ESPE Abstracts

Introduction: Multisystem inflammatory syndrome in children (MIS-C) is associated with Covid-19. MIS-C was first reported in April 2020 with similar symptoms to Kawasaki disease and has several treatment options, one of which is glucocorticoids.Autopsy studies in Covid-19 patients have shown degenerative adrenal changes.It has been reported that rarely Covid-19 may affect adrenal function and cause both primary and secondary adrenal insufficiency.Here we present an 11-year-old boy with MIS-C and developed adrenal insufficiency.

Case: An 11-year-old boy was referred with a five-day history of fever, vomiting and rash.He had Covid-19 one month previously and had recovered within two-days. At presentation hypotension (80/50 mmHg), tachypnea, tachycardia and rashes that faded under pressure were evident. C-reactive protein and erythrocyte sedimentation rate were elevated (378 mg/l and 82 mm/h, respectively).Serum glucose was 85 mg/dL, sodium was 124 mmol/l, potassium 3.19 mmol/l, while other biochemistry was normal.Covid-19 IgM was 1.83 (<10), IgG was 6.1 (<1.4).He was evaluated by rheumatology and infectious diseases and was diagnosed with MIS-C.Adrenal function was not assessed at admission; normotension was achieved with fluid and inotropic treatments.He was started on 60 mg/day methylprednisolone after a dose of intravenous immunoglobulin.On the second day of treatment, he developed hyperglycemia, defined as stress hyperglycemia.The glucocorticoid regimen was changed on the third day of treatment to 500 mg methylprednisolone daily. After receiving 500 mg/day methylprednisolone for three days, the dose was reduced to 60 mg/day by the sixth day of treatment.On the eighth day of treatment, while on 40 mg of methylprednisolone/day, glucose and sodium decreased (from 140 to 129 mmol/l), and potassium increased (from 4.3 to 5.2 mmol/l).Serum adrenocorticotropic hormone was 18 pg/ml (0-45), cortisol 1.34 ug/dL (6-22), aldosterone 4.9 ng/dL (3.7-31) and plasma renin activity 0.02 ng/ml/h (0.06-4.69) which indicated relative adrenal insufficiency.Adrenocorticotropin stimulation test was not performed because of glucocorticoid therapy. Methylprednisolone was discontinued and hydrocortisone was started at 300 mg/m²/day. Serum sodium and potassium normalised within two days (138 and 3.6 mmol/l, respectively) and hydrocortisone dose was gradually reduced to 7.5 mg/m²/day. After three months of hydrocortisone treatment, the hypothalamus-pituitary-adrenal axis function was assessed as normal and hydrocortisone was discontinued.

Conclusion: Clinicians should be aware that there may be clinically significant impairment of adrenocortical response in Covid-19 infection. Hypothalamus-pituitary-adrenal axis should be evaluated, especially in Covid-19 patients with unexplained hypotension and hyponatremia.