Rhabdomyolysis With COVID-19

Abstract

To the Editor: W e describe a case of severe rhabdomyolysis in a patient with COVID-19. An 81-year-old woman presented to the emergency department with a 5-day history of generalized myalgia, weakness, malaise, loss of appetite, and a dry cough associated with mild dyspnea. She denied fever or chills but reported a history of exposure to the SARS-CoV-2 virus when she visited a relative around 10 days before presentation. She had amedical history of essential hypertension, hyperlipidemia, type 2 diabetes mellitus, and stage III chronic kidney disease. Her home medications included atorvastatin 40mg daily, losartan, glipizide, andmetformin. She denied any history of trauma, substance use, or prolonged immobility. At the time of presentation, she was afebrile (temperature, 37.6°C) and had a peripheral oxygen saturation of 89% on room air. Other vital signs were within normal ranges. On physical examination, she was noted to have dry mucous membranes. Notable laboratory findings included aD-dimer of 695 ng/dL (reference, <500 ng/dL); C-reactive protein, 22 mg/dL (reference, <1.0 mg/dL); lactate dehydrogenase, 876 U/L (reference, 100–200 U/L); ferritin, 221 ng/mL (reference, 10–200 ng/mL); aspartate aminotransferase, 45 U/L (reference, 7–40 U/L); blood urea nitrogen, 27mg/dL (reference, 7–25 mg/dL); creatinine, 1.14 mg/dL (reference, 0.4–1.0 mg/dL; patient s baseline, 0.7–0.9 mg/dL); serum myoglobin, >3680 ng/mL (reference, 0–65 ng/mL); and a creatine kinase (CK) of 6467 U/L (reference, 21–215 U/L). Creatine kinase had been within normal ranges in the past 7 years, ever since she was started on a high-intensity statin. Urinalysis demonstrated 3+ blood with 0–2 red blood cells/highpower field (ref. 0–3) and mild proteinuria (2+). A 2-view chest x-ray showedmildmixed patchy interstitial and alveolar infiltrates in the lower lung fields bilaterally, suggestive of pneumonia. She was admitted and given aggressive intravenous hydration with crystalloid fluids. The high-intensity statin was discontinued. A nasopharyngeal swab for Abbott RealTime SARS-CoV-2 polymerase chain reaction assay was positive. The patient was treated with supplemental oxygen and a 5-day course of hydroxychloroquine. Superimposed community-acquired pneumonia was of lower suspicion with a relatively low procalcitonin of 0.59 ng/mL, as well as negative Streptococcus and Legionella urinary antigens. However, a 7-day course of ceftriaxone/doxycycline for empiric treatment was given. On the second day of hospitalization, she was transferred to the medical intensive care unit for increasing oxygen requirements. Repeat chest x-ray showed progression of diffuse mixed opacities in both lungs. To prevent the development of pulmonary edema while receiving necessary intravenous crystalloid, intravenous furosemide was given to keep a net even fluid balance. Her CK peaked at 40,900 U/L on the fourth hospital day. She did not develop acute renal failure. Other causes of elevated CK and rhabdomyolysis were evaluated and were unremarkable, including troponin-I, serum thyroidstimulating hormone, nasopharyngeal swab respiratory viral panel (BioFire), HIV screen, Epstein-Barr virus, and Enterovirus polymerase chain reaction on blood, and a urine drug screen. As of this report, the patient has recovered completely from the acute hypoxemic respiratory failure secondary to COVID-19. She was seen in clinic for follow-up 8 weeks after discharge with no pulmonary issues.