Endocrine Abstracts

Introduction: Bilateral adrenal hemorrhage (BAH) is a rare clinical condition (estimated incidence between 0.14% –1.8%, according to postmortem studies) and life-threatening due to the development of adrenal crisis, after the destruction of 90% of each adrenal gland. A mortality rate of 15% has been reported despite treatment, but it depends on the severity of the underlying condition, reaching 90% in cases of sepsis, or even higher if it is not diagnosed quickly enough. Bilateral forms are common attributed to spasm or thrombosis of the adrenal vein. The main nontraumatic causes include stressful situations, such as surgery, severe burns, or sepsis, bleeding diathesis (-thrombocytopenia, anticoagulants therapies, especially in the setting of heparin-induced thrombocytopenia), thromboembolic disease (included antiphospholipid syndrome), adrenocorticotropic hormone (ACTH)hyperstimulation, and adrenal gland tumors, especially pheochromocytoma. The clinical suspicion of BAH is difficult because the clinical presentation is unspecific.

Case report: A 70-year-old man, with a medical history of prediabetes, went to the emergency department for presenting fever, asthenia, abdominal pain and cutaneomucosal hyperpigmentation for 15 days. Subsequently, he presented nausea, drowsiness and hemodynamic instability. The analysis reported lymphopenia, hyponatremia, hyperkalemia, elevated fibrinogen, PCR, ferritin, liver enzymes, LDH, D-dimer, and troponin-I. The cultures (blood and urine), conventional serologies and antiphospholipid antibodies were negative and the serology (IgM and IgG) for SARS-CoV-2 was positive. Imaging studies confirmed bilateral pneumonia, paralytic ileus and bilateral adrenal hemorrhage. He received hydroxychloroquine, azithromycin, thromboprophylaxis, intravenous fluid therapy, and hydrocortisone at stress doses. He was discharged at 7 days with hydrocortisone (20 mg/day) and fludrocortisone (0.1 mg/day).

Discussion: COVID-19 is a progressive endothelial thromboinflammatory syndrome, caused by the direct effects (cytokine storm, complement activation, extensive vascular deposition of C4d, C5b-9, MASP2 and fibrin) and the indirect effects of the infection (hypoxia, immobilization).Therefore, it is capable of causing vascular congestion and/or thrombosis of the adrenal vein, with the consequent increase in intraglandular pressure, collapse and adrenal bleeding.

Conclusion: There must be a high clinical suspicion of primary adrenal insufficiency in case of COVID-19 infection with abdominal pain, especially if it associates arterial hypotension refractory to fluid therapy, hyponatremia and hyperkalemia. Abdominal CT scan plays a crucial role in the confirmation diagnosis of BAH. If possible, ACTH and cortisol levels should be measured prior to corticosteroid therapy, without in any case delaying its administration. Replacement corticosteroid therapy should be started quickly.