key: cord-1014761-fzune84r
authors: Chan, Kok Hoe; Farouji, Iyad; Harnoud, Amany Abu; Slim, Jihad
title: Weakness and elevated creatinine kinase as the initial presentation of coronavirus disease 2019 (COVID-19)
date: 2020-05-11
journal: Am J Emerg Med
DOI: 10.1016/j.ajem.2020.05.015
sha: 466b52ca9b7508111e57b038e40a5a17b1b1895d
doc_id: 1014761
cord_uid: fzune84r

COVID-19 is a global public health emergency with more than one million positive cases across the globe. COVID-19 has a multifaceted presentation. We are herein to report two cases of SARS-CoV-2 induced rhabdomyolysis with an initial presentation of weakness and elevated creatinine kinase (CK). Both patients had no respiratory symptoms, they only complained of generalized weakness and were found to have elevated CK. Routine chest X-ray showed bilateral infiltrates in both cases and subsequently reverse-transcription polymerase chain reaction (RT-PCR) for SARS-CoV-2 was positive. To the best of our knowledge, there was only one literature to date documented SARS-CoV-2 induced rhabdomyolysis as a late complication of COVID-19 patient. Our cases showed that elevated CK and rhabdomyolysis can be the sole initial presentation of patients with COVID-19 and total CK should be ordered in every patient on admission.

. Nonetheless, in both of our cases, elevated CK and rhabdomyolysis seem to be the presenting symptom.

Laboratory abnormalities associated with COVID-19 include lymphopenia, prolonged prothrombin time, elevated D-dimer, fibrinogen and lactate dehydrogenase as well as elevated inflammatory markers such as ferritin and CRP [14] [15] [16] . Patient rarely have elevated CK. Bilateral infiltrates and ground-glass opacities were the common findings on chest X-ray and computed tomography (CT) scan of the chest [17] .

Both of our patient presented with typical symptoms of rhabdomyolysis with generalized weakness and muscle pain, although they did not complain of any dark urine. Surprisingly, both patients had no fever or respiratory symptoms at their initial presentation that raise the 

In conclusion, we report two unusual presentation of SARS-CoV-2 induced rhabdomyolysis.

To our knowledge, this atypical presentation of elevated CK and rhabdomyolysis in elderly patients as the initial manifestations of COVID-19 was not reported in the literature yet. Our cases emphasize the need to keep a high suspicion for COVID 19 in elderly patients presenting with non-specific findings, always obtain chest imaging and consider checking inflammatory markers, when in doubt obtain serology or RT-PCR for SARS-CoV-2.

Patient/Health proxy have given the written and oral informed consent to publish the cases including publication of images. 

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