Bilateral Adrenal Gland Infarction in the Setting of COVID-19 Infection

A 71-year-old man with past medical history pertinent for chronic kidney disease stage III, hypertension, hyperlipidemia, atrial fibrillation (AF) on oral anticoagulation, and hypothyroidism presented with acute on chronic kidney disease (AoCKD), elevated transaminases and failure to thrive. COVID-19 polymerase chain reaction (PCR) was positive. Chest x-ray showed patchy bilateral airspace disease. Computed tomography (CT) of chest, abdomen, pelvis and magnetic resonance imaging (MRI) abdomen were unremarkable apart from Bilateral patchy infiltrates in the lungs. The patient did not require steroids and/or remdesivir as he was not hypoxic. He was discharged five days later on rivaroxaban. A week after discharge, he presented with worsening generalized weakness, worse in the lower extremities, culminating in a fall. On readmission, laboratory studies revealed rhabdomyolysis, AoCKD, and elevated transaminases. Additionally, a leukocytosis was present without symptoms concerning for infection. COVID-19 testing was repeated and was positive, with the remainder of the infectious workup including blood cultures being unremarkable. A repeat CT scan of chest, abdomen, pelvis with contrast demonstrated fat stranding around both adrenals concerning for infarction in the setting of COVID-19 infection (image 1). Subsequently, a morning cortisol was obtained, which was low concerning for adrenal insufficiency. This suspicion was confirmed with cosyntropin stimulation testing, which demonstrated adrenal insufficiency. He was started on hydrocortisone and fludrocortisone with improvement in symptoms over the next three days. Common causes of adrenal infarction and hemorrhage include thromboembolic disease, hypercoagulable states, HIT, physical trauma, the postoperative state, sepsis, and any cause of severe physiologic stress. We are still gaining insight into the multisystem disease manifestations of COVID-19 and its prothrombotic effects despite chronic oral anticoagulation therapy at prophylactic doses for other maladies like AF. Adrenal insufficiency due to infarction should be considered in patients who present with non-specific symptoms such as weakness, hypotension, electrolyte abnormalities, abdominal pain, nausea and/or vomiting in the setting of COVID-19 infection when other causes have been ruled out. Adrenal infarction has been reported in patients with COVID-19 infection, such as our patient. The adrenal glands are susceptible to infarction and hemorrhage due to their vascularity. It has been hypothesized that the hypercoagulable state wrought by SARS-CoV-2 viremia poses a particular risk to the adrenal microvasculature. In turn, reperfusion injury and hemorrhage can ensue due to anticoagulant therapy and secondary adrenal necrosis.