Coxsackie B infections can have varying clinical presentations. Necrotizing myopathy and rhabdomyolysis with remarkably high creatine phosphokinase levels is a rare complication associated with high morbidity and mortality. A 28-year-old male presented with complaints of weakness, body aches, and decreased urine output. Initial lab work showed a creatine phosphokinase level estimated at 5,366,100 U/l. Initial Coxsackie B4 titers were at 1:160. Muscle biopsy of the right calf revealed necrotizing myopathy consistent with viral myopathy. This case highlights Coxsackie B4 as a potential pathogen that can cause extensive muscle necrosis producing extreme creatine phosphokinase levels leading to rhabdomyolysis. Taking a comprehensive history is essential to identify viral prodromal symptoms to guide broader serological testing for uncommon viral species.

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