Introduction: Literature has already described some cases of hypophysitis related to acute respiratory syndrome coronavirus 2 (SARS-Cov2). The pituitary is indeed target for the virus due to the angiotensin-converting-enzyme-2 expression. Hypophysitis patients present with mass effect and pituitary dysfunction related symptoms. ACTH and TSH deficiencies are the most reported, along with central diabetes insipidus (CDI). The best way to manage these hypophysitis is still undefined. However, it must be considered that the prompt correction of Glucocorticoid (GC) therapy in Adrenal insufficiency (AI) is aimed at saving the life of the patients. We describe our experience in the management of hypophisitis in patients who tested positive for SarsCov2, focusing on its two most challenging presentations: adrenal insufficiency and diabetes insipidus.
Discussion: If COVID-19 infection was mild and without fever, we chose to conservatively treat AI patients, with surveillance of symptoms of the onset of adrenal crisis, as nausea, vomiting, abdominal pain and hypotension. Furthermore, we suggested to the patients to monitor their body temperature and to take a careful water balance. If COVID-19 infection was moderate and in any patients at risk of adrenal crisis, we immediately increased the dose of Hydrocortisone to 100 mg (i.m. or i.v) and hospitalized the patients. We raised the GC dose up to Hydrocortisone 300 mg/day for those patients whose clinical condition worsened into acute respiratory distress syndrome (ARDS). In severe COVID-19, the patients who developed central DI may be vulnerable to life-threatening hypernatremia. Patients with severe dehydration were treated with hypotonic fluids, either enterally (using water) or intravenously (using 5% Glucose solution). Desmopressin was administered as occurred, according to the evaluation of the fluid balance, the dosage of natriemia and of plasmatic and urine osmolality. We measured the plasma sodium at frequent intervals (every 12 hours). We accepted mild hypernatraemia (<155 mmol/l) as the price of preventing pulmonary oedema. No patient developed secondary consequences linked to both corticosteroid insufficiency and fatal hypernatremia/hyponatriemia. In hospitalized patients thyroid function was tested at least weekly or more frequently when clinically indicated.
Conclusion: Because of the AI, hypophysitis patients present an increased risk of worsening of COVID-19 infection and developing ARDS. When associated with the central diabetes insipidus, this increases the risk of mortality in these patients. According to our experience, in order to avoid the deterioration of their clinical conditions, it is necessary to keep these patients under strict endocrinological control even when they are hospitalized.
21 May 2022 - 24 May 2022