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.

Background Accumulating body of evidence shows that SARS-CoV-2 infection in COVID-19 is linked to a variety of autoimmune complications including autoimmune endocrinopathies. Here we report a case of newly diagnosed Addison's disease post-COVID-19 infection. Case Description A 23-year-old male with a history of three episodes of acute disseminated encephalomyelitis (ADEM) in childhood, was brought into the emergency department (ED) by EMS after being found down with a blood glucose of 28 at the field. Prior to presentation, he reported 3 days of sore throat, nausea, vomiting, fatigue, and chills. He takes no home medications, and is not vaccinated against COVID-19. In the ED, the physical exam is notable for temperature 39°C, pulse 145, BP 80/42, RR 39, and no mucocutaneous hyperpigmentation. Labs revealed a positive COVID test, serum sodium 125 mmol/L (135-145), potassium 3.1 mmol/L (3.5-4.1), and persistent hypoglycemia. TSH 1.89 μIU/mL (0.45-4.12). A morning baseline cortisol was 4 mcg/dl (ref: &gt;18) with ACTH level of &gt;1250 pg/ml (0-45). A high-dose 250 mcg ACTH stimulation test followed; with cortisol levels of 3, and 3 mcg/dl (ref: &gt;18) at 30, and 60 minutes; respectively. Aldosterone &lt;3. 0 ng/dl (4. 0-31. 0), and anti-21-hydroxylase antibody was positive (ref: negative). A CT scan of the abdomen with contrast demonstrated mildly atrophied bilateral adrenal glands. The hypotension and hyponatremia resolved after initiation of intravenous hydrocortisone, and he was discharged on hydrocortisone and fludrocortisone. Conclusion The patient's symptoms, elevated ACTH, low cortisol, and presence of 21-hydroxylase antibodies, are consistent with autoimmune Addison's disease. Since ADEM is an autoimmune condition, it is likely that the patient had underlying undiagnosed Addison's disease and COVID-19 triggered an adrenal crisis. There is also a possibility that SARS-CoV-2 infection may have induced a higher titer of adrenal antibody, leading to the exacerbation of Addison's disease. The case highlights the importance of considering adrenal insufficiency as a diagnostic differential in hemodynamically unstable COVID-19 patients, especially those with underlying autoimmune conditions. Presentation: No date and time listed

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