202 - Decompensation to hypothalamic-pituitary-adrenal axis: Is COVID-19 to blame?

Case Diagnosis: Metabolic encephalopathy and sepsis secondary to COVID-19

Case Description: A 78-year-old male with panhypopituitarism secondary to pituitary adenoma resection was admitted to acute inpatient rehabilitation facility with myopathy following hospitalization for rhabdomyolysis and sepsis in the setting of COVID-19. The patient's rehabilitation course was complicated by an episode of vasovagal syncope with labs revealing low-normal cortisol, thyroid, and testosterone levels. Although known to be testosterone deficient, the patient did not receive testosterone supplementation during acute care hospitalization. The patient was restarted on topical testosterone and hydrocortisone regimen was increased. ACE wraps and abdominal binder were placed to combat orthostasis.

Discussions: The hypothalamic-pituitary-adrenal axis is a complex neuroendocrine system that serves to maintain physiological homeostasis. Panhypopituitarism is the deficiency of hormones produced by the anterior pituitary gland: thyroid stimulating hormone, adrenocorticotropic hormone, luteinizing hormone, follicle-stimulating hormone, growth hormone and prolactin. The consequence is decreased levels of cortisol, thyroid hormone and testosterone. Syncope and postural hypotension are the most common acute presentations of secondary adrenal insufficiency and panhypopituitarism in the emergency setting, as decreased cortisol can lower vascular tone. The fatigue and generalized weakness seen in rhabdomyolysis, and often witnessed in COVID-19, also can occur in patients with panhypopituitarism. Given the demands of acute inpatient rehabilitation requiring three hours of therapy daily in a patient with a decompensated pituitary axis secondary to COVID-19, medication adjustments were required to enhance support of the patient's neuroendocrine system.

Conclusions: Viral illness leading to decompensation of the hypothalamic-pituitary-adrenal axis can lead to functional deficits requiring multidisciplinary rehabilitation. Additionally, the presence of underlying panhypopituitarianism has the potential to exacerbate symptoms of weakness, fatigue, and syncope in patients receiving acute inpatient rehabilitation. Taking panhypopituitarianism into consideration in patients with new onset disability and collaborative management with endocrinology can help to direct treatment.