common causes include drugs , crush injuries , seizures , heat , exertion , and infection . viral infections , particularly influenza a , have been recognized as a cause of rhabdomyolysis . our report describes a 58-year - old male who presented with viral pneumonia secondary to influenza a virus infection . his hospital course was complicated by acute renal failure secondary to rhabdomyolysis , which was attributed to an overwhelming viremia . we discuss the differential diagnosis of rhabdomyolysis and review the literature for cases of influenza a - related rhabdomyolysis . rhabdomyolysis is being increasingly recognized as a complication of influenza a infection with considerable morbidity and mortality . influenza a is a negative - sense rna virus , a member of the orthomyxoviridae family . influenza a is associated with a spectrum of respiratory illnesses , ranging from mild upper respiratory infection to acute respiratory distress syndrome . infrequently , influenza can cause extra - pulmonary complications , including encephalitis , myocarditis , pericarditis and rhabdomyolysis . the latter has been reported more frequently in the past few years , particularly in association with the novel h1n1 influenza virus . we report an unusual case of massive rhabdomyolysis secondary to influenza a virus infection and review the literature for similar case . a 58-year - old male presented with a complaint of 4 days of fever , chills , worsening dry cough , generalized body aches and dark - colored urine . he was initially evaluated at a local urgent care center where he tested positive for flu - a using rapid antigen test . he had no known history of liver or kidney disease and was not on any medication . initial laboratory evaluation revealed leukocyte count of 12900/l , hemoglobin of 17.3 g / dl , platelet count of 203000/l , creatinine of 3.6 mg / dl and potassium of 4.6 patient was started on oseltamivir 75 mg twice daily and broad - spectrum antibiotics for suspected influenza pneumonia . work up for his renal failure included a negative renal ultrasound and serology for autoimmune etiologies . despite aggressive hydration and intravenous sodium bicarbonate , his kidney function continued to deteriorate and creatinine rose to 8.7 mg / dl . on the third hospital day patient developed respiratory insufficiency requiring intubation and mechanical ventilation . rhabdomyolysis is a potentially life - threatening clinical syndrome that results from damage to skeletal muscle resulting in the release of toxic intracellular contents . common causes include traumatic vs. non - traumatic , with the latter being far more common . the differential diagnosis for rhabdomyolysis includes drugs of abuse ( cocaine , heroin , amphetamine ) and alcohols ( ethanol , methanol and ethylene glycol ) , which we ruled out with a negative toxicology screen . our patient was not on any prescription or non - prescription drugs commonly associated with rhabdomyolysis , such as statins , fibrates , salicylates or steroids . a careful history and physical exam ruled out other common causes such as trauma , prolonged immobilization , excessive muscle activity , compartment syndrome , or heat exposure . electrolyte abnormalities can lead to rhabdomyolysis ; however , considering the timeline in our case , we believe they were a result rather than an etiology of muscle cell damage . a negative rheumatologic panel ruled out connective tissue disorders , such as polymyositis , dermatomyositis or sjogren 's syndrome . considering the clinical presentation , viral infections in particular have a recognized association with a wide spectrum of muscle disorders , ranging from acute non - specific myalgia to severe myositis and rhabdomyolysis . a report by tanaka et al . identified influenza virus as the implicated agent in nearly 33% of known viral - induced rhabdomyolysis . the earliest recognition of the syndrome was called  myalgia cruris epidemica  or  benign acute childhood myositis . it describes an acute myopathy during the convalescent phase of viral respiratory infections in children characterized by bilateral calf pain and tenderness , with resultant difficulty in ambulation . on april 2009 , a novel virulent influenza a virus of swine origin was identified , a / california/07/2009 , also known as  swine flu  . in june 2009 , it was declared pandemic by the world health organization after its global spread and confirmed human - to - human infectivity . the new strain was more virulent and caused significant morbidity and mortality in a younger patient population . describes 18 cases of 2009 influenza pneumonia , of which 62% had elevated creatinine kinase levels , one of the most consistent laboratory characteristics in addition to elevated lactate dehydrogenase . even moderate degree of creatinine kinase elevation has proven to be a biomarker of severity of illness in patients with influenza a infection . in a report of 505 patients from 148 icus in spain , creatinine kinase correlated with greater degree of renal dysfunction , more pulmonary involvement and increased duration of mechanical ventilation in patients with influenza a infection . the reported creatinine kinase levels ranged from ( 1,317 - 1,127,000 ) with a mean value of 206,908 . patients who did not require renal replacement therapy were treated with generous hydration and iv sodium bicarbonate . five patients were mechanically ventilated for respiratory insufficiency , two of whom died of multi - organ dysfunction . postulated hypotheses include : 
 direct muscle invasion by the influenza virus , immunologic reaction cytokine storm  resulting in collateral muscle damage , andcirculating viral toxins causing direct muscle injury . direct muscle invasion by the influenza virus , immunologic reaction  cytokine storm  resulting in collateral muscle damage , and circulating viral toxins causing direct muscle injury . most recently , desdouits et al . studied the susceptibility of cultured primary human skeletal muscle cells to influenza a virus . viral isolates from 2009 pandemic and 2008 seasonal influenza a were introduced to in vitro cultures of differentiated muscle cells ,  myotubes  , and undifferentiated muscle cells , they were also able to detect expression of 2,3 and 2 , 6-linked sialic acid receptors on the surface of muscle cells . these are the same receptors located on the surface of respiratory epithelium to which influenza virus is believed to bind . in addition , evidence of viral replication and budding , and subsequent muscle cell lysis were detected in their experiments . the levels of inflammatory cytokines were not elevated in the supernatants of cultured cells , arguing against the previous theory of cytokine induced muscle injury . their data showed evidence that influenza a virus can infect primary human muscle cells in vitro . since its emergence in 2009 , ph1n1 has continued to circulate every season . for the 2013 - 14 season it predominated , accounting for nearly 96% of the total subtyped influenza a viruses . more than 99% of the ph1n1 viruses tested by the cdc this season have been antigenically similar to a / california/7/2009 strain . according to our literature review , we are the first to report a case of influenza associated rhabdomyolysis for the 2013 - 14 season . we expect more cases to occur in light of the recently reported seasonal influenza trends . the scope of clinical manifestations extends beyond the typical respiratory syndromes to involve various organs . considering the extent of morbidity and mortality associated , a careful consideration should be given to the condition , especially to the patient with prominent body aches and weakness . aggressive fluid therapy , urine alkalization and early renal replacement therapy may be lifesaving if instituted early .
context : rhabdomyolysis is a serious clinical syndrome that results from damage to skeletal muscles . 
 common causes include drugs , crush injuries , seizures , heat , exertion , and infection . 
 viral infections , particularly influenza a , have been recognized as a cause of rhabdomyolysis.case report : our report describes a 58-year - old male who presented with viral pneumonia secondary to influenza a virus infection . 
 his hospital course was complicated by acute renal failure secondary to rhabdomyolysis , which was attributed to an overwhelming viremia . 
 we discuss the differential diagnosis of rhabdomyolysis and review the literature for cases of influenza a - related rhabdomyolysis . 
 we also discuss the proposed mechanisms for the condition.conclusion:the scope of clinical manifestations of influenza a infection extends beyond pulmonary syndromes . 
 rhabdomyolysis is being increasingly recognized as a complication of influenza a infection with considerable morbidity and mortality .