Sex: M
Vaccine: COVID19
Symptoms: Haptoglobin, Investigation, Laboratory test, Metabolic function test, Pain assessment
Clinical narrative: COVID-19 vaccine induced rhabdomyolysis; This is a literature report from the Diabetes & Metabolic Syndrome, 2021, volume 15(4), pages: 102170, DOI: 10.1016/j.dsx.2021.06.007, entitled COVID-19 vaccine induced rhabdomyolysis: Case report with literature review.  Herein the authors present the first case of COVID-19 vaccine-induced rhabdomyolysis to help clinicians easily identify such a problem in newly vaccinated patients. 1.1. Case presentation: The authors present a 21-year-old male patient with a past medical history of asthma who presented to the emergency department for progressively worsening pain and swelling in the lower back for one day after his first Pfizer/BioNTech COVID-19 vaccine injection. He described it as a 5 to 10 out of 10 sharp pain located at his mid to lower back with radiation to his left lateral thigh. The pain worsened with body movement. The patient tried over-the-counter pain medication with limited relief. He also noticed a darkened urine color before he came to the hospital. The patient did not use any medication regularly. He denied excessive exercise, heavy weightlifting or body trauma after vaccination. He had no family history of autoimmune or musculoskeletal diseases, and surgical history was only significant for an uncomplicated appendectomy. Patient endorsed social marijuana use but denied other drug, alcohol, or tobacco use. Transient elevated blood pressure was noticed at the beginning of the hospitalization, but other vital signs were unremarkable. Physical examination was positive for tenderness to the paraspinal lumbar area upon palpation. The straight leg test was negative. Pertinent lab results included Creatinine Phosphokinase (CPK) level more than 22,000 U/L (normal range 20-190 U/L), Aldolase 97.8 U/L (normal range 3.3-10.3 U/L), alanine aminotransferase 165 U/L (normal range 0 to 41 U/L), aspartate aminotransferase 675 U/L (normal range 5-40 U/L), high sensitive C-reactive protein 6.4 mg/L (normal range < 5.0 mg/L) and Lactate dehydrogenase 1525 U/L (normal range 135-225U/L). Urinalysis revealed clear yellow urine with positivity for blood and protein but negativity for Red Blood Cells (RBCs). Basic Metabolic Panel (BMP) showed normal potassium, bicarbonate, Blood Urea Nitrogen, and creatinine levels. Hepatitis B and C panels were negative except for hepatitis B surface antigen. Total and free carnitine levels were within the normal range. SARS-CoV-2 PCR was negative. Anti-aminoacyl-tRNA synthetase antibodies (ab) (includes anti- Jo-1, anti-PL-7, anti-PL-12, anti-EJ, anti-OJ), anti-SRP ab, anti-MI-2 ab, anti-TIF1-gamma ab, anti-MDA5 ab, anti-NXP2 ab, anti-PM/ Scl-100 ab, anti-U3 RNP ab, U2 snRNP Ab, ANTI-U1-RNP AB, anti- Ku antibodies, antieSSeA 52 KD ab IgG, ANA, and HIV antibodies were all negative. ESR, haptoglobin, TSH, and cortisol were in the normal range. No musculoskeletal abnormalities were found on CT scan of the thoracic and lumbar spine. The right upper quadrant sonogram showed no abnormality in the liver, biliary tracts, gallbladder, or pancreas. The patient had been hydrated with high volume IV normal saline for rhabdomyolysis. Morphine was given as needed for muscle pain. Follow-up lab results showed down-trending CPK and AST levels. Electrolyte level and renal functions have been within normal limits throughout the hospitalization. No change of urine color or urine output volume was noticed. The patient felt pain improved after treatments and was discharged after five days of hospital stay. In the patient, rhabdomyolysis was evident by clinical picture with muscular pain and laboratory confirmation showing markedly elevated CPK levels. He was treated adequately with fluids and discharged safely. All possible etiologies for rhabdomyolysis were searched for and were negative. Intake of Marijuana might have shared this problem, although patients have been using it daily and temporal correlation in favor of the vaccine. Also, Hepatitis B was reported in one case report to cause rhabdomyolysis, but the timing of the vaccine just one day before disease onset favors vaccine side effects as the cause of such a problem. Conclusion Although COVID-19 vaccines are generally safe and encouraged for everyone, side effects can happen. Rhabdomyolysis has been documented with COVID-19, but clinicians should be vigilant about the possibility of rhabdomyolysis following COVID-19 vaccination as early diagnosis and treatment carry an excellent prognosis.; Sender's Comments: Based on the information currently available,The casual association between the reported event and suspected vaccine BNT162B2 cannot be completely excluded. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to RAs, Ethics Committees, and Investigators, as appropriate.