Rhabdomyolysis associated with acute renal failure in patients with severe acute respiratory syndrome

Rhabdomyolysis in a patient with end-stage renal disease and SARS-CoV-2 infection: A case report

RATIONALE

Rhabdomyolysis can be an uncommon complication of coronavirus disease 2019 (COVID-19) infection. However, the diagnosis of rhabdomyolysis could be easily missed due to its atypical clinical presentations. We present a patient with a history of end-stage renal disease (ESRD) who contracted COVID-19 and subsequently developed rhabdomyolysis. We discuss and share our experience in the management of this patient.

PATIENT CONCERNS

An 85-year-old male with ESRD undergoing routine hemodialysis was tested positive for COVID-19. The patient had clinical symptoms of fatigue, muscle pain, and difficulty walking.

DIAGNOSIS

The serum creatine kinase (CK) level was markedly elevated to 32,492.9U/L, supporting the diagnosis of rhabdomyolysis. A computed tomography scan revealed muscle injuries throughout the body, confirming the diagnosis.

INTERVENTIONS

The patient was managed through electrolyte corrections and continuous renal replacement therapy.

OUTCOMES

Repeat tests showed decreased levels of serum CK and negative severe acute respiratory syndrome coronavirus 2. His clinical symptoms, including fatigue and muscle pain, had significantly improved.

LESSONS

COVID-19 infection can cause muscle pain and fatigue, which can mask the symptoms of rhabdomyolysis. A missed diagnosis of rhabdomyolysis can be severe, especially in patients with ESRD. The serum CK level should be tested with clinical suspicion. Appropriate management, including adequate hydration and electrolyte balance, should be provided. Continuous renal replacement therapy should be considered in affected patients with renal insufficiency.

COVID-19 and fibrosis: Mechanisms, clinical relevance, and future perspectives

Coronavirus 2019 (COVID-19), caused by severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) has had significant impacts worldwide since its emergence in December, 2019. Despite a high recovery rate, there is a growing concern over its residual, long-term effects. However, because of a lack of long-term data, we are still far from establishing a consensus on post-COVID-19 complications. The deposition of excessive extracellular matrix (ECM), known as fibrosis, has been observed in numerous survivors of COVID-19. Given the exceptionally high number of individuals affected, there is an urgent need to address the emergence of fibrosis post-COVID-19. In this review, we discuss the clinical relevance of COVID-19-associated fibrosis, the current status of antifibrotic agents, novel antifibrotic targets, and challenges to its management.

A Case of Rhabdomyolysis in a Young, Morbidly Obese, Asthmatic Woman With COVID-19

COVID-19 is a respiratory disease that has been shown to have extrapulmonary manifestations. One association with COVID-19 is rhabdomyolysis, which is defined as the breakdown of skeletal muscles. There have been increasing reports of rhabdomyolysis in obese, middle-aged male COVID-19 patients, but limited published cases affecting young adult females. This case discusses the early presentation of rhabdomyolysis in a young, morbidly obese, asthmatic woman with COVID-19.

A 28-year-old, unvaccinated, African American female with past medical history of asthma, tobacco abuse, and a BMI of 46 initially presented to the emergency department with a complaint of fever, cough, and shortness of breath for two days. She was initially diagnosed with an asthma exacerbation and was treated symptomatically, but her symptoms persisted despite treatment. She began to experience myalgias the next day, followed by bilateral lower extremity weakness and dark urine two days later. Urinalysis revealed gross hematuria, 2-4 red blood cells per high-power field, 100 mg/dL protein, >8.0 mg/dL urobilinogen, and 0-2 hyaline casts. Alanine aminotransferase (ALT), aspartate aminotransferase (AST), and creatine kinase (CK) levels were noted to be elevated. Her subsequent COVID-19 test was positive, and both blood and respiratory cultures were negative. She was diagnosed with rhabdomyolysis which was likely secondary to COVID-19. Her CK, ALT, and AST levels normalized after two weeks with the resolution of rhabdomyolysis, but she continued to have persistent COVID-19 infection and deteriorating respiratory status. She eventually required mechanical ventilation on day 20 and passed away on day 59 of hospitalization.

Rhabdomyolysis is an infrequent finding that can be associated with COVID-19. It has been increasingly reported in middle-aged obese male patients but is far less common in younger females. The presence of elevated CK has been associated with higher mortality among COVID-19 patients, but current literature demonstrates that the majority of these patients are older males. It is imperative to recognize and treat rhabdomyolysis in all patients, particularly younger females, to help mitigate the comorbidities of COVID-19.

Neurological and Head/Eyes/Ears/Nose/Throat Manifestations of COVID-19: A Systematic Review and Meta-Analysis

BACKGROUND/OBJECTIVE

Coronavirus disease 2019 (COVID-19) has been associated with various neurological and atypical head/eyes/ears/nose/throat (HEENT) manifestations. We sought to review the evidence for these manifestations.

METHODS

In this systematic review and meta-analysis, we compiled studies published until March 31, 2021 that examined non-respiratory HEENT, central, and peripheral nervous system presentations in COVID-19 patients. We included 477 studies for qualitative synthesis and 59 studies for meta-analyses.

RESULTS

Anosmia, ageusia, and conjunctivitis may precede typical upper/lower respiratory symptoms. Central nervous system (CNS) manifestations include stroke and encephalopathy, potentially with brainstem or cranial nerve involvement. MRI studies support CNS para-/postinfectious etiologies, but direct neuroinvasion seems very rare, with few cases detecting Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in the CNS. Peripheral nervous system (PNS) manifestations include muscle damage, Guillain-Barre syndrome (GBS), and its variants. There was moderate-to-high study heterogeneity and risk of bias. In random-effects meta-analyses, anosmia/ageusia was estimated to occur in 56% of COVID-19 patients (95% CI: 0.41-0.71, I2:99.9%), more commonly than in patients without COVID-19 (OR: 14.28, 95% CI: 8.39-24.29, I2: 49.0%). Neurological symptoms were estimated to occur in 36% of hospitalized patients (95% CI: 0.31-0.42, I2: 99.8%); ischemic stroke in 3% (95% CI: 0.03-0.04, I2: 99.2%), and GBS in 0.04% (0.033%-0.047%), more commonly than in patients without COVID-19 (OR[stroke]: 2.53, 95% CI: 1.16-5.50, I2: 76.4%; OR[GBS]: 3.43,1.15-10.25, I2: 89.1%).

CONCLUSIONS

Current evidence is mostly from retrospective cohorts or series, largely in hospitalized or critically ill patients, not representative of typical community-dwelling patients. There remains a paucity of systematically gathered prospective data on neurological manifestations. Nevertheless, these findings support a high index of suspicion to identify HEENT/neurological presentations in patients with known COVID-19, and to test for COVID-19 in patients with such presentations at risk of infection.

Potential neurological manifestations of COVID-19: a narrative review

Neurological manifestations are increasingly reported in a subset of COVID-19 patients. Previous infections related to coronaviruses, namely Severe Acute Respiratory Syndrome (SARS) and Middle Eastern Respiratory Syndrome (MERS) also appeared to have neurological effects on some patients. The viruses associated with COVID-19 like that of SARS enters the body via the ACE-2 receptors in the central nervous system, which causes the body to balance an immune response against potential damage to nonrenewable cells. A few rare cases of neurological sequelae of SARS and MERS have been reported. A growing body of evidence is accumulating that COVID-19, particularly in severe cases, may have neurological consequences although respiratory symptoms nearly always develop prior to neurological ones. Patients with preexisting neurological conditions may be at elevated risk for COVID-19-associated neurological symptoms. Neurological reports in COVID-19 patients have described encephalopathy, Guillain-Barré syndrome, myopathy, neuromuscular disorders, encephalitis, cephalgia, delirium, critical illness polyneuropathy, and others. Treating neurological symptoms can pose clinical challenges as drugs that suppress immune response may be contraindicated in COVID-19 patients. It is possible that in some COVID-19 patients, neurological symptoms are being overlooked or misinterpreted. To date, neurological manifestations of COVID-19 have been described largely within the disease trajectory and the long-term effects of such manifestations remain unknown.

Effects and Causes of Detraining in Athletes Due to COVID-19: A Review

Several aspects of systemic alterations caused by the SARS-CoV-2 virus and the resultant COVID-19 disease have been currently explored in the general population. However, very little is known about these particular aspects in sportsmen and sportswomen. We believe that the most important element to take into account is the neuromuscular aspect, due to the implications that this system entails in motion execution and coordination. In this context, deficient neuromuscular control when performing dynamic actions can be an important risk factor for injury. Therefore, data in this review refer mainly to problems derived in the short term from athletes who have suffered this pathology, taking into account that COVID-19 is a very new disease and the presented data are still not conclusive. The review addresses two key aspects: performance alteration and the return to regular professional physical activity. COVID-19 causes metabolic-respiratory, muscular, cardiac, and neurological alterations that are accompanied by a situation of stress. All of these have a clear influence on performance but at the same time in the strategy of returning to optimal conditions to train and compete again after infection. From the clinical evidence, the resumption of physical training and sports activity should be carried out progressively, both in terms of time and intensity.

Rhabdomyolysis Induced by Rhinovirus: A Case Report

The occurrence of rhabdomyolysis in pediatric patients is considered a rare complication that can follow certain viral infections in a syndrome better defined as virus-associated rhabdomyolysis. In this research, we will present the case of a ten-year-old male patient who presented to the emergency department with chief complaints of severe bilateral leg pain and inability to walk. Furthermore, the patient complained of dysphagia for both solid and liquid along with dark-colored urine. Initial investigations showed an increase in creatine kinase (CK), C-reactive protein (CRP), and liver enzymes. Additionally, urine analysis was obtained with positive traces of blood, protein, and white blood cell. X-ray was ordered with no significant finding. Finally, the diagnosis was reached in accordance to the results of the respiratory panel multiplex (PCR) as the third case of rhinovirus-induced rhabdomyolysis. He was treated with isotonic intravenous fluids, and he was discharged on hospital day 20 with a CK of 2062 IU/L. The patient was discharged fully recovered, was able to stand and walk alone, and with no complications. In this third to be reported case of rhinovirus-induced rhabdomyolysis, we aim to increase the knowledge among the general pediatric field regarding the possible presentation and treatment of any similar case.

Interaction between a fluoroquinolone derivative and RNAs with a single bulge

Interaction analysis between small molecules and RNA as well as structure determination of RNA-small molecule complexes will be the clues to search for compounds that bind to specific mRNA or non-coding RNA in drug discovery. In this study, the RNA-binding ability of a fluoroquinolone derivative, KG022, was examined against single-residue bulge-containing hairpin RNAs as RNA models. Nuclear magnetic resonance analysis indicated that KG022 interacts with the RNAs in the vicinity of the bulge residue, with preferring C and G as the bulge residues. The solution structures of the RNA-KG022 complexes showed that the KG022 binds to the RNAs at the bulge-out regions. Each substituent in KG022 interacts with specific position of RNAs around the bulge-out region probably contributing the specificity of the binding. This work provides a novel member for the RNA-targeted small molecules.

Combined Hyperglycemic Hyperosmolar Syndrome and Diabetic Ketoacidosis Associated with COVID-19 in a Pediatric Patient

Although most children with coronavirus disease 2019 (COVID-19) are asymptomatic or only with mild symptoms, many symptomatic children still require admission to the intensive care unit. Multiple cases of diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS) associated with COVID-19 have been reported in adults. However, to our knowledge, only few similar cases have been published in the pediatric population. We report one of the first few severe cases of mixed HHS with DKA associated with COVID-19 in an adolescent. Our patient was successfully treated with intravenous immunoglobulin, Remdesivir, and methylprednisolone. As the pandemic continues, clinicians should be aware of this syndrome and consider early use of Remdesivir and corticosteroids. Further studies are required to understand the pathophysiology of this syndrome occurring with COVID-19.

Asymptomatic Rhabdomyolysis in a Young Adult With COVID-19

The novel coronavirus disease 2019 (COVID-19) is an ongoing pandemic. Although COVID-19 is frequently associated with respiratory symptoms and complications, multiple extrapulmonary manifestations have been identified since the beginning of the pandemic. Rhabdomyolysis has been described in the literature as one of the extrapulmonary manifestations of COVID-19. Herein, we describe a 21-year-old male patient who presented with cough and fever secondary to COVID-19 confirmed by positive reverse-transcription polymerase chain reaction (RT-PCR) for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The patient presented with an extremely elevated creatinine kinase (CK) of 53,886 U/L (normal 10-170) without any classical symptoms of rhabdomyolysis or deterioration in his kidney function. He was successfully managed with aggressive intravenous fluids. The aim of reporting this case is to highlight the importance of including total CK in the initial evaluation of COVID-19 patients.

Rhabdomyolysis is Associated with In-Hospital Mortality in Patients with COVID-19

PURPOSE

Rhabdomyolysis (RM) has been associated with many viral infectious diseases, and associated with poor outcomes. We aim to evaluate the clinical features and outcomes of RM in patients with coronavirus disease 2019 (COVID-19).

METHOD

This was a single-center, retrospective, cohort study of 1,014 consecutive hospitalized patients with confirmed COVID-19 at the Huoshenshan Hospital in Wuhan, China, between February 17 and April 12, 2020.

RESULTS

The overall incidence of RM was 2.2%. Compared with patients without RM, those with RM tended to have a higher risk of deterioration. Patients with RM also constituted a greater percentage of patients admitted to the intensive care unit (90.9% vs. 5.3%, P < 0.001) and a greater percentage of patients undergoing mechanical ventilation (86.4% vs. 2.7% P < 0.001). Moreover, patients with RM had laboratory test abnormalities, including the presence of markers of inflammation, activation of coagulation, and kidney injury. Patients with RM also had a higher risk of in-hospital death (P < 0.001). Cox's proportional hazard regression model analysis confirmed that RM indicators, including peak creatine kinase levels > 1,000 IU/L (HR = 6.46, 95% CI: 3.02-13.86) and peak serum myoglobin concentrations > 1,000 ng/mL (HR = 9.85, 95% CI: 5.04-19.28), were independent risk factors for in-hospital death. Additionally, patients with COVID-19 that developed RM tended to have delayed viral clearance.

CONCLUSION

RM might be an important contributing factor to adverse outcomes in COVID-19 patients. The early detection and effective intervention of RM may help reduce mortality among COVID-19 patients.

COVID-19 IgG-related autoimmune inflammatory necrotizing myositis

The COVID-19 pandemic caused by the SARS-CoV-2 virus has affected millions of people around the globe. The most common presentation of COVID-19 is fever and upper and lower respiratory tract infection. Myalgia is fairly common in the prodromal phase of the viral illness which self-resolves. There is very scant literature on autoimmune myositis triggered by COVID-19 infection. We report a case of SARS-CoV-2 infection, who presented with progressive muscle weakness with rhabdomyolysis and necrotizing autoimmune myopathy on muscle biopsy. This case report imposes awareness of musculoskeletal autoimmune processes triggered by COVID-19 which requires clinical suspicion for early diagnosis and initiation of treatment.

Rhabdomyolysis in Severe COVID-19: Male Sex, High Body Mass Index, and Prone Positioning Confer High Risk

BACKGROUND

Bedside experience and studies of critically ill patients with coronavirus disease 2019 (COVID-19) indicate COVID-19 to be a devastating multisystem disease. We aim to describe the incidence, associated variables, and outcomes of rhabdomyolysis in critically ill COVID-19 patients.

MATERIALS AND METHODS

Data for all critically ill adult patients (≥18 years old) admitted to the ICU at a large academic medical center with confirmed COVID-19 between March 13, 2020 and April 18, 2020 were prospectively collected. Patients with serum creatine kinase (CK) concentrations greater than 1000 U/L were diagnosed with rhabdomyolysis. Patients were further stratified as having moderate (serum CK concentration 1000-4999 U/L) or severe (serum CK concentration ≥5000 U/L) rhabdomyolysis. Univariate and multivariate analyses were performed to identify outcomes and variables associated with the development of rhabdomyolysis.

RESULTS

Of 235 critically ill COVID-19 patients, 114 (48.5%) met diagnostic criteria for rhabdomyolysis. Patients with rhabdomyolysis more often required mechanical ventilation (P < 0.001), prone positioning (P < 0.001), pharmacological paralysis (P < 0.001), renal replacement therapy (P = 0.010), and extracorporeal membrane oxygenation (ECMO) (P = 0.025). They also had longer median ICU length of stay (LOS) (P < 0.001) and hospital LOS (P < 0.001). No difference in mortality was observed. Male sex, patients with morbid obesity, SOFA score, and prone positioning were independently associated with rhabdomyolysis.

CONCLUSIONS

Nearly half of critically ill COVID-19 patients in our cohort met diagnostic criteria for rhabdomyolysis. Male sex, morbid obesity, SOFA score, and prone position were independently associated with rhabdomyolysis.

Acute kidney injury associated with rhabdomyolysis in a patient with COVID-19

Rhabdomyolysis is defined as the breakdown of skeletal muscle leading to the release of muscle contents into the extracellular fluid. Patients with rhabdomyolysis can be asymptomatic or have myalgia symptoms, weakness, myoglobinuria with dark urine, significant electrolyte imbalance, and acute kidney injury. Here we describe a case on acute kidney injury associated to rhabdomyolysis in a patient with COVID-19.

Rhabdomyolysis as the Initial Presentation of SARS-CoV-2 in an Adolescent

The novel coronavirus disease 2019, caused by severe acute respiratory syndrome coronavirus 2, has created a global pandemic, with many cases affecting the elderly. However, children have been affected as well, with ∼2.4% to 3.7% of cases reported. This case is the first published case of an adolescent presenting with rhabdomyolysis as the first sign of novel coronavirus disease 2019, with extremely elevated creatinine kinase levels, approaching almost 400 000 U/L. This case adds to the growing body of literature of a variety of life-threatening manifestations associated with severe acute respiratory syndrome coronavirus 2 infection and highlights the importance of how prompt recognition of these unique presentations of the disease is important to mitigate complications.

Neurologic Manifestations of the World Health Organization's List of Pandemic and Epidemic Diseases

The World Health Organization (WHO) monitors the spread of diseases globally and maintains a list of diseases with epidemic or pandemic potential. Currently listed diseases include Chikungunya, cholera, Crimean-Congo hemorrhagic fever, Ebola virus disease, Hendra virus infection, influenza, Lassa fever, Marburg virus disease, Neisseria meningitis, MERS-CoV, monkeypox, Nipah virus infection, novel coronavirus (COVID-19), plague, Rift Valley fever, SARS, smallpox, tularemia, yellow fever, and Zika virus disease. The associated pathogens are increasingly important on the global stage. The majority of these diseases have neurological manifestations. Those with less frequent neurological manifestations may also have important consequences. This is highlighted now in particular through the ongoing COVID-19 pandemic and reinforces that pathogens with the potential to spread rapidly and widely, in spite of concerted global efforts, may affect the nervous system. We searched the scientific literature, dating from 1934 to August 2020, to compile data on the cause, epidemiology, clinical presentation, neuroimaging features, and treatment of each of the diseases of epidemic or pandemic potential as viewed through a neurologist's lens. We included articles with an abstract or full text in English in this topical and scoping review. Diseases with epidemic and pandemic potential can be spread directly from human to human, animal to human, via mosquitoes or other insects, or via environmental contamination. Manifestations include central neurologic conditions (meningitis, encephalitis, intraparenchymal hemorrhage, seizures), peripheral and cranial nerve syndromes (sensory neuropathy, sensorineural hearing loss, ophthalmoplegia), post-infectious syndromes (acute inflammatory polyneuropathy), and congenital syndromes (fetal microcephaly), among others. Some diseases have not been well-characterized from a neurological standpoint, but all have at least scattered case reports of neurological features. Some of the diseases have curative treatments available while in other cases, supportive care remains the only management option. Regardless of the pathogen, prompt, and aggressive measures to control the spread of these agents are the most important factors in lowering the overall morbidity and mortality they can cause.

Pain Symptoms in Patients with Coronavirus Disease (COVID-19): A Literature Review

PURPOSE

On 11 March, 2020, the coronavirus disease (COVID-19) outbreak was declared as a global pandemic by the World Health Organization. It brought substantial physical and psychological burden on individuals and financial loss across countries. Patients with COVID-19 may exhibit various symptoms, such as fever, cough, dyspnea, muscle pain, sore throat, headache, chest pain, and abdominal pain, at 2-14 days after exposure to the novel coronavirus (severe acute respiratory syndrome [SARS]-CoV-2). Pain symptoms present important challenge to clinicians' diagnosis when treating COVID-19 patients with mild symptoms. Considering the increasing number of confirmed COVID-19 cases, the pain symptoms should be systematically summarized.

RESULTS

The virus can invade different tissues of the body and cause different pain manifestations. SARS-CoV-2 primarily invades the respiratory system, and patients develop sore throat, fever, cough, and other pneumonia-associated symptoms. Moreover, it infects the nervous system (eg, headache, dizziness, and confusion), digestive system (eg, abdominal pain, diarrhea), and cardiovascular system (eg, chest pain, palmus, and cardiac injury). The incidence rate is 1.7-33.9% for headache, 0.7-47.1% for sore throat, 1.5-61.0% for myalgia/arthralgia, 1.6-17.7% for chest pain, and 1.9-14.5% for abdominal pain. In comparison with chest and abdominal pain, COVID-19 patients are more likely to develop headache, sore throat, and myalgia/arthralgia.

CONCLUSION

Different pain reflects the damage of different body systems. Therefore, the summary of pain symptoms for COVID-19 patients can help doctors improve the accuracy and efficiency of diagnosis when treating COVID-19 patients with atypical or mild symptoms and adopt more targeted treatment methods.

Pain during and after COVID-19 in Germany and worldwide: a narrative review of current knowledge

COVID-19 may potentially increase the incidence of persisting pain syndromes and worsen symptoms of preexisting chronic pain.

Pain is a common symptom accompanying the coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Nonspecific discomfort such as sore throat and body ache are frequent. Parainfectious pain such as headache, myalgia, or neuropathic pain has also been reported. The latter seems to be associated with an autoimmune response or an affection of the peripheral neuromuscular system or the central nervous system because of the viral infection. Furthermore, chronic pain can be a complication of intensive care unit treatment due to COVID-19 itself (such as intensive care–acquired weakness) or of secondary diseases associated with the SARS-CoV-2 infection, including Guillain–Barré syndrome, polyneuritis, critical illness polyneuropathy, or central pain following cerebrovascular events. Data on long-lasting painful symptoms after clinically manifest COVID-19 and their consequences are lacking. In addition, preexisting chronic pain may be exacerbated by limited and disrupted health care and the psychological burden of the COVID-19 pandemic. Medical providers should be vigilant on pain during and after COVID-19.

Rhabdomyolysis in Patients Hospitalized With COVID-19 Infection: Five Case Series

The novel SARS-CoV-2 virus (severe acute respiratory syndrome coronavirus 2) is now known to cause acute respiratory distress, cytokine storm, and coagulopathy. Multiple other manifestations have been published in recent literature. Rhabdomyolysis is a syndrome of muscle damage, with release of intracellular contents into circulation. It is characterized by marked elevations of creatinine kinase levels and myoglobinuria. In this article, we describe a series of 5 cases who were admitted with COVID-19 pneumonia and had severe muscle injury, as demonstrated by significant elevation (>5 times upper limit of normal) of creatinine kinase levels likely secondary to SARS-CoV-2 virus. The median age for these patients was 65 years, and most of them suffered from diabetes and hyperlipidemia. All patients were hypertensive males. Four out of 5 patients had preserved kidney function at baseline and were chronic kidney disease (CKD) stage 2 or better. However, most of them suffered significant kidney injury and at the time of discharge one patient was CKD stage 2 or better, 2 were CKD stage 3 or worse, and 2 patients had renal failure and died due to complications of SARS-CoV-2 infection.

Rhabdomyolysis in COVID-19 Patients: A Retrospective Observational Study

Background The coronavirus disease 2019 (COVID-19) pandemic has caused significant morbidity and mortality worldwide. Knowledge about the pathophysiology of the disease and its effect on multiple systems is growing. Kidney injury has been a topic of focus, and rhabdomyolysis is suspected to be one of the contributing mechanisms. However, information on rhabdomyolysis in patients affected by COVID-19 is limited. We aim to describe the incidence, clinical characteristics, and outcomes of patients hospitalized with COVID-19 who developed rhabdomyolysis. Materials and methods A retrospective observational cohort consisted of patients who were admitted and had an outcome between March 16 to May 27, 2020, inclusive of those dates at a single center in the Bronx, New York City. All consecutive inpatients with lab-confirmed COVID-19 were identified. Patients with peak total creatine kinase (CK) over 1,000 U/L were reviewed; 140 patients were included in the study. The main outcomes during hospitalization were new-onset renal replacement therapy and in-hospital mortality. Results The median age was 68 years (range: 21-93); 64% were males. The most common comorbidities were hypertension (73%), diabetes mellitus (47%), and chronic kidney disease (24%). Median CK on admission was 1,323 U/L (interquartile range [IQR]: 775 - 2,848). Median CK on discharge among survivors was 852 (IQR: 170 - 1,788). Median creatinine on admission was 1.78 mg/dL (IQR: 1.23 - 3.06). During hospitalization, 49 patients (35%) received invasive mechanical ventilation, 24 patients (17.1%) were treated with renal replacement therapy (RRT), and 66 (47.1%) died. Conclusions Rhabdomyolysis was a common finding among hospitalized patients with COVID-19 in our hospital in the Bronx. The incidence of new-onset renal replacement therapy and in-hospital mortality is higher in patients who develop rhabdomyolysis. McMahon score, rather than isolated creatine kinase levels, was a statistically significant predictor of new-onset RRT. Clinicians should maintain a high level of suspicion for rhabdomyolysis in COVID-19 patients throughout their admission and use validated scores like McMahon score to devise their treatment plan accordingly.

Acute Kidney Injury and Covid-19: A Scoping Review and Meta-Analysis

Acute kidney injury (AKI) is a fatal complication of the new severe acute respiratory syndrome coronavirus (SARS-CoV-2) which causes COVID-19 disease. Here, we performed a scoping review and meta-analysis including clinical studies on patients with SARS-CoV-2 infection with data on AKI assessment and characteristics, and the overall prevalence of AKI was estimated using a random-effects model. We identified 21 articles which passed the search criteria. All were quantitative observational studies which used a cross-sectional, retrospective, case report, or cohort methodology. This showed that aging, diabetes, cardiovascular disease, previous chronic disease, and other comorbidities were risk factors of AKI. Although the prevalence of proteinuria, hematuria, and increased serum creatinine was reported for up to 60% of the patients with COVID-19, the overall prevalence of AKI was estimated to be 8%. We conclude that although approximately two-thirds of patients with COVID-19 had symptoms of kidney damage, most of these did not meet the diagnostic criteria for AKI. Further studies should be performed to validate biomarkers for improved AKI diagnosis in COVID-19 patients and new treatment options are required to reduce the rate of mortality.

Kidney injury in COVID-19

Coronavirus disease 2019 (COVID-19) continues to affect millions of people around the globe. As data emerge, it is becoming more evident that extrapulmonary organ involvement, particularly the kidneys, highly influence mortality. The incidence of acute kidney injury has been estimated to be 30% in COVID-19 non-survivors. Current evidence suggests four broad mechanisms of renal injury: Hypovolaemia, acute respiratory distress syndrome related, cytokine storm and direct viral invasion as seen on renal autopsy findings. We look to critically assess the epidemiology, pathophysiology and management of kidney injury in COVID-19.

Coronavirus-associated kidney outcomes in COVID-19, SARS, and MERS: a meta-analysis and systematic review

OBJECTIVES

A meta-analysis and systematic review was conducted on kidney-related outcomes of three recent pandemics: SARS, MERS, and COVID-19, which were associated with potentially fatal acute respiratory distress syndrome (ARDS).

METHODS

A search of all published studies until 16 June 2020 was performed. The incidence/prevalence and mortality risk of acute and chronic renal events were evaluated, virus prevalence, and mortality in preexisting hemodialysis patients was investigated.

RESULTS

A total of 58 eligible studies involving 13452 hospitalized patients with three types of coronavirus infection were included. The reported incidence of new-onset acute kidney injury (AKI) was 12.5% (95% CI: 7.6%-18.3%). AKI significantly increased the mortality risk (OR = 5.75, 95% CI 3.75-8.77, p < 0.00001) in patients with coronavirus infection. The overall rate of urgent-start kidney replacement therapy (urgent-start KRT) use was 8.9% (95% CI: 5.0%-13.8%) and those who received urgent-start KRT had a higher risk of mortality (OR = 3.43, 95% CI 2.02-5.85, p < 0.00001). Patients with known chronic kidney disease (CKD) had a higher mortality than those without CKD (OR = 1.97, 95% CI 1.56-2.49, p < 0.00001). The incidence of coronavirus infection was 7.7% (95% CI: 4.9%-11.1%) in prevalent hemodialysis patients with an overall mortality rate of 26.2% (95% CI: 20.6%-32.6%).

CONCLUSIONS

Primary kidney involvement is common with coronavirus infection and is associated with significantly increased mortality. The recognition of AKI, CKD, and urgent-start KRT as major risk factors for mortality in coronavirus-infected patients are important steps in reducing future mortality and long-term morbidity in hospitalized patients with coronavirus infection.

Side Effects of Chloroquine and Hydroxychloroquine on Skeletal Muscle: a Narrative Review

Purpose of Review

Concerning adverse neuromuscular effects, there are quite a few reports about the incidence and prevalence of chloroquine (CQ) and hydroxychloroquine (HCQ) myopathy. Given the above, I decided to explore the relationships of these drugs with skeletal muscle in an attempt to clarify how they affect the muscle now and in the future, as millions of people are using CQ and HCQ.

Recent Findings

The literature review identified 28 publications about CQ/HCQ myopathy, totaling 56 patients, from 1963 to 2020. A compilation of all patients was carried out by computing demographic features, clinical aspects, laboratory exams, and clinical evolution. All articles but two represented a large series about incidence and prevalence of the myopathy. Fifty-nine percent used QC, mean daily dose was 393 mg per day, and mean duration of treatment was 37 months. The predominant underlying diseases were rheumatoid arthritis (42.8%) and lupus erythematosus (26.8%). Respiratory distress was present in 12.5% in patients with proximal muscle weakness (87.2%). Dysphagia and cervical and axial weakness were observed in a smaller percentage. Creatine kinase was elevated in 60.7%, and EMG showed a myopathic pattern in 54%. Muscle biopsy showed a vacuolar pattern in 53.7%, and curvilinear bodies (CB) were the predominant ultrastructural finding (86.8%). After drug withdrawal, 85.4% of patients improved, and 12.7% died from other causes than myopathy.

Summary

CQ and HCQ myopathy has been known for a long time, but the incidence is low, being described only with long-term use. The use of these drugs for a short period has not been reported, although a prolonged elimination half-life of these drugs actually exists.

Extrapulmonary manifestations of COVID-19: Radiologic and clinical overview

COVID-19 is principally a respiratory illness and pulmonary manifestations constitute main presentations of the disease. According to the reported studies, SARS-CoV-2 infection is not limited to the respiratory system and other organs can be also affected. Renal dysfunction, gastrointestinal complications, liver dysfunction, cardiac manifestations, mediastinal findings, neurological abnormalities, and hematological manifestations are among the reported extrapulmonary features. Considering the broad spectrum of clinical manifestations and the increasing worldwide burden of the disease, there is an urgent need to rapidly scale up the diagnostic capacity to detect COVID-19 and its complications. This paper focuses on the most common extrapulmonary manifestations in patients with COVID-19 pneumonia. Further studies are needed to elaborate and confirm the causative relationship between SARS-CoV-2 and the reported extrapulmonary manifestations of COVID-19.

Neurological manifestations in COVID-19 and its possible mechanism

In December 2019, the first cases of the acute respiratory illness now known as Corona Virus Disease 2019 (COVID-19) occurred in Wuhan, Hubei Province, China. The main clinical manifestations of COVID-19 are a fever, dry cough and general weakness, although in some patients, a headache, tight chest, diarrhea, etc. are the first clinical manifestations. Neurological practice is involved in all aspects of medicine, from primary care for patients with migraines to consultations with patients in the intensive care unit. Few disorders spare the nervous system, and newly emerging infections are no exception. As neurologists, we are concerned about the effects of SARS-CoV-2 infections on the nervous system. Multiple neuropathy, rhabdomyolysis, cerebrovascular disease, central nervous system infections and other common neurological diseases require attention during this outbreak.

Case Report: Rhabdomyolysis in a Patient with COVID-19: A Proposed Diagnostic-Therapeutic Algorithm

COVID-19 represents the greatest health challenge of modern years. The spectrum of illness comprises respiratory and non-respiratory manifestations. We report the case of an adult man with COVID-19 who presented with rhabdomyolysis as a principal extrapulmonary manifestation. Our patient presented with dyspnea, fever, and muscle pain. After a comprehensive approach, the diagnosis of COVID-19 and rhabdomyolysis was made. He developed acute kidney injury requiring renal replacement therapy without reversibility, despite optimal treatment. We performed a literature search for similar cases, discuss the potential mechanisms implied, and propose a diagnostic-therapeutic algorithm.

A case of corticosteroid-responsive SARS-CoV-2 related massive rhabdomyolysis

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SARS-CoV-2 infection may present with massive, non-ischemic rhabdomyolysis.

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COVID-19 related rhabdomyolysis may be a sign of an excessive inflammatory response.

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Corticosteroid use can resolve rhabdomyolysis without aggressive fluid replacement.

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Corticosteroid use may prevent progression of COVID-19 in select cases.

The 2019 coronavirus pandemic has united scientific and medical communities in a worldwide quest for understanding the pathophysiology of this rapidly spreading disease in order to develop effective treatments. We present a case of a 46-year-old woman with breast cancer who was found positive for SARS-CoV-2 in a screening test and developed massive rhabdomyolysis (creatinine kinase 87,456 U/liter) as well as new-onset lymphopenia and signs of lung disease starting on the 16th day of clinical surveillance, one month after the last administration of chemotherapy. Nasopharyngeal swab was still positive for SARS-CoV-2 RNA and serology revealed antibody response against the virus.

Considering the possibility of a systemic inflammatory response in the setting of post-chemotherapy immune reconstitution, we avoided aggressive fluid administration and initiated treatment with methylprednisolone and hydroxychloroquine, resulting in rapid clearance of pulmonary infiltrates and creatinine kinase.

Complete resolution after corticosteroid treatment may provide clinicians with a viable treatment option in similar situations and adds to the growing body of evidence pointing to dysregulated immune response as a major contributing factor to disease severity.

Coronavirus Disease 2019-Induced Rhabdomyolysis

Rhabdomyolysis is caused by necrosis of muscles and leakage of intracellular contents into blood circulation. It is most commonly caused by trauma, crush injuries, drugs, toxins, immobilization, compartment syndrome, prolonged surgical procedures, and less likely by infections. Infection-related rhabdomyolysis is rare, but not uncommon, and is seen in both viral and bacterial infections. Extrapulmonary manifestations of coronavirus disease 2019 (COVID-19) include thrombotic like pulmonary emboli, acute cerebrovascular accident, myocardial infarction, cardiac arrhythmias, liver injury, gangrene, diarrhea, acute renal failure, and so on. We here describe a case of COVID-19-induced rhabdomyolysis in a 19-year-old Hispanic male presenting with muscle aches, fatigue, fevers, and no pulmonary symptoms. 

Coronavirus disease 2019 presenting with rhabdomyolysis

Rhabdomyolysis is a clinical condition characterised by the breakdown of skeletal muscle. It has been attributed to viral infections. We describe a case of coronavirus disease 2019 (COVID-19) in a young male who presented with rhabdomyolysis. Myalgia and fatigue are common complaints in COVID-19 patients. We suggest that patients with COVID-19 be screened for rhabdomyolysis in order to facilitate early treatment with intravenous hydration, thus preventing complications such as acute kidney injury.

The neurology of COVID-19 revisited: A proposal from the Environmental Neurology Specialty Group of the World Federation of Neurology to implement international neurological registries

A comprehensive review of the neurological disorders reported during the current COVID-19 pandemic demonstrates that infection with SARS-CoV-2 affects the central nervous system (CNS), the peripheral nervous system (PNS) and the muscle. CNS manifestations include: headache and decreased responsiveness considered initial indicators of potential neurological involvement; anosmia, hyposmia, hypogeusia, and dysgeusia are frequent early symptoms of coronavirus infection. Respiratory failure, the lethal manifestation of COVID-19, responsible for 264,679 deaths worldwide, is probably neurogenic in origin and may result from the viral invasion of cranial nerve I, progressing into rhinencephalon and brainstem respiratory centers. Cerebrovascular disease, in particular large-vessel ischemic strokes, and less frequently cerebral venous thrombosis, intracerebral hemorrhage and subarachnoid hemorrhage, usually occur as part of a thrombotic state induced by viral attachment to ACE2 receptors in endothelium causing widespread endotheliitis, coagulopathy, arterial and venous thromboses. Acute hemorrhagic necrotizing encephalopathy is associated to the cytokine storm. A frontal hypoperfusion syndrome has been identified. There are isolated reports of seizures, encephalopathy, meningitis, encephalitis, and myelitis. The neurological diseases affecting the PNS and muscle in COVID-19 are less frequent and include Guillain-Barré syndrome; Miller Fisher syndrome; polyneuritis cranialis; and rare instances of viral myopathy with rhabdomyolysis. The main conclusion of this review is the pressing need to define the neurology of COVID-19, its frequency, manifestations, neuropathology and pathogenesis. On behalf of the World Federation of Neurology we invite national and regional neurological associations to create local databases to report cases with neurological manifestations observed during the on-going pandemic. International neuroepidemiological collaboration may help define the natural history of this worldwide problem.

Rhabdomyolysis in a Patient With Coronavirus Disease 2019

Coronavirus disease 2019 has rapidly enveloped the world in a pandemic after emerging in Wuhan, China, in December 2019. We describe a 49-year-old man presenting with fever, cough, dyspnea, and myalgia diagnosed with coronavirus disease 2019 along with rhabdomyolysis and acute kidney injury. The creatine phosphokinase was elevated to 23,800 U/L before trending down to normal levels. Rapid identification and treatment with aggressive intravenous hydration and correction of electrolyte abnormalities remain key to successful management. In a pandemic, often atypical presentations of this new disease have to be considered as differentials for early diagnosis and treatment of life-threatening conditions.

Rhabdomyolysis as an initial presentation in a patient diagnosed with COVID-19

The presence of rhabdomyolysis secondary to multiple infections has been reported, predominantly viral, but also bacterial and fungal. It is well known that COVID-19 can present a wide variety of complications during the course of infection; however, the presence of rhabdomyolysis as an initial condition has not been reported so far. We report a case of rhabdomyolysis as an initial presentation in a patient diagnosed with SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) infection.

A Rare Presentation of Coronavirus Disease 2019 (COVID-19) Induced Viral Myositis With Subsequent Rhabdomyolysis

A 38-year-old gentleman with no significant past medical history but had recent COVID-19 exposure presented to the hospital with the chief complaints of fever, shortness of breath, and generalized myalgia. He was unfortunately found to be severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive. Laboratory findings showed creatine kinase (CK) >42,670 U/L along with elevated inflammatory markers and unremarkable creatinine, cardiac troponin level. The cause of his rhabdomyolysis was discovered to be due to COVID-19 as he had no evidence of other viral infections, strenuous exercise, seizure, or other nontraumatic exertional etiologies. He received aggressive fluid resuscitation while we trended his CK levels along with other inflammatory markers throughout his hospitalization course. His diffuse myalgia improved with treatments, and he was found to maintain stable hemodynamics and was subsequently discharged home. 

COVID-19 and neuromuscular disorders

The coronavirus 2019 (COVID-19) pandemic has potential to disproportionately and severely affect patients with neuromuscular disorders. In a short period of time, it has already caused reorganization of neuromuscular clinical care delivery and education, which will likely have lasting effects on the field. This article reviews (1) potential neuromuscular complications of COVID-19, (2) assessment and mitigation of COVID-19-related risk for patients with preexisting neuromuscular disease, (3) guidance for management of immunosuppressive and immunomodulatory therapies, (4) practical guidance regarding neuromuscular care delivery, telemedicine, and education, and (5) effect on neuromuscular research. We outline key unanswered clinical questions and highlight the need for team-based and interspecialty collaboration. Primary goals of clinical research during this time are to develop evidence-based best practices and to minimize morbidity and mortality related to COVID-19 for patients with neuromuscular disorders.

Pediatric COVID-19-associated rhabdomyolysis: a case report

COVID-19 is the illness caused by infection with the novel coronavirus SARS-CoV-2. Although myalgia is common in adults, it has not been noted as a common symptom in children. There have been a few reported cases of COVID-19-associated rhabdomyolysis in adults. This case report describes a 16-year-old boy who presented with fever, myalgias, mild shortness of breath with exertion, and dark-colored urine. COVID-19 PCR was positive. His initial creatinine kinase (CK) level was 427,656 U/L. Serum creatinine was normal for age. He was treated with isotonic intravenous fluids containing sodium bicarbonate to maintain urine output of 100-200 mL/h and urine pH > 7.0. His serum creatinine remained normal throughout the hospital stay and he was discharged on hospital day 12 with a CK of 6526 U/L. To our knowledge, no pediatric cases of COVID-19-associated rhabdomyolysis have been previously reported. Adult cases of rhabdomyolysis have been reported and a few reports have noted patients with elevated CK levels without rhabdomyolysis. Given this pediatric case of COVID-19-associated rhabdomyolysis, pediatric clinicians should be aware of this complication and manage fluids appropriately in order to prevent acute kidney injury.

Severe acute respiratory syndrome (SARS)

This article reviews the virology, history, pathology, epidemiology, clinical presentations, complications, radiology, laboratory testing, diagnosis, treatment, and prevention of severe respiratory distress syndrome, with reference to documented outbreaks of the disease.

Rhabdomyolysis: a review of clinical presentation, etiology, diagnosis, and management

Rhabdomyolysis is a condition that results from many underlying etiologies and can present in a myriad of ways to the emergency physician. However, some clinical and laboratory features are almost always present and, if noted, can help in making the diagnosis. This review article will focus on the presenting symptoms, the various etiologies, the underlying mechanisms, and the current management of pediatric rhabdomyolysis.