SARS-CoV-2 associated rhabdomyolysis in 32 patients

Abstract

Background/aim: This mini-review aims at summarising and discussing previous and recent findings concerning the clinical manifestations, therapeutic management, and outcome of SARS-CoV-2 associated rhabdomyolysis. Materials and methods: literature search in the PubMed database applying appropriate search terms. Results: identified were 26 articles reporting SARS-CoV-2 associated rhabdomyolysis in 32 patients. Age ranged from 16 to 80 years. Four patients were female and 25 male. Onset of rhabdomyolysis was prior to onset of COVID-19 in 7 patients, and after onset of COVID-19 in the remaining patients. Exposure to myotoxic medication was identified in 18 patients. Myotoxic drugs these patients were taking at the time rhabdomyolysis included azithromycin, hydroxy-chloroquine, placitaxel, propofol, imastinib, piperacillin and meropenem, hydrochlorothiazide, and acetaminophen. Peak creatine-kinase values ranged from 328 to >427656 U/l. The outcome was unreported in 8 cases, favourable in 15 cases, incomplete in 3 cases, and lethal in 6 cases. Conclusions: SARS-CoV-2 associated rhabdomyolysis is rare, may be most frequently due to side effects of myotoxic anti-COVID-19 drugs, and only rarely due to virus myositis, and may have a favourable outcome in most patients.

Skeletal Muscle Damage in COVID-19: A Call for Action

“…Meta-analytic studies indicate that myalgia (muscle soreness)/fatigue is the third most common symptom (after unremitting fever and cough) in people with symptomatic SARS-CoV-2 infection [8,9]. The duration of myalgia depends primarily on disease severity [12,13]. Imaging data from hospitalized patients in China showed that muscle ache on admission is associated with abnormal images of the lung, and it predicts poor prognosis, especially in older people [14].…”

“…They also interfere with hormones that promote muscular integrity, such as testosterone [19]. In rare cases, viral-induced myotoxicity was reported [13]. Renal injury noted by macrohematuria or even renal failure is reported along with myalgia in COVID-19 patients with rhabdomyolysis, denoting a possible renal involvement in COVID-19-related muscle damage [13,20].…”

“…In rare cases, viral-induced myotoxicity was reported [13]. Renal injury noted by macrohematuria or even renal failure is reported along with myalgia in COVID-19 patients with rhabdomyolysis, denoting a possible renal involvement in COVID-19-related muscle damage [13,20]. Symptoms conducive to malnutrition, such as anorexia, nausea, and vomiting, are common in some COVID-19 patients pinpointing insufficient energy supply-a primary trigger for the breakdown of body protein to fuel metabolic needs [21][22][23][24][25][26].…”

“…(1) bed rest and being in the prone position for a long time is associated with muscle deconditioning [29][30][31], (2) certain antiviral drugs (e.g., hydroxychloroquine) and medications prescribed to critical patients, such as dexamethasone, evoke muscle damage, with a greater insult in immobile patients [13,15], (3) undernutrition associated with deficient or inappropriate nutritional formula may trigger muscle breakdown for the provision of necessary energy, (4) ICU-acquired weakness develops in critical patients with systemic inflammation (higher blood levels of interleukin (IL)-6, IL-8, IL-10, and fractalkine) [32]-severe COVID-19 patients are susceptible to this condition as one of the disease complications because of the cytokine storm, and (5) intubation and mechanical ventilation trigger body protein loss, including muscle protein, over a short period of time. Patients with a prolonged hospital stay, severe course of the disease, and cytokine storm express a considerable need to be followed up within 100 days following discharge from the hospital [29][30][31]33]. )…”

“…Pectoralis muscle index (cross-sectional areas of the pectoralis muscle/patient's height square (m 2 )) is a valid frailty index that can predict pulmonary functioning, length of hospital stays, and survival [37]. Magnetic resonance imaging (MRI) identified myositis in a case of COVID-19-related rhabdomyolysis [13]. It also uncovered a reduction in the maximal voluntary contraction for quadriceps and biceps in recovering patients (54% and 69% of the predicted normal value, respectively) [38].…”