Endocrine Abstracts

A recent case series commented on adverse COVID-19 outcomes among patients with Cushing’s syndrome, despite minimal symptoms and low inflammatory markers. Excessive glucocorticoids can impede adaptive immune response to viruses, leading to increased infection risks (1). Sarker et al discussed glucocorticoids binding to viral spike-proteins, inhibiting receptor interactions and contributing to prolonged positive swabs, in the absence of symptoms (2). We report the case of a 66-year-old Caucasian male who presented with pyrexia (39.2°c), whilst undergoing inpatient rehabilitation. He was recently diagnosed with transverse myelitis and commenced on high dose glucocorticoids (70mg Prednisolone). The patient denied respiratory symptoms, oxygen saturation was stable on air, and chest XR unremarkable. Bloods results showed; lymphocyte 0.9 x 109 L, CRP 51 mg/l. Combined nose and throat swab on March 14th 2020, was SARS-CoV-2 RNA positive via RT-PCR. Repeat testing 24-hours later remained positive (cycle threshold value 21). With no further pyrexia, he was discharged after an observation period. He remained well, until re-presenting two months later with urinary symptoms; suprapubic pain, polyuria and dysuria. He was hypotensive (90/56), pyrexical (40.2°c), urine dipstick positive for leucocytes and nitrites. Blood results showed: lymphocyte 0.3 x 109/L, CRP 293mg/L. CT and chest XR showed no infective changes. Nevertheless, he tested positive for COVID-19 RNA on May 12th 2020 (cycle threshold value 19.14). The microbiological findings, antibiotic response and urinary symptoms in the absence of respiratory signs, suggested sepsis secondary to E.coli, rather than SAR-CoV-2 re-infection. With chest XR showing no evidence of COVID-19 pneumonia, this supports prolonged asymptomatic SARS-CoV-2 shedding as opposed to chronic infection. This case highlights the role of immunosuppression in viral persistence, focally in patients using high dose exogenous steroids. Importantly, the patient discussed, had persistent RNA detection for 59-days despite no CT changes or respiratory symptoms. Interestingly, his family tested SARS-CoV-2 negative. Although this could suggest that persistently RNA positive individuals may not remain infectious; further peer-reviewed data is required.

References: 1. Belaya, Z., Golounina, O., Melnichenko, G et al. (2021). Clinical course and outcome of patients with ACTH-dependent Cushing’s syndrome infected with novel coronavirus disease-19 (COVID-19): case presentations. Endocrine, 72, 12–19.2. Sarker, H., Panigrahi, R., Hardy, E., Glover, et al (2022). Glucocorticoids Bind to SARS-CoV-2 S1 at Multiple Sites Causing Cooperative Inhibition of SARS-CoV-2 S1 Interaction With ACE2. Frontiers in Immunology, 13.