Adrenal Crisis in Elderly Patients with Adrenal Insufficiency Following COVID-19 Vaccination

Thursday, May 12, 2022

12:10 PM – 12:25 PM

Location: Station 13, Sapphire E

Submitter(s)

EA
Ehab A Embaby Abdelgyed, MBBCh
Internal Medicine Resident
Albany Medical Center
Albany, New York, United States

Primary Author(s)

EA
Ehab A Embaby Abdelgyed, MBBCh
Internal Medicine Resident
Albany Medical Center
Albany, New York, United States

Co-Author(s)

AG
Aidar Gosmanov, MD, PhD
Endocrinologist
Stratton VAMC

Introduction : Adrenal insufficiency (AI) is a life-threatening disorder requiring life-long glucocorticoid (GC) replacement therapy. There is no systematic evidence if COVID-19 vaccination can precipitate an adrenal crisis (AC) in patients with known AI.

Case Description : Case 1
75-year-old (yo) man with a history of (h/o) optimally controlled hypothyroidism and primary AI since 2006 on levothyroxine 150 mcg, prednisone 4 mg, and fludrocortisone 0.1 mg daily developed a subjective fever, nausea, fatigue, and weakness following 2nd dose of Moderna vaccine. Clinical and biochemical evaluation in a local medical center demonstrated the presence of dehydration, hypotension, moderate hyponatremia, and cortisol level of 0.1 mcg/dl suggesting that he was in adrenal crisis. Following the admission, he was treated with stress dose steroids and intravenous fluids for 3 days and was discharged home in stable condition.

Case 2
76-yo man with a h/o panhypopituitarism since 2003 on levothyroxine 150 mcg, hydrocortisone 20 mg in am and 10 mg in pm, and testosterone replacement therapy sought medical attention in the emergency department 1 day after he received 2nd dose of Moderna vaccine complaining of fatigue, generalized weakness, and chills. His blood pressure was 84/47 mmHg, heart rate was 130 bpm suggesting he was in adrenal crisis. Following the admission, he was treated with stress dose steroids and intravenous fluids for 4 days and was discharged home in stable condition.

Discussion : COVID-19 vaccination may cause various side effects including pain at the injection site, fatigue, headache, myalgias, arthralgias, chills, and fever which may place AI patients at risk for adrenal crisis as seen in our cases. In general, AI patients are instructed to increase the GC dose 2-3 times for several days during stressful situations. There is no evidence or clear recommendations if such advice should be offered to the AI patients receiving COVID-19 vaccination The survey of clinicians conducted by the Pituitary Society showed that most clinicians plan to maintain the current GC dose with vaccine administration with consideration of increasing GC dose in case of fever, arthralgias and/or myalgias. The UK Society of Endocrinology recommends that there is no need to routinely increase GC dose at the time of COVID 19 vaccination. We suggest that AI patients should be instructed to immediately implement the sick day rule and increase their GC dose if they develop any constitutional symptoms following the COVID‐19 vaccination. It is unknown if the prophylactic increase in GC dose should be advised as we have no information on the potential impact of excessive GC on the immune response to the vaccination.