Rhabdomyolysis Associated with Recent SARS-COV-2 Infection in a Patient with Carnitine Palmitoyltransferase II Deficiency

Abstract

Carnitine palmitoyltransferase II deficiency (CPT II) is an autosomal recessive inherited disorder of long-chain fatty acid oxidation in the mitochondrial matrix, resulting in an inability to utilize fat for energy in cells. The most frequent myopathic form occurs in young adults and is associated with recurrent episodes of exercise-induced rhabdomyolysis. The myopathic form is caused by the Ser113Leu mutation of the CPT II gene. Rarely, massive rhabdomyolysis could be complicated by acute kidney injury (AKI), cardiomyopathy, and respiratory insufficiency. We present a case of an 18-year old male with myalgia, muscular weakness, and dark-colored urine after prolonged exercise and a recent mildSARS-CoV-2infection. Massive rhabdomyolysis was diagnosed with markedly increased serum concentrations of myoglobin and creatine kinase, with normal kidney function. The patient experienced two similar episodes in the years 2017 and 2018, with rhabdomyolysis and AKI treated with hemodialysis. After excluding autoimmune and infectious diseases as causes of recurrent rhabdomyolysis, the patient was genetically tested and Ser113Leu mutation of the CPT II gene was confirmed. When a patient presents with myalgia and dark-colored urine triggered by minor physical activities, genetic testing for possible CPT II deficiency should be initiated. TheSARS-CoV-2infection could be a factor that triggers the occurrence of rhabdomyolysis and aggravates the severity of the attack in patients with CPT II deficiency.

Does SARS-Cov-2 Trigger Rhabdomyolysis in Carnitine-Palmitoyltransferase-II Deficiency?

“…Although the title, discussion, and conclusions suggest that there could be a causal link between the previous SARS-CoV-2 infection and rhabdomyolysis, we disagree with such a notion [1]. Generally, such a causal connection is not plucked out of thin air as several cases with SARS-CoV-2 infection triggered rhabdomyolysis have been reported [2].…”

“…The patient had already experienced two other episodes of rhabdomyolysis, one in 2017 and the other in 2018 [1]. The patient recovered completely under extensive fluid replacement therapy without requiring admission to the ICU or hemodialysis [1]. The study is excellent, but has limitations that are cause for concerns and should be discussed.…”

“…The patient recovered completely under extensive fluid replacement therapy without requiring admission to the ICU or hemodialysis [1]. The study is excellent, but has limitations that are cause for concerns and should be discussed.Although the title, discussion, and conclusions suggest that there could be a causal link between the previous SARS-CoV-2 infection and rhabdomyolysis, we disagree with such a notion [1]. Generally, such a causal connection is not plucked out of thin air as several cases with SARS-CoV-2 infection triggered rhabdomyolysis have been reported [2].…”

“…The patient had already experienced two other episodes of rhabdomyolysis, one in 2017 and the other in 2018 [1]. The patient recovered completely under extensive fluid replacement therapy without requiring admission to the ICU or hemodialysis [1]. The study is excellent, but has limitations that are cause for concerns and should be discussed.Although the title, discussion, and conclusions suggest that there could be a causal link between the previous SARS-CoV-2 infection and rhabdomyolysis, we disagree with such a notion [1].…”

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Letter to the EditorWe read with interest the article by Rambabova-Bushljetik et al on an 18 years-old male with carnitine-palmitoyl-transferase-II (CPT-II) deficiency who experienced severe rhabdomyolysis with a maximum creatine-kinase value of 102410U/l three weeks after onset of a mild SARS-CoV-2 infection and two days after a 9 km walk [1]. The patient had already experienced two other episodes of rhabdomyolysis, one in 2017 and the other in 2018 [1]. The patient recovered completely under extensive fluid replacement therapy without requiring admission to the ICU or hemodialysis [1].

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