RESUMO
CASE: A 46-year-old African-American female was evaluated for generalized body aches five days after receiving second dose of COVID mRNA-1273 (Moderna) vaccine. Six months prior, she received her first dose of Ad26 (Johnson & Johnson) vaccine without sequelae, Family history includes maternal systemic lupus erythematous. Patient has a history of cystic acne and, most notably, frequent episodes of muscle aches and weakness. In 2006 and 2016, patient was hospitalized for episodes of rhabdomyolysis after receiving influenza vaccine. Autoimmune myositis was ruled out. She has never received statin medication. In late 2017, she was admitted for rhabdomyolysis after upper respiratory tract infection. She reported dark urine but no rash or arthralgia. Patient had elevated CK 107,737 U/L, AST 379 U/L, and ALT 115 U/L. Her renal function, sed rate, TSH, HIV, influenza, direct Coombs, protein electrophoresis, and antinuclear antibodies were negative or within normal limits. She was treated with IV fluids, pain medication, and discharged. In her current admission for rhabdomyolysis, she presented with dark urine, CK 130,702 U/L, AST 692 U/L, ALT 208 U/L, and D-dimer 1,544 ng/mL. No acute renal injury was noted. Patient was treated with intravenous crystalloids and pain medication. CK and transaminases steadily trended down. Patient was discharged as she was asymptomatic and CK had dropped significantly. IMPACT/DISCUSSION: Rhabdomyolysis can be an adverse event to vaccine administration, most commonly influenza vaccination. Detection of SARS-CoV-2 inside skeletal muscle has not been documented. Reports on COVID- 19 vaccine-induced rhabdomyolysis focus on the type of vaccine the patient received, the number of doses that triggered the event, CK level, and presence of risk factors for developing rhabdomyolysis. Although no pathophysiologic mechanism has been established, several hypotheses exist to explain muscle damage including genetic factors, autoimmune reactions to the virus nucleic material, or external adjuvant. This has been described as autoimmune/inflammatory syndrome induced by adjuvants. Our patient had a history of recurrent episodes of rhabdomyolysis after receiving influenza and COVID immunizations, as well as viral infection. CONCLUSION: The mechanism of our patients' reaction is unknown. Reported cases support autoimmunity as the major risk factor for vaccinerelated rhabdomyolysis. This patient had elevated CK level on subsequent episodes of rhabdomyolysis fitting the pattern where a more exaggerated response of the immune system is observed every time patient is re-exposed to known insult. Genetic predisposition may also play a role. AfricanAmericans have higher prevalence of slow acetylation and carnitine palmitoyltransferase II deficiency, a disorder of fatty acid. The myopathic form presents with high CK values. Therefore, patients should be counseled to seek medical attention when symptoms occur and physicians should consider vaccination as a possible cause.
RESUMO
RATIONALE: New York City (NYC) was an epicenter of the coronavirus disease 2019 (COVID-19) outbreak in the United States during the spring of 2020 with approximately 203,000 laboratory-confirmed cases reported from March to May of 2020. Jamaica Hospital Medical Center (JHMC) and Flushing Hospital Medical Center (FHMC) are both located in Queens, New York, one of the NYC boroughs with the largest number of COVID-19 cases. While managing COVID-19 patients, we observed an increased prevalence of severe hyperglycemia and DKA in COVID-19 patients with increased insulin requirements. We conducted a study to compare the prevalence of DKA, insulin requirements, and time to resolution of DKA from March 15 to May 15 of 2019 to the same period in 2020. This study will help us better manage these patients during this ongoing pandemic. METHODS: This retrospective study included patients aged 18 years and older hospitalized for DKA at JHMC & FHMC between March 15th and May 15th of 2019 and 2020. We looked at age, sex, serum glucose, serum betahydroxybutyrate, steroid use, subcutaneous insulin requirements, time to resolution of DKA, etc., along with clinical notes. Our study was appropriately powered to find a 10 unit increase in daily subcutaneous insulin requirement. The statistical analysis was performed with SPSS version 19.0. Normalcy was assessed with the Shapiro-Wilk test. Statistical significance was assessed with the Mann-Whitney U Test. RESULTS: The number of DKA cases was 27 in 2019 versus 76 in 2020. Out of those 76 cases, 52 of them were COVID-19 positive. There was an increased use of steroids in patients with COVID-19 and DKA compared to the non-COVID-19 patients with DKA. Despite this, there was no statistically significant difference in time to resolution of DKA or insulin requirements in patients with COVID-19 and DKA identified in our study. CONCLUSION: COVID-19 is associated with an increased prevalence of DKA. There is no difference in time to resolution of DKA or insulin requirements in patients with DKA and COVID-19 compared to patients without COVID-19 identified in our study.