(12.06) COVID-19 Causing Chaos: Case of Panhypopituitarism post-SARS-CoV-2

SARS-CoV-2 (COVID-19) infection affects various organ systems including the hypothalamic-pituitary axis. It causes systemic involvement by entering cells through the angiotensin-converting enzyme 2 (ACE2) receptor which are ubiquitously expressed in our body. Reports in human and animal models show significant ACE2 mRNA expression in the hypothalamus and pituitary. COVID-19 can cause panhypopituitarism, often due to hypophysitis or pituitary apoplexy in the setting of preexisting pituitary adenomas. We present a patient who developed panhypopituitarism, diagnosed 1-year post COVID-19 infection, with incidental finding of partial empty sella.

Case(s) Description :

A 75-year-old man with history of severe COVID-19 infection with long hospital-stay due to septic shock and acute respiratory failure requiring intubation 1 year prior to presentation. He had a history of chronic opioid use for restless leg syndrome and intermittent oral steroid use for asthma. He presented with symptoms of worsening fatigue and erectile dysfunction that prompted evaluation for adrenal insufficiency.
Laboratory evaluation showed a mid-morning cortisol level of 3.6 (7-23 ug/dL), a 250 mcg cosyntropin stimulation test showed inadequate response with inappropriately normal ACTH level indicating central adrenal insufficiency.  He was found to have hypogonadotropic hypogonadism, central hypothyroidism, and growth hormone deficiency suggestive of panhypopituitarism. MRI of the brain showed partial empty sella which had been stable since prior to the COVID-19 infection.  He also had a CT of the abdomen performed prior for umbilical hernia repair which showed bilateral atrophic adrenal glands. He was started on multiple hormone replacement therapy with prednisone, levothyroxine, and testosterone for treatment of panhypopituitarism with significant improvement in his symptoms.

Discussion :

Patient is a 75-year-old man diagnosed with panhypopituitarism 1 year after COVID-19 infection. He had multiple other risk factors for adrenal insufficiency, such as severe septic shock, intermittent oral steroid use for asthma exacerbations and chronic opioid use.  Research suggests that the COVID-19 virus enters the cells utilizing the ACE2 receptors, which are also present in the pituitary gland. This can lead to inflammation causing hypophysitis. This was likely augmented in our patient by acute shock causing decreased in blood flow to the pituitary increasing risk of panhypopituitarism. It is important to evaluate the hypothalamic pituitary adrenal axis in patients with significant symptoms of fatigue after COVID-19 infection to diagnose adrenal insufficiency and other pituitary hormone deficiencies which can be life threatening.