Bacteremic Pneumococcal Pneumonia and Myoglobinuric Renal Failure PAUL L. MARINO, M.D. Ph.D. GEORGE T. NAHASS, B.S. WILLIAM NOVICK, M.D. Philadelphia, Pennsylvania A case of bacteremic pneumococcal pneumonia associated with rhab- domyolysis and myoglobinuric renal failure is presented. This may be the first report of the association of these two disorders, and may influence the choice of antibiotic selection in patients with rhabdomyo- lysis and a pulmonary infiltrate. The infectious agents commonly associated with pneumonia and rhabdo- myolysis with myoglobinuric renal failure are Legionelta pneumophila [l] and viruses, most notably influenza [2]. Therefore, when patients present with this combination of organ involvement, an infection with one of these agents is usually suspected. We present a case of bacteremic pneumo- coccal pneumonia associated with myoglobinuric renal failure, and pro- pose that pneumococcal infection should be considered in patients who present with pneumonia and myoglobinuric renal failure. CASE REPORT From the Graduate Hospital, Philadelphia, Penn- Sylvania. Requests for reprints should be ad- dressed to Dr. Paul L. Marino, Graduate Hospital, 19th and Lombard Streets, Philadelphia, Penn- Sylvania 19146. Manuscript accepted December 28, 1984. A 64-year-old black man presented to the emergency department with a four-day history of sore throat, cough productive of whitish sputum, and progressive dyspnea, along with a two-day history of progressive general- ized muscle weakness without myalgia or edema. The past medical history was unremarkable except that the patient consumed one quart of wine daily for several years, with no alcohol consumption in the four days prior to admission, Initial examination revealed an alert but disoriented patient in moderate respiratory distress. His temperature was 100.8°F, blood pres- sure was 134196 mm Hg, respiratory rate was 60 per minute, and pulse was 116 per minute. Auscultation of the lungs revealed diminished breath sounds on the right posteriorly. The remainder of the physical examination was unremarkable. Initial laboratory studies showed a hemoglobin value of 16.9 g/dl, hematocrit of 51.2 percent, white blood cell count of 9,000/mm3 (with 29 percent neutrophils, 50 percent band forms, 10 percent lympho- cytes, and 7 percent monocytes), serum bicarbonate of 16 mg/dl, blood urea nitrogen of 122 mg/dl, creatinine of 8.2 mg/dl, creatine phosphoki- nase of 25,930 units/liter (normal 35 to 232) lactic dehydrogenase of 889 units/liter (normal 100 to IgO), serum glutamic oxaloactic transaminase of 721 units/ml (normal 10 to 40), serum glutamic pyruvic transaminase of 150 units/ml (normal 3 to 36) total bilirubin of 2.2 mg/dl, and ethanol = 0. Serum sodium, potassium, calcium, phosphorus, and amylase levels were within normal limits. Arterial blood gas determination while the patient was breathing room air revealed a pH of 7.44, carbon dioxide tension of 20 mm Hg, and oxygen tension of 64 mm Hg. Urine was amber in color and revealed 3-f- hematuria and I+- proteinuria by dipstick. Microscopic exami- nation of the urine sediment showed up to one white blood cell, up to two red blood cells, and up to two hyaline casts per high-power field. Gram stain March 1986 The American Journal of Medicine Volume 80 521