Case Report

Rhabdomyolysis Induced by a Mild Case of Salmonella Gastroenteritis

Anjali Singla, Anunta Virapongse

• Lenox Hill Hospital, New York

• Submitted: March 01, 2013;
• Accepted: March 19, 2013;
• Published: May 07, 2013

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Rhabdomyolysis is a rare complication of Salmonella infection. We report a case of a 19-year-old male who presented with gastroenteritis, and was found to have rhabdomyolysis without other severe complications. It is important to recognize that a mild case of gastroenteritis may have accompanying severe clinical complications, such as rhabdomyolysis.

Objective

Recognize that rhabdomyolysis can be a rare complication of infectious diarrhea.

Introduction

Rhabdomyolysis is a rare complication of Salmonella infection, and generally presents with other severe complications, such as acute renal failure, septicemia, and multi-organ failure [3]. In our case, rhabdomyolysis was an isolated complication that presented simultaneously with gastroenteritis.

Case Report

We report a case of a 19-year-old male with no past medical history who presented with two days of abdominal pain, chills, bloody diarrhea, and dark colored urine. Upon presentation, he described dull left lower quadrant abdominal pain and cramping, as well as 10 bouts of bloody diarrhea over 24 hours. Personal and family history was negative for gastrointestinal disease. Patient denied subjective fevers, previous similar episodes, or alcohol use. On examination, patient was afebrile, stable vital signs, dry mucous membranes, and mild abdominal tenderness in the epigastric area and left lower quadrant, without guarding or rebound tenderness. Labs were significant for aspartate aminotransferase 1602 U/L, alanine aminotransferase 452 U/L, alkaline phosphatase 59 U/L, and white blood cells (WBC) 6.2x103/uL. Urinanalysis revealed 5-10 WBC/HPF, 5-10 RBC/HPF, and large blood, while negative for nitrite and leukocyte esterase. A computerized tomography scan of the abdomen showed wall thickening and pericolonic inflammatory changes consistent with infectious or inflammatory colitis. The patient was started on empiric antibiotics and stool studies were sent to the lab for likely gastroenteritis.

Upon further questioning, we discovered that four days prior to admission, the patient had exerted himself in strenuous running and weight-lifting for two consecutive days after lack of physical activity for several months. Serum creatinine kinase (CK) enzyme level was 112,360 U/L and erythrocyte sedimentation rate (ESR) was 11 mm/hr. Antibiotics were discontinued and intravenous hydration with normal saline was increased to 300cc/hour to treat rhabdomyolysis. We monitored the patient’s clinical status, CK level, renal function, electrolytes (calcium, phosphorous, potassium), and fluid balance to assure the patient was recovering from both the gastroenteritis and rhabdomyolysis. Symptoms and labs improved within the next 24-48 hours. Stool studies revealed Salmonella species (further speciation pending), few WBC, and few RBC, allowing us to recognize this as a case of Salmonella gastroenteritis complicated by rhabdomyolysis. Given the high levels of CK indicating severe muscle injury and trigger by Salmonella, this patient surprisingly did not suffer any complications, such as renal failure, compartment syndrome, bacteremia, or multi-organ failure.

Discussion

Rhabdomyolysis is a rare complication of Salmonella infection, and generally presents with other severe complications, such as acute renal failure, hepatitis, cholecystitis, pancreatitis, and septicemia [3]. Elevation of the serum marker creatinine kinase and the presence of myoglobinuria are typical manifestations of the extended muscle breakdown caused by rhabdomyolysis. It has been linked to systemic infections in some cases in the past [1-5], but more common causes include metabolic, toxic, ischemic, traumatic, and pharmacologic influences on a patient’s clinical status [5].

The pathophysiology behind Salmonella induced rhabdomyolysis is poorly understood, and is likely multifactorial [4]. Current literature suggests involvement of increased intracellular calcium concentrations, along with factors such as tissue hypoxia, bacterial toxin release, direct bacterial muscle invasion, and alteration of enzyme activity [1]. The principle disturbance linking infection and rhabdomyolysis seems to lie in the metabolism of skeletal muscle enzymes and electrolytes, causing decreased glycolytic and oxidative activity [5].

Conclusion

This atypical case of rhabdomyolysis associated with mild Salmonella gastroenteritis is reported to urge clinicians to monitor patients with gastroenteritis closely, as rhabdomyolysis, infectious involvement of other organs, sepsis, and multi-organ failure are all possible complications that can be avoided with early recognition and awareness. It is important to understand that one or more of these complications may develop with relatively mild infectious gastroenteritis and is often missed and underdiagnosed. Upon recognition of this association, clinicians can act on establishing a diagnosis and prompt initiation of treatment to improve patient outcomes.

Author’s Contribution

AS: literature search, prepared draft manuscript.
AV: concept and design, review and revision of manuscript.

Conflict of Interest

The authors declare that there are no conflicts of interest.

Ethical considerations

Consent was obtained from the patient to produce this case report.

Funding

None

Acknowledgment

None

References

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