Multiorgan failure and rhabdomyolysis in a recent émigré : Your diagnosis ?

A yearold East In dian man, who had ar rived to Can ada one month ear lier, was brought to the emer gency room be cause of fe ver and rig ors. He had been well un til nine days pre vi ous, when he first noted fe ver, nau sea, vom it ing, oral ul cera tions and odynophagia. Over the next few days, his fe ver per sisted and he noted dark en ing of his urine and thigh pain on walk ing. Dur ing the two days be fore ad mis sion, his symp toms in ten si fied, and he be came con fused and le thar gic. The pa tient had had no pre vi ous health prob lems, was not on any medi ca tions and had no al ler gies. There was no his tory of al co hol, to bacco or il licit drug use. He de nied any re cent con tact with ani mals or any one with a feb rile ill ness. Hav ing ar rived from In dia only one month ear lier, the pa tient was un em ployed. Physi cal ex ami na tion re vealed a well de vel oped but di shev eled ill look ing young man. The pulse was 110 beats/min, blood pres sure was 140/100 mmHg, res pi ra tory rate was 20 breaths/min and the tem pera ture was 37.9°C orally. The mu cous mem branes were ex tremely dry, and there were ul cera tions of the buc cal mu cosa. There were no ab nor mali ties on car diac or res pi ra tory ex ami na tion. There was no ab domi nal ten der ness and no masses or or ganomegaly. Bowel sounds were nor mal, and the stool was posi tive for oc cult blood. He was ori ented to per son and time only. There was no men ing is mus. He was som no lent but rousable, and there were no fo cal neu ro logical signs. Com plete blood count re vealed a he mo glo bin of 116 g/L, a leu ko cyte count of 2000/μL and a plate let count of 32,000/μL. Se rum elec tro lytes were as fol lows: so dium 142 mmol/L, po tas sium 6.1 mmol/L, chlo ride 106 mmol/L, and bi car bon ate 19 mmol/L. Other se rum val ues were as fol lows: blood urea 55 mmol/L, cre ati nine 1101 μmol/L, as par tate ami no tran fe rase 3028 U/L, al anine ami no tran fe rase 481 U/L, al ka line phos phatase (ALP) 92 U/L, bili rubin13 μmol/L, lac tic de hy dro ge nase (LDH) 7100 U/L, amy lase 177U/L, cal cium 1.7 mmol/L, phos phate 2.2 mmol/L, al bu min 34 g/L, and cre atine phos phoki nase (CPK) 102, 500 U/L. The co agu la tion stud ies re vealed an in ter na tional nor mal ized ratio of 1.39 and a par tial throm bo plas tin time of 43.8 s. A uri naly sis showed 3+ blood and 3+ pro tein. The sedi ment con tained few eryth ro cytes and many granu lar casts. In sum mary, this pa tient pre sented with fe ver, pan cy topenia, hepa ti tis, co agu lo pa thy, rhab do my oly sis and acute re nal fail ure. He was started on he mo dialy sis and re ceived a five unit plate let trans fu sion. The pa tient sub se quently passed a large quan tity of bright red blood per rec tum, with a fall in his he mo glo bin. A bleed ing scan re vealed in ter mit tent bleed ing lo cal ized to the cae cum. What is the di ag no sis?

Com plete blood count re vealed a he mo glo bin of 116 g/L, a leu ko cyte count of 2000/µL and a plate let count of 32,000/µL.Se rum elec tro lytes were as fol lows: so dium 142 mmol/L, potas sium 6.1 mmol/L, chlo ride 106 mmol/L, and bi car bon ate 19 mmol/L.Other se rum val ues were as fol lows: blood urea 55 mmol/L, cre ati nine 1101 µmol/L, as par tate ami no tran fe rase 3028 U/L, al anine ami no tran fe rase 481 U/L, al ka line phosphatase (ALP) 92 U/L, bili rubin13 µmol/L, lac tic de hy dro genase (LDH) 7100 U/L, amy lase 177U/L, cal cium 1.7 mmol/L, phos phate 2.2 mmol/L, al bu min 34 g/L, and cre atine phosphoki nase (CPK) 102, 500 U/L.The co agu la tion stud ies revealed an in ter na tional nor mal ized ratio of 1.39 and a par tial throm bo plas tin time of 43.8 s.A uri naly sis showed 3+ blood and 3+ pro tein.The sedi ment con tained few eryth ro cytes and many granu lar casts.
In sum mary, this pa tient pre sented with fe ver, pan cytopenia, hepa ti tis, co agu lo pa thy, rhab do my oly sis and acute re nal fail ure.He was started on he mo dialy sis and re ceived a five unit plate let trans fu sion.The pa tient sub se quently passed a large quan tity of bright red blood per rec tum, with a fall in his he mo glo bin.A bleed ing scan re vealed in ter mit tent bleed ing lo cal ized to the cae cum.
What is the di ag no sis?

DI AG NO SIS
Blood cul tures from ad mis sion grew Sal mo nella ty phi, sensi tive to ampicil lin and cipro floxa cin (Ci pro, Bayer Health care Di vi sion, To ronto, On tario).Thick and thin smears for ma laria were nega tive.Stool and urine cul tures were nega tive.Se rology for lep to spi ro sis, rick ett sia, den gue and triche nella were nega tive.A throat vi ral cul ture and mono spot were nega tive.The pa tient was treated with cipro floxa cin for 14 days.CPK and cre ati nine lev els fell to nor mal.His he ma to logi cal parame ters nor mal ized, and he stopped bleed ing.He had no further com pli ca tions and was dis charged four weeks af ter ad mis sion with nor mal re nal func tion.

DIS CUS SION
This pa tient ex pe ri enced many com mon com pli ca tions of ty phoid fe ver, such as pan cy topenia, de lir ium, hepa ti tis and gas tro in tes ti nal bleed ing.He also de vel oped two rare mani festa tions of the dis ease: rhab do my oly sis and re nal fail ure.There have only been two other re ported cases of rhab do my oly sis related to Sal mo nella ty phi in fec tion (1,2).How ever, there have been six re ported cases of rhab do my oly sis as so ci ated with Salmo nella enteri ti dis food-borne gas tro en teri tis (3,4).
Rhab do my oly sis is a syn drome char ac ter ized by ele vated se rum con cen tra tions of CPK and myo globin uria lead ing to renal dys func tion (5).This en tity can be pre cipi tated by nu merous fac tors (5).In fec tions are a well known but less com mon cause of rhab do my oly sis, and should al ways be con sid ered in the dif fer en tial di ag no sis.Singh and Scheld (4) re cently reviewed the lit era ture and com piled a com pre hen sive list of infec tions that have been re ported to cause rhab do my oly sis (4).The spec trum of in fec tious agents that have been im pli cated is broad in clud ing vi ruses, bac te ria, para sites and fungi.Vi ral in fec tions were found to be a fre quent cause of rhab do my oly -sis, with 59 re ported cases (4).In flu enza is the most com mon vi ral eti ol ogy fol lowed by HIV in fec tion and en tero vi ral in fection (cox sack ievi rus and echo vi rus).Other vi ruses re ported to have caused rhab do my oly sis in clude Epstein-Barr vi rus, varicella zos ter vi rus, cy tomega lovi rus and ad eno vi rus.Bac te ria were re ported to cause rhab do my oly sis in 60 cases (4).Legionella spe cies are the most com mon bac te ria fol lowed by Strep to coc cus spe cies, Fran cis cella tu lar en sis, Sal mo nella spe cies, Staphy lo coc cus au reus, Lis teria spe cies and Vi brio spe cies.There is a case re port of rhab do my oly sis from Her bicola lathyri (En tero bac ter ag glom er ans) con tami na tion of hypera li men ta tion fluid.Pseu do mo nal in fec tions and lep tospi ro sis have also been re ported to cause rhab do my oly sis (4).Fi nally, there have been two cases of ma laria, one case of candida in fec tion and one case of as per gil lus dis ease as so ci ated with rhab do my oly sis (4).The pro posed pa tho physio logi cal mecha nisms of how in fec tions cause rhab do my oly sis in clude vi ral or bac te rial in va sion of skele tal mus cle and toxin gen eration (4).
Rhab do my oly sis can be pre cipi tated by many con di tions, in clud ing in fec tions.Phy si cians should be aware of the as socia tion be tween in fec tions and rhab do my oly sis to aid op ti mal di ag no sis and man age ment of these pa tients.
Can J In fect Dis Vol 11 No 3 May/June 2000 CLINI CAL VI GNETTE 1 Di vi sion of In fec tious Dis eases, De part ment of Medi cine, Uni ver sity of To ronto; 2 De part ment of Medi cine, Uni ver sity of To ronto, To ronto, On tario Cor re spon dence and re prints: Dr John Maynard Conly, To ronto Gen eral Hos pi tal, Uni ver sity Health Net work, 200 Eliza beth Street, 13 Nor man Ur quart Wing, Suite 117, To ronto, On tario M5G 2C4.Tele phone: 416-340-4858, fax 416-340-5047, e-mail john.conly@uhn.on.ca