Clinical course and outcome of patients with ACTH-dependent Cushing's syndrome infected with novel coronavirus disease-19 (COVID-19): case presentations

Abstract

Objective: To analyze the clinical presentations of patients with endogenous Cushing's syndrome (CS) affected by Coronavirus disease-19 (COVID-19).

Materials and methods: Patients who were referred to our clinic with active CS from 31st March to 15th May 2020 were screened for COVID-19 using real-time reverse transcriptase-polymerase chain reaction (RT-PCR). Late-night serum cortisol (64-327 nmol/L), late-night salivary cortisol (LNSC) (0.5-9.4 nmol/L), or 24-h urinary free cortisol (24 hUFC) (100-379 nmol/24 h) were measured by electrochemiluminescence immunoassay.

Results: Among 22 patients with active CS we found three cases affected by COVID-19. Nonspecific inflammation markers were within the reference range or slightly elevated in these patients. A 71-year-old woman with newly diagnosed CS (late-night serum cortisol >1750 nmol/L, LNSC 908.6 nmol/L) developed dyspnea as an only symptom and died from bilateral polysegmantal hemorrhagic pneumonia 7 days later. A 38-year-old woman with a 5-year medical history of active Cushing's disease (CD) (late-night serum cortisol 581.3 nmol/L, 24 hUFC 959.7 nmol/24-h) suffered from dyspnea, cough, fever (39.3 °C) and chest pain. Oxygen therapy, antibiotics and symptomatic treatments lead to full recovery 24 days later. A 66-year-old woman with a 4-year medical history of mild CD (late-night serum cortisol 603.4 nmol/L, LNSC 10.03 nmol/L) tested positive for COVID-19 in routine screening and remained asymptomatic.

Conclusions: The outcome of COVID-19 in patients with CS depends on the severity of hypercortisolism. Thus, severe hypercortisolism is a warning sign that CS affected by COVID-19 could require emergency care despite a lack of clinical presentations and low inflammation biomarkers.

Keywords: ACTH-dependent Cushing’s syndrome; COVID-19; Cushing’s disease; Pneumonia; SARS-CoV-2.

Fig. 1

Patient 1 computed tomography (CT) of the lungs 3 days before death. Chest CT with diffuse bilateral pneumonia and air bronchograms in right upper lobe

Fig. 2

Patient 2 computed tomography (CT) of the lungs 1 month after COVID-19 recovery. Resolution of consolidation with minimal residual ground-glass opacities (arrows)

Fig. 3

Patient 3 computed tomography (СT) of the lungs at the time of COVID-19 diagnosis. А CT, axial images. Subsegmental fibroatelectasis (arrows). B CT, axial images. Residual ground-glass opacities with subpleural bands (arrows)