Letter to the Editor
Myopathy associated with severe SARS-CoV-2 infection
Miopatía asociada a infección grave por SARS-CoV-2
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Abenza Abildúa, M.T. Ramírez Prieto, R. Moreno Zabaleta, C. Algarra Lucas, C. Pérez López" "autores" => array:5 [ 0 => array:4 [ "nombre" => "M.J." "apellidos" => "Abenza Abildúa" "email" => array:1 [ 0 => "mjose.abenza@salud.madrid.org" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M.T." "apellidos" => "Ramírez Prieto" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "R." "apellidos" => "Moreno Zabaleta" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "C." "apellidos" => "Algarra Lucas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "C." "apellidos" => "Pérez López" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Sección de Neurología, Hospital Universitario Infanta Sofía, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Sección de Neumología, Hospital Universitario Infanta Sofía, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Neurocirugía, Complejo Universitario La Paz-Cantoblanco-Carlos III, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Miopatía asociada a infección grave por SARS-CoV-2" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1258 "Ancho" => 2953 "Tamanyo" => 235644 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Muscle atrophy in the tibialis anterior (A) and abductor digiti minimi (B).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The SARS-CoV-2 virus first appeared in China in December 2019, and reached Spain several weeks later. While infection mainly causes respiratory symptoms, cases have been reported since the beginning of the pandemic of symptoms suggesting neurological involvement: headache, anosmia, myalgia, asthenia, insomnia, confusion, bradyphrenia, etc. These symptoms have been reported both in mild cases and in more severe cases of COVID-19 requiring orotracheal intubation and intensive care unit (ICU) admission.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A widely accepted hypothesis is that the virus uses the angiotensin-converting enzyme 2 (ACE2) receptor to enter the cell. As the receptor is expressed in glial cells and neurons in physiological conditions, it is logical that the virus could cause neurological symptoms over the course of the infection.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Reports of neurological symptoms associated with the infection are increasingly frequent, and include cases of Guillain-Barré syndrome, stroke, intraparenchymal haemorrhage, and cerebral thrombosis.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–13</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">We present the case of a 45-year-old woman with no relevant history who was admitted to the ICU due to severe respiratory insufficiency secondary to bilateral pneumonia, with positive nasal swab PCR results for SARS-CoV-2; therefore, the patient met the World Health Organization criteria for COVID-19. She stayed in the ICU for 2 weeks, and was treated with hydroxychloroquine, azithromycin, tocilizumab, and ceftriaxone, and a 5-day cycle of high-dose intravenous corticosteroids (250 mg/day). Upon discharge from the ICU, she presented generalised weakness and myalgia. Physical examination revealed marked global muscle atrophy, which was more severe in the lower limbs, especially the tibialis muscles, and in the intrinsic muscles of the hands; no alterations were observed in tactile or pain sensitivity or in proprioception (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Muscle strength was 2/5 in the lower limbs and 3+/5 in the upper limbs. Patellar and biceps reflexes were present. She presented no cognitive alterations or cranial nerve involvement. A brain MRI scan and EEG study performed within 48 hours of admission yielded normal results.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">An electroneuromyography study showed completely normal motor conduction velocity in the median, ulnar, sural, and tibial nerves. F-wave duration was 48 ms in the tibial nerve. The muscle study showed positive sharp waves at rest, reduced motor unit potential amplitude and duration, and no polyphasia, especially in the abductor digiti minimi and the tibialis anterior (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Creatine phosphokinase levels ranged from 642 to 900 U/L.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">We initially suspected Guillain-Barré syndrome or critical illness polyneuropathy; however, given the presence of patellar and biceps reflexes and the short ICU stay, we opted to perform further testing. While creatine phosphokinase levels were not especially elevated, muscle atrophy was very pronounced, given the short duration of immobilisation. Hydroxychloroquine and corticosteroids can cause symptoms of myopathy, but we consider this hypothesis unlikely as the patient only received these drugs for one week. Our final diagnosis was acute inflammatory myopathy secondary to SARS-CoV-2 infection. Progression at 12 weeks was very favourable, and the patient was practically asymptomatic at the end of this period.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Myalgia and asthenia are very common in patients with COVID-19, and appear to be caused by the systemic inflammatory reaction to the virus; these cases of EMG-confirmed myopathy may also be explained by inflammatory causes.</p><p id="par0035" class="elsevierStylePara elsevierViewall">This study was approved by our centre’s research committee.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:1 [ "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Abenza Abildúa MJ, Ramírez Prieto MT, Moreno Zabaleta R, Algarra Lucas C, Pérez López C. Miopatía asociada a infección grave por SARS-CoV-2. Neurología. 2020;35:706–708.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1258 "Ancho" => 2953 "Tamanyo" => 235644 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Muscle atrophy in the tibialis anterior (A) and abductor digiti minimi (B).</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1951 "Ancho" => 2951 "Tamanyo" => 431018 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Electroneuromyography study showing normal conduction velocity and amplitude in the left ulnar nerve (A). Sensory amplitude in the superficial radial nerve was normal (B). Muscle study of the right tibialis anterior revealed small motor unit potential amplitudes, without polyphasic motor unit potentials (C).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:13 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evidence of the COVID-19 virus targeting the CNS: tissue distribution, host-virus interaction, and proposed neurotropic mechanisms" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. Mannan Baig" 1 => "A. Khaleeq" 2 => "A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 0 | 7 |
| 2024 October | 31 | 8 | 39 |
| 2024 September | 45 | 16 | 61 |
| 2024 August | 46 | 15 | 61 |
| 2024 July | 43 | 8 | 51 |
| 2024 June | 40 | 7 | 47 |
| 2024 May | 33 | 11 | 44 |
| 2024 April | 32 | 195 | 227 |
| 2024 March | 58 | 13 | 71 |
| 2024 February | 39 | 10 | 49 |
| 2024 January | 54 | 6 | 60 |
| 2023 December | 74 | 15 | 89 |
| 2023 November | 61 | 4 | 65 |
| 2023 October | 84 | 10 | 94 |
| 2023 September | 64 | 9 | 73 |
| 2023 August | 51 | 7 | 58 |
| 2023 July | 58 | 4 | 62 |
| 2023 June | 60 | 7 | 67 |
| 2023 May | 83 | 9 | 92 |
| 2023 April | 56 | 12 | 68 |
| 2023 March | 24 | 9 | 33 |
| 2023 February | 38 | 9 | 47 |
| 2023 January | 35 | 7 | 42 |
| 2022 December | 61 | 7 | 68 |
| 2022 November | 41 | 17 | 58 |
| 2022 October | 38 | 35 | 73 |
| 2022 September | 31 | 15 | 46 |
| 2022 August | 62 | 11 | 73 |
| 2022 July | 34 | 13 | 47 |
| 2022 June | 31 | 20 | 51 |
| 2022 May | 39 | 15 | 54 |
| 2022 April | 50 | 22 | 72 |
| 2022 March | 57 | 18 | 75 |
| 2022 February | 45 | 10 | 55 |
| 2022 January | 74 | 7 | 81 |
| 2021 December | 70 | 15 | 85 |
| 2021 November | 70 | 8 | 78 |
| 2021 October | 99 | 12 | 111 |
| 2021 September | 120 | 16 | 136 |
| 2021 August | 92 | 31 | 123 |
| 2021 July | 62 | 15 | 77 |
| 2021 June | 148 | 25 | 173 |
| 2021 May | 91 | 37 | 128 |
| 2021 April | 336 | 68 | 404 |
| 2021 March | 247 | 17 | 264 |
| 2021 February | 152 | 35 | 187 |
| 2021 January | 60 | 28 | 88 |
| 2020 December | 38 | 16 | 54 |
| 2020 November | 8 | 10 | 18 |
| 2020 October | 5 | 5 | 10 |
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