Heterotopic Ossification in COVID-19: A case report

Recent publications suggest HO as a non-traumatic sequela of severe COVID-19.The pathogenesis of HO and its association with COVID-19 is unclear.Prolonged immobilization and systemic inflammation may play a role.Cytokine storm associated with COVID-19 upregulates factors linked to HO formation 1 .We present a patient with increased body mass index (BMI) and severe COVID-19, requiring ICU admission and ABSTRACT COVID-19 may inflict damage beyond the respiratory system.The wide range of musculoskeletal complications secondary to acute COVID-19 are a significant source of morbidity in hospitalized patients.We present the case of a 47-year-old obese male with severe COVID-19 requiring four-month hospitalization in the intensive care unit (ICU).The first month of critical care hospitalization was notable for severe respiratory failure requiring sedatives, analgesics and muscle relaxants for the achievement of protective mechanical ventilation (MV).Additionally, the patient suffered multiple organ failure due to thromboembolic and septic complications.He underwent tracheostomy and gastrostomy.At the end of the second month, while the patient was awake, in the process of MV weaning with extensive painful polyneuromyopathy related to his critical illness, a follow-up computed tomography of the abdomen for infectious reasons incidentally revealed heterotopic ossification (HO) in muscles adjacent to hips.HO was further confirmed with plain radiographs of the pelvis.Additional x-rays demonstrated further involvement of knees and right elbow and a Three-phase bone scan revealed two more affected areas, adjacent to the right humerus head and to the inferior angle of the left scapula.The patient was prescribed analgesics and a physical therapy program of passive stretching to retain range of motion while in the ICU.Occurrence of a tracheoesophageal fistula extended further the patients' ICU stay but after its surgical repair the patient continued a rehabilitation program in the Physical Medicine and Rehabilitation Department of another hospital.To the best of our knowledge the current case is the third reported case of a severe COVID-19 patient presenting with widespread HO.COVID-19 and HO occurrence may not be directly associated; however, the need for further studies to fully establish a causal relationship between HO and COVID-19 is evident.