SIGNIFICANT CK ELEVATION IN HEAT-EXPOSURE ADULT RHABDOMYOLYSIS WITH CONCURRENT ASYMPTOMATIC SARS-COV2 INFECTION

ABSTRACT

CASE A 59 years old male with past medical history of type 2 diabetes presented in August of 2020 after 2 weeks of leg cramps, nausea, and dark urine that followed several weeks of poor fluid intake during his job as a construction worker. Patient reported that he had a similar episode in 2011, and was diagnosed with rhabdomyolysis with a CK value of 3442. Physical examination revealed a blood pressure of 138/79 mmHg, a pulse of 99 beats/min, respiratory rate of 16 breaths/min, temperature of 36.9 °C, and oxygen saturation of 96% on room air. He was alert and oriented, able to ambulate with pain, and no other significant cardiovascular, pulmonary, neurologic, and gastrointestinal findings. Notable elevation of plasma creatinine of 10.23 mg/dL, BUN of 90mg/dL, sodium of 123 mmol/L, potassium of 5.4 mmol/L, bicarbonate of 15 mmol/L, CRP of 115.4, D-dimer of 4305, Ferritin of 7927, Serum myoglobin of 5320 mcg/L, and total CK of 365148 U/L were noted. Nasopharyngeal swab at presentation was positive for Sars-CoV-2. Patient's urine drug/toxicology screen were negative. The patient was placed on intermittent hemodialysis, and IV fluids were administered. Given his unusually high CK level and COVID-19 positive status, viral myositis associated with COVID-19 was initially suspected. Muscle biopsy showed necrotizing myositis, and ANA titer and myositis specific antibodies were negative. Patient's sole complaint continued to be bilateral lower extremity spasm that gradually improved. The patient was discharged 13 days later with improving kidney functions and total CK of 1683. Patient did not follow up until January of 2021 when he presented to our emergency department for a gunshot wound. His kidney function was back to his baseline at the time. IMPACT/DISCUSSION: Multiple reports in the past 2 years have noted some relationship between rhabdomyolysis and SARS-CoV2 infection, including cases of rhabdomyolysis as a presenting and late complication of severe and mild COVID-19 pneumonia (Valente-Acosta et al, Min et al, and Suwanwongse et a). This case shows both an non- respiratory COVID-19 patient presenting with rhabdomyolysis as well as extremely high presenting CK of 365148 in a non-exercise associated adult rhabdomyolysis. While there are studies that suggests SARS-CoV2 can cause a direct viral injury on muscles, patient's muscle biopsy showing necrotizing myositis rather than direct viral injury suggests that this is not the likely mechanism that aggravated the disease. Rather, given that patient had significantly elevated d-dimer, ferritin, and CRP at presentation, the mechanism may be due to the significant inflammatory responses seen in COVID-19 patients. CONCLUSION: COVID-19 infection, regardless of severity, can significantly exacerbate rhabdomyolysis. Proper inpatient management in such cases can lead to no lasting musculoskeletal or renal complications despite severity. The relationship between COVID-19 infection and severe rhabdomyolysis may be based on the inflammatory responses.