ABSTRACT
Introduction: Acute kidney injury (AKI) is a common complication of SARSCoV- 2 infection. Multiple mechanisms have been proposed including acute tubular necrosis (ATN) due to shock, cytokine release syndrome, hypoxia or vascular injury and thrombosis. Direct viral injury to tubular epithelial cells and podocytes has also been described. Rhabdomyolysis has been reported in infection with SARS-CoV, Respiratory Syncytial Virus and Influenza A. Although mild CK elevation was reported in cohorts of patients with COVID-19 and there is a single case report of late onset rhabdomyolysis, overt rhabdomyolysis on presentation has not been described. To our knowledge this is the first patient who presented with signs and symptoms of severe rhabdomyolysis and AKI that was likely secondary to SARS-CoV-2 infection. Case Description: A 51 year-old male with hypertension and diabetes, presented with 2 days of diffuse myalgia and mild dry cough without shortness of breath. He denied trauma, new medications, changes in diet, strenuous exercise or illicit drug use. Physical exam notable for fever and mild tachypnea, but no hypoxia. Lungs were clear and all muscles groups were soft and non-tender. Polymerase chain reaction was positive for SARS-CoV-2. Serum creatinine was 2.4 mg/dL (baseline 1.3 mg/dL), Urinalysis showed 3+ blood, 2+protein and 1-2 RBC per high power field. Initial serum creatinine kinase was 340,000 U/L and peaked at 464,000 U/L on day 4. Serum and urine myoglobin levels were elevated at 15,175 mg/L and >5000 mcg/L respectively on day 5. He received isotonic intravascular (IV) fluids but developed oliguria on day 2, requiring diuresis to maintain urine output. BUN and creatinine increased to 130 and 19 mg/dL respectively by day 8 and hemodialysis was initiated. Renal clearance and urine output then slowly improved, and dialysis was discontinued by day 15. Discussion: Myalgia and fatigue are common symptoms of COVID-19 infection. In addition, dipstick hematuria is reported in up to 10% of patients. Thus diagnosis of rhabdomyolysis and myoglobinuria requires a high index of suspicion. Early consideration and timely diagnosis of rhabdomyolysis and the treatment of myoglobinuria with intravenous fluids is critically important to prevent ATN. However, administration of IV fluids may be challenging in COVID-19 patients at risk of hypoxia and acute respiratory distress syndrome.