Top

Current Rheumatology Reports

Published in:

01-08-2021 | Triage | Inflammatory Muscle Disease (L Diederichsen and H Chinoy, Section Editors)

COVID-19 and Myositis: What We Know So Far

Authors: Ahmad Saud, R Naveen, Rohit Aggarwal, Latika Gupta

Published in: Current Rheumatology Reports | Issue 8/2021

Abstract

Purpose

Myositis as a rare manifestation of COVID-19 is only recently being reported. This review examines the current literature on COVID-19-induced myositis focusing on etiopathogenesis, clinical presentations, diagnostic practices, and therapeutic challenges with immunosuppression, and the difficulties experienced by rheumatologists in established myositis in the COVID-19 era.

Recent Findings

COVID-19 is associated with a viral myositis attributable to direct myocyte invasion or induction of autoimmunity. COVID-19-induced myositis may be varied in presentation, from typical dermatomyositis to rhabdomyolysis, and a paraspinal affliction with back pain. It may or may not present with acute exponential elevations of enzyme markers such as creatine kinase (CK). Virus-mediated muscle inflammation is attributed to ACE2 (angiotensin-converting enzyme) receptor–mediated direct entry and affliction of muscle fibers, leading on to innate and adaptive immune activation. A greater recognition of the stark similarity between anti-MDA5-positive myositis with COVID-19 has thrown researchers into the alley of exploration — finding common etiopathogenic basis as well as therapeutic strategies. For patients with established myositis, chronic care was disrupted during the pandemic with several logistic challenges and treatment dilemmas leading to high flare rates. Teleconsultation bridged the gap while ushering in an era of patient-led care with the digital transition to tools of remote disease assessment.

Summary

COVID-19 has brought along greater insight into unique manifestations of COVID-19-related myositis, ranging from direct virus-induced muscle disease to triggered autoimmunity and other etiopathogenic links to explore. A remarkable shift in the means of delivering chronic care has led patients and caregivers worldwide to embrace a virtual shift with teleconsultation and opened doorways to a new era of patient-led care.

Galeotti C, Bayry J. Autoimmune and inflammatory diseases following COVID-19. Nat Rev Rheumatol. 2020 Aug;16(8):413–4.PubMedCrossRef

Hyrich KL, Machado PM. Rheumatic disease and COVID-19: epidemiology and outcomes. Nat Rev Rheumatol. 2021 Feb;17(2):71–2.PubMedCrossRef

3.••

Naveen R, Sundaram TG, Agarwal V, Gupta L. Teleconsultation experience with the idiopathic inflammatory myopathies: a prospective observational cohort study during the COVID-19 pandemic. Rheumatol Int. 2021;41(1):67–76. In a cohort of IIM, one-thirds resorted to voice-based teleconsultation services on an emergency basis. Over a quarter reported relapse, these being eight times more common in JDM than adult IIM.PubMedCrossRef

4.••

Gupta L, Misra DP, Agarwal V, Balan S, Agarwal V. Response to: ‘Telerheumatology in COVID-19 era: a study from a psoriatic arthritis cohort’ by Costa et al. Ann Rheum Dis. 2020:annrheumdis-2020-217953. Patients with IIM were underrepresented among teleconsultations but overrepresented among hospital admissions in the pandemic period, suggesting the need for a tele-triage protocol based on the type of rheumatic disease.

Zuo Y, Estes SK, Ali RA, Gandhi AA, Yalavarthi S, Shi H, et al. Prothrombotic autoantibodies in serum from patients hospitalized with COVID-19. Sci Transl Med. 2020;12(570):eabd3876.PubMedPubMedCentralCrossRef

Paliwal VK, Garg RK, Gupta A, Tejan N. Neuromuscular presentations in patients with COVID-19. Neurol Sci. 2020;41(11):3039–56.PubMedCrossRefPubMedCentral

Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan. China The Lancet. 2020;395(10223):497–506.CrossRef

Madjid M, Safavi-Naeini P, Solomon SD, Vardeny O. Potential effects of coronaviruses on the cardiovascular system: a review. JAMA Cardiol. 2020;5(7):831–40.PubMedCrossRef

Talotta R, Robertson E. Autoimmunity as the comet tail of COVID-19 pandemic. World J Clin Cases. 2020;8(17):3621–44.PubMedPubMedCentralCrossRef

10.

Jin M, Tong Q. Rhabdomyolysis as potential late complication associated with COVID-19. Emerg Infect Dis. 2020;26(7):1618–20.PubMedPubMedCentralCrossRef

11.

Suwanwongse K, Shabarek N. Rhabdomyolysis as a presentation of 2019 novel coronavirus disease. Cureus [Internet]. 2020 Apr 6 [cited 2021 Feb 10]. Available from: https://www.cureus.com/articles/30228-rhabdomyolysis-as-a-presentation-of-2019-novel-coronavirus-disease

12.•

Husain R, Corcuera-Solano I, Dayan E, Jacobi AH, Huang M. Rhabdomyolysis as a manifestation of a severe case of COVID-19: a case report. Radiol Case Rep. 2020;15(9):1633–7.PubMedPubMedCentralCrossRef

13.•

Singh B, Kaur P, Mechineni A, Maroules M. Rhabdomyolysis in COVID-19: report of four cases. Cureus [Internet]. 2020 27 [cited 2021 Feb 10]; Available from: https://www.cureus.com/articles/41837-rhabdomyolysis-in-covid-19-report-of-four-cases

14.•

Taxbro K, Kahlow H, Wulcan H, Fornarve A. Rhabdomyolysis and acute kidney injury in severe COVID-19 infection. BMJ Case Rep. 2020 Sep;13(9):e237616.PubMedPubMedCentralCrossRef

15.•

Beydon M, Chevalier K, Al Tabaa O, Hamroun S, Delettre A-S, Thomas M, et al. Myositis as a manifestation of SARS-CoV-2. Ann Rheum Dis. 2020; annrheumdis-2020-217573.

16.•

Zhang H, Charmchi Z, Seidman RJ, Anziska Y, Velayudhan V, Perk J. COVID-19–associated myositis with severe proximal and bulbar weakness. Muscle Nerve [Internet]. 2020 Sep [cited 2021 Feb 10];62(3). Available from: https://onlinelibrary.wiley.com/doi/abs/10.1002/mus.27003

17••.

Gokhale Y, Patankar A, Holla U, Shilke M, Kalekar L, Karnik ND, et al. Dermatomyositis during COVID-19 pandemic (a case series): is there a cause effect relationship? J Assoc Physicians India. 2020;68(11). This series describes four new cases of typical dermatomyositis where the onset of the illness was preceded by COVID-19 infection, raising the possibility of a direct pathogenic link.

18.••

Mehan WA, Yoon BC, Lang M, Li MD, Rincon S, Buch K. Paraspinal myositis in patients with COVID-19 infection. Am J Neuroradiol. 2020;41(10):1949–52. The importance of this article is for its reporting of para-spinal myositis cases which helps describe this rare complication not commonly reported in the literature following COVID-19 infection as well as re-emphasizing the extent and pervasiveness of the myositis associated with this disease.PubMedCrossRefPubMedCentral

19.

Ferri C, Giuggioli D, Raimondo V, L’Andolina M, Tavoni A, Cecchetti R, et al. COVID-19 and rheumatic autoimmune systemic diseases: report of a large Italian patients series. Clin Rheumatol. 2020 Nov;39(11):3195–204.PubMedPubMedCentralCrossRef

20.•

Sriwastava S, Tandon M, Kataria S, Daimee M, Sultan S. New onset of ocular myasthenia gravis in a patient with COVID-19: a novel case report and literature review. J Neurol [Internet]. 2020 Oct 12 [cited 2021 Feb 10]; Available from: http://link.springer.com/10.1007/s00415-020-10263-1

21.•

Assini A, Gandoglia I, Damato V, Rikani K, Evoli A, Del Sette M. Myasthenia gravis associated with anti-MuSK antibodies developed after SARS-CoV-2 infection. Eur J Neurol. 2021; ene.14721.

22.

Guan W, Ni Z, Hu Y, Liang W, Ou C, He J, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020;382(18):1708–20.PubMedCrossRef

23.

Rivas-García S, Bernal J, Bachiller-Corral J. Rhabdomyolysis as the main manifestation of coronavirus disease 2019. Rheumatology. 2020;59(8):2174–6.PubMedCrossRef

24.

Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395(10229):1054–62.PubMedPubMedCentralCrossRef

25.

Bahouth S, Chuang K, Olson L, Rosenthal D. COVID-19 related muscle denervation atrophy. Skeletal Radiol [Internet]. 2021 Jan 31 [cited 2021 Feb 10]; Available from: http://link.springer.com/10.1007/s00256-021-03721-y

26.•

Almadani M, Shiferson A, Swearingen B, Shih M, Jacob T, Rhee R. Compartment syndrome secondary to viral myositis as initial presentation in COVID-19 patient. J Vasc Surg Cases Innov Tech. 2020 Dec;6(4):524–7.PubMedPubMedCentralCrossRef

27.

Kumar NB. Does COVID-19-related cachexia mimic cancer-related cachexia? Examining mechanisms, clinical biomarkers, and potential targets for clinical management. J Cachexia Sarcopenia Muscle. 2021; jcsm.12681.

28.

Carfì A, Bernabei R, Landi F, for the Gemelli Against COVID-19 Post-Acute Care Study Group. Persistent symptoms in patients after acute COVID-19. JAMA. 2020;324(6):603.PubMedPubMedCentralCrossRef

29.

Vegosen LJ, Weinberg CR, O’Hanlon TP, Targoff IN, Miller FW, Rider LG. Seasonal birth patterns in myositis subgroups suggest an etiologic role of early environmental exposures. Arthritis Rheum. 2007;56(8):2719–28.PubMedPubMedCentralCrossRef

30.

Bolig TC, Abdulaziz N, Schiopu E. Complete recovery from COVID-19 bilateral pneumonia in an immunosuppressed man with immune-mediated necrotizing myopathy. Schiavon F, editor. Case Rep Rheumatol. 2020 Oct 21;2020:1–5.

31.

Fares E, Tayyar R, Pathak K, Damiano C, Kuntz C. Myasthenia gravis crisis triggered by COVID-19. Chest. 2020 Oct;158(4):A734.CrossRef

32.

Aksoy E, Oztutgan T. COVID-19 presentation in association with myasthenia gravis: a case report and review of the literature. Case Rep Infect Dis. 2020;2020:1–4.

33.

Muppidi S, Guptill JT, Jacob S, Li Y, Farrugia ME, Guidon AC, et al. COVID-19-associated risks and effects in myasthenia gravis (CARE-MG). Lancet Neurol. 2020 Dec;19(12):970–1.PubMedPubMedCentralCrossRef

34.

Camelo-Filho AE, Silva AMS, Estephan EP, Zambon AA, Mendonça RH, Souza PVS, et al. Myasthenia gravis and COVID-19: clinical characteristics and outcomes. Front Neurol. 2020;11:1053.PubMedPubMedCentralCrossRef

35.••

Giannini M, Ohana M, Nespola B, Zanframundo G, Geny B, Meyer A. Similarities between COVID-19 and anti-MDA5 syndrome: what can we learn for better care? Eur Respir J. 2020;56(3):2001618. This study draws striking parallels between anti-MDA5 syndrome (an autoimmune disease) and COVID-19 which both present with remarkably similar presentations suggesting that future studies should further examine whether there are similar pathological autoimmune mechanisms or pathways involved in both diseases. The potential role of corticosteroids in treating COVID-19 is discussed as corticosteroids have shown benefit in anti-MDA5 syndrome.PubMedPubMedCentralCrossRef

36.

De Lorenzis E, Natalello G, Gigante L, Verardi L, Bosello SL, Gremese E. What can we learn from rapidly progressive interstitial lung disease related to anti-MDA5 dermatomyositis in the management of COVID-19? Autoimmun Rev. 2020 Nov;19(11):102666.PubMedPubMedCentralCrossRef

37.

Morris AG. Interferons. Immunol Suppl. 1988;1:43–5.PubMed

38.

Sato S, Hoshino K, Satoh T, Fujita T, Kawakami Y, Fujita T, et al. RNA helicase encoded by melanoma differentiation-associated gene 5 is a major autoantigen in patients with clinically amyopathic dermatomyositis: Association with rapidly progressive interstitial lung disease. Arthritis Rheum. 2009 Jul;60(7):2193–200.PubMedCrossRef

39.

Alunno A, Najm A, Machado PM, Bertheussen H, Burmester GR, Carubbi F, et al. EULAR points to consider on pathophysiology and use of immunomodulatory therapies in COVID-19. Ann Rheum Dis. 2021; annrheumdis-2020-219724.

40.

Schoot TS, Kerckhoffs APM, Hilbrands LB, van Marum RJ. Immunosuppressive drugs and COVID-19: a review. Front Pharmacol. 2020;11:1333.PubMedPubMedCentralCrossRef

41.

Elhabyan A, Elyaacoub S, Sanad E, Abukhadra A, Elhabyan A, Dinu V. The role of host genetics in susceptibility to severe viral infections in humans and insights into host genetics of severe COVID-19: A systematic review. Virus Res. 2020;289:198163.PubMedPubMedCentralCrossRef

42.

Ciaffi J, Meliconi R, Ruscitti P, Berardicurti O, Giacomelli R, Ursini F. Rheumatic manifestations of COVID-19: a systematic review and meta-analysis. BMC Rheumatol. 2020;4(1):65.PubMedPubMedCentralCrossRef

43.

Dalakas MC. Guillain-Barré syndrome: The first documented COVID-19–triggered autoimmune neurologic disease: more to come with myositis in the offing. Neurol - Neuroimmunol Neuroinflammation. 2020 Sep;7(5):e781.CrossRef

44.

Aboudounya MM, Heads RJ. COVID-19 and Toll-like receptor 4 (TLR4): SARS-CoV-2 may bind and activate TLR4 to increase ACE2 expression, facilitating entry and causing hyperinflammation. In: Dozio E, editor. Mediators Inflamm. 2021 Jan 14;2021:1–18.

45.••

Megremis S, Walker TDJ, He X, Ollier WER, Chinoy H, Hampson L, et al. Antibodies against immunogenic epitopes with high sequence identity to SARS-CoV-2 in patients with autoimmune dermatomyositis. Ann Rheum Dis. 2020;79(10):1383–6. This study found immunogenic epitopes in patients with dermatomyositis that resemble epitopes from SARS-CoV-2. These epitopes are believed to activate CD8 T cells and should guide further studies looking at inflammatory mechanisms in COVID-19-induced myositis.PubMedCrossRef

46.

Thepmankorn P, Bach J, Lasfar A, Zhao X, Souayah S, Chong ZZ, et al. Cytokine storm induced by SARS-CoV-2 infection: the spectrum of its neurological manifestations. Cytokine. 2021 Feb;138:155404.PubMedCrossRef

47.•

Zhang Q, Shan KS, Minalyan A, O’Sullivan C, Nace T. A rare presentation of Coronavirus Disease 2019 (COVID-19) induced viral myositis with subsequent rhabdomyolysis. Cureus [Internet]. 2020 May 12 [cited 2021 Feb 10]; Available from: https://www.cureus.com/articles/31422-a-rare-presentation-of-coronavirus-disease-2019-covid-19-induced-viral-myositis-with-subsequent-rhabdomyolysis

48.

Naylor CD, Jevnikar AM, Witt NJ. Sporadic viral myositis in two adults. CMAJ Can Med Assoc J J Assoc Medicale Can. 1987 Nov 1;137(9):819–21.

49.

Gupta L, Gupta P. Telecommunication in the Covid19 era: as an assessment tool for patient with dermatomyositis. Indian J Rheum 2021. [in press]. 2021.

50.•

Gupta L, Misra DP, Agarwal V, et al. Management of rheumatic diseases in the time of covid-19 pandemic: perspectives of rheumatology practitioners from India. Ann Rheum Dis 2020. doi:10.1136/annrheumdis-2020-217509. [Epub ahead of print: 16 Apr 2020].

51.••

Gupta L, Lilleker JB, Agarwal V, Chinoy H, Aggarwal R. COVID-19 and myositis – unique challenges for patients. Rheumatology. 2021;60(2):907–10. COVID-19 has incurred a detrimental effect on patients with myositis, with widespread difficulties in procuring medicines, delayed biologic infusions, and disrupted physiotherapy sessions. Such delays and omissions in clinical care may translate to poorer outcomes in the future.PubMedCrossRef

52.

Opinc A, Łukasik Z, Makowska J. The attitude of Polish rheumatology patients towards telemedicine in the age of the COVID-19 pandemic. Reumatologia/Rheumatology. 2020;58(3):134–41.PubMedCrossRef

53.

Kaiser UB, Mirmira RG, Stewart PM. Our response to COVID-19 as endocrinologists and diabetologists. J Clin Endocrinol Metab. 2020;105(5):1299–301.CrossRef

54.

Huang C, Huang L, Wang Y, Li X, Ren L, Gu X, et al. 6-month consequences of COVID-19 in patients discharged from hospital: a cohort study. Lancet. 2021 Jan;397(10270):220–32.PubMedPubMedCentralCrossRef

55.

Hollander JE, Carr BG. Virtually perfect? Telemedicine for Covid-19. N Engl J Med. 2020;382(18):1679–81.PubMedCrossRef

56.

Kocoloski A, Ward C, Koontz D, Oddis C, Aggarwal R. Functional measures and patient home self-assessments in the idiopathic inflammatory myopathies [abstract]. Arthritis Rheumatol [Internet]. 2017 [cited 2021 Feb 13];69 (supp 10). Available from: https://acrabstracts.org/abstract/functional-measures-and-patient-home-self-assessments-in-the-idiopathic-inflammatory-myopathies/

57.

Oldroyd A, Yimer B, Little M, Dixon W, Chinoy H. Daily myositis symptom changes collected via a smartphone-based app are associated with flare occurrence – providing evidence of potential digital biomarkers [abstract]. Arthritis Rheumatol [Internet]. 2020 [cited 2021 Feb 14];72 (supp 10). Available from: https://acrabstracts.org/abstract/daily-myositis-symptom-changes-collected-via-a-smartphone-based-app-are-associated-with-flare-occurrence-providing-evidence-of-potential-digital-biomarkers/.

58.

Ahmed S, Gupta L. Perception about social media use by rheumatology journals: survey among the attendees of IRACON 2019. Indian J Rheumatol 2020;0(0):0.

59.

Lu C-H, Tsang Y-M, Yu C-W, Wu M-Z, Hsu C-Y, Shih TT-F. Rhabdomyolysis: magnetic resonance imaging and computed tomography findings. J Comput Assist Tomogr. 2007 Jun;31(3):368–74.PubMedCrossRef

60.

Delaney-Sathy LO, Fessell DP, Jacobson JA, Hayes CW. Sonography of diabetic muscle infarction with MR imaging, CT, and pathologic correlation. Am J Roentgenol. 2000 Jan;174(1):165–9.CrossRef

61.

Khan FY. Rhabdomyolysis: a review of the literature. Neth J Med. 2009 Oct;67(9):272–83.PubMed

62.

Crum-Cianflone NF. Bacterial, fungal, parasitic, and viral myositis. Clin Microbiol Rev. 2008 Jul;21(3):473–94.PubMedPubMedCentralCrossRef

63.

Pancheri E, Lanzafame M, Zamò A, Angheben A, Sartoris S, Zorzi A, et al. Benign acute viral myositis in African migrants: a clinical, serological, and pathological study. Muscle Nerve. 2019 Nov;60(5):586–90.PubMedCrossRef

64.

Pinal-Fernandez I, Casal-Dominguez M, Mammen AL. Immune-mediated necrotizing myopathy. Curr Rheumatol Rep. 2018 Apr;20(4):21.PubMedPubMedCentralCrossRef

65.

Ritter ML, Pirofski L. Mycophenolate mofetil: effects on cellular immune subsets, infectious complications, and antimicrobial activity. Transpl Infect Dis Off J Transplant Soc. 2009 Aug;11(4):290–7.CrossRef

Title: COVID-19 and Myositis: What We Know So Far
Authors: Ahmad Saud
R Naveen
Rohit Aggarwal
Latika Gupta
Publication date: 01-08-2021
Publisher: Springer US
Keywords: Triage
Diseases of the neuromuscular synapses and muscles
COVID-19
Telemedicine
Dermatomyositis
Myopathy
Published in: Current Rheumatology Reports / Issue 8/2021
Print ISSN: 1523-3774
Electronic ISSN: 1534-6307
DOI: https://doi.org/10.1007/s11926-021-01023-9

Live Webinar | 27-06-2024 | 18:00 (CEST)

Keynote webinar | Spotlight on medication adherence

Reserve your place

Live: Thursday 27th June 2024, 18:00-19:30 (CEST)

WHO estimates that half of all patients worldwide are non-adherent to their prescribed medication. The consequences of poor adherence can be catastrophic, on both the individual and population level.

Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.

Prof. Kevin Dolgin

Prof. Florian Limbourg

Prof. Anoop Chauhan

Developed by: Springer Medicine

Obesity Clinical Trial Summary

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.

Developed by: Springer Medicine

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose

Recent Findings

Summary

Please log in to get access to this content

Other articles of this Issue 8/2021

Enzymatic Machinery of Ubiquitin and Ubiquitin-Like Modification Systems in Chondrocyte Homeostasis and Osteoarthritis

Wind of Change in the Treatment of Childhood-Onset Takayasu Arteritis: a Systematic Review

Imaging in Axial Spondyloarthritis: What is Relevant for Diagnosis in Daily Practice?

MicroRNAs in Axial Spondylarthritis: an Overview of the Recent Progresses in the Field with a Focus on Ankylosing Spondylitis and Psoriatic Arthritis

Current Understanding of Multisystem Inflammatory Syndrome (MIS-C) Following COVID-19 and Its Distinction from Kawasaki Disease

Re-Examining Myofascial Pain Syndrome: Toward Biomarker Development and Mechanism-Based Diagnostic Criteria

Keynote webinar | Spotlight on medication adherence

Live: Thursday 27th June 2024, 18:00-19:30 (CEST)

At a glance: The STEP trials