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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2022  |  Volume : 33  |  Issue : 1  |  Page : 189-192
Severe Rhabdomyolysis Leading to Acute Kidney Injury in a Case of Dengue Fever

Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat, India

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Date of Web Publication16-Jan-2023


Rhabdomyolysis is not a well-known complication in dengue fever and only a few cases are reported. We report a patient of dengue, with severe body ache and myalgia, passed reddish-brown urine with a very high creatine-phosphokinase level. He also developed oliguria, hypertension, and raised creatinine. This suggests rhabdomyolysis occurred which led to acute kidney injury. This can complicate otherwise stable patients with dengue and affect the outcome. This complication needs to be explored when a similar clinical picture is encountered.

How to cite this article:
Thacker JP, Nimbalkar S, Chaudhari AJ. Severe Rhabdomyolysis Leading to Acute Kidney Injury in a Case of Dengue Fever. Saudi J Kidney Dis Transpl 2022;33:189-92

How to cite this URL:
Thacker JP, Nimbalkar S, Chaudhari AJ. Severe Rhabdomyolysis Leading to Acute Kidney Injury in a Case of Dengue Fever. Saudi J Kidney Dis Transpl [serial online] 2022 [cited 2023 Jan 29];33:189-92. Available from: https://www.sjkdt.org/text.asp?2022/33/1/189/367814

   Introduction Top

Dengue fever poses a serious public health problem in many parts of the world. Most of the infection manifests itself by an undifferentiating viral illness and on the other spectrum severe dengue with complications such as prolonged shock, massive bleeding, or multiorgan dysfunction.[1] Rhabdomyolysis is characterized by the rapid breakdown of skeletal muscle with leakage of muscle cell contents into the circulation. The resulting myonecrosis presents clinically as limb weakness, myalgia, and myoglobinuria. Acute renal failure is a common complication of rhabdomyolysis and is due to the toxic effect of filtering excessive quantities of myoglobin.[2] Rhabdomyolysis is associated with some viral infections most notably influenza A and B virus, human immunodeficiency virus, Coxsackie virus, and cytomegalovirus.[2],[3] In the dengue infection, the presence of rhabdomyolysis is not a common occurrence. There are several case reports, but none of the standard textbooks mention this. We come across a similar case.

   Case Report Top

A 17-year-old male, with no known chronic illnesses presented with fever for four days and headache, abdominal pain, intense body ache, and generalized muscle weakness in all four limbs for one day. Investigations on admission revealed hemoconcentration (53%), positive dengue NS1, and deranged liver function tests. After admission, the patient passed reddish-brown urine with oliguria and hypertension. The urine dipstick test was showing blood 3+, but on microscopy, only 10–12 red blood cell (RBC)/hpf and no dysmorphic RBCs were seen. No other bleeding manifestations were noted, neither petechiae. No obvious edema, abdominal distension, or tachypnea were present. However, there was weight gain from 67.7 kg on admission to 70.6 kg by day 6. The patient’s general condition remained stable throughout with no signs of shock, respiratory distress, or altered sensorium. Systemic examination findings were unremarkable apart from liver palpable 1 cm below the costal margin. Fever persisted for four days after admission. Investigation showed raised creatinine and mild hyperkalemia. On the 3rd day creatinephosphokinase (CPK) was done, which was very high (285,200 U/L), against the normal (39–309 U/L). Ultrasonography was suggestive of bilateral raised renal cortical echogenicity, however, corticomedullary differentiation was preserved. Dengue serology was positive on the 3rd day. C3, C4, anti-nuclear antibody, and antistreptolysin O were negative; prothrombin time and activated partial thrombin time were normal. The patient was managed conservatively with judicious intravenous fluids and alkalinization, with rigorous monitoring of urine output, vitals, and serial blood investigations. Dialysis was not required. The patient continued to pass reddish urine for up to six days. Antihypertensive was added on the 7th day and continued for a month. CPK levels decreased gradually and after the initial rise of creatinine for the initial days, it also began to normalize. The patient had Vitamin D deficiency (possibly unrelated) with hypocalcemia and a low normal range of phosphorous. Calcium and Vitamin D supplementation were given in a corrective dose. He was discharged after 10 days with normal urine output and color. CPK normalized within 15 days of discharge and creatinine after one month.

The details of investigations and serial urine output and blood pressure readings are listed in [Table 1].
Table 1: Daily details of laboratory investigations and some physical examination findings serially

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The author obtained all appropriate consent forms from the patient’s parents/guardians for the publication of this case report.

   Discussion Top

There are several case reports depicting rhabdomyolysis complicating dengue fever.[4],[5],[6],[7] We find male preponderance in this background and only one case in a female.[4],[6] There is only one case report below 18 years, the rest all being adults.[6],[8] Our case is 17 years old male. From the reported cases in the literature, two case mortalities have been reported in this background,[5],[6],[9] though in either of the cases, mortality cannot be directly attributed to the acute kidney injury (AKI) followed by rhabdomyolysis, as both the cases were of severe dengue with multiorgan dysfunction. The likely cause of muscle injury postulated as the release of myotoxic cytokines such as tumor necrosis factor and interferon-alpha in response to viral infection rather than direct viral invasion into the muscle cells.[5] A study of muscle biopsy specimens of dengue patients revealed a range of findings, from mild lymphocytic infiltrate to foci of severe myonecrosis, which is similar to findings reported for other viruses that cause severe myositis.[10] However, this study targeted checking histological changes in patients with myalgia in dengue and they did not observe myoglobinuria or rise in CPK level. Severe rhabdomyolysis is usually complicated by AKI regardless of the cause, and the development of renal failure usually implies a poor prognosis. The increased concentration of myoglobin within renal tubules leads to intrarenal vasoconstriction, ischemic tubular injury, and tubular obstruction by pigment casts contribute to renal failure. The treatment of rhabdomyolysis induced AKI includes volume repletion with targeted urine output, electrolyte maintenance, alkalization, and renal replacement therapy at the end.[2]

In our case, the patient had the classical triad of rhabdomyolysis – generalized weakness, myalgia, and red-colored urine associated with more than five times rise of CPK.[2] The patient did not have any history of well-known causes of rhabdomyolysis such as trauma, drugs/ toxins, metabolic and electrolyte disorders, or strenuous exercise. The patient neither had a history suggestive of myopathy nor any other renal disease. This makes the diagnosis of AKI due to rhabdomyolysis following dengue viral infection more probable. The presence of Vitamin D deficiency and hypocalcemia was notable in our case, which was considered as an underlying nutritional deficiency. Although, the significance of this finding needs to be studied further.

   Conclusion Top

Although rhabdomyolysis leading to AKI is a rare complication in the dengue fever, this can worsen outcome even in the absence of severe dengue with hemorrhage or shock. This might not be very rare but is an under-reported complication,[5] thus if included in mainstream literature, can timely be picked up and addressed.

Conflict of interest: None declared.

   References Top

Dengue and Severe Dengue. Factsheet. World Health Organization; 2020. Available from: https://www.who.int/news-room/factsheets/detail/dengue-and-severe-dengue. [Last accessed on 2020 Mar 23].  Back to cited text no. 1
Bosch X, Poch E, Grau JM. Rhabdomyolysis and acute kidney injury. N Engl J Med 2009; 361:62-72.  Back to cited text no. 2
You J, Lee J, Park YS, Lee JH. Virusassociated rhabdomyolysis in children. Child Kidney Dis 2017;21:89-93.  Back to cited text no. 3
Gunasekera HH, Adikaram AV, Herath CA, Samarasinghe HH. Myoglobinuric acute renal failure following dengue viral infection. Ceylon Med J 2000;45:181.  Back to cited text no. 4
Davis JS, Bourke P. Rhabdomyolysis associated with dengue virus infection. Clin Infect Dis 2004;38:e109-11.  Back to cited text no. 5
Sargeant T, Harris T, Wilks R, Barned S, Galloway-Blake K, Ferguson T. Rhabdomyolysis and dengue fever: A case report and literature review. Case Rep Med 2013;2013: 101058.  Back to cited text no. 6
Jha R, Gude D, Chennamsetty S. Nonhemorrhagic dengue fever with rhabdomyolysis. Saudi J Kidney Dis Transpl 2013;24: 1207-9.  Back to cited text no. 7
[PUBMED]  [Full text]  
Nakamura M, Ikeda S, Nagahara H, et al. A patient with dengue fever presenting with rhabdomyolysis. Intern Med 2015;54:1657-60.  Back to cited text no. 8
Karakus A, Banga N, Voorn GP, Meinders AJ. Dengue shock syndrome and rhabdomyolysis. Neth J Med 2007;65:78-81.  Back to cited text no. 9
Malheiros SM, Oliveira AS, Schmidt B, Lima JG, Gabbai AA. Dengue. Muscle biopsy findings in 15 patients. Arq Neuropsiquiatr 1993;51:159-64.  Back to cited text no. 10

Correspondence Address:
Jigar P Thacker
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.367814

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