Rhabdomyolysis Associated With 2009 Influenza A

Well, I’ve had pretty good news for awhile, so now it’s time for some that is not so great — but important to be aware of.

A case report of a lacto-vegetarian boy from Italy with rhabdomyolysis was published in the American Journal of Physical Medicine & Rehabilitation (1).

Rhabdomyolysis is a potentially life-threatening disease of severe muscle damage.

Let me quote the authors:

“The patient is a 16-yr-old boy who was a nationally ranked swimmer at that time. In the 2 wks preceding this episode, he was undergoing training 5 days per week, 2–3 hrs per day, in addition to the 4 hrs per week of school-based physical activity.”

“During the week before the visit [to the doctor's], the boy experienced progressive weakness and intermittent muscle ache particularly in the legs and reported those symptoms to his coach. At the time of the medical encounter, he also reported malaise, episodic tachycardia, and nausea.”

“A dietary history revealed that, since the age of 14 yrs, his diet had contained adequate energy but very little protein. In particular, he reported to have avoided eating meat, fish, eggs, cheese and dairy products, and legumes. The only source of protein was 100 ml of milk in the morning and soy-derived products once or twice a week. For unexplained reasons, his diet mainly and monotonously comprised pasta, bread, tomatoes, salad, carrots, fruits, white pizza, and potatoes.”

Laboratory results of interest were:
Reference Range
Vitamin B12 120 pg/ml 190 – 1200
Ferritin 12.5 ng/ml 20 – 300
CK 9952 units/L 39 – 308

CK is creatine kinase, which is a marker for muscular breakdown.

The authors believed that a low protein intake was the main problem with this boy. Upon adding meat four times a week as well as dairy to his diet, and a B12 supplement, he made a complete recovery.

I am not convinced that it was only, or even mainly, a low protein intake that caused this boy’s problems. It could have been another nutrient deficiency or a combination of deficiencies, including some that were not tested for (such as calcium and magnesium).

Of course, he could have gotten all the necessary nutrients and stayed with his vegetarian diet. Although the authors note that vegetarian diets can be healthy for athletes, they apparently did not find out why the boy was vegetarian or instruct him on how he could maintain a healthy vegetarian diet.
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Rhabdomyolysis Associated With 2009 Influenza A

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Recommended: NCI PDQ for rhabdomyosarcoma
On this site: Warning Signs of Childhood Cancer: Rhabdomyosarcoma
Rhabdomyosarcoma is a fast-growing, highly malignant tumor which accounts for over half of the soft tissue sarcomas in children. Less frequently, other soft tissue sarcomas are found in children: fibrosarcoma, mesenchymoma, synovial sarcoma, and liposarcoma.

Rhabdomyosarcoma often causes a noticeable lump on a child’s body. If the tumor is located internally, the symptoms depend on its location. For example, tumors in the nasal passage may put pressure on the eustachian tubes; a bladder tumor can cause trouble urinating; an orbital tumor may cause the eye to protrude.
About Rhabdomyosarcoma

Rhabdomyosarcoma tumors arise from a cell called a “rhabdomyoblast”, which is a primitive muscle cell. Instead of differentiating into striated muscle cells, the rhabdomyoblasts grow out of control. Since this type of muscle is located throughout the body, the tumors can appear at numerous locations. The four major sites in which rhabdomyosarcoma is found are:

* head and neck; around the eyes — 35-40%
* genitourinary tract — 20%
* extremities — 15-20%
* trunk (chest and lungs) — 10-15%

Depending on the “histology” of the cells (how they look under a microscope), the tumors are classified as one of the following:

Embryonal rhabdomyosarcoma. Most common type, usually found in children under 15 and in the head and neck region and genitourinary tract.

Botryoid type. A variant of the embryonal type; the tumor arises as a grape-like lesion in mucosal-lined hollow organs such as the vagina and urinary bladder.

Alveolar type. A more aggressive tumor which usually involves the muscles of the extremities or trunk.

Pleomorphic type. Usually seen in adults and arises in muscles of the extremities.

Embryonal rhabdomyosarcoma is considered the most treatable form of the disease. The prognosis is also affected by the location of the primary tumor. Orbital and genitourinary track rhabdomyosarcomas have a better prognosis than do tumors which originate in the head and neck, extremity, pelvic, and trunk locations.

Prognosis also depends on the stage of the tumor. The Intergroup Rhabdomyosarcoma Study Group has defined a set of guidelines, which assign the tumor to groups 1-4 depending on the extent of the disease. For more information, see the PDQ on the staging of rhabdomyosarcoma.
Treatment

Rhabdomyosarcoma is treated by a combination of surgery, chemotherapy, and radiation.

Surgery. Resection (removal) of the primary tumor. If necessary after chemotherapy or radiation has shrunk the tumor.

Chemotherapy. The following chemotherapy agents are commonly used: vincristine, cyclophosphamide, dactinomycin, adriamycin, ifosfamide, VP-16.

Radiation. External beam radiation is used in some cases of rhabdomyosarcoma.

Rhabdomyosarcoma clinical trials, NCI search form.
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