Bilateral Neonatal Adrenal Hemorrhage Associated With Severe Maternal COVID-19 Infection

Concepción-Zavaleta, Marcio José; Ildefonso-Najarro, Sofía Pilar; Dueñas, Esteban Alberto Plasencia; Arroyo, Julia; Zavaleta-Gutiérrez, Francisca Elena; Concepción-Urteaga, Luis Alberto; Revoredo, Frederick Massucco; Ramos-Yataco, Anthony; Meza, Kelly

doi:10.7759/cureus.20007

Cited by 2 publications

(4 citation statements)

References 17 publications

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“…Possible mechanisms include the direct invasion of the virus into the adrenal gland, as evidenced by postmortem studies, or the binding of the virus to angiotensin-converting enzyme II (ACE2) receptors present in adrenocortical cells [ 20 , 21 ]. Other causes of primary adrenal insufficiency associated with COVID-19 infection have been described, including bilateral adrenal hemorrhage [ 22 , 23 ] and infarction [ 24 , 25 , 26 ]. The majority of those cases are reported in adults, with the exception of a neonatal case, a full-term baby boy born to a mother with severe COVID-19, who developed bilateral adrenal hemorrhage on the 7th day of life [ 23 ].…”

Section: Discussionmentioning

confidence: 99%

“…Other causes of primary adrenal insufficiency associated with COVID-19 infection have been described, including bilateral adrenal hemorrhage [ 22 , 23 ] and infarction [ 24 , 25 , 26 ]. The majority of those cases are reported in adults, with the exception of a neonatal case, a full-term baby boy born to a mother with severe COVID-19, who developed bilateral adrenal hemorrhage on the 7th day of life [ 23 ].…”

Section: Discussionmentioning

confidence: 99%

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New-Onset Primary Adrenal Insufficiency and Autoimmune Hypothyroidism in a Pediatric Patient Presenting with MIS-C

2022

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Introduction: There is emerging speculation that the inflammatory state associated with SARS-CoV-2 infection may trigger autoimmune conditions, but no causal link is established. There are reports of autoimmune thyroiditis, and adrenal insufficiency in adults post-COVID-19. We describe the first pediatric report of autoimmune adrenal insufficiency and hypothyroidism after COVID-19. Case Presentation: A 14-year-old previously healthy girl, with vitiligo, presented in shock following one-week of fever, lethargy, diarrhea, and vomiting. Three weeks prior, she had congestion and fatigue, and known familial exposure for COVID-19. Labs were remarkable for sodium 129mmol/L, K 4.3mmol/L, creatinine 2.9mg/dL, hemoglobin 8.3 g/dL and positive COVID-19 PCR and SARS CoV-2 IgG. She was resuscitated with normal saline and required pressor support. EKG showed abnormal repolarization presumed secondary to myocarditis. She met criteria for Multisystem Inflammatory Syndrome in Children (MIS-C), received intravenous immune globulin and IL-1R antagonist, and was admitted for intensive care. Persistent hypotension despite improved inflammatory markers, and an undetectable cortisol led to initiation of hydrocortisone. She was then able to rapidly wean off vasopressors and hydrocortisone within 48 hours. Thereafter, tests undertaken for persistent bradycardia confirmed autoimmune hypothyroidism with TSH 131mcunit/ml, freeT4 0.85ng/dL, and positive thyroid autoantibodies. Basal and stimulated cortisol were <1 mcg/dL on a standard 250mcg cosyntropin stimulation test, with baseline ACTH >1250pg/mL confirming primary adrenal insufficiency. Treatment was initiated with hydrocortisone, levothyroxine, and fludrocortisone. Adrenal sonogram did not reveal any hemorrhage and anti-adrenal antibody titers were positive. The family retrospectively reported oligomenorrhea, increased salt craving in the months prior, and family history of autoimmune thyroiditis. The cytokine panel was notably different from other cases of MIS-C. Conclusion: This is the first pediatric report, to our knowledge, of primary adrenal insufficiency and hypothyroidism following COVID-19, leading to a unique presentation of autoimmune polyglandular syndrome type 2. The initial presentation was attributed to MIS-C, but the subsequent clinical course suggests the possibility of adrenal crisis. It remains unknown if COVID-19 had a causal relationship in triggering the autoimmune adrenal insufficiency and hypothyroidism.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

New-Onset Primary Adrenal Insufficiency and Autoimmune Hypothyroidism in a Pediatric Patient Presenting with MIS-C

2022

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“…Our search identified a total of 25 cases of COVID‐19‐related AH (Figure 1). In particular, these included 9 cases of AH 8–17 and four cases of adrenal infarction 18–21 in the context of COVID‐19 infection. All four cases of adrenal infarction were bilateral, with no radiological features of haemorrhage, while 6/9 cases of AH were bilateral (66%) with three unilateral (2 left and 1 right sided).…”

Section: Resultsmentioning

confidence: 99%

“…Our search identified a total of 25 cases of COVID-19-related AH (Figure 1). In particular, these included 9 cases of AH [8][9][10][11][12][13][14][15][16][17] and four cases of adrenal infarction [18][19][20][21] UK-based patients from the systematic review, who were not captured through the survey resulting in a total of 18 cases (Figure 1). The details regarding the patient's demographic and clinical characteristics, the clinical presentation, and the outcome are reported in Tables 2-4, respectively.…”

Section: Overview Of the Literaturementioning

confidence: 99%

COVID‐19‐related adrenal haemorrhage: Multicentre UK experience and systematic review of the literature

Elhassan

Iqbal

Arlt

et al. 2023

Clinical Endocrinology

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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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Bilateral Neonatal Adrenal Hemorrhage Associated With Severe Maternal COVID-19 Infection

Cited by 2 publications

References 17 publications

New-Onset Primary Adrenal Insufficiency and Autoimmune Hypothyroidism in a Pediatric Patient Presenting with MIS-C

New-Onset Primary Adrenal Insufficiency and Autoimmune Hypothyroidism in a Pediatric Patient Presenting with MIS-C

COVID‐19‐related adrenal haemorrhage: Multicentre UK experience and systematic review of the literature

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