Pediatric Nephrology (2020) 35:1517–1520

https://doi.org/10.1007/s00467-020-04617-0

RAPID COMMUNICATION

Pediatric COVID-19-associated rhabdomyolysis: a case report

Ashley M. Gefen 1 & Nancy Palumbo 2 & Suresh K. Nathan 2 & Pamela S. Singer 1 & Laura J. Castellanos-Reyes 1 &
Christine B. Sethna 1

Received: 12 May 2020 / Accepted: 13 May 2020 / Published online: 23 May 2020
# IPNA 2020

Abstract
COVID-19 is the illness caused by infection with the novel coronavirus SARS-CoV-2. Although myalgia is common in adults, it
has not been noted as a common symptom in children. There have been a few reported cases of COVID-19-associated rhabdo-
myolysis in adults. This case report describes a 16-year-old boy who presented with fever, myalgias, mild shortness of breath
with exertion, and dark-colored urine. COVID-19 PCR was positive. His initial creatinine kinase (CK) level was 427,656 U/L.
Serum creatinine was normal for age. He was treated with isotonic intravenous fluids containing sodium bicarbonate to maintain
urine output of 100–200 mL/h and urine pH > 7.0. His serum creatinine remained normal throughout the hospital stay and he was
discharged on hospital day 12 with a CK of 6526 U/L. To our knowledge, no pediatric cases of COVID-19-associated rhabdo-
myolysis have been previously reported. Adult cases of rhabdomyolysis have been reported and a few reports have noted patients
with elevated CK levels without rhabdomyolysis. Given this pediatric case of COVID-19-associated rhabdomyolysis, pediatric
clinicians should be aware of this complication and manage fluids appropriately in order to prevent acute kidney injury.

Keywords SARS-CoV-2 . Coronavirus . Creatine kinase . Children

Introduction usually defined by a serum creatine kinase (CK) of > 1000 U/

L, which is five times the upper limit of normal [11]. Patients
COVID-19 is the illness caused by infection with the novel co- with rhabdomyolysis can be asymptomatic or present with
ronavirus SARS-CoV-2. SARS-CoV-2 first emerged in China in myalgia, weakness, myoglobinuria with dark urine, signifi-
December 2019 and shortly thereafter spread worldwide. In cant electrolyte imbalance, and acute kidney injury [11].
adults, the most common presenting symptoms are fever (76– Rhabdomyolysis in children is commonly caused by viral
91%), cough (63–65%), fatigue (38.5–50%), dyspnea (14–44%), myositis, trauma, connective tissue disorders, and drug over-
anorexia (12–24%), diarrhea (15–28%), and myalgia (11–22%) dose [11]. The most common viral causes of rhabdomyolysis
[1–3]. In children, fever (36–41.5%), cough (19–48.5%), and are influenza A and B viruses followed by HIV and enterovi-
diarrhea (9–12%) are most common [4–6]. Although myalgias ruses [12]. Rarely, other viruses have been reported to cause
are common in adults, no studies in children noted the presence rhabdomyolysis, including coronaviruses such as SARS-
of myalgias [4, 5]. There have been a few reported cases of CoV-1 [12, 13]. Here we present a case of pediatric
COVID-19-associated rhabdomyolysis in adults, but no such COVID-19-associated rhabdomyolysis.
cases have been reported in children [7–10].
Rhabdomyolysis is defined as the breakdown of skeletal
muscle leading to leaking of muscle contents into the extra-
cellular fluid [11]. Although there is no official consensus, it is Case report

A 16-year-old boy with autism spectrum disorder, attention

* Christine B. Sethna
csethna@northwell.edu
deficit hyperactivity disorder, morbid obesity, obstructive
sleep apnea, and eczema presented with fever, myalgias,
1
Division of Pediatric Nephrology, Department of Pediatrics, Cohen shortness of breath with exertion, and dark-colored urine.
Children’s Medical Center of New York, New Hyde Park, NY, USA Five days prior to admission, he began to feel fatigue. Four
2
Department of Pediatrics, Cohen Children’s Medical Center of New days prior to admission, he noted myalgias of his arms, legs,
York, New Hyde Park, NY, USA abdomen, and back, as well as mild shortness of breath on
1518 Pediatr Nephrol (2020) 35:1517–1520

exertion. One day prior to admission, he was evaluated by an On hospital day 2, CK was down to 108,059 U/L. Sodium
urgent care center where he was febrile to 38.9 °C. He denied and albumin normalized. Urine pH was > 7.0. On hospital day
any congestion, rhinorrhea, anosmia, inability to taste, dys- 4, he continued to have significant myalgias requiring acet-
uria, nausea, vomiting, or diarrhea. Of note, he was found to aminophen and morphine. His fluids were reduced to 100 mL/
have cola-colored urine. When asked about the duration of h as his CK had decreased to 53,977 U/L, and his serum
dark urine, he stated it had been occurring for 2 days, but his creatinine remained normal. However, on hospital day 6, his
mother was not certain that his estimation was accurate given CK doubled from the previous day to 159,675 U/L, and his
his autism spectrum disorder. He took acetaminophen inter- fluids were increased back to 200 mL/h. His blood pressures
mittently in the days prior and denied taking any non-steroidal became persistently elevated and amlodipine 5 mg daily was
anti-inflammatory agents. The family history was significant initiated. Starting on hospital day 7, he no longer complained
for hypertension and type 2 diabetes mellitus. of myalgias and did not require further analgesic medications.
In the emergency department, vital signs were as follows: On hospital day 9, his CK was 36,294 U/L and his urine was
maximum temperature of 37.8 °C, heart rate of 122 BPM, respi- negative for blood, so the fluid rate was decreased. Urine
ratory rate of 18–20 breaths/min, and oxygen saturation of 99– myoglobin was resent and was elevated at 45 mcg/L. On hos-
100% on room air. His blood pressure was initially elevated at pital day 11, his CK was 11,732 U/L and urine remained
133/87 mmHg but lowered to normal range without intervention. negative for blood. His fluids were stopped along with his
He was well appearing on exam, with the only focal findings amlodipine as his blood pressures normalized. He was
being pharyngeal erythema and diffuse abdominal pain. Initial discharged on hospital day 12 with a CK of 6526 U/L. The
laboratory work-up revealed a slight elevation in white blood cell CK trend is illustrated in Fig. 1.
count at 10.74 K/uL and slightly low platelets at 138 K/uL.
Serum creatinine was normal for age at 0.89 mg/dL and electro-
lytes were within normal range. AST and ALT were elevated at Discussion
839 U/L and 157 U/L, respectively, and GGT was normal at
37 U/L. Urinalysis showed a pH of 6.0, large blood with 11– Herein, we present a case of severe rhabdomyolysis without
25 RBC/HPF and 6–10 WBC/HPF. Random urine protein-to- acute kidney injury that was associated with COVID-19 in-
creatinine ratio was elevated at 0.81 mg/mg. Kidney ultrasound fection in a pediatric patient. To our knowledge, no cases of
with Doppler and abdominal ultrasound were normal. COVID-19-associated rhabdomyolysis have been previously
Respiratory pathogen PCR panel was negative, but COVID-19 reported in children or adolescents.
PCR was positive. Hepatitis and cytomegalovirus serologies A few adult cases have been reported recently, none of
were negative. Epstein-Barr serologies were indicative of re- which had CK levels nearly as high as our patient’s. In a
solved past infection. Antistreptolysin O screen was not elevated series of 1099 patients with COVID-19 in China, 2 pa-
and throat culture was negative. C3 and C4 were normal. tients were diagnosed with rhabdomyolysis. The ages of
Antinuclear antibody, double-stranded DNA, and anti- these patients were not specified, but of all the study pa-
glomerular basement membrane IgG results were all negative. tients, < 1% of patients were less than 15-years-old [10].
The patient’s CK level was 427,656 U/L. Another group in China analyzed the autopsies of 26 adult
On admission, vital signs were as follows: weight 162 kg, patients with COVID-19 and found pigmented casts asso-
body mass index 54.3 kg/m2 (> 99th percentile), blood pres- ciated with high CK levels in 3 patients [7]. One case of
sure 122/72 mmHg, temperature 37.7 °C, heart rate 110 BPM,
respiratory rate 20 breaths/min, and oxygen saturation of 98–
100% on room air. Physical exam was notable for obesity, 450000
acanthosis nigricans, and tenderness to palpation of distal an- 400000
Creatine Kinase (U/L)

terior lower legs. Repeat CK was 296,396 U/L. Urine myo- 350000
globin was sent but did not result. His sodium decreased to 300000
130 mmol/L, albumin decreased to 3.2 g/dL, and creatinine 250000
remained normal for age at 0.68 mg/dL. Ferritin was normal, 200000
but procalcitonin (0.22 ng/mL), lactate dehydrogenase
150000
(2184 U/L), C-reactive protein (24.9 mg/L), and troponin
100000
(58 ng/L) were elevated. Echocardiogram was normal.
50000
Toxicology screen was negative. Incidentally, hemoglobin
A1c was found to be elevated in the diabetic range at 8.2%. 0
-1 1 2 3 4 5 6 7 8 9 10 11 12
He was given a 1000 mL normal saline bolus and started on
isotonic intravenous fluids containing sodium bicarbonate and Hospital Day
potassium chloride at 200 mL/h. Fig. 1 Creatine kinase trend over time
Pediatr Nephrol (2020) 35:1517–1520 1519

COVID-19-associated rhabdomyolysis was reported in a Data availability Data will be made available upon request.
60-year-old male in Wuhan, China, with a maximum CK
of 17,434 U/L without any subsequent acute kidney injury Compliance with ethical standards
[14]. The only case of COVID-19-associated rhabdomy-
Conflicts of interest The authors declare that they have no conflict of
olysis reported in the USA was of an 88-year-old male
interest.
with a maximum CK of 13,581 U/L with subsequent de-
velopment of mild acute kidney injury that resolved with
intravenous fluid administration [8].
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