Newly diagnosed autoimmune Addison’s disease in a patient with COVID-19 with autoimmune disseminated encephalomyelitis

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.

Schmidt syndrome mimicking depression and refractory hypotension in critically ill patient – Case Report and Literature Review

“…Although some published cases describe COVID-19 infection as a direct trigger for Addison's disease [20,21], the authors of this case report believe that the patient suffered from Schmidt syndrome before contracting COVID-19. Yet, COVID-19 was a strong enough infection to require hospital admission and allowed us to extend the patient's diagnosis.…”

Addison’s Disease: Diagnosis and Management Strategies

“…This is the first case of AD in a patient with a history of autoimmune disseminated encephalomyelitis that experienced the coronavirus infection. 143 A first case of 4A syndrome (alacrima, achalasia, and AI and autonomic nervous system anomalies) was suspected of COVID-19 and reported. 144 Collaterally, we mention a matched case-control study on 6769 patients with achalasia (versus 27,076 controls) that was strongly associated with AD as reflected by an OR of 3.83 (95% CI: 1.83–8.04).…”

Endocrine Petrified Ear: Associated Endocrine Conditions in Auricular Calcification/Ossification (A Sample-Focused Analysis)

“…Generally, serositis may accompany autoimmune endocrine conditions and symptomatic pericardial effusion has been reported mostly due to severe deficiency of the thyroid hormones potentially associated with reduced levels of cortisol that also causes hypotension and shock; nevertheless the differential diagnosis with other causes of pericarditis/pleural involvement in subjects with an endocrine background should be performed [ 64 , 65 , 66 ]. Recently, COVID-19 pandemic turned out to be a trigger of various autoimmune conditions the infection itself or the vaccine against coronavirus might aggravate an acute adrenal insufficiency in prior undiagnosed subjects or even in previously treated patients [ 67 , 68 , 69 ].…”