Exertional Rhabdomyolysis: Link To Live Influenza Vaccine In A 29 Year Old Athlete

Abstract

HISTORY: 29 year old female soldier presented with 2 day history of diffuse muscle pain associated with dark urine following a workout 2 days prior. Patient reported typical workout consisting of squats, push-ups, sit-ups, and shoulder press. The following morning she noted increasing diffuse muscle pain with severe upper arm and leg pain exacerbated by movement. She denied any recent heat exposure, medications, or supplements. PMH: none. She takes oral contraceptives. She does not smoke, and drinks alcohol occasionally. She recently completed a Half Ironman triathlon and does weight training 3 times weekly. Family history is significant for an older sister who passed away 1 month prior from H1N1 complications. Patient reports receiving the live influenza vaccine 3 weeks prior. Patient was admitted for exertional rhabdomyolysis without renal complications. After CK peaked, the patient was discharged home with aggressive oral hydration & recommended physical rest. 2 months later, after resuming low-impact exercise, patient developed symptoms again. This time, she reported that she had received the H1N1 vaccine 3 weeks prior. Due to the recurrence of symptoms, an exercise intolerance mutation panel was done. The patient opted to have a muscle biopsy for further evaluation. PHYSICAL EXAMINATION: Exam significant for diffusely tender muscles and pain on passive ROM. DIFFERENTIAL DIAGNOSIS: Exertional rhabdomyolysis TEST AND RESULTS: First episode: CK: 66,000; BUN 8; Cr 0.8; AST 441, ALT 220, UA: 1.006, small blood, no RBCs. Second episode: CK: 1,300; BUN 8, Cr 0.8; AST 99, ALT 40. UA: 1.001, small blood, no RBCs. Exercise Intolerance Mutatuin Panel showed no mutations for myophysphorylase deficiency, carnitine palmitoyltransferase II deficiency, or myoadenylate deaminase defiency. Muscle biopsy: negative FINAL/WORKING DIAGNOSIS: Exertional Rhabdomyolysis TREATMENT AND OUTCOMES: As this patient was used to eccentric exercise, it seems rare that she would develop unprecipitated symptoms of rhabdomyolysis without a predisposing factor. Given the timeline of live-virus influenza vaccines 3 weeks prior to each episode of symptoms, as well as a negative genetic work-up, it is hypothesized that the live influenza virus vaccine in combination with eccentric exercise caused rhabdomyolysis.