Endocrine Abstracts

Background: Isolated adrenocorticotropic hormone (ACTH) deficiency is a rare entity defined by secondary adrenal insufficiency and normal secretion of all other pituitary hormones. Delays in adrenal insufficiency (AI) diagnosis frequently encounter among older patients because of non-specific symptoms. The occurrences of actual or incipient adrenal crises following coronavirus disease 2019 (COVID-19) vaccine administration are increasingly reported over the last year after vaccine rollout program. Here, we present an interesting case of incipient adrenal crisis following ChAdOx1 SARS-CoV-2 vaccination in a patient with undiagnosed isolated ACTH deficiency.

Clinical case: A 73-year-old Thai woman with underlying uncontrolled type 2 diabetes mellitus and unclear etiology of AI presented with a 2-week history of general malaise, dizziness, nausea, and weight loss of 4 kilograms following the first dose of AstraZeneca (ChAdOx1 SARS-CoV-2) vaccination. She had a past history of AI diagnosed at age of 52 from the previous hospital and had taken prednisolone 2.5 mg per day thereafter. Patient denied history of postpartum hemorrhage and was able to lactate after pregnancy and never had serious traumatic head injury. She also denied the use of other exogenous glucocorticoids and other medications except her current prescribed oral prednisolone. When seen in our hospital 2 weeks after immunization, physical examination and vital signs were unremarkable. Re-evalutation of AI after prednisolone discontinuation for 3 days was performed with the standard 250-microgram ACTH stimulation test. The diagnosis of secondary AI was confirmed. Brain MRI showed normal pituitary gland and evaluation of other anterior pituitary hormones revealed normal results. Isolated ACTH deficiency was diagnosed and the patient had been instructed to increase the dose of prednisolone to 15 mg per day. Insulin treatment was also up-titrated to tightly control glycemic control. Her symptoms considerably improved over a week and backed to the usual weight over a few months. With increasing the dose of prednisolone on the day of vaccination, the patient was uneventful following the second dose of AstraZeneca vaccination.

Conclusions: Late-onset isolated ACTH deficiency is a rare entity but has emerged as a cause of AI. Healthcare professionals should be vigilant about the possible diagnosis or worsening of AI especially in elderly patients who receive COVID-19 vaccine administration. Ongoing educations of sick day management should be emphasized in all AI patients.