Is It the COVID-19 and Untreated Panhypopituitarism a Deadly Combination: A Case Report?

Burekovic, Azra; Divanovic, Anida

Background: The possible long-term consequences of coronavirus disease (COVID-19) on the endocrine system are still not known. With the number of cases rising we have reported the first possible implications of COVID-19 on panhypopituitarism in Bosnia and Herzegovina. Clinical Case: A 59-year-old man was referred to the Endocrinology Counseling Center on 12/10/2020. For 15 years he did not take thyroid and adrenal replacement therapy. As a child, he was treated for short stature, as well as his two sisters. He had signs and symptoms of myxedema. He was urgently hospitalized to the Department of Endocrinology. His condition has worsened in the last month, more intensely in the last 10 days. He complained of general weakness, malaise, drowsiness, shortness of breath, fatigue, constipation, swelling of the lower legs. The patient was enormously adipose and moved harder with help of a walking stick. The thyroid gland appeared smaller on palpation. Laboratory investigations showed low and borderline levels of the following hormones TSH 0.590 (0.3-4.2 mU/L), FT4 1.44 (12.0-22.0 pmol/L), FT3 0.858 (3.1-6.8 pmol/L), ACTH at 8 am 2.59, ACTH at 16 pm 8.44 (7.20-63.3 pg/ml), GH 0.090 (0.0-14.0), FSH <0.7 (1.6-9.7 IU/L), LH <0.7 (0.7-7.8 IU/L), prolactin <30.8 (78-380 uIU/ml), testosterone 1.01 (above 50 years 2.5-21.6 nmol/l), cortisol at 8 am 557, cortisol at 16 pm 674, cortisol at 11 pm 674 (morning: 123-626 nmol/L, afternoon 46-389 nmol/L), DHS 1.87 (2.17-11.7 nmol/L). On 12/10/2020 he tested negative for SARS-CoV-2 infection. On 14/10/2020 his condition worsened. He was somnolent, and even though he was admitted to diuretic therapy, he had decreased urine output. His D-dimer was 3.93 (0-0.055 mcg/mL). CT findings of thoracic organs described cardiomegaly, atherosclerotic altered thoracic aorta, and changes in the pulmonary parenchyma on both sides. On 16/10/2020 the patient was transferred to the cardiology department. SARS-CoV-2 test was repeated, and it was positive. The patient exited due to pulmonary arrest on 17/10/2020. Conclusion: There are several possible mechanisms that may describe that COVID-19 infection exacerbates the symptoms of myxedema and panhypopituitarism, and consequently leads the patient to severe acute respiratory failure.