NDT Advance Access originally published online on October 12, 2005
Nephrology Dialysis Transplantation 2006 21(2):530-531; doi:10.1093/ndt/gfi195
© The Author [2005]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
Case Report
Influenza vaccine-induced rhabdomyolysis leading to acute renal transplant dysfunction
K. S. Raman1,
T. Chandrasekar1,
R. S. Reeve2,
M. E. Roberts3 and
P. A. Kalra1
1 Department of Nephrology, 2 Department of Cellular Pathology and 3 Department of Neurosciences, Hope Hospital, Salford, UK
Correspondence and offprint requests to: K. S. Raman, Department of Nephrology, Hope Hospital, Salford, UK. Email: ramankris1{at}yahoo.com; ramankrish{at}hotmail.com
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Introduction
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Rhabdomyolysis is a well-known cause of renal failure and is
commonly associated with drugs, toxins and infections. There
has been one reported case of rhabdomyolysis attributed to influenza
vaccine causing renal failure in native kidneys.
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Case Report
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A 57-year-old Caucasian man was diagnosed to have focal segmental
glomerlosclerosis (FSGS) in 1995. He eventually underwent a
cadaveric renal transplantation in February 2002 and because
this was complicated by delayed graft function, his creatinine
plateaued at a baseline of 266 µmol/l (creatinine clearance
34 ml/min).
In November 2002, he presented with a 4 week history of generalized malaise, dark urine, poor appetite, widespread muscle aches and difficulty in using his proximal muscles. The symptoms had begun about 1 week after he had received an inactivated influenza vaccine (split virion—Avantis Pasteur). His concurrent medications included cyclosporin A 125 mg BD, prednisolone 10 mg OD, azathioprine 150 mg OD and simvastatin 20 mg OD. He had taken the statin for at least 6 years without complications and the monitored creatine kinase (CK) had always been within the normal range. There was no family history of neurological or muscular disease. Neurological examination revealed flaccid weakness involving the proximal muscles of both upper and lower limbs, but no muscle fasciculation or tenderness. Abdominal examination revealed a non-tender renal transplant.
His blood urea was 33.5 mmol/l and creatinine 649 µmol/l (creatinine clearance 10 ml/min). The creatinine kinase (CK) was markedly elevated at 17 000 U/l. The urine dipstick revealed large quantities of protein and blood. The measured urinary myoglobin was 238 600 µg/l (normal less than 15 µg/l). Other admission laboratory data was normal except for potassium 6.3 mmol/l, phosphate 2.36 mmol/l and haemoglobin 88 g/l. Calcium was 2.47 mmol/l and white cell count 4.6 x 109/l. Serum cyclosporin A level was 167 ng/ml. A full renal immunological screen was negative. A transplant ultrasound was normal. Transplant biopsy revealed moderate tubular atrophy with tubulitis and the presence of brown granular tubular casts consistent with myoglobin. A muscle biopsy revealed scattered regenerating and degenerating fibres with no significant inflammatory infiltrate, compatible with a toxic myositis. Further investigations ruled out the possibility of primary muscle disease or metabolic myopathy. Other causes of toxic myositis, like drugs and viral infections, were excluded. There had been no recent change in the patient's medication. A neurological opinion agreed that the influenza vaccination was the most likely cause of the toxic myositis. The prednisolone was increased to 60 mg per day and the renal function gradually improved with serum creatinine falling to 370 µmol/l. Although the CK value normalized on day 10, his muscle weakness gradually improved over several weeks.
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Discussion
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Adverse reactions to influenza vaccines vary and non-specific
systemic side effects have been reported to occur in 5–35%
of vaccinated patients [
1,
2]. Specific adverse reactions to
influenza vaccines have also been reported in the past and these
include neurological disorders such as Gullian–Barre,
peripheral neuropathy and demyelinating disease [
3,
4]. Muscle
syndromes such as myalgias, myositis and rhabdomyolysis are
recognised to not infrequently complicate viral infections,
the most common associations being with influenza A and B, cytomegalovirus,
adenovirus, Coxsackie virus, Herpes virus and Epstein-Barr virus
[
5]. However, muscle syndromes have only rarely been reported
as attributable to influenza vaccine. Plotkin
et al. reported
a case of acute renal failure due to rhabdomyolysis following
an influenza vaccination in a patient with no previous history
of renal disease. This patient had been treated with cerivastatin
and bezafibrate and it was concluded that the vaccine acted
as a trigger for the development of rhabdomyolysis on a background
of statin/fibrate therapy [
6].
Here we provide the first report of acute renal failure due to rhabdomyolysis following an influenza vaccination in a renal transplant recipient who had been on simvastatin and cyclosporin A therapy. We believe that given the time course of events and the absence of other causes, this may well have represented an immunologically mediated response to the vaccine. Although Chazan et al. found no clinical or laboratory evidence that influenza vaccine could cause myopathy in patients taking statins [7], we conclude that there is a risk of rhabdomyolysis developing following influenza vaccinations in patients who receive concomitant myotoxic drugs. The possibility of this clinical presentation should not be overlooked in patients receiving this therapeutic combination.
Conflict of interest statement. None declared.
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References
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- Margolis KL, Poland GA, Nichol KL et al. Frequency of adverse reactions after Influenza vaccination. Am J Med 1990; 88: 27–30[CrossRef][Web of Science][Medline]
- Ryan MP, MacLeod AF. A Comparison of 2 influenza vaccines, and the influence on subsequent uptake. J R Coll Gen Pract 1984; 34: 442–444[Web of Science][Medline]
- Roscelli JD, Bass JW, Pang L. Gullian-Barre syndrome and influenza vaccination in the US army. 1980–1988. Am J Epidemiol 1991; 133: 952–955[Abstract/Free Full Text]
- De La Monte SM, Ropper AH, Dickerson GR, Harris NL, Ferry JA, Richardson JPJ. Relapsing central and peripheral demyelinating diseases. Unusual pathologic features. Arch Neurol 1986; 43: 626–629[Abstract/Free Full Text]
- Patel U, Bradley JR, Hamilton DV. Henoch-Schonlein purpura after influenza vaccination. Br Med J 1988; 296: 1800[Free Full Text]
- Plotkin E, Bernheim J, Ben-Chetrit S, Mor A, Korzets Z. Influenza vaccine-A possible trigger of rhabdomyolysis induced acute renal failure due to the combined use of cerivastatin and bezafibrate. Nephrol Dial Transplant 2000; 15: 740–741[Free Full Text]
- Chazan B, Weiss R, Tabenkin H, Mines M, Raz R. Influenza vaccine does not produce myopathy in patients taking statins. J Fam Pract 2002; 51: 986–988[Web of Science][Medline]
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Introduction
Case Report