1
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Reimondo G, Solitro F, Puglisi S, Balbi M, Tiranti GM, Perini AME, Cultrera A, Brero D, Botto C, Perotti P, Caramello V, Boccuzzi A, Pia A, Veltri A, Terzolo M. Serendipitous Adrenal Hyperplasia in Patients Admitted to the Emergency Department for Suspected SARS-CoV-2 Infection is Linked to Increased Mortality. Arch Med Res 2024; 55:103010. [PMID: 38805767 DOI: 10.1016/j.arcmed.2024.103010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 05/13/2024] [Accepted: 05/15/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND Few data are available on adrenal morphology in patients with acute diseases, although it is known that endogenous glucocorticoids are essential for survival under stress conditions and that an adequate response is driven by activation of the hypothalamic-pituitary-adrenal (HPA) axis. AIMS The aim of this study was to assess adrenal morphology in patients with acute disease compared with patients with non-acute disease. METHODS This cross-sectional study included: 402 patients admitted to the emergency department (ED) for suspected SARS-CoV-2 infection (March-May, 2020) [main cohort]; 200 patients admitted to the ED for acute conditions (December 2018-February 2019) [control group A]; 200 outpatients who underwent radiological evaluation of non-acute conditions (January-February 2019) [control group B]. Chest and/or abdominal CT scans were reviewed to identify adrenal nodules or hyperplasia. RESULTS In the main cohort, altered adrenal morphology was found in 24.9% of the patients (15.4% adrenal hyperplasia; 9.5% adrenal nodules). The frequency of adrenal hyperplasia was higher both in the main cohort (15.4%) and control group A (15.5%) compared to control group B (8.5%; p = 0.02 and p = 0.03, respectively). In the main cohort, 14.9% patients died within 30 d. According to a multivariate analysis, adrenal hyperplasia was an independent risk factor for mortality (p = 0.04), as were older age (p <0.001) and active cancer (p = 0.01). CONCLUSIONS The notable frequency of adrenal hyperplasia in patients with acute diseases suggests an exaggerated activation of the HPA axis due to stressful conditions. The increased risk of short-term mortality found in patients with adrenal hyperplasia suggests that it may be a possible hallmark of worse prognosis.
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Affiliation(s)
- Giuseppe Reimondo
- Internal Medicine 1, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Federica Solitro
- Radiology Unit, Department of Oncology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Soraya Puglisi
- Internal Medicine 1, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy.
| | - Maurizio Balbi
- Radiology Unit, Department of Oncology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Giorgio Maria Tiranti
- Radiology Unit, Department of Oncology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Anna Maria Elena Perini
- Internal Medicine 1, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Alessandra Cultrera
- Internal Medicine 1, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Dalila Brero
- Internal Medicine 1, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Cristina Botto
- Internal Medicine 1, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Paola Perotti
- Internal Medicine 1, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | | | - Adriana Boccuzzi
- Emergency Medicine, San Luigi Gonzaga Hospital, Orbassano, Italy
| | - Anna Pia
- Internal Medicine 1, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Andrea Veltri
- Radiology Unit, Department of Oncology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Massimo Terzolo
- Internal Medicine 1, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
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2
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Taieb A, Nassim BHS, Asma G, Jabeur M, Ghada S, Asma BA. The Growing Understanding of the Pituitary Implication in the Pathogenesis of Long COVID-19 Syndrome: A Narrative Review. Adv Respir Med 2024; 92:96-109. [PMID: 38392036 PMCID: PMC10886368 DOI: 10.3390/arm92010013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 02/01/2024] [Accepted: 02/06/2024] [Indexed: 02/24/2024]
Abstract
Long COVID-19, also known as post-acute sequelae of SARS-CoV-2 infection, is a condition where individuals who have recovered from the acute phase of COVID-19 continue to experience a range of symptoms for weeks or even months afterward. While it was initially thought to primarily affect the respiratory system, it has become clear that Long COVID-19 can involve various organs and systems, including the endocrine system, which includes the pituitary gland. In the context of Long COVID-19, there is a growing understanding of the potential implications for the pituitary gland. The virus can directly affect the pituitary gland, leading to abnormalities in hormone production and regulation. This can result in symptoms such as fatigue, changes in appetite, and mood disturbances. Long COVID-19, the persistent and often debilitating condition following acute COVID-19 infection, may be explained by deficiencies in ACTH and Growth hormone production from the pituitary gland. Corticotropin insufficiency can result in the dysregulation of the body's stress response and can lead to prolonged feelings of stress, fatigue, and mood disturbances in Long COVID-19 patients. Simultaneously, somatotropin insufficiency can affect growth, muscle function, and energy metabolism, potentially causing symptoms such as muscle weakness, exercise intolerance, and changes in body composition. Recently, some authors have suggested the involvement of the pituitary gland in Post COVID-19 Syndrome. The exact mechanisms of viral action on infected cells remain under discussion, but inflammatory and autoimmune mechanisms are primarily implicated. The aim of our study will be to review the main pituitary complications following COVID-19 infection. Moreover, we will explain the possible involvement of the pituitary gland in the persistence of Post COVID-19 Syndrome.
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Affiliation(s)
- Ach Taieb
- Department of Endocrinology, University Hospital of Farhat Hached Sousse, Sousse 4000, Tunisia; (B.H.S.N.); (G.A.); (S.G.); (B.A.A.)
- Faculty of Medicine of Sousse, University of Sousse, Sousse 4000, Tunisia;
- Laboratory of Exercise Physiology and Pathophysiology, L.R.19ES09, Sousse 4054, Tunisia
| | - Ben Haj Slama Nassim
- Department of Endocrinology, University Hospital of Farhat Hached Sousse, Sousse 4000, Tunisia; (B.H.S.N.); (G.A.); (S.G.); (B.A.A.)
- Faculty of Medicine of Sousse, University of Sousse, Sousse 4000, Tunisia;
| | - Gorchane Asma
- Department of Endocrinology, University Hospital of Farhat Hached Sousse, Sousse 4000, Tunisia; (B.H.S.N.); (G.A.); (S.G.); (B.A.A.)
- Faculty of Medicine of Sousse, University of Sousse, Sousse 4000, Tunisia;
| | - Methnani Jabeur
- Faculty of Medicine of Sousse, University of Sousse, Sousse 4000, Tunisia;
- Laboratory of Exercise Physiology and Pathophysiology, L.R.19ES09, Sousse 4054, Tunisia
| | - Saad Ghada
- Department of Endocrinology, University Hospital of Farhat Hached Sousse, Sousse 4000, Tunisia; (B.H.S.N.); (G.A.); (S.G.); (B.A.A.)
- Faculty of Medicine of Sousse, University of Sousse, Sousse 4000, Tunisia;
| | - Ben Abdelkrim Asma
- Department of Endocrinology, University Hospital of Farhat Hached Sousse, Sousse 4000, Tunisia; (B.H.S.N.); (G.A.); (S.G.); (B.A.A.)
- Faculty of Medicine of Sousse, University of Sousse, Sousse 4000, Tunisia;
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3
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Lauri C, Campagna G, Glaudemans AWJM, Slart RHJA, van Leer B, Pillay J, Colandrea M, Grana CM, Stigliano A, Signore A. SARS-CoV-2 Affects Thyroid and Adrenal Glands: An 18F-FDG PET/CT Study. Biomedicines 2023; 11:2899. [PMID: 38001898 PMCID: PMC10669868 DOI: 10.3390/biomedicines11112899] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 10/12/2023] [Accepted: 10/23/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Since most endocrine glands express ACE-2 receptors and can be infected by SARS-CoV-2 virus, this retrospective multicentre observational study aims to assess the metabolic activity of thyroid and adrenal glands of COVID-19 patients by 18F-FDG PET/CT. METHODS We retrospectively evaluated the 18F-FDG PET/CT scans of COVID-19 patients admitted by three different centres, either in a low-intensity department or in the intensive care unit (ICU). A visual assessment and a semi-quantitative evaluation of areas of interest in thyroid and adrenal glands were performed by recording SUVmax and SUVmean. The 18F-FDG PET/CT uptake in COVID-19 patients was compared with those observed in normal age-matched controls. RESULTS Between March 2020 and March 2022, 33 patients from three different centres (twenty-eight patients in a low-intensity department and five patients in ICU), were studied by 18F-FDG PET/CT during active illness. Seven of them were also studied after clinical remission (3-6 months after disease onset). Thirty-six normal subjects were used as age-matched controls. In the thyroid gland, no statistically significant differences were observed between control subjects and COVID-19 patients at diagnosis. However, at the follow-up PET/CT study, we found a statistically higher SUVmax and SUVmean (p = 0.009 and p = 0.004, respectively) in the thyroid of COVID-19 patients. In adrenal glands, we observed lower SUVmax and SUVmean in COVID-19 patients at baseline compared to control subjects (p < 0.0001) and this finding did not normalize after clinical recovery (p = 0.0018 for SUVmax and p = 0.002 for SUV mean). CONCLUSIONS In our series, we observed persistent low 18F-FDG uptake in adrenal glands of patients at diagnosis of COVID-19 and after recovery, suggesting a chronic hypofunction. By contrast, thyroid uptake was comparable to normal subjects at disease onset, but after recovery, a subgroup of patients showed an increased metabolism, thus possibly suggesting the onset of an inflammatory thyroiditis. Our results should alert clinicians to investigate the pituitary-adrenal axis and thyroid functionality at the time of infection and to monitor them after recovery.
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Affiliation(s)
- Chiara Lauri
- Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, Sant’Andrea University Hospital, “Sapienza” University of Rome, 00161 Rome, Italy; (G.C.); (A.S.)
| | - Giuseppe Campagna
- Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, Sant’Andrea University Hospital, “Sapienza” University of Rome, 00161 Rome, Italy; (G.C.); (A.S.)
| | - Andor W. J. M. Glaudemans
- Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands; (A.W.J.M.G.); (R.H.J.A.S.); (B.v.L.)
| | - Riemer H. J. A. Slart
- Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands; (A.W.J.M.G.); (R.H.J.A.S.); (B.v.L.)
| | - Bram van Leer
- Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands; (A.W.J.M.G.); (R.H.J.A.S.); (B.v.L.)
- Department of Critical Care, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands;
| | - Janesh Pillay
- Department of Critical Care, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands;
| | - Marzia Colandrea
- Nuclear Medicine Division, European Institute of Oncology—IRCCS, 20141 Milan, Italy; (M.C.); (C.M.G.)
| | - Chiara Maria Grana
- Nuclear Medicine Division, European Institute of Oncology—IRCCS, 20141 Milan, Italy; (M.C.); (C.M.G.)
| | - Antonio Stigliano
- Endocrinology, Department of Clinical and Molecular Medicine, Sant’Andrea University Hospital, “Sapienza” University of Rome, 00161 Rome, Italy;
| | - Alberto Signore
- Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, Sant’Andrea University Hospital, “Sapienza” University of Rome, 00161 Rome, Italy; (G.C.); (A.S.)
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4
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Cozzolino A, Hasenmajer V, Newell-Price J, Isidori AM. COVID-19 pandemic and adrenals: deep insights and implications in patients with glucocorticoid disorders. Endocrine 2023; 82:1-14. [PMID: 37338722 PMCID: PMC10462567 DOI: 10.1007/s12020-023-03411-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 05/25/2023] [Indexed: 06/21/2023]
Abstract
PURPOSE Coronavirus disease-19 (COVID-19) has spread throughout the world. It was initially defined as a potentially severe syndrome affecting the respiratory tract, but it has since been shown to be a systemic disease with relevant extrapulmonary manifestations that increase mortality. The endocrine system has been found to be vulnerable to COVID-19 infection. The current review aims to evaluate the available data on the impact of COVID-19 infection and treatment, as well as COVID-19 vaccines, on adrenal gland function, particularly in patients with GC disorders. METHODS A thorough search of published peer-reviewed studies in PubMed was performed using proper keywords. RESULTS Adrenal viral tropism and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) replication in the adrenal glands have been demonstrated, and adrenal insufficiency (AI) is a rare, but potentially severe complication in COVID-19 disease, whose recognition can be difficult if only for the empirical treatments administered in the early stages. Glucocorticoid (GC) treatment have had a pivotal role in preventing clinical deterioration in patients with COVID-19, but long-term GC use may increase COVID-19-related mortality and the development of iatrogenic AI. Patients with GC disorders, especially AI and Cushing's syndrome, have been identified as being at high risk of COVID-19 infection and complications. Published evidence suggests that AI patient awareness and proper education may help adjust GC replacement therapy appropriately when necessary, thereby reducing COVID-19 severity. The COVID-19 pandemic has had an impact on AI management, particularly in terms of adherence to patients' care plans and self-perceived challenges. On the other hand, published evidence suggests that the clinical course of COVID-19 may be affected by the severity of hypercortisolism in patients with CS. Therefore, to ameliorate the risk profile in these patients, cortisol levels should be adequately controlled, along with careful monitoring of metabolic and cardiovascular comorbidities. To date, the COVID-19 vaccine remains the only available tool to face SARS-CoV-2, and it should not be treated differently in patients with AI and CS. CONCLUSION SARS-CoV-2 infection has been linked to adrenal damage and AI is a rare complication in COVID-19 disease, requiring prompt recognition. Educational efforts and patient awareness may reduce COVID-19 severity in patients with AI. Control of cortisol levels and monitoring of complications may improve the clinical course of COVID-19 in patients with CS.
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Affiliation(s)
- Alessia Cozzolino
- Department of Experimental Medicine, Sapienza University of Rome, IT, Rome, Italy
| | - Valeria Hasenmajer
- Department of Experimental Medicine, Sapienza University of Rome, IT, Rome, Italy
| | - John Newell-Price
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, UK
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, IT, Rome, Italy.
- Centre for Rare Diseases (ENDO-ERN accredited), Policlinico Umberto I, Rome, Italy.
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5
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Durcan E, Hacioglu A, Karaca Z, Unluhizarci K, Gonen MS, Kelestimur F. Hypothalamic-Pituitary Axis Function and Adrenal Insufficiency in COVID-19 Patients. Neuroimmunomodulation 2023; 30:215-225. [PMID: 37703857 PMCID: PMC10614450 DOI: 10.1159/000534025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 09/04/2023] [Indexed: 09/15/2023] Open
Abstract
The outbreak of COVID-19 has affected more than half a billion people worldwide and caused more than 6 million deaths since 2019. The responsible virus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), primarily affects the lungs, but it has multisystemic effects. It is well known that dysfunction of multiple endocrine organs may occur during or after COVID-19. Impairment of the hypothalamic-pituitary-adrenal (HPA) axis is of utmost importance as it may lead to death if went undiagnosed. SARS-CoV-2 may cause both primary and secondary adrenal insufficiencies (AIs). The clinical manifestations of AI are generally non-specific and might be attributed to the complications caused by the infection itself. The underlying pathogenetic mechanisms were explained by the immunogenic, vascular effects of the infection or the direct effects of the virus. The diagnosis of AI in critically ill patients with COVID-19 is not straightforward. There is lack of consensus on the cut-off values of basal serum cortisol levels and stimulation tests during the disease. Here we review the literature with a special regard on the evaluation of the HPA axis in patients with COVID-19. We conclude that the possibility of AI should always be kept in mind when dealing with patients with COVID-19, and repeated basal cortisol measurements and the ACTH stimulation test results could guide the clinician during the diagnostic process.
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Affiliation(s)
- Emre Durcan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Aysa Hacioglu
- Department of Endocrinology, Medical School, Erciyes University, Kayseri, Turkey
| | - Zuleyha Karaca
- Department of Endocrinology, Medical School, Erciyes University, Kayseri, Turkey
| | - Kursad Unluhizarci
- Department of Endocrinology, Medical School, Erciyes University, Kayseri, Turkey
| | - Mustafa Sait Gonen
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Fahrettin Kelestimur
- Department of Endocrinology, Medical School, Yeditepe University, Istanbul, Turkey
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6
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Majety P, Erlikh N, Hou R. Vanishing Adrenal Glands: Bilateral Adrenal Hemorrhage With Adrenal Insufficiency in COVID-19 Infection. Cureus 2023. [PMID: 37525808 PMCID: PMC10387330 DOI: 10.7759/cureus.41210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) has been associated with thrombotic and endocrine complications, including adrenal insufficiency in the setting of adrenal hemorrhage. We present a patient diagnosed with antiphospholipid syndrome (APLS) in the setting of COVID-19 infection resulting in bilateral adrenal hemorrhage, subsequently leading to adrenal insufficiency. Acute adrenal hemorrhage is an underrecognized cause of decompensation, multisystem failure, and death in severe illness. Reports of adrenal insufficiency in the setting of COVID-19 infection revealed microscopic infarction, which can increase the risk of hemorrhage. Other mechanisms include severe hyperinflammatory response and cytokine storm leading to endothelial dysfunction, vascular injury, adrenal parenchymal damage, and hemorrhage. COVID-19 infection can be associated with coagulopathy and thromboembolic events and can lead to adrenal hemorrhage. Adrenal insufficiency is life-threatening and needs to be recognized promptly. There can be a latent phase between hemorrhagic events and adrenal failure; hence, close monitoring and timely intervention are important.
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7
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Elhassan YS, Ronchi CL, Wijewickrama P, Baldeweg SE. Approach to the Patient With Adrenal Hemorrhage. J Clin Endocrinol Metab 2023; 108:995-1006. [PMID: 36404284 PMCID: PMC9999363 DOI: 10.1210/clinem/dgac672] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 11/15/2022] [Accepted: 11/16/2022] [Indexed: 11/22/2022]
Abstract
Adrenal hemorrhage is an uncommon, underrecognized condition that can be encountered in several clinical contexts. Diagnosing adrenal hemorrhage is challenging due to its nonspecific clinical features. Therefore, it remains a diagnosis that is made serendipitously on imaging of acutely unwell patients rather than with prospective clinical suspicion. Adrenal hemorrhage can follow abdominal trauma or appear on a background of predisposing conditions such as adrenal tumors, sepsis, or coagulopathy. Adrenal hemorrhage is also increasingly reported in patients with COVID-19 infection and in the context of vaccine-induced immune thrombocytopenia and thrombosis. Unexplained abdominal pain with hemodynamic instability in a patient with a predisposing condition should alert the physician to the possibility of adrenal hemorrhage. Bilateral adrenal hemorrhage can lead to adrenal insufficiency and potentially fatal adrenal crisis without timely recognition and treatment. In this article, we highlight the clinical circumstances that are associated with higher risk of adrenal hemorrhage, encouraging clinicians to prospectively consider the diagnosis, and we share a diagnostic and management strategy.
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Affiliation(s)
- Yasir S Elhassan
- Correspondence: Yasir Elhassan, MBBS, MRCP, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom.
| | - Cristina L Ronchi
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TT, UK
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2WB, UK
- Division of Endocrinology and Diabetes, University Hospital University Würzburg, Würzburg 97080, Germany
| | - Piyumi Wijewickrama
- Department of Diabetes and Endocrinology, University College London Hospital NHS Foundation Trust, London NW1 2BU, UK
| | - Stephanie E Baldeweg
- Department of Diabetes and Endocrinology, University College London Hospital NHS Foundation Trust, London NW1 2BU, UK
- Centre for Obesity and Metabolism, Department of Experimental and Translational Medicine, Division of Medicine, University College London, London WC1E 6BT, UK
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8
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Matsumoto C, Shibata S, Kishi T, Morimoto S, Mogi M, Yamamoto K, Kobayashi K, Tanaka M, Asayama K, Yamamoto E, Nakagami H, Hoshide S, Mukoyama M, Kario K, Node K, Rakugi H. Long COVID and hypertension-related disorders: a report from the Japanese Society of Hypertension Project Team on COVID-19. Hypertens Res 2023; 46:601-619. [PMID: 36575228 PMCID: PMC9793823 DOI: 10.1038/s41440-022-01145-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 12/09/2022] [Accepted: 12/12/2022] [Indexed: 12/28/2022]
Abstract
The coronavirus disease 2019 (COVID-19) affects infected patients even after the acute phase and impairs their health and quality of life by causing a wide variety of symptoms, referred to as long COVID. Although the evidence is still insufficient, hypertension is suspected to be a potential risk factor for long COVID, and the occurrence of cardiovascular diseases seems to be a key facet of multiple conditions observed in long COVID. Nonetheless, there are few reports that comprehensively review the impacts of long COVID on hypertension and related disorders. As a sequel to our previous report in 2020 which reviewed the association of COVID-19 and hypertension, we summarize the possible influences of long COVID on hypertension-related organs, including the cardiovascular system, kidney, and endocrine system, as well as the pathophysiological mechanisms associated with the disorders in this review. Given that the clinical course of COVID-19 is highly affected by age and sex, we also review the impacts of these factors on long COVID. Lastly, we discuss areas of uncertainty and future directions, which may lead to better understanding and improved prognosis of clinical problems associated with COVID-19.
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Affiliation(s)
- Chisa Matsumoto
- Department of Cardiology, Preventive medicine, Tokyo Medical University, Tokyo, Japan.
| | - Shigeru Shibata
- Division of Nephrology, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan.
| | - Takuya Kishi
- Department of Graduate School of Medicine (Cardiology), International University of Health and Welfare, Okawa, Japan
| | - Satoshi Morimoto
- Department of Endocrinology and Hypertension, Tokyo Women's Medical University, Tokyo, Japan
| | - Masaki Mogi
- Department of Pharmacology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Koichi Yamamoto
- Department of Geriatric and General Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Kazuo Kobayashi
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
- Kobayashi Internal Medicine Clinic, Sagamihara, Japan
| | - Masami Tanaka
- Department of Internal Medicine, Adachi Medical Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Kei Asayama
- Department of Hygiene and Public Health, Teikyo University School of Medicine, Tokyo, Japan
| | - Eiichiro Yamamoto
- Department of Cardiovascular Medicine, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Hironori Nakagami
- Department of Health Development and Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
- Center for Infectious Disease Education and Research, Osaka University, Osaka, Japan
| | - Satoshi Hoshide
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Masashi Mukoyama
- Department of Nephrology, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University, Saga, Japan
| | - Hiromi Rakugi
- Department of Geriatric and General Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
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9
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Clarke SA, Phylactou M, Patel B, Mills EG, Muzi B, Izzi‐Engbeaya C, Choudhury S, Khoo B, Meeran K, Comninos AN, Abbara A, Tan T, Dhillo WS. Letter to the editor of clinical endocrinology: Assessment of adrenal function in patients who survive COVID-19. Clin Endocrinol (Oxf) 2023; 98:270-272. [PMID: 35986449 PMCID: PMC9538615 DOI: 10.1111/cen.14816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 03/27/2022] [Accepted: 03/28/2022] [Indexed: 01/04/2023]
Affiliation(s)
- Sophie A. Clarke
- Division of Diabetes, Endocrinology and Metabolism, Department of MetabolismDigestion and Reproduction, Imperial College LondonLondonUK
- Department of EndocrinologyImperial College Healthcare NHS TrustLondonUK
| | - Maria Phylactou
- Division of Diabetes, Endocrinology and Metabolism, Department of MetabolismDigestion and Reproduction, Imperial College LondonLondonUK
- Department of EndocrinologyImperial College Healthcare NHS TrustLondonUK
| | - Bijal Patel
- Division of Diabetes, Endocrinology and Metabolism, Department of MetabolismDigestion and Reproduction, Imperial College LondonLondonUK
| | - Edouard G. Mills
- Division of Diabetes, Endocrinology and Metabolism, Department of MetabolismDigestion and Reproduction, Imperial College LondonLondonUK
| | - Beatrice Muzi
- Division of Diabetes, Endocrinology and Metabolism, Department of MetabolismDigestion and Reproduction, Imperial College LondonLondonUK
| | - Chioma Izzi‐Engbeaya
- Division of Diabetes, Endocrinology and Metabolism, Department of MetabolismDigestion and Reproduction, Imperial College LondonLondonUK
- Department of EndocrinologyImperial College Healthcare NHS TrustLondonUK
| | - Sirazum Choudhury
- Division of Diabetes, Endocrinology and Metabolism, Department of MetabolismDigestion and Reproduction, Imperial College LondonLondonUK
- Department of Clinical BiochemistryImperial College Healthcare NHS TrustLondonUK
| | - Bernard Khoo
- Department of Endocrinology, Division of Medicine, Faculty of Medical Sciences, Royal Free CampusUniversity College LondonLondonUK
| | - Karim Meeran
- Division of Diabetes, Endocrinology and Metabolism, Department of MetabolismDigestion and Reproduction, Imperial College LondonLondonUK
- Department of EndocrinologyImperial College Healthcare NHS TrustLondonUK
| | - Alexander N. Comninos
- Division of Diabetes, Endocrinology and Metabolism, Department of MetabolismDigestion and Reproduction, Imperial College LondonLondonUK
- Department of EndocrinologyImperial College Healthcare NHS TrustLondonUK
| | - Ali Abbara
- Division of Diabetes, Endocrinology and Metabolism, Department of MetabolismDigestion and Reproduction, Imperial College LondonLondonUK
- Department of EndocrinologyImperial College Healthcare NHS TrustLondonUK
| | - Tricia Tan
- Division of Diabetes, Endocrinology and Metabolism, Department of MetabolismDigestion and Reproduction, Imperial College LondonLondonUK
- Department of EndocrinologyImperial College Healthcare NHS TrustLondonUK
| | - Waljit S. Dhillo
- Division of Diabetes, Endocrinology and Metabolism, Department of MetabolismDigestion and Reproduction, Imperial College LondonLondonUK
- Department of EndocrinologyImperial College Healthcare NHS TrustLondonUK
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10
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Elhassan YS, Iqbal F, Arlt W, Baldeweg SE, Levy M, Stewart PM, Wass J, Pavord S, Aled Rees D, Ronchi CL. COVID-19-related adrenal haemorrhage: Multicentre UK experience and systematic review of the literature. Clin Endocrinol (Oxf) 2023; 98:766-778. [PMID: 36710422 DOI: 10.1111/cen.14881] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 01/10/2023] [Accepted: 01/22/2023] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Adrenal haemorrhage (AH) is an uncommon, usually incidental imaging finding in acutely unwell patients. AH has been reported during coronavirus disease 2019 (COVID-19) infection and following ChAdOx1 nCoV-19 (Oxford-AstraZeneca) vaccination. The Society for Endocrinology (SfE) established a task force to describe the UK experience of COVID-19-related AH. DESIGN A systematic literature review was undertaken. A survey was conducted through the SfE clinical membership to identify patients with COVID-19-related AH using a standardized data collection tool. RESULTS The literature search yielded 25 cases of COVID-19-related AH (19 bilateral; 13 infection-related, and 12 vaccine-related). Eight UK centres responded to the survey with at least one case. A total of 18 cases were included in the descriptive study, including 11 from the survey and 7 UK-based patients from the systematic review. Seven patients (4 males; median age 53 (range 26-70) years), had infection-related AH (four bilateral). Median time from positive COVID-19 test to AH detection was 8 (range 1-30) days. Eleven cases of vaccine-related AH (eight bilateral) were captured (3 males; median age 47 (range 23-78) years). Median time between vaccination (nine Oxford-AstraZeneca and two Pfizer-BioNTech) and AH was 9 (range 2-27) days; 9/11 AH occurred after the first vaccine dose. Acute abdominal pain was the commonest presentation (72%) in AH of any cause. All 12 patients with bilateral AH and one patient with unilateral AH required glucocorticoid replacement. CONCLUSION Adrenal haemorrhage with consequential adrenal insufficiency can be a complication of COVID-19 infection and vaccination. Adrenal function assessment is mandatory to avoid the potentially fatal consequences of unrecognized adrenal insufficiency.
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Affiliation(s)
- Yasir S Elhassan
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Institute of Metabolism and Systems Research, College of Medical and Dental sciences, University of Birmingham, Birmingham, UK
| | - Fizzah Iqbal
- Neuroscience and Mental Health Research Institute, School of Medicine, Cardiff, UK
| | - Wiebke Arlt
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Institute of Metabolism and Systems Research, College of Medical and Dental sciences, University of Birmingham, Birmingham, UK
| | - Stephanie E Baldeweg
- Department of Diabetes & Endocrinology, Department of Experimental & Translational Medicine, Division of Medicine, University College London Hospitals & Centre for Obesity & Metabolism, University College London, London, UK
| | - Miles Levy
- Department of Endocrinology, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Paul M Stewart
- Faculty of Medicine & Health, University of Leeds, Leeds, UK
| | - John Wass
- Department of Endocrinology, Oxford Centre for Endocrinology, Diabetes and Metabolism, Churchill Hospital, Oxford, UK
| | - Sue Pavord
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - D Aled Rees
- Neuroscience and Mental Health Research Institute, School of Medicine, Cardiff, UK
| | - Cristina L Ronchi
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Institute of Metabolism and Systems Research, College of Medical and Dental sciences, University of Birmingham, Birmingham, UK
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11
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Beshay L, Wei K, Yang Q. Newly diagnosed autoimmune Addison's disease in a patient with COVID-19 with autoimmune disseminated encephalomyelitis. BMJ Case Rep 2022; 15:15/12/e250749. [PMID: 36593594 PMCID: PMC9723877 DOI: 10.1136/bcr-2022-250749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
Abstract
A man in his 20s with a history of acute disseminated encephalomyelitis (ADEM) was brought into the emergency department (ED) after his family found him at home collapsed on the floor unresponsive with a blood glucose of 28 mg/dL at the field. In the ED, the patient was tachycardic, tachypnoeic and hypotensive, requiring pressors and intubation at 9 hours and 12 hours after arrival, respectively. Laboratory results revealed a positive COVID-19 test, serum sodium of 125 mmol/L and persistent hypoglycaemia. The patient was given a high dose of dexamethasone for COVID-19 treatment 1 hour before pressors were started. He was then continued on a stress dose of intravenous hydrocortisone with rapid clinical improvement leading to his extubation, and discontinuation of vasopressors and glucose on day 2 of admission. The patient received his last dose of intravenous hydrocortisone on day 4 in the early afternoon with the plan to order adrenal testing the following morning prior to discharge. On day 5, the aldosterone <3.0 ng/dL, adrenocorticotropic hormone (ACTH) level >1250 pg/mL, and ACTH stimulation test showed cortisol levels of 3 and 3 µg/dL at 30 and 60 min, respectively. The anti-21-hydroxylase antibody was positive. The patient was discharged on hydrocortisone and fludrocortisone. The patient's symptoms, elevated ACTH, low cortisol and presence of 21-hydroxylase antibodies are consistent with autoimmune Addison's disease. This is the first case reporting autoimmune Addison's disease in a patient with COVID-19 with a history of ADEM. The case highlights the importance of considering adrenal insufficiency as a diagnostic differential in haemodynamically unstable patients with COVID-19.
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Affiliation(s)
- Lauren Beshay
- Endocrinology, University of California Irvine, Irvine, California, USA
| | - Kevin Wei
- Endocrinology, University of California Irvine, Orange, California, USA
| | - Qin Yang
- Endocrinology, University of California Irvine, Irvine, California, USA
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12
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Mangone A, Yousuf Q, Arlt W, Prete A, Shaheen F, Krishnasamy SK, Elhassan YS, Ronchi CL. A case of unilateral post-COVID-19 adrenal haemorrhage and follow-up during pregnancies. Endocrinol Diabetes Metab Case Rep 2022; 2022:22-0337. [PMID: 36541667 PMCID: PMC9782420 DOI: 10.1530/edm-22-0337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022] Open
Abstract
Summary The spectrum of endocrine-related complications of COVID-19 infection is expanding; one of the most concerning of which is adrenal haemorrhage due to the risk of catastrophic adrenal crisis. In this study, we present a case that highlights the challenging management of a large, indeterminate unilateral adrenal mass during pregnancy and draws attention to a rare yet probably underestimated complication of COVID-19. During hospitalization for severe COVID-19 pneumonia, a 26-year-old woman was incidentally found to have a 12.5 cm heterogeneous left adrenal mass. Soon after the discovery, she became pregnant and upon referral, she was in the seventh week of gestation, without clinical or biochemical features of hormonal excess. The uncertainty of the diagnosis and the risks of malignancy and surgical intervention were discussed with the patient, and a period of radiological surveillance was agreed upon. An MRI scan performed 3 months later showed a size reduction of the adrenal lesion to 7.9 cm, which was against malignancy. A Doppler ultrasound showed a non-vascular, well-defined round lesion consistent with an adrenal haematoma, likely a complication of the recent COVID-19 infection. The multidisciplinary team recommended further radiological follow-up. The patient then spontaneously had miscarriage at 12 weeks gestation. Subsequent radiological surveillance showed a further size reduction of the adrenal lesion to 5.5 cm. The patient conceived again during follow-up, and the repeated Doppler ultrasound showed stable appearances of the adrenal mass, and thus, it was agreed to continue radiological monitoring after delivery. The pregnancy was uneventful, and the patient delivered a healthy baby. An MRI scan performed after delivery showed a stable but persistent lesion consistent with a likely underlying adrenal lesion. Learning points Unilateral adrenal haemorrhage can occur as a complication of COVID-19 and should be considered in the differential diagnosis of heterogeneous adrenal masses if there is a history of recent infection. Management of large indeterminate adrenal masses during pregnancy poses several challenges and should be led by an experienced multidisciplinary team. Underlying adrenal tumours may trigger non-traumatic haemorrhages, especially if exacerbated by stressful illness.
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Affiliation(s)
- Alessandra Mangone
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Institute of Metabolism and System Research, University of Birmingham, Birmingham, UK
| | - Quratulain Yousuf
- University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Wiebke Arlt
- Institute of Metabolism and System Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Alessandro Prete
- Institute of Metabolism and System Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Fozia Shaheen
- Institute of Metabolism and System Research, University of Birmingham, Birmingham, UK
| | | | - Yasir S Elhassan
- Institute of Metabolism and System Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Cristina L Ronchi
- Institute of Metabolism and System Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology and Diabetes, University Hospital of Wurzburg, Wurzburg, Germany
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13
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Paul T, Ledderose S, Bartsch H, Sun N, Soliman S, Märkl B, Ruf V, Herms J, Stern M, Keppler OT, Delbridge C, Müller S, Piontek G, Kimoto YS, Schreiber F, Williams TA, Neumann J, Knösel T, Schulz H, Spallek R, Graw M, Kirchner T, Walch A, Rudelius M. Adrenal tropism of SARS-CoV-2 and adrenal findings in a post-mortem case series of patients with severe fatal COVID-19. Nat Commun 2022; 13:1589. [PMID: 35332140 PMCID: PMC8948269 DOI: 10.1038/s41467-022-29145-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 02/25/2022] [Indexed: 12/15/2022] Open
Abstract
Progressive respiratory failure and hyperinflammatory response is the primary cause of death in the coronavirus disease 2019 (COVID-19) pandemic. Despite mounting evidence of disruption of the hypothalamus-pituitary-adrenal axis in COVID-19, relatively little is known about the tropism of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to adrenal glands and associated changes. Here we demonstrate adrenal viral tropism and replication in COVID-19 patients. Adrenal glands showed inflammation accompanied by inflammatory cell death. Histopathologic analysis revealed widespread microthrombosis and severe adrenal injury. In addition, activation of the glycerophospholipid metabolism and reduction of cortisone intensities were characteristic for COVID-19 specimens. In conclusion, our autopsy series suggests that SARS-CoV-2 facilitates the induction of adrenalitis. Given the central role of adrenal glands in immunoregulation and taking into account the significant adrenal injury observed, monitoring of developing adrenal insufficiency might be essential in acute SARS-CoV-2 infection and during recovery.
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Affiliation(s)
- Tanja Paul
- Institute of Pathology, Faculty of Medicine, Ludwig-Maximilians University Munich, Munich, Germany
| | - Stephan Ledderose
- Institute of Pathology, Faculty of Medicine, Ludwig-Maximilians University Munich, Munich, Germany
| | - Harald Bartsch
- Institute of Pathology, Faculty of Medicine, Ludwig-Maximilians University Munich, Munich, Germany
| | - Na Sun
- Research Unit Analytical Pathology, German Research Center for Environmental Health, Helmholtz Zentrum München, Munich, Germany
| | - Sarah Soliman
- Institute of Pathology, Faculty of Medicine, Ludwig-Maximilians University Munich, Munich, Germany
| | - Bruno Märkl
- Institute of Pathology, University of Augsburg, Augsburg, Germany
| | - Viktoria Ruf
- Institute of Neuropathology, Ludwig-Maximilians University Munich, Munich, Germany
| | - Jochen Herms
- Institute of Neuropathology, Ludwig-Maximilians University Munich, Munich, Germany
| | - Marcel Stern
- Max von Pettenkofer Institut, Ludwig-Maximilians University Munich, Munich, Germany
| | - Oliver T Keppler
- Max von Pettenkofer Institut, Ludwig-Maximilians University Munich, Munich, Germany
| | - Claire Delbridge
- Institute of Pathology, Division of Neuropathology, TUM School of Medicine, Technical University Munich, Munich, Germany
| | - Susanna Müller
- Institute of Pathology, Faculty of Medicine, Ludwig-Maximilians University Munich, Munich, Germany
| | - Guido Piontek
- Institute of Pathology, Faculty of Medicine, Ludwig-Maximilians University Munich, Munich, Germany
| | - Yuki Schneider Kimoto
- Institute of Pathology, Faculty of Medicine, Ludwig-Maximilians University Munich, Munich, Germany
| | - Franziska Schreiber
- Institute of Pathology, Faculty of Medicine, Ludwig-Maximilians University Munich, Munich, Germany
| | - Tracy Ann Williams
- Medizinische Klinik und Poliklinik IV, Klinikum der University Munich, Munich, Germany
| | - Jens Neumann
- Institute of Pathology, Faculty of Medicine, Ludwig-Maximilians University Munich, Munich, Germany
| | - Thomas Knösel
- Institute of Pathology, Faculty of Medicine, Ludwig-Maximilians University Munich, Munich, Germany
| | - Heiko Schulz
- Institute of Pathology, Faculty of Medicine, Ludwig-Maximilians University Munich, Munich, Germany
| | - Ria Spallek
- Medizinische Klinik und Poliklinik III, Technical University Munich, Munich, Germany
| | - Matthias Graw
- Institute of Forensic Medicine, Ludwig-Maximilians University Munich, Munich, Germany
| | - Thomas Kirchner
- Institute of Pathology, Faculty of Medicine, Ludwig-Maximilians University Munich, Munich, Germany
| | - Axel Walch
- Research Unit Analytical Pathology, German Research Center for Environmental Health, Helmholtz Zentrum München, Munich, Germany
| | - Martina Rudelius
- Institute of Pathology, Faculty of Medicine, Ludwig-Maximilians University Munich, Munich, Germany.
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14
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Post-mortem histopathology of pituitary and adrenals of COVID-19 patients. Leg Med (Tokyo) 2022; 57:102045. [PMID: 35334433 PMCID: PMC8873038 DOI: 10.1016/j.legalmed.2022.102045] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 02/08/2022] [Accepted: 02/13/2022] [Indexed: 12/22/2022]
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15
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Amiri-Dashatan N, Koushki M, Parsamanesh N, Chiti H. Serum cortisol concentration and COVID-19 severity: a systematic review and meta-analysis. J Investig Med 2022; 70:766-772. [DOI: 10.1136/jim-2021-001989] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2021] [Indexed: 12/11/2022]
Abstract
The novel COVID-19 outbreak is a major health threat to human beings with multiorgan injuries. However, its endocrine system manifestations are much less studied. In this study, we aimed to reassess the available findings on the association between cortisol level and severity of COVID-19 infection. We conducted a systematic search on Medline/PubMed, Scopus, Web of Science, and Cochrane Library databases. To pool data, a random-effects model was performed depending on the heterogeneity among studies. Sensitivity analysis was also carried out by removing each study systematically. In addition, subgroup and meta-regression analyses were performed depending on the presence of the variables of sex and age. Subsequently, 11 studies (5 observational studies and 6 case reports) were included in the meta-analysis. Pooled analysis on the observational studies showed significantly higher levels of cortisol in patients with severe COVID-19 in comparison with those with mild-to-moderate COVID-19 (standardized mean difference: 1.48 µg/dL; 95% CI (0.51 to 2.46); p=0.003). Assessment of the results of case reports revealed that the patients with severe COVID-19 demonstrated higher cortisol levels than the patients with mild-to-moderate COVID-19. No publication bias was observed using the Begg’s (p=0.08) and Egger’s tests (p=0.09). Meta-regression illustrated a significant correlation between cortisol levels with sex. The serum cortisol level seems to be higher in patients with severe COVID-19 infection. This finding could be helpful to detect patients with poor prognosis at early stages of the disease, although age and sex may modify this level.
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16
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Popescu M, Terzea DC, Carsote M, Ghenea AE, Costache A, Popescu IAS, Biciuşcă V, Busuioc CJ, Ghemigian AM. COVID-19 infection: from stress-related cortisol levels to adrenal glands infarction. ROMANIAN JOURNAL OF MORPHOLOGY AND EMBRYOLOGY = REVUE ROUMAINE DE MORPHOLOGIE ET EMBRYOLOGIE 2022; 63:39-48. [PMID: 36074666 PMCID: PMC9593124 DOI: 10.47162/rjme.63.1.03] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Cortisol is a key element in acute stress including a severe infection. However, in coronavirus-associated disease, 20% of subjects experience hypocortisolemia due to direct or immune damage of pituitary and adrenal glands. One extreme form of adrenal insufficiency is found in 2∕3 of cases with viral and post-viral adrenal infarction (AI) (with∕without adrenal hemorrhage) that is mostly associated with a severe coronavirus disease 2019 (COVID-19) infection; it requires prompt glucocorticoid intervention. Some reports are incidental findings at computed tomography (CT)∕magnetic resonance imaging (MRI) scans for non-adrenal complications like pulmonary spreading and others are seen on post-mortem analysis. This is a review of PubMed-accessible, English papers focusing on AI in addition to the infection, between March 1, 2020 and November 1, 2021. Exclusion criteria were acute adrenal insufficiency without the histopathological (HP) and∕or imaging report of adrenal enlargement, necrosis, etc., respective adrenal failure due to pituitary causes, or non-COVID-19-related adrenal events. We identified a total of 84 patients (different levels of statistical evidence), as follows: a retrospective study on 51 individuals, two post-mortem studies comprising nine, respectively 12 patients, a case series of five subjects, seven single-case reports. HP aspects include necrosis associated with ischemia, cortical lipid degeneration (+/- focal adrenalitis), and infarcts at the level of adrenal cortex, blood clot into vessels, acute fibrinoid necrosis in arterioles and capsules, as well as subendothelial vacuolization. Collateral potential contributors to adrenal damage are thrombotic events, coagulation anomalies, antiphospholipid syndrome, endothelial dysfunction, severe COVID-19 infection with multiorgan failure, etc. Clinical picture is variable from acute primary adrenal insufficiency to asymptomatic or mild evolution, even a retrospective diagnostic; it may be a part of long COVID-19 syndrome; glucocorticoid therapy for non-adrenal considerations might mask cortisol deficient status due to AI∕hemorrhage. Despite its rarity, the COVID-19-associated AI/hemorrhage represents a challenging new chapter, a condition that is essential to be recognized due to its gravity since prompt intervention with glucocorticoid replacement is lifesaving.
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Affiliation(s)
- Mihaela Popescu
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, C.I. Parhon National Institute of Endocrinology, Bucharest, Romania;
| | - Dana Cristina Terzea
- Department of Pathology and Immunohistochemistry, C.I. Parhon National Institute of Endocrinology, Bucharest, Romania; Department of Pathology and Immunohistochemistry, Monza Onco Team Diagnostic, Bucharest, Romania
| | - Mara Carsote
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; Department of Endocrinology, C.I. Parhon National Institute of Endocrinology, Bucharest, Romania
| | - Alice Elena Ghenea
- Department of Bacteriology–Virology–Parasitology, University of Medicine and Pharmacy of Craiova, Romania
| | - Andrei Costache
- PhD Student, Doctoral School, University of Medicine and Pharmacy of Craiova, Romania
| | - Iulian Alin Silviu Popescu
- Department of Internal Medicine, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, Romania
| | - Viorel Biciuşcă
- Department of Internal Medicine, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, Romania
| | - Cristina Jana Busuioc
- Department of Histology, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, Romania
| | - Adina Mariana Ghemigian
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; Department of Endocrinology, C.I. Parhon National Institute of Endocrinology, Bucharest, Romania
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17
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Abstract
The coronavirus disease 2019 (COVID-19) pandemic continues to exert a significant impact on global health care systems, causing devastating mortality and morbidity. As time passes and our understanding of this novel respiratory virus deepens, it is increasingly clear that its effects extend beyond that of the respiratory system. The coronavirus responsible for COVID-19, severe acute respiratory syndrome coronavirus 2, obtains cellular access through the angiotensin-converting enzyme 2 (ACE2) receptor in a process requiring the transmembrane serine protease 2 (TMPRSS2) protein. Both ACE2 and TMPRSS2 are widely expressed in many endocrine glands. This, along with several case reports of thyroid and pituitary disruption in patients with COVID-19, has resulted in significant interest in its impact on the endocrine system. Indeed, as mortality is abated by the increasing availability of effective vaccines, there is increasing focus on the long-term effects on health in COVID-19 survivors. This review summarizes data investigating the effects of COVID-19 on each of the endocrine axes to guide appropriate investigations and optimal management.
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Affiliation(s)
- Sophie A Clarke
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London W12 0NN, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London W6 8RF, UK
| | - Ali Abbara
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London W12 0NN, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London W6 8RF, UK
| | - Waljit S Dhillo
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London W12 0NN, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London W6 8RF, UK
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18
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Machado IFR, Menezes IQ, Figueiredo SR, Coelho FMA, Terrabuio DRB, Ramos DV, Fagundes GFC, Maciel AAW, Latronico AC, Fragoso MCBV, Cancado ELR, Mendonca BB, Almeida MQ. Primary adrenal insufficiency due to bilateral adrenal infarction in COVID-19: a case report. J Clin Endocrinol Metab 2022; 107:e394–e400. [PMID: 34324679 DOI: 10.1210/clinem/dgab557] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Coronavirus disease 2019 (COVID-19) is a proinflammatory and prothrombotic condition, but its impact on adrenal function has not been adequately evaluated. CASE REPORT A 46-year-old woman presented with abdominal pain, hypotension, skin hyperpigmentation after COVID-19 infection. The patient had hyponatremia, serum cortisol <1.0 ug/dL, ACTH of 807 pg/mL and aldosterone <3 ng/dL. Computed tomography (CT) findings of adrenal enlargement with no parenchymal and minimal peripheral capsular enhancement after contrast were consistent with bilateral adrenal infarction. The patient had autoimmune hepatitis and positive antiphospholipid antibodies, but no previous thrombotic events. The patient was treated with intravenous hydrocortisone, followed by oral hydrocortisone and fludrocortisone. DISCUSSION Among 115 articles, we identified nine articles, including case reports, of new-onset adrenal insufficiency and/or adrenal hemorrhage/infarction on CT in COVID-19. Adrenal insufficiency was hormonally diagnosed in five cases, but ACTH levels were measured in only three cases (high in one case and normal/low in other two cases). Bilateral adrenal non- or hemorrhagic infarction was identified in five reports (two had adrenal insufficiency, two had normal cortisol levels and one case had no data). Interestingly, the only case with well-characterized new-onset acute primary adrenal insufficiency after COVID-19 had a previous diagnosis of antiphospholipid syndrome. In our case, antiphospholipid syndrome diagnosis was established only after the adrenal infarction triggered by COVID-19. CONCLUSIONS Our findings support the association between bilateral adrenal infarction and antiphospholipid syndrome triggered by COVID-19. Therefore, patients with positive antiphospholipid antibodies should be closely monitored for symptoms or signs of acute adrenal insufficiency during COVID-19.
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Affiliation(s)
- Iza F R Machado
- Unidade de Suprarrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Divisão de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil
| | - Isabel Q Menezes
- Unidade de Suprarrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Divisão de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil
| | - Sabrina R Figueiredo
- Departamento de Gastroenterologia, Divisão de Gastroenterologia e Hepatologia Clínica, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil
| | | | - Debora R B Terrabuio
- Departamento de Gastroenterologia, Divisão de Gastroenterologia e Hepatologia Clínica, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil
| | - Davi V Ramos
- Departamento de Gastroenterologia, Divisão de Gastroenterologia e Hepatologia Clínica, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil
| | - Gustavo F C Fagundes
- Unidade de Suprarrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Divisão de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil
| | - Ana Alice W Maciel
- Unidade de Suprarrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Divisão de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil
| | - Ana Claudia Latronico
- Unidade de Suprarrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Divisão de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil
| | - Maria Candida B V Fragoso
- Unidade de Suprarrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Divisão de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil
- Unidade de Oncologia Endocrinologia, Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil
| | - Eduardo L R Cancado
- Departamento de Gastroenterologia, Divisão de Gastroenterologia e Hepatologia Clínica, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil
| | - Berenice B Mendonca
- Unidade de Suprarrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Divisão de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil
| | - Madson Q Almeida
- Unidade de Suprarrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Divisão de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil
- Unidade de Oncologia Endocrinologia, Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil
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Vakhshoori M, Heidarpour M, Bondariyan N, Sadeghpour N, Mousavi Z. Adrenal Insufficiency in Coronavirus Disease 2019 (COVID-19)-Infected Patients without Preexisting Adrenal Diseases: A Systematic Literature Review. Int J Endocrinol 2021; 2021:2271514. [PMID: 34539780 PMCID: PMC8443384 DOI: 10.1155/2021/2271514] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 08/27/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) manifestations varied completely from its time of emergence. However, the assessment of adrenal insufficiency (AI) in this pandemic is lacking. In this review, we aimed to evaluate the status of AI among COVID-19-infected individuals. METHODS A systematic literature screening in PubMed/MEDLINE, Scopus, and Web of Science was performed until May 23, 2021. We collected relevant published peer-reviewed studies that reported AI occurrence in patients who suffered from COVID-19. RESULTS A total of 10 records (cross-sectional studies: 3, N = 256, males: 176 (68.7%), and case reports: 7, N = 7, males: 4 (57.1%)) were recruited. The age spectrum ranged from 22 to 96 years. AI was diagnosed with laboratory assessment or radiologic findings. The AI prevalence ranged from 3.1% to as high as 64.3% in different studies. Except for one patient, all other patients were discharged in stable conditions in published case reports. CONCLUSION This review indicates that AI occurrence in the COVID-19 pandemic seems quite probable; however, the extent and type (primary, secondary, and functional) need to be clarified yet. Appropriate early diagnostic and therapeutic interventions should be done, especially in critically ill patients, to prevent lethal outcomes.
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Affiliation(s)
- Mehrbod Vakhshoori
- Heart Failure Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Maryam Heidarpour
- Isfahan Endocrine and Metabolism Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Niloofar Bondariyan
- Department of Clinical Pharmacy, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Niyousha Sadeghpour
- Heart Failure Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Zohreh Mousavi
- Metabolic Syndrome Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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