LAUSR

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: SARS-CoV-2 has been known to be primarily linked to pulmonic pathology. Endocrine complications of COVID-19 continue to remain elusive. Specifically, adrenal insufficiency in COVID-19 has been thought to be acquired through steroid use. This case describes a 46-year-old woman who suffered from mild COVID-19 illness without hypoxia or prolonged steroid therapy who developed secondary adrenal insufficiency. CASE PRESENTATION: This 46-year-old female presented to the emergency department with hypoglycemia of 40mg/dL. She had associated symptoms of nausea, fatigue, poor oral intake for 2 days. Her past medical history is significant for scleroderma with pulmonary hypertension, Raynaud's phenomenon, and mild COVID-19 infection four weeks prior to current admission. She was treated with Remdesivir and one dose of dexamethasone. She was discharged home without supplemental oxygen. Vital signs were significant for a low blood pressure at 90/50 and the patient was admitted to the ICU. Physical exam was unremarkable. Her initial labs were significant for hyponatremia (131 mmol/L), and hypoglycemia (40 mg/dL). Further lab work showed a low morning cortisol level of 2.1ug/dL (6-18) and ACTH of 4.2pg/mL (10-50). Her subsequent cosyntropin stimulation test showed low cortisol levels at 1.3 (6-18), 5.4 (8), and 7.9 (16) respectively, indicating adrenal insufficiency. Her other labs were normal including TSH, aldosterone, and renin level. Adrenal autoantibodies to 21-hydroxylase and 17-alpha hydroxylase were negative. She had a CT scan of the abdomen which showed no adrenal lesions. She was started on hydrocortisone 10mg twice daily with rapid resolution of all her symptoms. DISCUSSION: Adrenal insufficiency in COVID-19 typically occurs in the setting of hypothalamic-pituitary-adrenal (HPA) axis suppression due to steroid use. True secondary adrenal insufficiency is rare. SARS-CoV-2 infection has not been known to directly attack the adrenal glands. However, SARS-CoV-2 could induce an autoimmune response against ACTH via molecular mimicry. Another prevailing theory is that thromboembolic events at the adrenal level result in impaired hormone production. Initial assessment starts with AM cortisol and ACTH. If low, patients should undergo corticotropin stimulation testing as the gold standard of diagnosis. A complete work up should include an assay of autoantibodies. Lastly, investigation of potential adrenal lesions should be explored with contrast-enhanced CT scan or MRI. Treatment is straightforward: supplementation of glucocorticoids, 2-3 times daily. CONCLUSIONS: No algorithm currently exists to detect adrenal insufficiency;clinical suspicion should guide further work-up. As COVID-19 adrenal insufficiency has an unclear prognosis, the treatment course is also uncertain. As a patient's symptoms and labs normalize, there is a possibility to discontinue treatment altogether. REFERENCE #1: Heidarpour M, Vakhshoori M, Abbasi S, Shafie D, Rezaei N. Adrenal insufficiency in coronavirus disease 2019: A case report. J Med Case Rep. 2020;14(1):10-13. REFERENCE #2: Scaroni C, Armigliato M, Cannavò S. COVID-19 outbreak and steroids administration: are patients treated for Sars-Cov-2 at risk of adrenal insufficiency? J Endocrinol Invest. 2020;43(7):1035-1036. REFERENCE #3: Bellastella G, Maiorino MI, Esposito K. Endocrine complications of COVID-19: what happens to the thyroid and adrenal glands? J Endocrinol Invest. 2020;43(8):1169-1170. DISCLOSURES: no disclosure on file for Justin Dolan;No relevant relationships by Andrew Kim, source=Web Response No relevant relationships by Amy Van, source=Web Response