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Volume 26, Number 9—September 2020
Letter

Rhabdomyolysis as Potential Late Complication Associated with COVID-19

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To the Editor: We provide follow-up information on a case discussed in Emerging Infectious Diseases of a man with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection who reportedly had late-onset rhabdomyolysis with lower limb pain and fatigue (1). After the patient was stabilized, he was transferred to Wuhan Union Hospital, where he disclosed symmetric weakness (Medical Research Council grade 4/5) in both lower limbs with weakened deep tendon reflexes and decreased sensation to light touch and pinprick distally. Because weakness and paresthesia persisted after biochemistries normalized, we feel that these observations are not explained solely by rhabdomyolysis.

The patient was discharged 43 days after admission and was able to walk normally but with reduced endurance. Electromyography (day 120) showed motor and sensory fiber involvement in both lower extremities, presenting as axonal injury accompanied by demyelination (Tables 1, 2). Despite his 10-year history of diabetes, the patient reported no history of paresthesia or reduced motor endurance, which ruled against preexisting diabetic neuropathy or myopathy. We believe he developed peripheral neuropathy during his COVID-19 illness, which may have been missed during the acute phase. We are unsure what caused this neuropathy. In addition to hematologic or lymphatic spread, coronaviruses may directly invade the peripheral nerve terminals and interfere with subsequent synaptic transfer (2). Indirect causes, such as cytokine-mediated damage, should also be considered in this patient (3). Finally, thromboembolism has the potential to cause peripheral nerve ischemia and necrosis (4). However, the coagulation indices, including fibrinogen (7.95 g/L, reference 24 g/L), d-dimer (>20 mg/L, reference <0.5mg/L), and fibrinogen degradation products (80 μg/mL, reference <5 μg/mL), were at the highest level at the onset of rhabdomyolysis and gradually decreased with enoxaparin treatment. We cannot offer a definitive diagnosis and were limited by the lack of muscle biopsies and complete electromyography; however, several factors may have caused his peripheral neuropathy.

Dr. He is a neurologist and Dr. Chen is an emergency physician in Fujian Provincial Hospital, Fujian, China. During the COVID-19 outbreak, they worked as a support medical team in the isolation ward of Union Hospital, Tongji Medical College, Wuhan, China.

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Ying-Chao He and Feng ChenComments to Author 

Author affiliations: Fujian Provincial Hospital, Fuzhou, Fujian, China

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References

  1. Jin  M, Tong  Q. Rhabdomyolysis as potential late complication associated with COVID-19. Emerg Infect Dis. 2020;26:161820. DOIPubMed
  2. Jin  M, Tong  Q. Rhabdomyolysis as potential late complication associated with COVID-19. Emerg Infect Dis. 2020 Mar 20 [Epub ahead of print].
  3. Ding  Y, He  L, Zhang  Q, Huang  Z, Che  X, Hou  J, et al. Organ distribution of severe acute respiratory syndrome (SARS) associated coronavirus (SARS-CoV) in SARS patients: implications for pathogenesis and virus transmission pathways. J Pathol. 2004;203:62230. DOIPubMed
  4. Ye  Q, Wang  B, Mao  J. The pathogenesis and treatment of the ‘Cytokine Storm’ in COVID-19. J Infect. 2020;80:60713. DOI
  5. Wichmann  D, Sperhake  J-P, Lütgehetmann  M, Steurer  S, Edler  C, Heinemann  A, et al. Autopsy findings and venous thromboembolism in patients with COVID-19. Ann Intern Med. 2020 May 6 [Epub ahead of print].

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Tables

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Cite This Article

DOI: 10.3201/eid2609.201463

Original Publication Date: August 11, 2020

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Table of Contents – Volume 26, Number 9—September 2020

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Feng Chen, Emergency Department, Fujian Provincial Hospital, Fujian Provincial Clinical College of Fujian Medical University, Fuzhou, Fujian 350001, China

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Page created: August 11, 2020
Page updated: August 20, 2020
Page reviewed: August 20, 2020
The conclusions, findings, and opinions expressed by authors contributing to this journal do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.
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