Child Health Update

Viral myositis in children

Haley Magee MD  Ran D. Goldman MD FRCPC

Abstract
Question  I recently evaluated a child in my clinic after an emergency department visit where she presented
having woken up that morning refusing to walk and was crawling around the house. The parents reported she
was getting over a cold, and I recall similar cases of myositis during the H1N1 influenza epidemic a few years
ago. What are the key features of myositis that I should recognize? Which investigations are needed to confirm
the diagnosis and how should affected patients be managed?

Answer  Benign acute childhood myositis is a mild and self-limited sudden onset of lower extremity pain
during or following recovery from a viral illness. Presentation can include tiptoe gait or refusal to walk,
secondary to symmetric bilateral lower extremity pain that resolves quickly, usually within 3 days. In general,
no investigation is needed except in severe cases for which screening bloodwork and a urine myoglobin
test can confirm the diagnosis and rule out complications. Myoglobinuria and highly elevated creatine
phosphokinase levels are rare but should be a consideration for admission to hospital. Prognosis is excellent
and management might include rest and analgesia.

A child complaining of leg pain or refusing to walk is

of concern to both parents and health care providers.
Benign acute childhood myositis (BACM) is a common,
bring BACM to the forefront of clinicians’ minds. The
reliability of BACM’s presentation enables physicians to
make a clinical diagnosis while excluding other, more
self-limited condition and a frequently missed cause of sinister, conditions (Box 1).1,2,6 Clinicians need to differ-
lower leg pain in children.1,2 This muscle-related condi- entiate reluctance to walk secondary to pain in BACM
tion is also known as influenza-associated myositis, viral from muscle weakness associated with other conditions.
myositis, and acute myositis. Benign acute childhood myositis predominantly
It was first documented in 1905 by Leichtenstern as occurs in school-aged children, 4,6-8 at a median age
tender thigh and calf pain, suggested as a complication of 8.3 years (range 7.3 to 10.3 years)5 with a male-to-
of influenza.3 In 1957, Lunderberg formally recognized female ratio of 2:1.5,7 A history of contact with other sick
the condition among school-aged children who devel- individuals is frequently not evident in BACM, nor is a
oped a high-grade fever and catarrhal prodrome that previous history or family history of a similar presenta-
subsided after 4 days, only for severe pain to develop tion. Providers should inquire about any family history
in the calf muscles that caused difficulty walking. He of neuromuscular disease, recent vigorous exercise or
named the syndrome myalgia cruris epidemica.4
The exact incidence and prevalence remains undeter-
mined, and no clear management guidelines exist.2,5 The Box 1. Differential diagnoses to consider in BACM
characteristic clinical and laboratory features of BACM
allow for rapid diagnosis, without further investigation Consider the following:
or admission to hospital for most children. • Trauma or nonaccidental injury
• Guillain-Barré syndrome
Distinguishing BACM from • Rhabdomyolysis
serious disease processes • Osteomyelitis
The primary complaint of pain in the calves in a child • Deep vein thrombosis
presenting with a history of recent viral illness should • Juvenile rheumatoid arthritis
• Malignancy
• Dermatomyositis
This article is eligible for Mainpro+ certified • Polymyositis
Self-Learning credits. To earn credits, go to • Muscular dystrophy
www.cfp.ca and click on the Mainpro+ link. • Intracranial pathology
La traduction en français de cet article se trouve à
www.cfp.ca dans la table des matières du numéro BACM—benign acute childhood myositis.
de mai 2017 à la page e266. Data from Tippett and Clark,1 Jain and Kolber,2 and Mackay et al.6

Vol 63:  may • mai 2017 | Canadian Family Physician • Le Médecin de famille canadien  365
 Child Health Update

trauma, drug or medication use, similar episodes with

myalgias or pigmentation, and any relevant past medi-
cal history, particularly metabolic, musculoskeletal, or
thyroid disease.
Abrupt onset of reluctance to walk with severe lower
leg pain occurs at a median of 3 days as the initial viral
illness resolves.5,7,9 Common prodromal symptoms of
these viral illnesses include rhinorrhea, low-grade fever,
sore throat, cough, and malaise.7 The classic symmet-
ric bilateral leg pain is typically isolated to the gastroc-
nemius and soleus complex; however, some children
might have associated tenderness in the anteromedial
thighs5,7 and can rarely have associated pain or tender-
ness in the upper extremities or trunk.6 Pain is often
worse after a period of rest.7
A thorough physical examination will further support
the clinical diagnosis of BACM. Patients might be afe-
brile or have a mildly elevated temperature but otherwise
should have normal vital signs. The distinguishing fea-
ture with BACM is the findings of bilaterally symmetric
lower extremity examination.1 On inspection, the child’s
gait might appear wide based (tiptoe walking or stiff
legged).2,6 No common external signs are seen other than
occasional mild swelling, and on palpation there can be
exquisite tenderness, which usually resolves after 2 to
4 days.1 The child will have normal range of motion of
the knee and hip joints but might hold the feet in plantar
flexion, often refusing active and even passive dorsiflex-
ion.7 There should be no sensory or motor deficits, altered
deep tendon reflexes, or change in plantar reflexes.

Investigations
Laboratory testing should be limited to children who
will not walk at all. An elevated creatine phosphokinase
(CPK) level is one of the most common laboratory find-
ings in BACM.1,2,6,10,11 In one study, 95% of patients dem-
onstrated elevated CPK levels at a median of 4100 U/L,
and CPK levels rose as high as 20 times the upper limit
of normal in another study.9 High CPK values with a pro-
tracted elevation are associated with muscular dystro-
phy, while in BACM elevated CPK levels will peak after
2 weeks. 2,7,10 Patients can have normal or decreased
white blood cell and platelet counts and elevated ami-
notransferase levels.6,7 Viral studies and muscle biopsies
or myelography should not be done routinely.
Imaging studies should only be used to exclude
alternative diagnoses. Indications to perform imaging
include concern about trauma, osteomyelitis, malig-
nancy, or deep vein thrombosis. Magnetic resonance
imaging might serve as a noninvasive confirmatory tool
but is not currently recommended.12
There are no clear guidelines for investigation in chil-
dren with suspected BACM. Based on 5 cases in a ret-
rospective series and review of the literature, Agyeman
et al suggested confirming BACM using CPK level and

Vol 63:  may • mai 2017 | Canadian Family Physician • Le Médecin de famille canadien  367
Child Health Update
viral studies. 5 In children with a rapidly worsening findings, any signs of inflammation, a lack of improve-
condition or no symptomatic resolution after a few days, ment after 3 days, or asymmetrical lower extremity pain,
the investigators suggested urine and renal function BACM is unlikely and an alternative diagnosis should
studies in order to rule out rhabdomyolysis and renal be sought.1 Patients should have screening bloodwork
failure. Tippett and Clark recommended that workup urine myoglobin measured to confirm the diagnosis
include routine complete blood count, C-reactive protein and rule out more harmful alternatives and complica-
levels, creatine kinase levels, liver function tests, and tions. Myoglobinuria is rare and when it occasionally
urine myoglobin measurement—all in an effort to rule occurs these patients should be admitted to hospital for
out other, more ominous, disease processes.1 monitoring. Parents and providers should be reassured
that prognosis for BACM is excellent and patients can
Management be effectively managed with simple analgesia at home.
Clinical recovery is expected at a median of 3 days7,9,10 Clinical follow-up can be arranged with full clinical and
and few patients, if any, require admission to hospital. laboratory recovery expected at 2 weeks. 
In a large Canadian prospective study, over 2 influenza Competing interests
None declared
seasons, 5 of 26 children between the ages of 5 and
Correspondence
15 were admitted. Only 1 patient had a prolonged ill- Dr Ran D. Goldman; e-mail [email protected]
ness with intermittent leg pain and gait abnormalities References
for 7 weeks, while all others fully recovered after 2 to 3 1. Tippett E, Clark R. Benign acute childhood myositis following human parain-
fluenza virus type-1 infection. Emerg Med Australas 2013;25(3):248-51. Epub
weeks.7 Moon et al reported complete recovery of 100% 2013 Apr 8.
of patients, as did Agyeman and colleagues in their ret- 2. Jain S, Kolber MR. A stiff-legged gait: benign acute childhood myositis. CMAJ
2009;181(10):711-3. Epub 2009 Oct 13.
rospective analysis of 5 patients.5,9 In a case series of 3. Leichtenstern O. Influenza. In: Mannaberg J. Malaria, influenza and dengue.
4 children with H1N1-associated BACM none of them Nothnagel’s encyclopedia of practical medicine. Philadelphia, PA: W.B. Saunders
& Co; 1905. p. 523-701.
was admitted to hospital, with full recovery after 4 days 4. Lundberg A. Myalgia cruris epidemica. Acta Paediatr 1957;46(1):18-31.
on average,10 despite influenza A syndrome notoriously 5. Agyeman P, Duppenthaler A, Heininger U, Aebi C. Influenza-associated myo-
sitis in children. Infection 2004;32(4):199-203.
being more severe than other viruses.5,6 6. Mackay MT, Kornberg AJ, Shield LK, Dennett X. Benign acute childhood
Rhabdomyolysis is an infrequently reported com- myositis: laboratory and clinical features. Neurology 1999;53(9):2127-31.
7. Middleton PJ, Alexander RM, Szymanski MT. Severe myositis during recovery
plication of BACM. In one review, 10 of 316 patients from influenza. Lancet 1970;2(7672):533-5.
developed rhabdomyolysis, 8 of whom had renal fail- 8. Neocleous C, Spanou C, Mpampalis E, Xatzigeorgiou S, Pavlidou C, Poulos E,
et al. Unnecessary diagnostic investigations in benign acute childhood myosi-
ure.5 All but 1 patient, who had predisposing familial tis: a case series report. Scott Med J 2012;57(3):182.
carnitine palmityl transferase deficiency, recovered. 5,13 9. Moon JH, Na JY, Kim JH, Yum MK, Oh JW, Kim CR, et al. Neurological and
muscular manifestations associated with influenza B infection in children.
Rhabdomyolysis was 4 times more likely to occur in Pediatr Neurol 2013;49(2):97-101.
girls than boys, and 86% of all cases were associated 10. Rubín E, De la Rubia L, Pascual A, Domínguez J, Flores C. Benign acute
myositis associated with H1N1 influenza A virus infection. Eur J Pediatr
with influenza A.5 Compartment syndrome was reported 2010;169(9):1159-61. Epub 2010 Mar 7.
in 2 of the 311 patients reviewed, and in 1 patient a per- 11. Rennie LM, Hallam NF, Beattie TF. Benign acute childhood myositis in an
accident and emergency setting. Emerg Med J 2005;22(10):686-8.
manent disability was documented.5 For children with 12. Kawarai T, Nishimura H, Taniguchi K, Saji N, Shimizu H, Tadano M, et al.
rhabdomyolysis, admission to hospital for monitoring Magnetic resonance imaging of biceps femoris muscles in benign acute child-
hood myositis. Arch Neurol 2007;64(8):1200-1.
of renal function is warranted in order to ensure timely 13. Kelly KJ, Garland JS, Tang TT, Shug AL, Chusid MJ. Fatal rhabdomyolysis fol-
diagnosis of acute renal failure, electrolyte abnormali- lowing influenza infection in a girl with familial carnitine palmityl transferase
deficiency. Pediatrics 1989;84(2):312-6.
ties, or compartment syndrome.5
Once an ominous diagnosis has been excluded,
children with BACM can be managed as outpatients Child Health Update is produced by
with analgesia and appropriate clinical and laboratory the Pediatric Research in Emergency
follow-up in 2 to 3 weeks.11 Recurrence is uncommon6 Therapeutics (PRETx) program
Pediatric Research in Emergency Therapeutics

but was identified in 10 of 311 cases in one report.5 (www.pretx.org) at the BC Children’s
Antivirals are unlikely to be beneficial.10 A relationship Hospital in Vancouver, BC. Dr Magee is a member and Dr Goldman is
Director of the PRETx program. The mission of the PRETx program is
between influenza vaccinations and BACM has yet to be
to promote child health through evidence-based research in
established.2
therapeutics in pediatric emergency medicine.
  Do you have questions about the effects of drugs, chemicals,
Conclusion radiation, or infections in children? We invite you to submit them to
Benign acute childhood myositis is a mild and self- the PRETx program by fax at 604 875-2414; they will be addressed
limited process that can be diagnosed clinically. If in future Child Health Updates. Published Child Health Updates are
there is any muscle weakness or abnormal neurologic available on the Canadian Family Physician website (www.cfp.ca).

368  Canadian Family Physician • Le Médecin de famille canadien | Vol 63:  may • mai 2017