Adrenal Insufficiency in Post COVID Patient

         Dr. Bhagwan Mantri¹, Dr. Pratik Katyayan², Dr. Aayushi Gupta³ , Dr. Sundeep Malla⁴,  Dr. Rajesh Meena⁵
 

1. Consultant Pulmonologist, Moolchand Khairatiram Hospital, Delhi

2. Medicine Resident, Moolchand Khairatiram Hospital, Delhi

3. Medicine Resident, Moolchand Khairatiram Hospital, Delhi

4. Consultant, Radiology department, Moolchand Khairatiram Hospital, Delhi

5. Consultant, Medicine department, Moolchand Khairatiram Hospital, Delhi

Corresponding Author: Dr. Bhagwan Mantri, Consultant Pulmonologist, Moolchand Khairatiram Hospital, H-9B , Saket H block, New Delhi.

Copy Right: © 2021 Dr. Bhagwan Mantri. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.  

Received Date: August 06, 2021

Published date: September 01, 2021

Abstract

Background: A novel coronavirus disease (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has affected over 18 crore individuals, claiming more than 38 lakhs lives, till date 24 June 2021, worldwide ever since its mysterious outbreak in Wuhan, China in December 2019.

COVID-19 has a broad spectrum of severity, ranging from asymptomatic to multiorgan dysfunction [1,2,3].

Keyword: Post covid, Cortisol deficiency, Adrenal insufficiency, Post Covid complications.

Introduction

Several complications of COVID-19 already have been described in

?Respiratory failure

?Cardiac and cardiovascular complications.  4,5,6,7

?Thromboembolic complications .8,9,10,11

?Neurologic complications – 12 ,13

Autopsy studies have noted detectable SARS-CoV-2 RNA (and, in some cases, antigen) in the kidneys, liver, heart, brain, and blood in addition to respiratory tract specimens, suggesting that the virus disseminates systemically in some cases; whether direct viral cytopathic effects at these sites contribute to the complications observed is uncertain .14,16,17

Similarly adrenal gland suppression (responsible for secretion of cortisol via Hypothalamo Pituitary Axis) has been already reported as a rare finding in covid patients.

We have also found a rare case of adrenal insufficiency in post covid patient.

Case Reports

A 24-year-old female presented to the emergency department with complaints of dizziness which was on and off since one month which is increased in severity for the last 4-5 days. Patient also has history of blurring of vision which is associated with light-headedness which was present since last five days. No history of fever, loose stool, shortness of breath, chest pain or palpitations, change in intensity of dizziness on changing postures, hearing problem.

Patient has a history of Covid RT PCR positive on 24/4/21. During that time, she was having fever & dry cough for 4 days for which Covid RT PCR was done. Patient had persistent fever till Day 6 of illness for which she  was started on treatment as per covid protocol (including oral steroid therapy from 26 April 2021 to 13th may 2021).

On further evaluation of past history, patient is a known case of polycystic ovarian disease & acyanotic congenital heart disease (fossa ovalis ASD 9mm) with Left to right shunt with post ASD repair status in 2010. Before Covid she was physically active and even involving in boxing activity.

In emergency on arrival, her BP was 80/50, Pulse rate was 72 per minute, bilateral radial pulse volume was low, temperature was 98.6F, oxygen saturation was 98 % on room air, GCS was E4V4M5, bilateral chest was clear, S1S2 was present & no murmurs were audible. Patient was started on iv fluid therapy immediately in the emergency 1.5litres iv fluid was transfused as bolus followed by continuous transfusion. Patient was shifted to the intensive care unit for further management. Despite the fluid therapy her average blood pressure was 90/50 (earlier her baseline BP was 120/70) and had persistent dizziness. Cardiology opinion was taken, echocardiogram was advised which showed situs solitus, normal Inferior vena cava, Left Ventricular ejection fraction of 60% , intact interventricular septum , mild pulmonary stenosis with peak pressure gradient of 25 mm Hg .Covid Rt PCR  sent as per hospital protocol, which came negative . Routine investigations were normal in study (Hemoglobin 10.4gm %, Total Leucocyte Count 4300, SGOT 29, SGPT 37, Urea 21, Creatinine 0.71, Calcium 8.2, Sodium 135, Potassium 3.8). Patient was still hypotensive even after continuous iv fluid infusion.In view of Persistent hypotension despite adequate intravenous fluid therapy with post covid history , adrenal insufficiency was suspected after which blood sample for Serum cortisol & ACTH (reports attached) was sent as per standard timing & iv steroids was started .Serum cortisol came significantly low ,less than 1 microgram per decilitre ( biological reference range at  8 am is 5-23 mcg / dl) , whereas ACTH was under normal range , 19.5pg/ml (  8am reference range is 10-50 pg/ ml) ( report attached ).Endocrinologist opinion was taken, abdominal non contrast  CT  for adrenal gland was advised which showed bilateral normal morphology of adrenal gland. (Fig1&2).Patient was continued on iv hydrocortisone 100 mg stat dose followed by 50 mg twice daily for next 3 days  after which average blood pressure came to 120/70 and patient improved significantly . She was discharged after 3 days, on oral steroids and doing well.

Figure 1

Figure 2

Figure 3

Figure 4