Rhabdomyolysis and systemic infection

A Case of Legionnaires’ Disease with Severe Rhabdomyolysis Misdiagnosed as COVID-19

Background

COVID-19 case numbers have begun to rise with the recently reported Omicron variant. In the last two years, COVID-19 is the first diagnosis that comes to mind when a patient is admitted with respiratory symptoms and pulmonary ground-glass opacities. However, other causes should be kept in mind as well. Here we present a case of Legionnaires’ disease misdiagnosed as COVID-19.

Case Presentation

A 48-year-old male was admitted with complaints of dry cough and dyspnea. Chest computed-tomography revealed bilateral ground-glass opacities; therefore, a preliminary diagnosis of COVID-19 was made. However, two consecutive COVID PCR tests were negative and the patient deteriorated rapidly. As severe rhabdomyolysis and acute renal failure were present, Legionnaires’ disease was suspected. Urine antigen test for Legionella and Legionella pneumophila PCR turned out to be positive. The patient responded dramatically to intravenous levofloxacin and was discharged successfully.

Discussion

Legionnaires’ disease and COVID-19 may present with similar signs and symptoms. They also share common risk factors and radiological findings.

Conclusions

Shared clinical and radiological features between COVID-19 and other causes of acute respiratory failure pose a challenge in diagnosis. Other causes such as Legionnaires’ disease must be kept in mind and appropriate diagnostic tests should be performed accordingly.

Established association of legionella with rhabdomyolysis and renal failure: A review of the literature

Legionella causes 2–15% of community acquired pneumonia cases that require hospitalization and it is the second most common cause of serious pneumonia that needs admission in an intensive care unit. Since the first published case in 1980, there are a further 22 published case reports on the direct correlation between rhabdomyolysis, renal failure and Legionnaires' disease. All but two patients survived with antibiotics and dialysis. Clinicians should be cognisant of this established triad and correlation of Legionnaires’ disease, renal failure and rhabdomyolysis, as failure to do so and initiate treatment early has proven to increase mortality significantly in affected patients.

A Klebsiella pneumoniae liver abscess presenting with myasthenia and tea-colored urine: A case report and review of 77 cases of bacterial rhabdomyolysis

RATIONALE

Rhabdomyolysis is a well-known syndrome in clinical practice, although rhabdomyolysis caused by a liver abscess is rarely reported and the patient may lack symptoms that are associated with a primary site of infection. Early recognition of this possibility is needed to avoid diagnostic delay and facilitate treatment. We report the case of a 71-year-old woman with a Klebsiella pneumoniae (KP) pyogenic liver abscess who presented with myasthenia and tea-colored urine and also review the 77 reported cases of bacterial rhabdomyolysis.

PATIENT CONCERNS

The patient was 71 years old and presenting with a 7-day history of myasthenia and a 3-day history of tea-colored urine, but without fever or abdominal pain.

DIAGNOSES

Laboratory testing in our case revealed rhabdomyolysis, and blood culture revealed KP. Abdominal ultrasonography revealed a hypoechoic enclosed mass, and computed tomography (CT) revealed an enclosed low-density mass (8.3 × 6.6 × 6.1 cm). The main diagnoses were a pyogenic liver abscess with rhabdomyolysis.

INTERVENTIONS

Empirically intravenous piperacillin-sulbactam and intravenous potassium treatment, as well as fluid infusions and other supportive treatments were provided after admission. After the diagnosis was confirmed and susceptibility test results were available, we adjusted the antibiotics to cefoperazone and sulbactam, which were maintained for 6 weeks.

OUTCOMES

The patient's symptoms relieved and the abnormal laboratory parameters corrected. Follow-up abdominal ultrasonography at 24 months after her discharge revealed that the abscess had disappeared.

LESSONS

Early recognition and careful consideration of the underlying cause of rhabdomyolysis are critical to improving the patient's prognosis. Thus, physicians should carefully consider the underlying cause in elderly patients who present with rhabdomyolysis, as they may lack symptoms of a primary infection.

Pneumonie à Légionelle compliquée d'une insuffisance rénale aiguë par rhabdomyolyse : à propos d'un cas

The infectious origin of non-traumatic rhabdomyolysis is rare (5% of cases). An elevated muscle enzyme level is often reported in the legionnaire's disease. We report the case of a 39-year-old male, with no previous medical history, admitted for renal failure (creatininemia=977 micromol/l) secondary to rhabdomyolysis and a twelve-day history of infectious syndrome with pneumonia in the left base. Legionella pneumophila was considered responsible for these symptoms because of a positive serology. The other microbial assessments were negative. After rehydration and three weeks of antibiotics, the outcome was favorable: the renal failure resolved completely and the muscle enzyme level returned to normal.