COVID-19 and Adrenal Insufficiency: Unmasking the Link

Abstract

We describe a case of a 28-year-old male who presented with general malaise, fatigue, anorexia, occasional epigastric pain, and vomiting a few days after a mild severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Clinical evolution led to weight loss (6 kg in six months) and craving for salty foods. Physical examination revealed dehydration, hypotension, and hyperpigmentation of the skin and mucosal surfaces. Laboratory tests demonstrated normocytic normochromic anemia, acute kidney injury, hyperkalemia, hyponatremia, and compensated metabolic acidosis. Adrenal workup allowed us to establish a diagnosis of adrenal insufficiency (AI) due to autoimmune adrenalitis, considering findings of a low cortisol and positive 21-hydroxylase antibodies (21OH-Abs), as well as high serum renin and adrenocorticotropic hormone (ACTH). Atypical presentations and comorbidities may appear regarding coronavirus disease 2019 (COVID-19), such as the association between COVID-19 and the hypothalamic-pituitary-adrenal (HPA) axis, which may be affected in any patient with SARS-CoV-2 infection, thus making adrenal insufficiency a diagnosis to consider.

Keywords: addison's disease; adrenal cortex; adrenal disorders; adrenal insufficiency (ai); autoimmune adrenal insufficiency; covid-19.

Figure 1. Chronologic timeline of patient's clinical evolution.

SARS-CoV-2: severe acute respiratory syndrome coronavirus 2

Figure 2. Addisonian skin hyperpigmentation.

Figure 3. Addisonian pigmentation of the buccal mucosa (A, yellow arrows) compared to the non-altered buccal mucosa eight months prior (B).