Recurrent rhabdomyolysis and mild acute renal failure associated with acute Brucella infection

Sir,

Various infectious agents have been reported to cause rhabdomyolysis [1–5]. We present a case of acute Brucella infection, complicated with recurrent rhabdomyolysis and mild renal failure.

A 39-year old man was admitted to hospital because of muscular pain and dark urine. Ciprofloxacine was begun 1 day before his referral with the possible diagnosis of urinary infection. He reported consumption of unpasteurized milk products 1 month before his admission. Physical examination was normal except for high fever (38.2°C). Abnormal laboratory results were as follows: erythrocyte sedimentation rate 70 mm/h, C-reactive protein 14.0 mg/dl (normal: 0.0–8.0 mg/dl), creatine phosphokinase (CK) 2365 U/l, CK-MB 60 U/l, aspartate aminotransferase (AST) 383 U/l and alanine aminotranseferase (ALT) 549 U/l. The standard tube agglutination (STA) test for brucellosis, other serological tests for infectious agents and cultures were negative. Urinalysis revealed dark brown urine with a positive dipstick reaction for blood. Renal ultrasonography was normal. The estimated glomerular filtration rate by the Cockcroft–Gault formula was 90 ml/min and it decreased to 65 ml/min on the second day. On the third day, temperature and most of the biochemical tests returned to normal, and on the fifth day the patient was discharged. Ciprofiloxacine was continued for 2 weeks. Twenty days after his discharge, the patient was re-admitted with high fever (39.2°C) and muscular pain (Figure 1). Reconsumption of unpasteurized milk products or other risk factors for brucellosis were not found. Laboratory tests were as follows: CK 1545 U/l, AST 48 U/l, ALT 65 U/l, urea 23 mg/dl and creatinine 1.01 mg/dl. Urinalysis revealed dark brown urine with a positive dipstick reaction for blood. The Brucella STA test was positive at the titre of 1:80, and a Brucella spp. was isolated from blood using a rapid isolation technique (BACTEC) and was identified as B.melitensis with conventional culture techniques. Doxycycline, rifampicin and saline infusion were started. Antibiotic therapy was continued for 6 weeks and the symptoms had disappeared at the end of the treatment. After 3 months of follow up, no relapse was reported.



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Fig. 1. Time course of serum creatine phosphokinase (CK) and axillary temperature levels.

 
The most frequent causes of rhabdomyolysis are excessive muscular activity, alcohol, drugs and infections. Commonly implicated infectious agents are Influenza, Legionella and Streptococcus [1–5]. In this case, the diagnosis of rhabdomyolysis was established with appropiate clinical signs: elevated serum CK levels and dark urine with a positive dipstick reaction for blood in the absence of red cells. The main possible causes of rhabdomyolysis were excluded by history and laboratory tests. At first admission, attempts to isolate the infectious agent from blood were unsuccessful, possibly because of ciprofloxacine, which is an adjunctive agent in the treatment of brucellosis [5,6]. Blood cultures are positive in 15–70% of patients with brucellosis, and rapid isolation techniques are also reported to be satisfactory for recovering Brucella. A Brucella STA titre of ≥1:160 or a 4-fold rise in titre is considered positive for diagnosis [5]. In the index case, the low titre might have been due to early treatment with ciprofloxacine. Two weeks of ciprofloxacine is not enough for the complete therapy of brucellosis [5,6]. Cessation of ciprofloxacine for 12 days between the two admissions might be the reason for the reappearance of clinical and laboratory abnormalities. Only one case of Brucella infection-induced rhabdomyolysis accompanied by acute renal failure has been described in English literature [1]. Although the effect of inflammatory cytokines and the direct toxic effect of infectious agents on the muscle tissue are the possible mechanisms of rhabdomyolysis in other infections, the mechanism of rhabdomyolysis in brucellosis is unknown [1–4]. The different presentation of this case was recurrent rhabdomyolysis. No such case was found in the literature.

In conclusion, acute Brucella infection should be considered in the differential diagnosis of rhabdomyolysis, particularly in those areas where brucellosis is endemic.

Conflict of interest statement. None declared.

Omer Toprak1, Figen Kaptan2, Mustafa Cirit1, Bahar Ormen2, Atilla Uzum1, Rifki Ersoy1 and Nesrin Turker2

1 Department of Nephrology2 Department of Infectious Diseases and Clinical Microbiology Ataturk Research and Training Hospital Izmir Turkey Email: info{at}omertoprak.com

References

  1. Wasserheit JN, Dugdale DC, Agosti JM. Rhabdomyolysis and acute renal failure: a new presentation of acute brucellosis. J Infect Dis 1984; 150: 782–783[ISI][Medline]
  2. Singh U, Scheld MW. Infectious etiologies of rhabdomyolysis: three case reports and review. Clin Infect Dis 1996; 22: 642–649[ISI][Medline]
  3. Seibold S, Merkel F, Weber M, Marx M. Rhabdomyolysis and acute renal failure in an adult with measles virus infection. Nephrol Dial Transplant 1998; 13: 1829–1831[Abstract]
  4. Blanco JR, Zabalza M, Salcedo J, Echeverria L, Garcia A, Vallejo M. Rhabdomyolysis of infectious and noninfectious causes. South Med J 2002; 95: 542–544[ISI][Medline]
  5. Young EJ. Brucella species. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas and Bennett's Principles and Practice of Infectious Diseases, 5th edn. Churchill Livingstone, Philadelphia; 2000: 2368–2393
  6. Akova M, Uzun O, Akalin HE, Hayran M, Unal S, Gur D. Quinolones in the treatment of human brucellosis: comparative trial of ofloxacin–rifampicin versus doxycycline–rifampicin. Antimicrob Agents Chemother 1993; 37: 1831–1834[Abstract]




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