Elsevier

Endocrine Practice

Volume 27, Issue 2, February 2021, Pages 83-89
Endocrine Practice

Original Article
The Impact of COVID-19 Viral Infection on the Hypothalamic-Pituitary-Adrenal Axis

https://doi.org/10.1016/j.eprac.2020.10.014Get rights and content

Abstract

Objective

To study the adrenocortical response to an acute coronavirus disease-2019 (COVID-19) infection.

Methods

Morning plasma cortisol, adrenocorticotropic hormone (ACTH), and dehydroepiandrosterone sulfate levels were measured in 28 consecutive patients with COVID-19 (16 men, 12 women, median age 45.5 years, range 25-69 years) on day 1 to 2 of hospital admission. These tests were repeated twice in 20 patients and thrice in 15 patients on different days. The hormone levels were correlated with severity of the disease.

Results

The median morning cortisol level was 196 (31-587) nmol/L. It was <100 nmol/L in 8 patients (28.6%), <200 nmol/L in 14 patients (50%), and <300 nmol/L in 18 patients (64.3%). The corresponding ACTH values had a median of 18.5 ng/L (range 4-38 ng/L), and the ACTH level was <10 ng/L in 7 patients (26.9%), <20 ng/L in 17 patients (60.7%), and <30 ng/L in 23 patients (82.1%). The repeated testing on different days showed a similar pattern. Overall, if a cutoff level of <300 nmol/L is considered abnormal in the setting of acute disease, 9 patients (32%) had cortisol levels below this limit, regardless of whether the test was done only once (3 patients) or 3 times (6 patients). When the disease was more severe, the patients had lower cortisol and ACTH levels, suggesting a direct link between the COVID-19 infection and impaired glucocorticoid response.

Conclusion

Unexpectedly, the adrenocortical response in patients with COVID-19 infection was impaired, and a significant percentage of the patients had plasma cortisol and ACTH levels consistent with central adrenal insufficiency.

Key words

ACTH
cortisol
COVID-19
glucocorticoids
hypothalamic-pituitary-adrenal axis
SARS-CoV-2

Abbreviations

ACE2
angiotensin-converting enzyme 2
ACTH
adrenocorticotropic hormone
ARDS
acute respiratory distress syndrome
COVID-19
coronavirus disease-2019
CT
computed tomography
DHEAS
dehydroepiandrosterone sulfate
HPA
hypothalamic-pituitary-adrenal
ICU
intensive care unit
SARS
severe acute respiratory syndrome
WHO
World Health Organization

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Note: This paper uses SI units for cortisol values. To convert cortisol in nmol/L to mcg/dL, divide by 27.6.

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