A case of Streptococcus pneumoniae inducing pneumonia in a patient whose chief complaint was gate disturbance caused by rhabdomyolysis.

Sir,

We herein report the first case of streptococcus pneumonia inducing pneumonia in a patients whose chief complaint was gate disturbance caused by rhabdomyolysis.

An 85-year-old male was unable to move his leg due to pain. He had a history of hypertension, hyperlipidemia, diabetes mellitus, depression, and renal cancer. His vital signs were stable and bilateral legs were cramps resolved by stretching. A complete blood count and serum biochemistry showed a white blood cell level of 26,200/mm3 and a creatine phosphokinase level of 5200 IU/L. He received a diagnosis of muscle cramps induced by rhabdomyolysis. Computed tomography performed to detect the cause of leukocytosis revealed a ground glass appearance in the bilateral lung fields [Figure 1]. He was found to be positive for Streptococcus pneumoniae antigens in the urine and exhibited a high fever with shivering on the 2nd hospital day. Therefore, he received a diagnosis of pneumonia induced by S. pneumoniae with rhabdomyolysis. Later, a positive culture of S. pneumoniae in the sputum was also confirmed. The patient's clinical signs improved after the infusion of ceftriaxone.

Figure 1

Chest computed tomography obtained on arrival reveals a ground glass appearance in the bilateral lung fields

Takayanagi, et al. reported a study of patients with community-acquired pneumonia with rhabdomyolysis. Among 594 cases of pneumonia, 25 patients (2.4%) developed rhabdomyolysis. The leading cause of rhabdomyolysis was Legionella species in 11 cases, influenza virus in six cases, S. pneumonia in four cases, Chlamydia psittaci in three cases, mycoplasma pneumonia in two cases, and unknown in three cases.[1] Blanco, et al. reported that, when S. pneumonia infection is combined with rhabdomyolysis, the leading disease is pneumonia followed by meningitis and arthritis.[2] One hypothesis of the mechanism underlying the development of rhabdomyolysis induced by S. pneumonia is direct infection in the muscle and/or muscle injury caused by toxins produced by S. pneumonia; however, this hypothesis has not been proven yet.[1]

The patient lacked the typical signs and symptoms of pneumonia upon arrival. This may be because local inflammatory reactions tend to weaken due to reduced immunoreactions caused by a high age and diabetes mellitus.[3]

Physicians should be aware that elderly persons with decreased immunoreactions might exhibit a lack of signs and symptoms of primary infections, while accessory complications such as rhabdomyolysis may be at the forefront.