PC2165: Covid-induced Rhabdomyolysis in an Adolescent Female Without Predisposing Risk Factors

Introduction: Rhabdomyolysis has increasingly been reported as a potential complication of SARS-CoV-2 over the course of the pandemic. Non-exertional rhabdomyolysis has been described in both the acute and recovery periods of COVID-19; however, the majority of these cases involve patients with significant comorbidities or critical illness. In this case, we describe severe COVID-related rhabdomyolysis in an otherwise healthy adolescent female.

Case Description: An 11-year-old girl presented to the hospital for inability to ambulate due to bilateral leg pain. Her symptoms followed a positive nasopharyngeal COVID polymerase chain reaction (PCR) swab and four days of dry cough and malaise. Initial evaluation revealed an elevated creatine kinase level (CK) to 19,000 U/L, as well as evidence of secondary complications including hypovolemia, synthetic liver dysfunction, and acidemia. Reduced lower extremity perfusion on examination raised concerns for compartment syndrome. The patient was admitted for fluid hydration, analgesia, and monitoring. Compartment testing revealed normal pressures and renal function was preserved. She had no clear inciting or predisposing factors by history, aside from positive COVID testing. Specifically, she had no recent exertion, chronic medical conditions, prior episodes of viral myositis or rhabdomyolysis, or elevated body-mass index. The patient required an extended stay for persistent pain and a rise in her CK to 99,000 despite an initial downtrend. She remained hemodynamically stable and without need for oxygen support. Her blood pressures were elevated for the first half of admission, but were within normal values for age once her pain resolved. Additionally, although fever was not present prior to her COVID diagnosis, the patient fevered during her hospitalization and raised concern for multisystem inflammatory syndrome (MIS-C); no further work-up was pursued as fevers self-resolved after 48 hours without additional intervention. A blood culture was also negative. Once the patient demonstrated improved oral intake, independent ambulation, and her CK trended below 5,000, she was successfully discharged home.

Discussion: Non-exertional rhabdomyolysis is a phenomenon more common in pediatric patients than in adults, with the most common etiology in children being viral infections. Amongst pediatric cases of COVID-19-related rhabdomyolysis described thus far, we theorize that obesity or prior severe viral myositis, among other comorbidities, represent possible predisposing factors. This case shows the potential for severe rhabdomyolysis related to COVID in otherwise healthy pediatric patients.

Conclusion: This case report highlights the potential for severe disease manifestations in pediatric patients with acute COVID-19, even among those who have no evident comorbidities or predisposing historical factors. Providers should maintain suspicion for unusual extra-pulmonary processes, as symptoms may be non-specific. Based on the growing body of evidence regarding COVID-19 and rhabdomyolysis, it is likely that this virus should be considered a potential causal pathogen for children presenting with rhabdomyolysis in the setting of febrile or upper respiratory illnesses.