Epstein-Barr Virus Infection Associated with Rhabdomyolysis and Acute Renal Failure

Abstract

ACUTE RENAL FAILURE associated with nontraumatic rhabdomyolysis has been well documented in several studies'-' and represents between 5 to 7 percent of the cases of acute renal failure treated at two institutions},2 However, a review of the literature has described only 11 cases of rhabdomyolysis and renal failure in conjunction with viral infections.1,3-12 The majority of documented cases have been associated with Influenza A virus.5-&dquo;,&dquo; There is only one previous case reported in the literature that described Epstein-Barr virus infection as the etiology of acute rhabdomyolysis and acute renal failure.' We would like to report another case of rhabdomyolysis and nonoliguric renal failure in a child with Epstein-Barr virus infection. Case ReportA 6-year old American-born Ugandan girl was hospitalized with a 36-hour history of vomiting and severe watery diarrhea. Three days prior to admission the patient reported weakness, myalgia, pharyngitis, and fever up to 104.4°F. She was brought to the local emergency room because of continuous diarrhea and dehydration.Review of systems revealed no history of toxic material or drug ingestion, exposure to similarly sick individuals, contaminated food ingestion, or travel abroad. There was no family history of muscle disease. On admission, physical examination revealed an apathetic but oriented child weighing 46 pounds with a pulse of 180/minute, respiratory rate of 40/minute, blood pressure not obtainable at this time, and palpable pulses present only in femoral arteries. Her pharynx was erythematous, the mucous membranes were dry, and enlarged tender cervical lymph nodes were noted. Her skin showed poor perfusion. Her abdomen was diffusely tender without organomegaly. The remainder of the examination was unremarkable.Laboratory data on admission included the following : hematocrit 43.9%, hemoglobin 14.3 gm/dl, WBC 9,900/mm!l with 8% neutrophils, 61% bands, 13% monocytes, 1% eosinophils, 13% lymphocytes, 3% metamelocytes, 1 % myelocytes. Platelet count was 145,000/mms, BUN 79 mg/dl, creatinine 2.9 mg/dl, sodium 130 mEq/1, potassium 4.8 mEq/1, C02 6 mEq/ I, SGOT 171 IU/1, SGPT 40 IU/1, LDH 454 IU/1, and alkaline phosphatase 182 It/1.The patient was clinically assessed as being severely dehydrated and in shock. Treatment was begun with intravenous saline solution and fresh frozen plasma, after which blood pressure returned to 100 mmHg systolic. Approximately 8 hours after admission, the patient voided dark-colored urine. The urine was reddish brown, positive for protein ( 1 +) and occult blood (3+) with 0 RBC/hpf and 0-3 WBC/hpf and a specific gravity of 1.011. The urine output in the first 8 hours was 1.8 ml/kg/hr, increasing to 3.9 ml/kg/hr over the next 24 hours.She was started on antibiotics, but these were discontinued after 5 days when the initial urine, stool, blood, and throat cultures revealed no pathogenic organisms.The patient continued to have dark-colored urine and a repeat urinalysis on the second day of hospitalization showed 3+ occult blood, 1 + protein...

Unexplained acute renal failure in a toddler: a rare complication of Epstein-Barr virus

“…Thirteen of the patients were less than 18 years of age, 4 were less than 6 years old, and the youngest reported was 4 years old. Of the 4 young children, 1 had associated dehydration, shock, and rhabdomyolysis [6], and the other 3 were minimally affected [7]. Renal biopsies were performed in 13 patients; 10 had interstitial nephritis and/or fibrosis while 2 had immune complex glomerulonephritis [5].…”

Rhabdomyolysis and acute renal failure in children

“…However, ARF is less common in children with rhabdomyolysis, being reported mostly as single cases or as a small series of patients [11,14,15,16,17,18,19,20,21,22,23]. Several conditions provoking rhabdomyolysis and ARF have been reported in children.…”

“…Several conditions provoking rhabdomyolysis and ARF have been reported in children. These include infections such as influenza A virus [11,14,15], Epstein-Barr virus [16], and malaria [17], viper bite [18], diabetic coma [19], hyperthermia and status epileptics [20], sodium valproate intoxication [21], hypernatremia [22,23], and trauma [23]. While the precise mechanisms by which rhabdomyolysis causes renal failure remain unclear, three potential mechanisms are postulated.…”

“…In adult patients, the presence of dehydration [24], metabolic acidosis, and aciduria [1], the degree of increase in serum CK concentration [1,24], myoglobinemia [1], and increases in urinary myoglobin [5] have been reported as predictive factors of the development of ARF in patients with rhabdomyolysis. Although case studies of children with rhabdomyolysis and ARF have been reported [11,14,15,16,17,18,19,20,21,22,23,25], the contributing factors for the development of ARF have not been clarified. This study revealed that as in adults the presence of dehydration, massive muscular necrosis (high levels of serum myoglobin, CK, AST, LDH, and urinary myoglobin), metabolic acidosis, and aciduria were contributing factors to the development of ARF in children with rhabdomyolysis.…”

Acute Pediatric Rhabdomyolysis: Causes and Rates of Renal Failure

“…7 The pathogenesis of rhabdomyolysis in the pediatric ambulatory population and the risk of developing ARF are poorly characterized. [9][10][11] Our clinical impression has been that rhabdomyolysis in children is a more benign condition, with only a small risk of ARF. Our study objectives were to establish more clearly the pathogenesis of rhabdomyolysis and the associated rates of ARF in pediatric patients, to establish predictors of ARF in these patients, and to explore the relationship of maximal creatinine levels with fluid and bicarbonate administration.…”