COVID-19 infection may present as severe rhabdomyolysis in children, clinicians in Chicago report. In the journal Pediatrics, they describe a 16-year-old boy presenting with rhabdomyolysis as the first sign of COVID-19, "with extremely elevated creatinine kinase levels, approaching almost 400,000 U/L," Dr. Shawnese Gilpin of John H. Stroger Jr. Hospital of Cook County and co-authors report. With appropriate care, the patient was discharged after a nine-day hospital stay that included care in the pediatric intensive-care unit. Children and adolescents with COVID-19 have increasingly been found to have unique presentations of this disease, including immune thrombocytopenia, respiratory failure, severe thrombocytopenia, multisystem inflammatory syndrome, and myocarditis. Dr. Gilpin and colleagues say theirs is the first published case of rhabdomyolysis as the initial presentation of SARS-CoV-2 in an adolescent. "This case adds to the growing body of literature of a variety of life-threatening manifestations associated with severe acute respiratory syndrome coronavirus 2 infection and highlights the importance of how prompt recognition of these unique presentations of the disease is important to mitigate complications," they write. "Continuous monitoring and publications of novel presentations will be important for clinicians as this disease continues to manifest itself in various ways," they add. A related paper in Pediatrics describes two previously healthy children who suffered disabling arterial ischemic strokes due to acute intracranial large vessel occlusion within three to four weeks of COVID-19 infection. "These cases illustrate that systemic postinfectious arteritis with cerebrovascular involvement may complicate COVID-19 infection in previously healthy school-aged children, and their presentations may overlap but not fulfill criteria for multisystem inflammatory syndrome in children or focal cerebral arteriopathy," write Dr. Brian Appavu of Phoenix Children's Hospital and College of Medicine in Arizona and colleagues. One case involved an 8-year-old American Indian girl who experienced severe iron deficiency anemia requiring blood transfusion and presented with bilateral middle cerebral artery (MCA) distribution strokes three weeks later. The patient underwent successful mechanical thrombectomy of the left MCA but experienced reocclusion of that artery five hours after intervention. The patient also had evidence of cerebral arteritis on catheter angiography and vessel-wall imaging. The other case involved a 16-year old African American boy with evidence of arteritis on brain magnetic resonance angiography and serological markers of cardiac and renal injury accompanied by positive lupus anticoagulant antibodies. Dr. Appavu and colleagues say the children described in this report express clinical features "inconsistent with focal cerebral arteriopathy, including elevated markers of systemic inflammation in both bilateral MCA strokes in one case and multiple organ system dysfunction in the other case. Neither patient fulfilled criteria for multisystem inflammatory syndrome in children, given absence of fever." "Pediatric health care providers should be aware of this COVID-19 complication. Awareness of this entity may facilitate early diagnosis and treatment of affected children. Pediatric patients experiencing stroke generally suffer from diagnostic delays. Prompt recognition of stroke symptoms and early initiation of treatment have been associated with improved clinical outcomes," they advise. —Megan Brooks Source
