Possible association between rhabdomyolysis and mRNA SARS-CoV-2 vaccination in a patient with RYR1 gene mutation.

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Date: Feb. 22, 2022
Publisher: CMA Impact Inc.
Document Type: Clinical report
Length: 2,640 words
Lexile Measure: 1780L

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A 30-year-old woman presented to hospital 8 days after vaccination against SARS-CoV-2 with the second dose of the Moderna mRNA vaccine. One day postvaccination, she noted flu-like symptoms, including chills and nausea. Three days postvaccination, she developed neuromuscular symptoms, including progressive bilateral upper and lower limb myalgia and weakness. At 7 days, she noticed cola-coloured urine. She had been vaccinated with the first dose of Moderna mRNA SARSCoV-2 vaccine 6 months earlier, and had not displayed these symptoms or any complications.

The patient had no known history of SARS-CoV-2 infection. Her medical history included 5 previous episodes of rhabdomyolysis since age 10, usually triggered by viral infections. She had a previously identified mutation in the ryanodine receptor 1 (RYR1) gene at the canonical splice site (c.12624+1_124+2insT), which increased her risk for development of malignant hyperthermia and rhabdomyolysis. She had not had rhabdomyolysis following previous vaccinations. Additional medical history included schizoaffective disorder, latent tuberculosis 5 years ago, polycystic ovarian syndrome, iron deficiency anemia and obstructive sleep apnea. Her medications were atorvastatin, clozapine, lithium, flupentixol, ferrous gluconate and vitamin D. Her antipsychotic medications had been prescribed since 2015. She had not had any recent dose adjustments or additions to her medication regimen. She reported not taking any herbal or over-the-counter substances.

The patient had no focal neurologic deficits, rashes or arthralgias. She had not had recent strenuous exercise, trauma or prolonged heat exposure, and she reported no alcohol or recreational drug consumption. At presentation, her blood pressure was 143/88 mm Hg, her heart rate was 118 beat/min, her respiratory rate was 16 breaths/min, her oxygen saturation was 98% on room air, and she had a temperature of 36.3[degrees]C. Cardiovascular, respiratory, abdominal and dermatologic examinations were unremarkable. Neurological findings included symmetric muscle power in the proximal and distal upper and lower limbs (4/5 using the Medical Research Council's scale for muscle strength), with an otherwise normal musculoskeletal examination. No altered mental status, diaphoresis, rigidity or hyperreflexia were evident.

Key points

* We report a case of severe rhabdomyolysis in a patient with a ryanodine receptor 1 (RYR1) gene mutation who presented 8 days after receiving a second dose of Moderna mRNA vaccine against SARS-CoV-2.

* Onset of rhabdomyolysis after SARS-CoV-2 vaccination is variable, ranging from less than 24 hours to 7 days after the administration of the vaccine, with symptoms that include limb myalgia, weakness and difficulty ambulating.

* In severe cases of rhabdomyolysis, clinicians should consider neuroleptic malignant syndrome, malignant hyperthermia and serotonin syndrome in their differential diagnosis.

* The mainstay of treatment for rhabdomyolysis is intravenous fluid resuscitation.

* For patients with an underlying medical condition that may make them more susceptible to rhabdomyolysis (e.g., muscle dystrophy, metabolic or mitochondrial myopathy, RYR1-related disease), clinicians should counsel on signs of rhabdomyolysis and should check the patient's creatinine kinase level within 1 week of vaccination.

Our differential diagnosis included rhabdomyolysis, malignant hyperthermia, serotonin syndrome and neuroleptic malignant syndrome, as well as viral infection. Although our patient was taking antipsychotic medication, neuroleptic malignant syndrome and serotonin syndrome were unlikely...

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Gale Document Number: GALE|A693706870