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

Advance in the mechanism and clinical research of myalgia in long COVID

As severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continues to evolve, mortality rates of coronavirus disease 2019 (COVID-19) have significantly decreased. However, a variable proportion of patients exhibit persistent prolonged symptoms of COVID-19 infection (long COVID). This virus primarily attacks respiratory system, but numerous individuals complain persistent skeletal muscle pain or worsening pre-existing muscle pain post COVID-19, which severely affects the quality of life and recovery. Currently, there is limited research on the skeletal muscle pain in long COVID. In this brief review, we review potential pathological mechanisms of skeletal muscle pain in long COVID, and summarize the various auxiliary examinations and treatments for skeletal muscle pain in long COVID. We consider abnormal activation of inflammatory response, myopathy, and neurological damages as pivotal pathological mechanisms of skeletal muscle pain in long COVID. A comprehensive examination is significantly important in order to work out effective treatment plans and relieve skeletal muscle pain. So far, rehabilitation interventions for myalgia in long COVID contain but are not limited to drug, nutraceutical therapy, gut microbiome-targeted therapy, interventional therapy and strength training. Our study provides a potential mechanism reference for clinical researches, highlighting the importance of comprehensive approach and management of skeletal muscle pain in long COVID. The relief of skeletal muscle pain will accelerate rehabilitation process, improve activities of daily living and enhance the quality of life, promoting individuals return to society with profound significance.

Profound Rhabdomyolysis and Viral Myositis Due to SARS-CoV-2: A Case Report

The novel SARS-CoV-2 introduced several new inflammatory conditions including SARS-CoV-2-associated rhabdomyolysis and viral myositis. We present a 22-year-old man who noted a week of cough followed by myalgias, dark-colored urine, and decreased oral intake. He was found to have acute nontraumatic rhabdomyolysis after an acutely positive SARS-CoV-2 test. Initial creatine kinase (CK) level was above the reference range as were liver enzymes reflective of muscle breakdown. Treatment involved fluid resuscitation and pain control, with close monitoring of kidney, liver, and skeletal markers over five days of hospitalization till there was clinical and symptomatic improvement.

Compartment Syndrome of All Extremities in the Setting of COVID-19-Induced Systemic Capillary Leak Syndrome With Superimposed Myositis

Three years following the pandemic's emergence, COVID-19 has continued to affect much of the symptomatic population with widely varied respiratory complaints, fevers, numerous unexpected prodromal manifestations, and unknown long-term consequences. Scattered cases involving myopathies, rhabdomyolysis, and compartment syndrome have also been reported throughout the pandemic. Some similar cases have been attributed to systemic capillary leak syndrome (SCLS). Here, we report the development of compartment syndrome involving all extremities in a 57-year-old vaccinated female known to have COVID-19. In retrospect, we believe the clinical severity and the patient's sudden deterioration can also be attributed to the lesser-known SCLS. Treatment required fasciotomies of both forearms, arms, and legs. This is the most significantly involved case, leading to survival reported thus far. Lab abnormalities, misleading imaging, and symmetric involvement of all extremities posed a significant challenge to proper diagnosis and treatment. This case serves as a reminder for providers to remain cognizant of neurovascular emergencies during the workup of critically ill patients when the presentation is unrecognized and usual treatments are refractory. Its purpose is also to contribute to the global understanding of and response to COVID-19.

Neurological Complications of SARS-CoV-2 Infection and COVID-19 Vaccines: From Molecular Mechanisms to Clinical Manifestations

Coronavirus Disease 2019 (COVID-19) is an infectious disease, caused by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), that reached pandemic proportions in 2020. Despite the fact that it was initially characterized by pneumonia and acute respiratory distress syndrome, it is now clear that the nervous system is also compromised in one third of these patients. Indeed, a significant proportion of COVID-19 patients suffer nervous system damage via a plethora of mechanisms including hypoxia, coagulopathy, immune response to the virus, and the direct effect of SARS-CoV-2 on endothelial cells, neurons, astrocytes, pericytes and microglia. Additionally, a low number of previously healthy individuals develop a variety of neurological complications after receiving COVID-19 vaccines and a large proportion of COVID-19 survivors experience longlasting neuropsychiatric symptoms. In conclusion, COVID-19 is also a neurological disease, and the direct and indirect effects of the virus on the nervous system have a significant impact on the morbidity and mortality of these patients. Here we will use the concept of the neurovascular unit, assembled by endothelial cells, basement membrane, perivascular astrocytes, neurons and microglia, to review the effects of SARS-CoV-2 in the nervous system. We will then use this information to review data published to this date on the neurological manifestations of COVID-19, the post- COVID syndrome and COVID-19 vaccines.

Acute neuromuscular syndromes with respiratory failure during COVID-19 pandemic: where we stand and challenges ahead

Coronavirus disease 2019 (COVID-19), a disease caused by the novel betacoronavirus SARS-COV-2, has become a global pandemic threat. SARS- COV-2 is structurally similar to SARS-COV, and both bind to the angiotensin-converting enzyme 2 (ACE2) receptor to enter human cells. While patients typically present with fever, shortness of breath, sore throat, and cough, in some cases neurologic manifestations occur due to both direct and indirect involvement of the nervous system. Case reports include anosmia, ageusia, central respiratory failure, stroke, acute necrotizing hemorrhagic encephalopathy, toxic-metabolic encephalopathy, headache, myalgia, myelitis, ataxia, and various neuropsychiatric manifestations. Some patients with COVID-19 may present with concurrent acute neuromuscular syndromes such as myasthenic crisis (MC), Guillain–Barré syndrome (GBS) and idiopathic inflammatory myopathies (IIM); these conditions coupled with respiratory failure could trigger a life-threatening condition. Here, we review the current state of knowledge on acute neuromuscular syndromes with respiratory failure related to COVID-19 infection in an attempt to clarify and to manage the muscle dysfunction overlapping SARS-COV-2 infection.

The Musculoskeletal Involvement After Mild to Moderate COVID-19 Infection

COVID-19, a disease caused by the novel coronavirus SARS-CoV-2, has been drastically affecting the daily lives of millions of people. COVID-19 is described as a multiorgan disease that affects not only the respiratory tract of infected individuals, but it has considerable effects on the musculoskeletal system, causing excessive fatigue, myalgia, arthralgia, muscle weakness and skeletal muscle damage. These symptoms can persist for months, decreasing the quality of life of numerous individuals. Curiously, most studies in the scientific literature focus on patients who were hospitalized due to SARS-CoV-2 infection and little is known about the mechanism of action of COVID-19 on skeletal muscles, especially of individuals who had the mild to moderate forms of the disease (non-hospitalized patients). In this review, we focus on the current knowledge about the musculoskeletal system in COVID-19, highlighting the lack of researches investigating the mild to moderate cases of infection and pointing out why it is essential to care for these patients. Also, we will comment about the need of more experimental data to assess the musculoskeletal manifestations on COVID-19-positive individuals.

Long COVID from rheumatology perspective - a narrative review

Long-term sequel of acute COVID-19, commonly referred to as long COVID, has affected millions of patients worldwide. Long COVID patients display persistent or relapsing and remitting symptoms that include fatigue, breathlessness, cough, myalgia, arthralgia, sleep disturbance, cognitive impairment and skin rashes. Due to the shared clinical features, laboratory and imaging findings, long COVID could mimic rheumatic disease posing a diagnostic challenge. Our comprehensive literature review will help rheumatologist to be aware of long COVID manifestations and differentiating features from rheumatic diseases to ensure a timely and correct diagnosis is reached.

Effect of Vitamin D Supplementation on Muscle Status in Old Patients Recovering from COVID-19 Infection

Background and Objectives: Vitamin D, in addition to its effect on mineral homeostasis, plays a key role in muscle metabolism. Vitamin D supplementation is involved in muscle recovery after damage as a consequence of either pathology or after high-intensity exercise. In this context, the aim of this study was to analyze the effect of vitamin D on muscle fitness in elderly patients in the recovery phase after SARS-CoV-2 (COVID-19) infection. Materials and Methods: This pilot study was conducted at the Soria Norte Health Center. The study consisted of a double-blind trial with two groups of men (placebo and vitamin D-supplemented) (n = 15/group). Treatment with vitamin D (cholecalciferol: 2000 IU/day) and placebo was carried out for 6 weeks. Circulating hematological and biochemical parameters (total protein, glucose, vitamin D, urea, uric acid, aspartate aminotransferase/glutamic-oxaloacetic transaminase, alanine aminotransferase/glutamic-pyruvic transaminase, creatine kinase, lactate dehydrogenase, aldolase, gamma-glutamyl transferase and myoglobin) and the hormones cortisol and testosterone were determined. As for respiratory function tests, FEV1 and respiratory flow were also studied. For physical fitness tests, the “six-minute walk test” (6MWT) was used. Results: After vitamin D supplementation, we observed that serum creatine kinase levels returned to optimal values. This change suggests a protective role of vitamin D against muscle catabolism compared to placebo. In terms of physical test results, we observed only slight non-significant improvements, although patients reported feeling better. Conclusions: Vitamin D supplementation produces decreases in indicators of muscle damage, which may ultimately contribute to improving the health status and quality of life of patients who have suffered from COVID-19, during the recovery process.

Myositis in a patient with coronavirus disease 2019: A rare presentation

The world is presently struggling with coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A patient with COVID-19 typically presents with fever, non-productive cough, dyspnea, and myalgia. A 49-year-old female presented with complaints of subacute onset and progressive symmetrical proximal muscle weakness of both upper limbs and lower limbs with no sensory, cranial nerve deficit. She had elevated creatine phosphokinase levels of 906 U/L, an aspartate aminotransferase level of 126 IU/L, a lactate dehydrogenase level of 354 U/L, and an erythrocyte sedimentation rate of 68 mm/1 hr, and magnetic resonance imaging of the pelvis and thigh revealed muscle edema suggestive of myositis. Her reverse transcriptase-polymerase chain reaction result for SARS-CoV-2 was positive. Her evaluation for other causes of myositis was negative. She was managed with intravenous immunoglobulins and supportive care. She showed rapid improvement in symptoms and motor weakness. To our knowledge, this is the first reported case of COVID-19 related disabling myositis in India.

Steroid-Responsive Myositis Associated With Acute Hepatitis E Infection

Acute hepatitis E virus (HEV) infection is usually self-limiting and presents as mild jaundice accompanied by malaise, anorexia, nausea, vomiting, abdominal pain, or fever. Rarely, it can lead to fulminant hepatic failure especially in pregnant women or cause extrahepatic manifestations. We report a case of a young woman already diagnosed with acute HEV infection who presented with a generalized body rash and weakness in all four limbs. She was subsequently diagnosed with inflammatory myositis and treated successfully with steroids. We have reviewed relevant literature for a possible association. Myositis is a rare but known complication of HEV. If timely diagnosed and managed, there is a significant reduction in morbidity.

COVID-19 and Myositis: What We Know So Far

PURPOSE

Myositis as a rare manifestation of COVID-19 is only recently being reported. This review examines the current literature on COVID-19-induced myositis focusing on etiopathogenesis, clinical presentations, diagnostic practices, and therapeutic challenges with immunosuppression, and the difficulties experienced by rheumatologists in established myositis in the COVID-19 era.

RECENT FINDINGS

COVID-19 is associated with a viral myositis attributable to direct myocyte invasion or induction of autoimmunity. COVID-19-induced myositis may be varied in presentation, from typical dermatomyositis to rhabdomyolysis, and a paraspinal affliction with back pain. It may or may not present with acute exponential elevations of enzyme markers such as creatine kinase (CK). Virus-mediated muscle inflammation is attributed to ACE2 (angiotensin-converting enzyme) receptor-mediated direct entry and affliction of muscle fibers, leading on to innate and adaptive immune activation. A greater recognition of the stark similarity between anti-MDA5-positive myositis with COVID-19 has thrown researchers into the alley of exploration - finding common etiopathogenic basis as well as therapeutic strategies. For patients with established myositis, chronic care was disrupted during the pandemic with several logistic challenges and treatment dilemmas leading to high flare rates. Teleconsultation bridged the gap while ushering in an era of patient-led care with the digital transition to tools of remote disease assessment. COVID-19 has brought along greater insight into unique manifestations of COVID-19-related myositis, ranging from direct virus-induced muscle disease to triggered autoimmunity and other etiopathogenic links to explore. A remarkable shift in the means of delivering chronic care has led patients and caregivers worldwide to embrace a virtual shift with teleconsultation and opened doorways to a new era of patient-led care.

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.

Muscle manifestations and CK levels in COVID infection: results of a large cohort of patients inside a Pandemic COVID-19 Area

Objective

To investigate both muscular manifestations and CK levels in a large cohort of patients with COVID-19 infection and to determine whether hyperckemia is associated with morbidity and mortality.

Methods

Data of 615 patients discharged from ASST Ovest Milanese (Milan, Lombardy, Italy) with final diagnosis of COVID-19 infection were retrospectively extracted from electronical medical records from 21 February to 1 May 2020. Patients were descriptively analyzed with respect to the following variables: sex, age, muscular manifestations (myalgia and/or arthralgia), fatigue, respiratory involvement (SARS pneumonia or respiratory failure) and history of falls. Association between patients’ characteristics and CK levels was investigated. In addition, the proportion of patients who died following access to the ER was calculated. Finally, the effect of CK levels and other patients’ features on mortality was estimated using a logistic regression model.

Results

176 (28.6%) patients had raised serum CK levels. CK levels were significantly associated with history of falls, male gender, SARS pneumonia, respiratory failure and in-hospital death. No correlation was found between hyperckemia and muscular manifestations.

Conclusions

Our study provides preliminary evidence that hyperckemia is associated with respiratory failure and fatal outcome in patients with COVID-19 infection.

In these patients, among other testing, CK dosage is recommended.

Survived COVID-19 patient presented with death on arrival: A case report

Introduction and importance

Although Corona virus primarily infects respiratory system, several complications have been reported. The aim of this paper is to report a strange case of corona virus disease presented with death on arrival and survived after rigorous cardiopulmonary resuscitation.

Case presentation

A 35-year-old male present as a sudden loss of consciousness 10 min before admission. The patient was unconscious, pulseless, there was no sign of breathing, the pupils fixed, did not react to light. Blood sugar was 112 mg/dl. Cardiopulmonary resuscitation (CPR) commenced with insertion of two wide bore cannulas. The patient developed ventricular fibrillation. Later, he reverted to pulseless ventricular tachycardia. After several minutes of CPR, the patient returned back to sinus rhythm. He underwent percutaneous coronary intervention and became healthy one month after the intervention.

Clinical discussion

Cardiac involvement in case of COVID-19 might be explained by the presence of the angiotensin-converting enzyme 2 (ACE2) receptor which is a transmembrane soluble protein regulating the local actions of the renin-angiotensin apparatus in cardio-vascular system.

Conclusion

death on arrival could be the first presentation of COVID-19. Aggressive CPR is necessary to revive the victim.

COVID-19-induced sarcopenia and physical deconditioning may require reassessment of surgical risk for patients with cancer

Background

The long-term physiological consequences of SARS-CoV-2 (severe acute respiratory syndrome coronavirus) infection are not known. The ability of COVID-19 to cause chronic illness, sarcopenia, and physical deconditioning may be underestimated and go beyond the anticipated respiratory sequelae. Myalgia, lethargy, and anorexia are common symptoms even in mild to moderate cases and have the potential to exacerbate frailty. How this impacts on risk-stratification for patients requiring surgery for time-critical conditions, such as malignancy, requires further urgent investigation.

Main body

The deleterious effect of sarcopenia and poor physical capacity are well recognised in cancer surgery. This review commentary highlights current evidence which suggests skeletal muscle as an under recognised cause of COVID-19-related functional deconditioning. The mechanisms behind this are via direct (viral induced myositis, nutritional decline, cytokine-mediated myopathy) and indirect mechanisms (social isolation, inactivity, and psychological consequences).

Conclusion

Further mechanistic research is required to explore the processes behind the deconditioning effects of SARS-CoV-2 infection and how this impacts on treatment of malignant disease.

SARS-CoV-2: influence of phosphate and magnesium, moderated by vitamin D, on energy (ATP) metabolism and on severity of COVID-19

The use of vitamin D to reduce the severity of COVID-19 complications is receiving considerable attention, backed by encouraging data. Its purported mode of action is as an immune modulator. Vitamin D, however, also affects the metabolism of phosphate and Mg, which may well play a critical role in SARS-CoV-2 pathogenesis. SARS-CoV-2 may induce a cytokine storm that drains ATP whose regeneration requires phosphate and Mg. These minerals, however, are often deficient in conditions that predispose people to severe COVID-19, including older age (especially males), diabetes, obesity, and usage of diuretics. Symptoms observed in severe COVID-19 also fit well with those seen in classical hypophosphatemia and hypomagnesemia, such as thrombocytopenia, coagulopathy, dysfunction of liver and kidneys, neurologic disturbances, immunodeficiency, failure of heart and lungs, delayed weaning from a respirator, cardiac arrhythmia, seizures, and, finally, multiorgan failure. Deficiencies of phosphate and Mg can be amplified by kidney problems commonly observed in patients with COVID-19 resulting in their wastage into urine. Available data show that phosphate and Mg are deficient in COVID-19, with phosphate showing a remarkable correlation with its severity. In one experiment, patients with COVID-19 were supplemented with a cocktail of vitamin D3, Mg, and vitamin B12, with very encouraging results. We, thus, argue that patients with COVID-19 should be monitored and treated for phosphate and Mg deficiencies, ideally already in the early phases of infection. Supplementation of phosphate and Mg combined with vitamin D could also be implemented as a preventative strategy in populations at risk.

Electrophysiologic findings in patients with COVID-19 and quadriparesia in the northwest of Iran, A case series study and literature review

BACKGROUND

As a global health pandemic, the novel severe acute respiratory syndrome-coronavirus 2 (SARS- CoV2) outbreak began in December 2019 which rapidly spread to more than 200 countries. Respiratory complications and fever are the most obvious symptoms. Sometimes the neurological features are superimposed on the main disease and complicate patient's status.

CASE PRESENTATION

We describe 6 patients with COVID-19 and concomitant quadriparesia who underwent electrodiagnosis using EMG/NCS and results indicated 3 axonal variants of Guillain-Barré syndrome (GBS), including; 2 cases AMAN (acute motor axonal neuropathy), 1 case AMSAN (acute motor and sensory axonal neuropathy), three myopathies, including one combination of CIN/CIM (critical illness neuropathy/critical illness myopathy), one CIM and one acute polymyositis in these cases.

CONCLUSION

Early diagnosis of the neuromuscular disorders of coronavirus could help for correct planning in the treatment of COVID-19 patients. Since GBS and inflammatory myopathies have an autoimmune basis, the immunotherapies such as IVIG, steroids, plasma exchange and other novel treatments as hemoperfusion can promise better and faster recovery in respiratory function and neuromuscular activity among COVID-19 patients who have musculature paralysis concomitantly. However, all these treatments are challenging and further clinical trials should be done to confirm the efficacy and safety of mentioned therapies.

Neurological manifestations of COVID-19: a systematic review and meta-analysis of proportions

BACKGROUND

Coronaviruses mainly affect the respiratory system; however, there are reports of SARS-CoV and MERS-CoV causing neurological manifestations. We aimed at discussing the various neurological manifestations of SARS-CoV-2 infection and to estimate the prevalence of each of them.

METHODS

We searched the following electronic databases; PubMed, MEDLINE, Scopus, EMBASE, Google Scholar, EBSCO, Web of Science, Cochrane Library, WHO database, and ClinicalTrials.gov . Relevant MeSH terms for COVID-19 and neurological manifestations were used. Randomized controlled trials, non-randomized controlled trials, case-control studies, cohort studies, cross-sectional studies, case series, and case reports were included in the study. To estimate the overall proportion of each neurological manifestations, the study employed meta-analysis of proportions using a random-effects model.

RESULTS

Pooled prevalence of each neurological manifestations are, smell disturbances (35.8%; 95% CI 21.4-50.2), taste disturbances (38.5%; 95%CI 24.0-53.0), myalgia (19.3%; 95% CI 15.1-23.6), headache (14.7%; 95% CI 10.4-18.9), dizziness (6.1%; 95% CI 3.1-9.2), and syncope (1.8%; 95% CI 0.9-4.6). Pooled prevalence of acute cerebrovascular disease was (2.3%; 95%CI 1.0-3.6), of which majority were ischaemic stroke (2.1%; 95% CI 0.9-3.3), followed by haemorrhagic stroke (0.4%; 95% CI 0.2-0.6), and cerebral venous thrombosis (0.3%; 95% CI 0.1-0.6).

CONCLUSIONS

Neurological symptoms are common in SARS-CoV-2 infection, and from the large number of cases reported from all over the world daily, the prevalence of neurological features might increase again. Identifying some neurological manifestations like smell and taste disturbances can be used to screen patients with COVID-19 so that early identification and isolation is possible.

Neuromuscular presentations in patients with COVID-19

COVID-19 is caused by the coronavirus SARS-CoV-2 that has an affinity for neural tissue. There are reports of encephalitis, encephalopathy, cranial neuropathy, Guillain-Barrè syndrome, and myositis/rhabdomyolysis in patients with COVID-19. In this review, we focused on the neuromuscular manifestations of SARS-CoV-2 infection. We analyzed all published reports on SARS-CoV-2-related peripheral nerve, neuromuscular junction, muscle, and cranial nerve disorders. Olfactory and gustatory dysfunction is now accepted as an early manifestation of COVID-19 infection. Inflammation, edema, and axonal damage of olfactory bulb have been shown in autopsy of patients who died of COVID-19. Olfactory pathway is suggested as a portal of entry of SARS-CoV-2 in the brain. Similar to involvement of olfactory bulb, isolated oculomotor, trochlear and facial nerve has been described. Increasing reports Guillain-Barrè syndrome secondary to COVID-19 are being published. Unlike typical GBS, most of COVID-19-related GBS were elderly, had concomitant pneumonia or ARDS, more prevalent demyelinating neuropathy, and relatively poor outcome. Myalgia is described among the common symptoms of COVID-19 after fever, cough, and sore throat. Duration of myalgia may be related to the severity of COVID-19 disease. Few patients had muscle weakness and elevated creatine kinase along with elevated levels of acute-phase reactants. All these patients with myositis/rhabdomyolysis had severe respiratory complications related to COVID-19. A handful of patients with myasthenia gravis showed exacerbation of their disease after acquiring COVID-19 disease. Most of these patients recovered with either intravenous immunoglobulins or steroids.

Clinical Characteristics and Multisystem Imaging Findings of COVID-19: An Overview for Orthopedic Surgeons

The COVID-19 pandemic holds widespread implications for global public health, economies, societies, and the practice of orthopedic surgery. As our knowledge of the transmissibility of SARS-CoV-2 and the symptomatology and management of COVID-19 expands, orthopedic surgeons must remain up to date on the latest medical evidence and surgical perspectives. While COVID-19 primarily manifests with pulmonary symptoms, cardiovascular, neurologic, and other major organ systems may also be affected and present with hallmark imaging findings. This article reviews initial and emerging literature on clinical characteristics and imaging findings of COVID-19.

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.

Pathogenesis, clinical manifestations and complications of coronavirus disease 2019 (COVID-19)

Aim: Despite the similarities in the pathogenesis of the beta coronaviruses, the precise infective mechanisms of SARS-CoV-2 remain unclear. Objective: In this review, we aim to focus on the proposed theories behind the pathogenesis of SARS-CoV-2 and highlight the clinical complications related to COVID-19. Methods: We conducted a literature search in Pubmed, Scopus and Google Scholar for the relevant articles regarding clinical complications and pathogenesis of COVID-19. Results: Related articles were included and discussed. Conclusion: Respiratory system and the lungs are the most commonly involved sites of COVID-19 infection. Cardiovascular, liver, kidneys, gastrointestinal and central nervous systems are involved with different frequencies and degrees of severity.

COVID-19 Presenting as Severe Rhabdomyolysis With Normal Renal Function

Coronavirus disease 2019 (COVID-19) continues to increase morbidity and mortality. Early recognition of symptoms, along with prompt intervention, is required to improve patient outcomes. COVID-19 can have a multifaceted presentation, which can be a diagnostic challenge. Here, we report the first case of COVID-19 presenting as severe rhabdomyolysis with creatine kinase > 500,000 U/L with normal renal function in a young adult.

Genetic Polymorphisms Complicate COVID-19 Therapy: Pivotal Role of HO-1 in Cytokine Storm

Coronaviruses are very large RNA viruses that originate in animal reservoirs and include severe acute respiratory distress syndrome (SARS) and Middle East respiratory syndrome (MERS) and other inconsequential coronaviruses from human reservoirs like the common cold. SARS-CoV-2, the virus that causes COVID-19 and is believed to originate from bat, quickly spread into a global pandemic. This RNA virus has a special affinity for porphyrins. It invades the cell at the angiotensin converting enzyme-2 (ACE-2) receptor and binds to hemoproteins, resulting in a severe systemic inflammatory response, particularly in high ACE-2 organs like the lungs, heart, and kidney, resulting in systemic disease. The inflammatory response manifested by increased cytokine levels and reactive oxygen species results in inhibition of heme oxygenase (HO-1), with a subsequent loss of cytoprotection. This has been seen in other viral illness like human immunodeficiency virus (HIV), Ebola, and SARS/MERS. There are a number of medications that have been tried with some showing early clinical promise. This illness disproportionately affects patients with obesity, a chronic inflammatory disease with a baseline excess of cytokines. The majority of the medications used in the treatment of COVID-19 are metabolized by cytochrome P450 (CYP) enzymes, primarily CYP2D6. This is further complicated by genetic polymorphisms of CYP2D6, HO-1, ACE, and ACE-2. There is a potential role for HO-1 upregulation to treat/prevent cytokine storm. Current therapy must focus on antivirals and heme oxygenase upregulation. Vaccine development will be the only magic bullet.