponin I at 3.60 ng/ml and 0.54 ng/mL, respectively. Elevation of CRP 23.5 mg/dl, ALT 1,966 U/L, AST 5,956 U/L, and Ferritin 712.1 ng/ml. Patient had dark brown urine, which was positive for blood, and urine myoglobin peaked at 2690 ng/mL. Her renal function was normal with blood urea nitrogen 8 mg/dl and creatinine 0.4 mg/dl. C3 and C4 levels were decreased, 45 mg/dl and 5 mg/dl, respectively. Anti-dsDNA negative, ANCA negative, and ANA negative. Nasopharyngeal PCR was negative for Mycoplasma pneumoniae, influenza A and B. Blood enterovirus PCR negative. COVID PCR and antibodies negative. Neuromuscular genetic testing was non-diagnostic. Her echocardiography showed thin rim of pericardial effusion and normal ejection fraction. Cardiac MRI demonstrated myocardial edema and regional sub-epicardial delayed enhancement consistent with acute myocarditis. Patient was started on hyperhydration therapy, Solumedrol and intravenous immunoglobulin. The rhabdomyolysis resulted in severe extremity weakness requiring prolonged rehabilitation. Her condition and biomarkers normalized and was subsequently discharged home. Follow up cardiac MRI 6 months later showed increased extracellular volume (ECV) of 38% suggestive of focal and diffuse areas of fibrosis. Patient remains under physical activity restrictions and is being followed by cardiology service.
Discussion: Our case highlights severe rhabdomyolysis in association with acute myocarditis and subsequent cardiac structural abnormalities. Although it remains unclear whether myocarditis evolved as a complication of rhabdomyolysis or was triggered by same inciting agent, an infectious etiology overall remains the most likely culprit.