Letters to the Editor

Case Reports: Rhabdomyolysis Associated with COVID-19

 

Am Fam Physician. 2020 Dec 1;102(11):645-648.

Published online September 25, 2020.

To the Editor: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease 2019 (COVID-19), has caused a global health crisis. COVID-19 can present with a variety of complications during the course of infection. Rhabdomyolysis is characterized by muscle necrosis and the release of intracellular muscle constituents into the systemic circulation. A prompt diagnosis is a prerequisite for successful treatment and avoiding complications.

We report on 10 patients with rhabdomyolysis associated with COVID-19 who presented to our hospital through the emergency department. COVID-19 diagnosis was made by polymerase chain reaction assay. Pertinent clinical characteristics are summarized in Table 1.

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TABLE 1.

Clinical Characteristics of Patients with COVID-19 and Rhabdomyolysis

CharacteristicsCase 1Case 2Case 3Case 4Case 5Case 6Case 7Case 8Case 9Case 10

Age (years)

54

54

34

71

88

56

57

64

36

39

Sex

Male

Male

Male

Male

Male

Male

Male

Male

Male

Male

Race

Hispanic

White

White

Black

White

Hispanic

Hispanic

White

White

Black

Medical history

Asthma, diabetes mellitus, hypertension, obesity

None

Obesity, prediabetes,

Hypertension, schizophrenia, seizures

Diabetes, hypertension

Hypertension, prediabetes

None

None

None

Hypertension

Presenting signs and symptoms

Cough, SOB, fever

Myalgias, fever, cough, SOB

Fever, cough, SOB, weakness

Fever, cough, SOB

Confusion

Fever, cough, SOB

Cough, fever

Myalgias, fever, cough, SOB

Fever, cough, SOB

Myalgias, fever, cough, SOB

CK on presentation (U per L/μkat per L)

4,590 (76.65)

3,068 (51.24)

623 (10.40)

5,498 (91.82)

2,628 (43.89)

5,388 (89.98)

4,643 (77.54)

1,793 (29.94)

5,388 (89.98)

4,330 (72.31)

Peak CK total/corresponding day

7,337 (122.53)/4

3,068 (51.24)/1

5,454 (91.08)/4

10,247 (171.12)/3

2,628 (43.89)/1

5,388 (89.98)/1

37,524 (626.65)/14

6,435 (107.46)/4

5,531 (92.37)/5

4,330 (72.31)/1

Potassium (mEq per L) on presentation

5.0

3.9

3.6

3.8

3.9

3.1

4.0

4.8

4.0

4.0

Phosphorus (mg per dL/mmol per L) on presentation

3.6 (1.16)

ND

2.8 (0.90)

5.5 (1.78)

2.8 (0.90)

3.4 (1.10)

2.4 (0.78)

8.5 (2.75)

2.4 (0.78)

ND

Creatinine (mg per dL/μmol per L) on presentation

0.7 (61.88)

1.1 (97.24)

0.89 (78.68)

4.1 (362.44)

2.25 (198.90)

0.8 (70.72)

1.1 (97.24)

1.01 (89.28)

1.03 (91.05)

3.8 (335.92)

Acute renal replacement therapy

No

No

Yes

No

No

No

No

No

Yes

No

Aspartate transaminase/alanine transaminase on presentation (U per L)

25/28

100/48

100/86

125/44

115/60

299/170

125/44

101/80

154/111

131/65

Peak aspartate transaminase/alanine transaminase (U per L)

161/59

91/231

100/86

128/120

117/63

299/170

511/153

113/79

177/101

131/65

C-reactive protein (mg per dL/mg per L)

48 (480)

2.14 (213.6)

12.89 (128.9)

30.90 (309)

6.76 (67.6)

9.58 (95.8)

15.4 (154)

24.7 (247)

29.7 (297)

8.5 (85)

Erythrocyte sedimentation rate (mm per hour)

69

111

87

73

33

81

40

34

35

43

Ferritin (ng per mL)

602

4,462

639

327

106

836

7,500

ND

4,746

1,170

Fibrinogen (mg per dL/g per L)

ND

992 (29.16)

797 (23.43)

675 (19.84)

392 (11.52)

ND

760 (22.34)

559 (16.43)

784 (23.05)

ND

Outcome

Died

Discharged

Died

Died

Died

Discharged

Died

Died

Died

Died


Note: Reference ranges are CK 30 to 223 U per L (0.50 to 3.72 μkat per L), potassium 3.5 to 5 mEq per L (3.50 to 5.0 mmol per L), phosphorus 2.5 to 5 mg per dL (0.81 to 1.61 mmol per L), creatinine 0.6 to 1.30 mg per dL (53.04 to 114.92 μmol per L), aspartate transaminase 13 to 39 U per L (0.22 to 0.65 μkat per L), alanine transaminase 7 to 52 U per L (0.12 to 0.87 μkat per L), erythrocyte sedimentation rate 0 to 32 mm per hour, C-reactive protein less than 10 mg per dL (100 mg per L), fibrinogen 183 to 503 mg per dL (5.38 to 14.79 g per L), and ferritin 12 to 300 ng per mL (12 to 300 mcg per L).

CK = creatine kinase; COVID-19 = coronavirus disease 2019; ND = not done; SOB = shortness of breath.

TABLE 1.

Clinical Characteristics of Patients with COVID-19 and Rhabdomyolysis

CharacteristicsCase 1Case 2Case 3Case 4Case 5Case 6Case 7Case 8Case 9Case 10

Age (years)

54

54

34

71

88

56

57

64

36

39

Sex

Male

Male

Male

Male

Male

Male

Male

Male

Male

Male

Race

Hispanic

White

White

Black

White

Hispanic

Hispanic

White

White

Black

Medical history

Asthma, diabetes mellitus, hypertension, obesity

None

Obesity, prediabetes,

Hypertension, schizophrenia, seizures

Diabetes, hypertension

Hypertension, prediabetes

None

None

None

Hypertension

Presenting signs and symptoms

Cough, SOB, fever

Myalgias, fever, cough, SOB

Fever, cough, SOB, weakness

Fever, cough, SOB

Confusion

Fever, cough, SOB

Cough, fever

Myalgias, fever, cough, SOB

Fever, cough, SOB

Myalgias, fever, cough, SOB

CK on presentation (U per L/μkat per L)

4,590 (76.65)

3,068 (51.24)

623 (10.40)

5,498 (91.82)

2,628 (43.89)

5,388 (89.98)

4,643 (77.54)

1,793 (29.94)

5,388 (89.98)

4,330 (72.31)

Peak CK total/corresponding day

7,337 (122.53)/4

3,068 (51.24)/1

5,454 (91.08)/4

10,247 (171.12)/3

2,628 (43.89)/1

5,388 (89.98)/1

37,524 (626.65)/14

6,435 (107.46)/4

5,531 (92.37)/5

4,330 (72.31)/1

Potassium (mEq per L) on presentation

5.0

3.9

3.6

3.8

3.9

3.1

4.0

4.8

4.0

4.0

Phosphorus (mg per dL/mmol per L) on presentation

3.6 (1.16)

ND

2.8 (0.90)

5.5 (1.78)

2.8 (0.90)

3.4 (1.10)

2.4 (0.78)

8.5 (2.75)

2.4 (0.78)

ND

Creatinine (mg per dL/μmol per L) on presentation

0.7 (61.88)

1.1 (97.24)

0.89 (78.68)

4.1 (362.44)

2.25 (198.90)

0.8 (70.72)

1.1 (97.24)

1.01 (89.28)

1.03 (91.05)

3.8 (335.92)

Acute renal replacement therapy

No

No

Yes

No

No

No

No

No

Yes

No

Aspartate transaminase/alanine transaminase on presentation (U per L)

25/28

100/48

100/86

125/44

115/60

299/170

125/44

101/80

154/111

131/65

Peak aspartate transaminase/alanine transaminase (U per L)

161/59

91/231

100/86

128/120

117/63

299/170

511/153

113/79

177/101

131/65

C-reactive protein (mg per dL/mg per L)

48 (480)

2.14 (213.6)

12.89 (128.9)

30.90 (309)

6.76 (67.6)

9.58 (95.8)

15.4 (154)

24.7 (247)

29.7 (297)

8.5 (85)

Erythrocyte sedimentation rate (mm per hour)

69

111

87

73

33

81

40

34

35

43

Ferritin (ng per mL)

602

4,462

639

327

106

836

7,500

ND

4,746

1,170

Fibrinogen (mg per dL/g per L)

ND

992 (29.16)

797 (23.43)

675 (19.84)

392 (11.52)

ND

760 (22.34)

559 (16.43)

784 (23.05)

ND

Outcome

Died

Discharged

Died

Died

Died

Discharged

Died

Died

Died

Died


Note: Reference ranges are CK 30 to 223 U per L (0.50 to 3.72 μkat per L), potassium 3.5 to 5 mEq per L (3.50 to 5.0 mmol per L), phosphorus 2.5 to 5 mg per dL (0.81 to 1.61 mmol per L), creatinine 0.6 to 1.30 mg per dL (53.04 to 114.92 μmol per L), aspartate transaminase 13 to 39 U per L (0.22 to 0.65 μkat per L), alanine transaminase 7 to 52 U per L (0.12 to 0.87 μkat per L), erythrocyte sedimentation rate 0 to 32 mm per hour, C-reactive protein less than 10 mg per dL (100 mg per L), fibrinogen 183 to 503 mg per dL (5.38 to 14.79 g per L), and ferritin 12 to 300 ng per mL (12 to 300 mcg per L).

CK = creatine kinase; COVID-19 = coronavirus disease 2019; ND = not done; SOB = shortness of breath.

The median age of the participants was 55 years and all were male. Presenting symptoms included cough, shortness of breath, fever, myalgias, and confusion. None of the patients were receiving statins or other medications known to cause rhabdomyolysis or had risk factors for rhabdomyolysis. The median creatine kinase level on presentation was 4,460 U per L (74.48 μkat per L). Three patients had acute kidney injury on presentation and liver enzymes were elevated in all patients except one. Inflammatory markers (erythrocyte sedimentation rate, C-reactive protein, fibrinogen, and ferritin) were elevated in all patients. Influenza was negative in five patients and other viral causes of rhabdomyolysis (e.g., parainfluenza, enterovirus, adenovirus) were negative in four patients.1 Eight out of 10 patients died.

Acute viral infections associated with rhabdomyolysis include influenza A and B, coxsackieviruses, Epstein-Barr virus, herpes simplex, parainfluenza, adenovirus, echo-virus, HIV, and cytomegalovirus.2 Others have reported cases of rhabdomyolysis associated with COVID-19.3,4 The pathologic mechanism leading to this complication is currently unknown. Clinicians should be aware of this life-threatening manifestation of COVID-19 so that prompt and appropriate interventions can be undertaken if it is suspected or confirmed. Further studies are needed to characterize the muscle injury consequences of SARS-CoV-2 infection.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Gabow PA, Kaehny WD, Kelleher SP. The spectrum of rhabdomyolysis. Medicine (Baltimore). 1982;61(3):141–152....

2. Pesik NT, Otten EJ. Severe rhabdomyolysis following a viral illness: a case report and review of the literature. J Emerg Med. 1996;14(4):425–428.

3. Chong WH, Saha B. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) associated with rhabdomyolysis and acute kidney injury (AKI) [published online July 28, 2020]. Am J Med Sci. 2020;S0002-9629(20)30344-X.

4. Valente-Acosta B, Moreno-Sanchez F, Fueyo-Rodriguez O, et al. Rhabdomyolysis as an initial presentation in a patient diagnosed with COVID-19. BMJ Case Rep. 2020;13(6):e236719.

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