Adrenal Insufficiency in Coronavirus Disease 2019

A Case Report

Maryam Heidarpour; Mehrbod Vakhshoori; Saeed Abbasi; Davood Shafie; Nima Rezaei


J Med Case Reports. 2020;14(134) 

In This Article

Case Presentation

On 27 February 2020, a 69-year-old Iranian man was referred to our hospital, complaining of fever, dyspnea, and dry cough. He had a history of hypertension, which was well controlled with antihypertensive agents. His symptoms started 5 days before admission. Initial vital signs included a blood pressure of 130/80 mmHg, heart rate of 109 beats per minute (bpm), respiratory rate of 28 per minute, O2 saturation of 88% on room air, and temperature of 38.3 °C. Laboratory data are shown in Table 1. Due to his respiratory problems, he underwent a chest computed tomography (CT) scan, which showed bilateral and peripheral ground-glass pulmonary opacities suspicious for COVID-19 infection (Figure 1). His reverse transcriptase-polymerase chain reaction (RT-PCR) test became positive. As a COVID-19 diagnosis was finalized, he was hospitalized in an isolated room. The next day, his dyspnea worsened, and he was intubated and transferred to an intensive care unit (ICU). He received oseltamivir (75 mg every 12 hours) and chloroquine (200 mg every 12 hours), according to the national protocol. However, his fever continued to peak at 39 °C. Blood culture, tracheal aspirate, and urine cultures were taken, and empirical antibiotics were prescribed. His status was complicated on the fifth day with an acute hypotensive episode (systolic blood pressure of 65 mmHg) and diarrhea, which initially responded to fluid resuscitation, but recurred 1 hour later. Despite being on multiple vasopressors and intravenously administered hydration, his blood pressure was consistently low. Blood sugar was within the normal ranges. An electrocardiogram showed sinus tachycardia with no ST-T segment changes. Therefore, as his case was suspicious for adrenal insufficiency, hydrocortisone was administered at a dose of 100 mg, followed by 10 mg per hour administered intravenously after taking a blood sample for a random plasma cortisol level measurement. This method has been suggested to be as effective as a four-dose divided intravenous hydrocortisone prescription.[5] The serum total cortisol level was 12 μg/dl, therefore, no cosyntropin stimulation test was ordered.[6] Intravenously administered hydrocortisone had been administered up to 3 days after the stabilization of our patient's clinical status in the absence of a vasopressor prescription. His blood pressure remained stable at 110/75 mmHg, and he did not receive any antihypertensive agents because of a prior history of hypertension. He had several further episodes of hypotension in the absence of any vasopressor agent administration during his ICU admission when his corticosteroid regimen was reduced or withheld to perform repeated serum cortisol levels measurement. During his hospitalization, he had three episodes of fever due to nosocomial infections. He was prescribed antibiotics based on the results of blood, tracheal aspirate, and urine cultures. On the 53rd day, his general condition was good, and he received supplementary oxygen via a venturi mask at 40% as well as daily orally administered prednisolone with a dosage of 10 mg.

Figure 1.

Bilateral and peripheral ground-glass pulmonary opacities